AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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• Clinical
• Differentials
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• Follow-up
• Miscellaneous
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Background

Biliary colic and cholecystitis are in the spectrum of biliary tract disease. This spectrum ranges from asymptomatic gallstones to biliary colic, cholecystitis, choledocholithiasis, and cholangitis. In the United States, autopsies have shown that at least 20% of women and 8% of women older than 40 years have gallstones.

Gallstones are divided into 2 categories: Cholesterol (80%) and pigment (20%) ones temporarily obstruct the cystic duct or pass through into the common bile duct, gallstones become symptomatic, and biliary colic develops. Cholecystitis occurs when this obstruction is prolonged (usually several hours) resulting in inflammation of the gallbladder wall. Choledocholithiasis occurs when the stones become lodged in the common bile duct, resulting in possible cholangitis and ascending infections.

Pathophysiology

Cholecystitis is an inflammation of the gallbladder caused by obstruction of the cystic duct. A gallstone usually causes the obstruction (calculous cholecystitis). The inflammation may be sterile or bacterial. The obstruction may be acalculous or caused by sludge. This obstruction can result in gallbladder distention, gallbladder wall edema, ischemia, and necrosis. Additional inflammatory mediators, specifically prostaglandins, are released resulting in increased gallbladder inflammation.

Bacterial infection is thought to be a consequence, not a cause, of cholecystitis. In the early stages of acute cholecystitis, bile is sterile. Approximately 20-75% of bile cultures are eventually positive with the most common organisms being Escherichia coli, Klebsiella species, Enterococci, and Enterobacter. Common bile duct stones (choledocholithiasis, 10%) are either secondary (from the gallbladder) or primary (formed in bile ducts).

Frequency

United States

Prevalence of cholelithiasis is affected by many factors, including race, ethnicity, gender, age, medical problems, and fertility. Between 10-20% of adults (approximately 20 million people) in the United States have gallstones. Each year, only 1-3% of people with stones develop symptoms of gallstones.

International

People of Hispanic or northern European countries are more likely to have stones.

Mortality/Morbidity

• Asymptomatic gallstones result in morbidity and mortality when they become symptomatic.
• Mortality can be as high as 15% in immunocompromised patients.
• Complicated cholecystitis has 25% mortality (eg, gangrene, empyema of gallbladder). Perforation of gallbladder occurs in 3-15% of patients with cholecystitis and is associated with 60% mortality.

Race

• Racial or ethnic influences are important in gallbladder disease. Fair people of northern European descent are more likely to have gallstones.
• African Americans are at decreased risk for gallstones unless they have a hematologic reason for stones (eg, sickle cell anemia).
• Asians with stones are more likely than other populations to have pigmented stones. In elderly Pima Indians, incidence of gallstones is approximately 75%. Increased incidence of stones may be observed in people of Hispanic ethnicity.

Sex

• The phrase "fair, female, fat, and fertile" summarizes the major risk factors for development of gallstones. Although gallstones and cholecystitis are more common in women, men with gallstones are more likely to develop cholecystitis than women with gallstones.
• Whether women who are pregnant or have multiple pregnancies are more likely to develop stones or whether they are simply more symptomatic with stones is unknown.
• Some oral contraceptives or estrogen replacement therapy may increase the risk of gallstones.

Age

• Age increases rates of gallstones, cholecystitis, and common bile duct stones. Elderly patients are more likely to go from asymptomatic gallstones to serious complications of gallstones without gallbladder colic.
• Children are more likely than adults to have acalculous gallstones. If stones exist, they are more likely pigmented stones from hemolytic diseases (eg, sickle cell diseases, spherocytosis, G-6-PD deficiency) or chronic diseases (eg, total parenteral nutrition, burns, trauma).
• Teenagers have the same etiologies of gallstones as adults, with a higher incidence in girls and during pregnancy.

