Diferencia entre revisiones de «Acute calculous cholecystitis»
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==Background== | ==Background== | ||
[[ | *Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones | ||
*Most common complication of [[cholelithiasis]] | |||
*10-20% of patients with gallstones will develop cholecystitis | |||
*Risk factors (5 F's — mnemonic): | |||
**Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent) | |||
**Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide) | |||
*Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%) | |||
*Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, [[emphysematous cholecystitis]] | |||
==Clinical Features== | ==Clinical Features== | ||
*RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves) | |||
* | *Pain radiates to right scapula or shoulder (phrenic nerve irritation) | ||
*Murphy | *Nausea and vomiting (common) | ||
** | *Fever (low-grade; high fever suggests complications) | ||
*Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%) | |||
**Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific | |||
*RUQ guarding, rebound tenderness (suggests peritonitis) | |||
*Jaundice suggests [[choledocholithiasis]] (common bile duct stone) or [[cholangitis]] (Charcot triad/Reynolds pentad) | |||
== | ==Differential Diagnosis== | ||
*[[ | *[[Biliary colic]] (most important to distinguish — resolves within 4-6h) | ||
*[[ | *[[Choledocholithiasis]] / [[cholangitis]] | ||
*[[Hepatitis]] | |||
*[[Peptic ulcer disease]] | |||
*[[Pancreatitis]] | |||
*[[Appendicitis]] (especially high-riding appendix) | |||
*[[Pneumonia]] (RLL) | |||
*[[Pyelonephritis]] / [[nephrolithiasis]] | |||
*[[MI]] (inferior — especially in elderly/diabetics) | |||
*[[Fitz-Hugh-Curtis syndrome]] (perihepatitis) | |||
{{RUQ pain DDX}} | |||
{{DDX | |||
==Evaluation== | ==Evaluation== | ||
===Labs=== | |||
*WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis | |||
*LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone | |||
*Lipase: rule out concurrent [[pancreatitis]] ([[gallstone pancreatitis]]) | |||
=== | *Lactate: if septic | ||
*Blood cultures: if febrile or septic | |||
* | *Pregnancy test in reproductive-age women | ||
* | |||
* | |||
=== | ===RUQ Ultrasound (Test of Choice)=== | ||
* | *Sensitivity 88%, specificity 80% for acute cholecystitis | ||
**Gallstones | *Findings: | ||
**Gallstones (echogenic foci with posterior acoustic shadowing) | |||
** | **Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis) | ||
**Pericholecystic fluid | **Pericholecystic fluid | ||
**Sonographic Murphy | **Sonographic Murphy sign (most predictive single finding) | ||
*** | **Gallbladder distension (>10 cm long or >5 cm transverse) | ||
*Combined findings increase diagnostic accuracy | |||
* | |||
* | ===HIDA Scan=== | ||
*Most accurate test for cholecystitis (sensitivity 97%, specificity 90%) | |||
* | *Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction) | ||
*Takes 1-4 hours to complete — not practical for acutely ill ED patients | |||
*Use when US equivocal and diagnosis uncertain | |||
=== | ===CT=== | ||
* | *Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding | ||
*Useful for identifying complications (perforation, abscess, emphysematous changes) | |||
==Management== | ==Management== | ||
=== | ===ED Management=== | ||
*NPO | |||
*IV fluid resuscitation | |||
*Pain control: | |||
**Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation) | |||
**'''Opioids''' (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated | |||
*Antiemetics: ondansetron 4 mg IV | |||
*Antibiotics if complicated (febrile, septic, diabetic, immunocompromised): | |||
**Piperacillin-tazobactam 3.375-4.5g IV OR | |||
**Ceftriaxone 2g IV + metronidazole 500 mg IV | |||
**Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes | |||
*Surgical consultation for cholecystectomy | |||
===Definitive Treatment=== | |||
*Laparoscopic cholecystectomy (standard of care) | |||
*Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates<ref>Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). ''Ann Surg''. 2013;258(3):385-393. PMID 24022431</ref> | |||
*Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities) | |||
=== | ===Special Populations=== | ||
* | *Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases) | ||
* | *Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men | ||
*Elderly/diabetics: higher risk of complications, may present atypically | |||
==Disposition== | ==Disposition== | ||
*Admit | *Admit all patients with acute cholecystitis | ||
*ICU if septic, gangrenous, or emphysematous cholecystitis | |||
