Acute calculous cholecystitis

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

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)

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

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

Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding
Useful for identifying complications (perforation, abscess, emphysematous changes)

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

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)

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

↑ 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

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