CLINICAL

Section 3 of 11  

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History

• Typical gallbladder colic is 1-5 hours of constant pain, most commonly in the epigastrium or right upper quadrant. Pain may radiate to the right scapular region or back. Peritoneal irritation by direct contact with the gallbladder localizes the pain to the right upper quadrant. Pain is severe, dull or boring, and constant (not colicky). Patients tend to move around to seek relief from the pain. Onset of pain develops hours after a meal, occurs frequently at night, and awakens the patient from sleep. Associated symptoms include nausea, vomiting, pleuritic pain, and fever.
• Up to 70% of patients with cholecystitis report having experienced similar episodes in the past that spontaneously resolved. Persistence of biliary obstruction leads to cholecystitis and persistent right upper quadrant pain. Character of pain is similar to gallbladder colic except that it is prolonged and lasts hours (usually >6 h) or days. Nausea, vomiting, and low-grade fever are associated more commonly with cholecystitis
• Indigestion, belching, bloating, and fatty food intolerance are thought to be typical symptoms of gallstones; however, these symptoms are just as common in people without gallstones and frequently are not cured by cholecystectomy.
• Most gallstones (60-80%) are asymptomatic at a given time. Smaller stones are more likely to be symptomatic than larger ones. Almost all patients develop symptoms prior to complications.
• Symptoms of cholecystitis are steady pain in the right hypochondrium or epigastrium, nausea, vomiting, and fever. Acute attack often is precipitated by a large or fatty meal.

Physical

• Vital signs parallel the degree of illness. Patients with cholangitis are more likely to have fever, tachycardia, and/or hypotension. Patients with gallbladder colic have relatively normal vital signs. In a retrospective study, only 32% of patients with cholecystitis had fever. Fever may be absent, especially in elderly patients.
• Patients with cholecystitis are usually more ill appearing than simple biliary colic patients, and they usually lie still on the examination table since any movement may aggravate any peritoneal signs.
• Abdominal examination in gallbladder colic and cholecystitis is remarkable for epigastric or right upper quadrant tenderness and abdominal guarding. The Murphy sign (an inspiratory pause on palpation of the right upper quadrant) can be found on abdominal examination. Singer et al found that a positive Murphy sign was extremely sensitive (97%) and predictive (PPV, 93%) for cholecystitis.¹ However, in elderly patients, this sensitivity may be decreased.
• When observed, peritoneal signs should be taken seriously. Most uncomplicated cholecystitis does not have peritoneal signs; thus, search for complications (eg, perforation, gangrene) or other sources of pain.
• Gallbladder gangrene can be a complication in up to 20% of cases of cholecystitis and is usually in diabetics, elderly, or immunocompromised persons.
• A palpable fullness in the RUQ may be appreciated in 20% of cases.
• As in all patients with abdominal pain, perform a complete physical examination, including rectal and pelvic examinations in women.
• In elderly patients and those with diabetes, occult cholecystitis or cholangitis may be the source of fever, sepsis, or mental status changes.
• Jaundice is unusual in the early stages of acute cholecystitis and may be found in fewer than 20% of patients.
• A very high bilirubin should prompt the physician to pay special attention to the common bile duct and pancreatic region.

Causes

Risk factors for biliary colic and cholecystitis include pregnancy, elderly population, obesity, certain ethnic groups, and drugs.

Risk factors for acalculous cholecystitis include diabetes, HIV, vascular disease, total parenteral nutrition, prolonged fasting, or being an ICU patient.

DIFFERENTIALS

Section 4 of 11  

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• Clinical
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• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

WORKUP

Section 5 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
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Lab Studies