*Surgical consultation in ED for early cholecystectomy | |||
* | |||
* | |||
==See Also== | ==See Also== | ||
*[[ | *[[Biliary colic]] | ||
*[[ | *[[Choledocholithiasis]] | ||
*[[Cholangitis]] | |||
*[[Gallstone pancreatitis]] | |||
*[[Acalculous cholecystitis]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
*Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. ''J Hepatobiliary Pancreat Sci''. 2018;25(1):41-54. PMID 29032636 | |||
*Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. ''World J Emerg Surg''. 2016;11:25. PMID 27307785 | |||
*Trowbridge RL, et al. Does this patient have acute cholecystitis? ''JAMA''. 2003;289(1):80-86. PMID 12503981 | |||
[[Category:GI]] | [[Category:GI]] | ||
Revisión actual - 09:29 22 mar 2026
Background
- Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones
- Most common complication of cholelithiasis
- 10-20% of patients with gallstones will develop cholecystitis
- Risk factors (5 F's — mnemonic):
- Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent)
- Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide)
- Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%)
- Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, emphysematous cholecystitis
Clinical Features
- RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves)
- Pain radiates to right scapula or shoulder (phrenic nerve irritation)
- Nausea and vomiting (common)
- Fever (low-grade; high fever suggests complications)
- Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%)
- Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific
- RUQ guarding, rebound tenderness (suggests peritonitis)
- Jaundice suggests choledocholithiasis (common bile duct stone) or cholangitis (Charcot triad/Reynolds pentad)
Differential Diagnosis
- Biliary colic (most important to distinguish — resolves within 4-6h)
- Choledocholithiasis / cholangitis
- Hepatitis
- Peptic ulcer disease
- Pancreatitis
- Appendicitis (especially high-riding appendix)
- Pneumonia (RLL)
- Pyelonephritis / nephrolithiasis
- MI (inferior — especially in elderly/diabetics)
- Fitz-Hugh-Curtis syndrome (perihepatitis)
Evaluation
Labs
- WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis
- LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone
- Lipase: rule out concurrent pancreatitis (gallstone pancreatitis)
- Lactate: if septic
- Blood cultures: if febrile or septic
- Pregnancy test in reproductive-age women
RUQ Ultrasound (Test of Choice)
- Sensitivity 88%, specificity 80% for acute cholecystitis
- Findings:
- Gallstones (echogenic foci with posterior acoustic shadowing)
- Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis)
- Pericholecystic fluid
- Sonographic Murphy sign (most predictive single finding)
- Gallbladder distension (>10 cm long or >5 cm transverse)
- Combined findings increase diagnostic accuracy
HIDA Scan
- Most accurate test for cholecystitis (sensitivity 97%, specificity 90%)
- Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction)
- Takes 1-4 hours to complete — not practical for acutely ill ED patients
- Use when US equivocal and diagnosis uncertain
CT
- Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding
- Useful for identifying complications (perforation, abscess, emphysematous changes)
Management
ED Management
- NPO
- IV fluid resuscitation
- Pain control:
- Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation)
- Opioids (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated
- Antiemetics: ondansetron 4 mg IV
- Antibiotics if complicated (febrile, septic, diabetic, immunocompromised):
- Piperacillin-tazobactam 3.375-4.5g IV OR
- Ceftriaxone 2g IV + metronidazole 500 mg IV
- Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes
- Surgical consultation for cholecystectomy
Definitive Treatment
- Laparoscopic cholecystectomy (standard of care)
- Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates[1]
- Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities)
Special Populations
- Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases)
- Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men
- Elderly/diabetics: higher risk of complications, may present atypically
Disposition
- Admit all patients with acute cholecystitis
- ICU if septic, gangrenous, or emphysematous cholecystitis
- Surgical consultation in ED for early cholecystectomy
See Also
References
- ↑ Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). Ann Surg. 2013;258(3):385-393. PMID 24022431
- Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. PMID 29032636
- Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25. PMID 27307785
- Trowbridge RL, et al. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86. PMID 12503981