• Labs with cholelithiasis and gallbladder colic should be completely normal. WBC, aspirate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and alkaline phosphate may be helpful in the diagnosis of cholecystitis. However, presence of normal lab values does not exclude cholecystitis.
• Because biliary obstruction is limited to the gallbladder in uncomplicated cholecystitis, elevation in the serum total bilirubin and alkaline phosphatase concentrations may not be present. A study by Singer et al examined the utility of laboratory values in acute cholecystitis diagnosed by hepatic 2,6-dimethyliminodiacetic acid (HIDA) scan.¹ No difference was found in mean WBC, AST, ALT, bilirubin, and alkaline phosphate between patients diagnosed with cholecystitis and those without.
• An elevated WBC is expected but not reliable. In a retrospective study, only 61% of patients with cholecystitis had a WBC greater than 11,000. A WBC greater than 15,000 may indicate perforation or gangrene.
• Comprehensive metabolic panel with bicarbonate may exhibit the following:
• • AST, ALT, and alkaline phosphate levels may be elevated; however, as with other laboratory tests, these levels are not sensitive for excluding cholecystitis. When the AST and ALT are elevated significantly, a common bile duct stone is more likely.
  • An elevation of AST, ALT, or alkaline phosphate should raise the possibility of other biliary system pathology such as cholangitis, choledocholithiasis, or the Mirizzi syndrome (obstruction of the common bile duct by an impacted stone in the distal cystic duct).
  • Note calcium level (Ranson criteria) if evidence of biliary pancreatitis exists.
  • Other abnormalities (eg, renal insufficiency) are not related to cholecystitis but may indicate a comorbid condition.
• Mild elevation of amylase up to 3 times normal may be found in cholecystitis, especially when gangrene is present.
• Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are not expected to be elevated unless sepsis or underlying cirrhosis is present. Coagulation profiles are helpful if the patient needs operative intervention.
• For febrile patients, send 2 sets of blood cultures to attempt to isolate the organism.
• Although expected to be normal, urinalysis is essential in the workup of patients with abdominal pain to exclude pyelonephritis and renal calculi.
• Conduct a pregnancy test for women of childbearing age.

Imaging Studies

• Ultrasonography and nuclear medicine studies are the best imaging studies for the diagnosis of both cholecystitis and cholelithiasis. Plain radiography, CT scans, and endoscopic retrograde cholangiopancreatography (ERCP) are diagnostic adjuncts.
• Abdominal radiographs
• • The advantages of abdominal radiographs include their readily availability and low cost. However, abdominal radiographs have low sensitivity and specificity in evaluating biliary system pathology, but they can be helpful in excluding other abdominal pathology such as renal colic, bowel obstruction, perforation. Between 10 and 30% of stones have a ring of calcium and, therefore, are radiopaque. A porcelain gallbladder also may be observed on plain films.
  • Emphysematous cholecystitis, cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation may show air in the biliary tree. Air in the gallbladder wall indicates emphysematous cholecystitis due to gas-forming organisms such as clostridial species and Escherichia coli.
• Computed tomography scan
• • CT scan is not the test of choice and is recommended only for the evaluation of abdominal pain if the diagnosis is uncertain. CT scan can demonstrate gallbladder wall edema, pericholecystic stranding and fluid, and high-attenuation bile.
  • A helical CT scan with fine cuts through the biliary tract has not been well studied and may be useful.
  • Advantages: For complications of cholecystitis and cholangitis, gallbladder perforation, pericholecystic fluid, and intrahepatic ductal dilation, CT scan may be adequate. CT scan provides better information of the surrounding structures than sonogram and HIDA. CT scan is also noninvasive.
  • Disadvantages: CT scan misses 20% of gallstones because the stones may be of the same radiographic density as bile. CT scan is also more expensive and takes longer since the patient usually has to drink oral contrast. Also, given the radiation dose, it may not be ideal in the pregnant patient.
• Ultrasonography
• • Ultrasonography is the most common test used in the ED for the diagnosis of biliary colic and acute cholecystitis. It is 90-95% sensitive for cholecystitis and 78-80% specific. For simple cholelithiasis, it is 98% sensitive and specific.
  • Ultrasonography may be diagnostic for biliary disease, help exclude biliary disease, or may reveal alternative causes of the patient's symptoms.
  • Findings include gallstones or sludge and one or more of the following conditions:
    • Gallbladder wall thickening (>2-4 mm) - False-positive wall thickening found in hypoalbuminemia, ascites, congestive heart failure, and carcinoma
    • Gallbladder distention (diameter > 4 cm, length >10 cm)
    • Pericholecystic fluid from perforation or exudate may be seen as a hypoechoic or anechoic region seen along the anterior surface of the gallbladder within the hepatic parenchyma.
    • Air in the gallbladder wall (indicating gangrenous cholecystitis)
    • Sonographic Murphy sign (86-92% sensitive, 35% specific), pain when the probe is pushed directly on the gallbladder (not related to breathing)
  • Some ED sonographers recommend the diagnosis of cholecystitis if both a sonographic Murphy sign and gallstones (without evidence of other pathology) are present.
  • In a study by Ralls et al, a positive sonographic Murphy sign and the presence of gallstones had a positive predictive value of 92% for the diagnosis of acute cholecystitis.²
  • Additional findings in the presence or absence of gallstones: Dilated common bile duct or dilated intrahepatic ducts of the biliary tree indicate common bile duct stones. In the absence of stones, a solitary stone may be lodged in the common bile duct, a location difficult to visualize sonographically.
  • Advantages of sonography include the following:
    • Images other structures (eg, aorta, pancreas, liver)
    • Identifies complications (eg, perforation, empyema, abscess)
    • Rapidly performed at the bedside and by the ED physician
    • No radiation (important in pregnancy)
  • Disadvantages of sonography include the following:
    • Operator dependent and patient dependent
    • Inability to image the cystic duct
    • Decreased sensitivity for common bile duct stones
• Biliary scintigraphy (HIDA, diisopropyl iminodiacetic acid [DISIDA]), nuclear medicine studies
• • Depending on the ED, either sonography or nuclear medicine testing is the test of choice for cholecystitis. HIDA scans have sensitivity (94%) and specificity (65-85%) for acute cholecystitis. They are sensitive (65%) and specific (6%) for chronic cholecystitis. Oral cholecystography is not practical for the ED.
  • HIDA and DISIDA scans are functional studies of the gallbladder. Technetium-labeled analogues of iminodiacetic acid (IDA) or diisopropyl IDA-DISIDA are administered intravenously (IV) and secreted by hepatocytes into bile, enabling visualization of the liver and biliary tree.
  • Normal scans are characterized by normal visualization of gallbladder in 30 minutes.
  • With cystic duct obstruction (cholecystitis), the HIDA scan shows nonvisualization (ie, considered positive) of the gallbladder at 60 minutes and uptake in the intestine as the bile is excreted directly into the duodenum.
  • Obstruction of the common bile duct causes nonvisualization of the small intestine.
  • The rim sign is increased tracer adjacent to the gallbladder at 60 minutes and suggests gangrenous cholecystitis.
  • False-negative results (filling in 30 minutes) are found in 0.5% of studies, and filling between 30-60 minutes also gives a 20% false-negative rate. False-negative rates are decreased by the use of morphine, which increases the tone of the sphincter of Oddi.
  • False-positive results occur when the gallbladder does not visualize despite a nonobstructed cystic duct. Causes include fasting patients receiving total parenteral nutrition; severe liver disease, which leads to abnormal uptake of the tracer; and biliary sphincterotomy, which decreases resistance to bile flow leading to excretion of the tracer into the duodenum.
  • Morphine cholescintigraphy is used in critically ill patients in whom routine HIDA scanning may result in false-positive results. Morphine is given intravenously during the HIDA scan in order to increase the tone of the sphincter of Oddi and increase back pressure to fill the gallbladder.
  • Advantages of HIDA/DISIDA scans include the following:
    • Assessment of function
    • Normal-appearing gallbladder (by ultrasound); obstructed cystic duct abnormal on DISIDA scan but not ultrasound.
    • Simultaneous assessment of bile ducts
  • Disadvantages of HIDA/DISIDA scans include the following:
    • High bilirubin (>4.4 mg/dL) possibly decreases sensitivity
    • Recent eating or fasting for 24 hours also possibly affects study
    • No imaging of other structures in the area

Other Tests

• Endoscopic retrograde cholangiopancreatography
• • ERCP provides both endoscopic and radiographic visualization of the biliary tract. It can be diagnostic and therapeutic by direct removal of common bile duct stones.
  • Ultrasound is 50-75% sensitive for choledocholithiasis. CT and HIDA scans are not better. Therefore, when a dilated common bile duct is found or elevated LFTs are present, suspicion should remain high for common bile duct stones, and an ERCP should be considered.
  • Debate exists as to when an ERCP should be performed. In general, since cholecystitis is caused by obstruction of the ducts, the risk of common bile duct stones is approximately 10%. Given its potential for complications, ERCP should be used when there is a high potential for intervention and it should not be used solely as a diagnostic modality.
  • Some studies have classified people as low risk for common bile duct stones based on (1) lack of jaundice, (2) elevated transaminases, and (3) a common bile duct diameter of less than 8 mm. In this population, the risk of common bile duct stones may be as low as 1%. In patients with any of the risk factors, the rate of stones was 39%. Therefore, in general, people with any of the risk factors for common bile duct stones should undergo operative or ERCP evaluation of the common bile duct.
  • Major complications of ERCP include pancreatitis and cholangitis.

TREATMENT

Section 6 of 11  

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Prehospital Care

• Patients with gallbladder colic or cholecystitis usually present in the prehospital setting with severe abdominal pain. Transport patients with minor symptoms to the hospital with an IV in place and monitor. However, the diagnosis of cholecystitis is not a prehospital diagnosis.
• In patients with severe pain (eg, differential includes abdominal aortic aneurysm, myocardial infarction) and in patients with hypotension and/or fever who may have cholecystitis or cholangitis, prehospital care should include the following:
• • As with all emergencies, airway, breathing, and circulation take priority and should be assessed immediately.
  • Monitoring (pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
  • Stabilization (oxygen, placement of 2 large-bore IVs, administration of IV fluids to unstable patients)
  • Rapid transport

Emergency Department Care

• Suspect gallbladder colic in patients with less than 4-6 hours of right upper quadrant pain that radiates to the back. Consider acute uncomplicated cholecystitis in patients with pain of longer duration and with or without low-grade fever. Severe cholecystitis can develop into sepsis or cholangitis, especially in patients with diabetes or elderly patients, in whom the diagnosis may be delayed.
• After assessment of the ABCs, perform the standard opening gambit of IV, pulse oximetry, oxygen, ECG, and monitoring. Send labs when the IV is placed; include blood cultures if the patient is febrile.
• Primary goal of ED care is diagnosis of cholecystitis with laboratory and sonography or HIDA scan. Once diagnosis of acute cholecystitis is made, it usually is treated by hospitalization. This may include medical and/or surgical therapy. Some patients may be treated as outpatients.
• In patients who are unstable or have severe pain, consider a bedside ultrasound to exclude an abdominal aortic aneurysm and assist in the diagnosis of cholecystitis.
• Replace volume loss with normal saline, then maintenance fluids. Make patients nothing by mouth (NPO). Nasogastric suction may be needed in patients with persistent vomiting or abdominal distention.
• Pain control considerations are as follows:
• • Several studies now have shown that early pain control in ED patients with abdominal pain does not hinder the diagnosis. Therefore, administer pain control early, without waiting for the diagnosis or surgical consult. A courtesy call to the surgical consultant prior to administration of narcotics offers the expedient opportunity to examine the patients without narcotics, which occasionally diminishes surgical resistance to prediagnosis narcotic use.
  • Pain control should be with opiate analgesics such as meperidine (Demerol). Morphine is generally not recommended since it can increase the tone of the sphincter of Oddi.
  • Anticholinergic antispasmodics, such as dicyclomine (Bentyl), are also recommended in the initial management of acute biliary colic and cholecystitis.
  • Anti-inflammatory medications such as ketorolac or indomethacin have been reported to be effective in relieving pain from gallbladder distention. Because the release of prostaglandins results in gallbladder distension, inhibition of these prostaglandins may help alleviate some of the symptoms. However, they may not be as effective when biliary colic is complicated by infection.
  • Antiemetics such as metoclopramide or prochlorperazine can be used.

Consultations

• Historically, cholecystitis was operated on emergently, resulting in increased mortality. Currently, practice is to cool off the gallbladder and perform a cholecystectomy after several days or readmit the patient at a later date.
• Emergent cholecystectomy is usually performed in 20% of cases of acute cholecystitis that has become complicated (ie, gangrene, perforation).
• In high surgical risk patients, placement of a percutaneous cholecystostomy is an acceptable alternative and can be performed at the bedside with ultrasound guidance.
• Prescribe an urgent gastroenterology consultation for ERCP for patients with evidence of choledocholithiasis (ie, common bile duct stones seen on sonography, dilated common bile ducts, elevated LFTs, pancreatitis).
• Surgical consult is appropriate, and depending on the institution, either medicine or surgery may admit the patient for conservative care.

MEDICATION

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Although surgical therapy is treatment of choice for acute cholecystitis, many patients require hospitalization for stabilization and "cooling off" of the gallbladder prior to surgery. Indications for urgent surgical intervention include patients with complications such as empyema, emphysematous cholecystitis, or perforation. Medical therapy of gallbladder colic includes antiemetics and pain control. In mild cholecystitis, in which inflammation is the primary process, antibiotics are prophylactic but usually are used. In acute cholecystitis, broad-spectrum antibiotic coverage is used.

The following dosages are general recommendations. Please check current sources prior to administration.

Drug Category: Anticholinergics

Antispasmodics and anticholinergics are thought to decrease gallbladder and biliary tree tone, which decreases pain associated with gallstones.

Drug Category: Analgesics

When dicyclomine (Bentyl) is not effective, a narcotic is appropriate. The narcotic of choice is meperidine due to potential problems of increased tone of sphincter of Oddi with morphine.

Drug Category: Antiemetics

Cholecystitis and particularly obstruction of common bile duct can cause nausea and vomiting; therefore, antiemetics can be helpful.

Drug Category: Antibiotics

Treatment of acute cholecystitis usually requires single-agent therapy, but for more serious infections, combination drug treatment has increased broad-spectrum coverage. Debate exists as to whether the most effective antibiotics must have high biliary concentrations. Antibiotics should be guided to target the most common organisms found in biliary tract pathology. These include E coli, Klebsiella species, and Streptococcus species.

Single-agent regimens include the following: piperacillin and tazobactam, ampicillin and sulbactam, mezlocillin, imipenem, meropenem, ticarcillin, and clavulanate.

Good combinations include the following: penicillin (including piperacillin, ampicillin, or penicillin) and metronidazole; the above plus an aminoglycoside (gentamicin or tobramycin); and aminoglycoside and third-generation cephalosporin.

FOLLOW-UP

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Further Inpatient Care

• Cholecystectomy may be performed after the first 48 hours or after the inflammation has subsided. In approximately 30% of patients with uncomplicated cholecystitis, medical therapy is not sufficient and these patients usually need cholecystectomy within 24-72 hours. Unstable patients may need more urgent intervention with ERCP, percutaneous drainage, or cholecystectomy.
• Laparoscopic cholecystectomy is very effective and has few complications. Approximately 5% must be converted to an open cholecystectomy. In acute cholecystectomy, the conversion rate can be as high as 50%.
• Immediate laparoscopic cholecystectomy (within 24 h) is now being increasingly performed by surgeons because it has been shown to be safe, not more difficult than laparoscopic cholecystectomy performed later, and shortens the hospital length of stay.
• Patients who are not good surgical risks but who are toxic may benefit from percutaneous gallbladder drainage and placement of a T tube if common bile duct stones are suspected. The alternative is ERCP to attempt endoscopic opening of the common bile duct or cystic duct.
• Delayed surgical intervention can be used for patients who have high-risk medical conditions and are unstable for surgery and in patients in whom the diagnosis in doubt.
• In patients younger than 60 years, the mortality rate for emergent cholecystectomy is approximately 3%, whereas mortality in early or elective cholecystectomy approaches 0.5%.

Further Outpatient Care

• For acute cholecystitis, some patients may be treated as outpatients. The patients must meet the following criteria:
• • Afebrile and normal vital signs
  • Minimal amount of pain and tenderness
  • No markedly abnormal labs, normal common bile duct on sonography, and no pericholecystic fluid or biliary air
  • No underlying medical problems (eg, diabetes, cirrhosis, vascular condition, steroids), advanced age, or pregnancy
  • Next day follow-up visit
  • Discharge on oral antibiotics and a small number of pain medications
• In pregnancy, since symptoms may be recurrent, refer women to their OB/GYN as well as a surgeon. Second trimester cholecystectomy is the safest time period because the risk of premature labor is lower, and the uterus does not push on the gallbladder.
• Other therapies: For simple gallbladder colic, other therapies rarely are performed because they require long-term therapy (oral dissolution), cause complications (shock wave therapy), and ultimately do not prevent the recurrence of gallstones.
• • Oral dissolution therapy: Bile acid therapy consists of ursodeoxycholic acid sometimes in combination with chenodeoxycholic acid. With this treatment, cholesterol saturation of bile is decreased, and dissolution of small gallstones (<5 mm) is possible with 6-12 months of therapy; however, over one half recur. This treatment has several disadvantages including the time frame of up to 2 years. Fewer than 10% of patients with symptomatic gallstones are candidates for this therapy. The doses are not listed because this treatment option is chosen rarely, and it is not in the purview of the ED.
  • Extracorporeal shock-wave lithotripsy: This is another little-used therapy due to the recurrence of stones. This therapy is not popular because only small, <2 cm, stones can be fragmented and also a recurrence of gallstones occurs in up 30% of patients within 5 years.
  • Dissolution therapy: Percutaneous contact dissolution by injection of methyl tert-butyl ether into the gallbladder to dissolve stones rarely is used.

Deterrence/Prevention

• Some literature supports dietary modification of decreased fat intake to decrease occurrence of biliary colic.

Complications

• Cholangitis
• Sepsis
• Pancreatitis
• Gallbladder perforation
• • Gallbladder perforation occurs in 10% of patients with cholecystitis. When perforation is localized, it may be seen as pericholecystic fluid by ultrasound. Abscess formation is common.
  • Free perforation also can occur, releasing bile and inflammatory matter intraperitoneally, causing peritonitis.
• Gallstone ileus
• • When perforation occurs next to a hollow viscus, a gallbladder enteric fistula can be formed.
  • Fistulas into the duodenum are most common. When gallstones are passed directly through the fistula into the small bowel, if they are greater than 2.5 cm, they can obstruct the ileocecal valve. This causes gallstone ileus.
  • Mortality can be up to 20% because diagnosis is difficult.
  • Treatment includes cholecystectomy, CBC exploration, and closure of the fistulous tract.
• Hepatitis
• Choledocholithiasis (10%)

Prognosis

• Uncomplicated cholecystitis has a low mortality.
• Emphysematous gallbladder of infection by gas-forming organisms (eg, Clostridium species) is more common in patients with diabetes and men. Mortality is 15%. Perforation of the gallbladder occurs in 3-15% of cholecystitis with up to 60% mortality.
• Gangrenous or empyema of the gallbladder carries 25% mortality.

Patient Education

• Advise patients with biliary colic to refrain from eating fatty or spicy foods. They should contact their physician for persistent recurrence of pain or fever.
• For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education article Gallstones.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Delay in diagnosis of acute cholecystitis can result in complications, such as gangrene and perforation, and eventually increased morbidity and mortality. ED physicians should consider this in patient populations that may have atypical presentations such as diabetics, elderly, and children. Generally, all patients with a diagnosis of acute cholecystis should be admitted to the hospital for IV antibiotics and scheduled for cholecystectomy within 24-72 hours.

Special Concerns

• Gallstones are more likely to be symptomatic in pregnancy. For gallbladder colic in pregnancy, since symptoms may be recurrent, women should be referred to their OB/GYN as well as a surgeon. Second trimester cholecystectomy is the safest time period because the risk of premature labor is lower, and the uterus does not push on the gallbladder.
• Children form gallstones uncommonly; if they do, they are more likely to have congenital anomalies, biliary anomalies, or hemolytic (pigment) stones.
• Incidence of gallstone increases with age. Elderly patients are more likely to go from asymptomatic gallstones to serious complications of gallstones without gallbladder colic. Be careful with elderly patients and those with diabetes with cholecystitis who may present with sepsis and nonlocalized abdominal tenderness.
• Acalculous cholecystitis occurs in critically ill patients and localized pain and tenderness can sometimes not be present. Patients with burns or sepsis and postoperative and trauma patients are all at risk for acalculous cholecystitis.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
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• Multimedia
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Media file 1:  The ultrasound only shows gallstones within the gallbladder but no evidence of cholecystitis (ie, gallbladder wall thickening, pericholecystic fluid, common bile duct dilatation, sonographic Murphy sign).
	View Full Size Image
Media type:  Ultrasound

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

1. Singer AJ, McCracken G, Henry MC, et al. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):267-72. [Medline].
2. Ralls PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD Jr, Ngo C. Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs. Radiology. Jun 1985;155(3):767-71. [Medline].
3. American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium. Ann Emerg Med. Oct 2006;48(4):487-510. [Medline].
4. Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am. Nov 2003;41(6):1203-16. [Medline].
5. Burrell MI, Zeman RK, Simeone JF, et al. The biliary tract: imaging for the 1990s. AJR Am J Roentgenol. Aug 1991;157(2):223-33. [Medline].
6. Flasar MH, Cross R, Goldberg E. Acute abdominal pain. Prim Care. Sep 2006;33(3):659-84, vi. [Medline].
7. Giurgiu DI, Roslyn JJ. Treatment of gallstones in the 1990s. Prim Care. Sep 1996;23(3):497-513. [Medline].
8. Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):273-7. [Medline].
9. Houdart R, Perniceni T, Darne B, et al. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am J Surg. Jul 1995;170(1):38-43. [Medline].
10. Janowitz P, Kratzer W, Zemmler T, et al. Gallbladder sludge: spontaneous course and incidence of complications in patients without stones. Hepatology. Aug 1994;20(2):291-4. [Medline].
11. Kim MK, Strait RT, Sato TT, Hennes HM. A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med. Apr 2002;9(4):281-7. [Medline].
12. McHale PM, LoVecchio F. Narcotic analgesia in the acute abdomen--a review of prospective trials. Eur J Emerg Med. Jun 2001;8(2):131-6. [Medline].
13. McSherry CK, Ferstenberg H, Calhoun WF, et al. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann Surg. Jul 1985;202(1):59-63. [Medline].
14. Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emerg Med Clin North Am. Nov 1996;14(4):719-37. [Medline].
15. Saini S. Imaging of the hepatobiliary tract. N Engl J Med. Jun 26 1997;336(26):1889-94. [Medline].
16. Shea JA, Berlin JA, Escarce JJ. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. Nov 28 1994;154(22):2573-81. [Medline].
17. Stevens KA, Chi A, Lucas LC, Porter JM, Williams MD. Immediate laparoscopic cholecystectomy for acute cholecystitis: no need to wait. Am J Surg. Dec 2006;192(6):756-61. [Medline].
18. Strasberg SM, Clavien PA. Overview of therapeutic modalities for the treatment of gallstone diseases. Am J Surg. Apr 1993;165(4):420-6. [Medline].
19. Swisher SG, Schmit PJ, Hunt KK, et al. Biliary disease during pregnancy. Am J Surg. Dec 1994;168(6):576-9; discussion 580-1. [Medline].
20. Tait N, Little JM. The treatment of gall stones. BMJ. Jul 8 1995;311(6997):99-105. [Medline].
21. Talley NJ. Gallstones and upper abdominal discomfort. Innocent bystander or a cause of dyspepsia?. J Clin Gastroenterol. Apr 1995;20(3):182-3. [Medline].
22. Thomas SH, Borczuk P, Shackelford J. Patient and physician agreement on abdominal pain severity and need for opioid analgesia. Am J Emerg Med. Oct 1999;17(6):586-90. [Medline].
23. Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg. Jan 2003;90(1):5-9. [Medline].
24. Thomas SH, Silen W, Cheema F. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg. Jan 2003;196(1):18-31. [Medline].
25. Traverso LW. Clinical manifestations and impact of gallstone disease. Am J Surg. Apr 1993;165(4):405-9. [Medline].
26. Tsimoyiannis EC, Antoniou NC, Tsaboulas C, Papanikolaou N. Cholelithiasis during pregnancy and lactation. Prospective study. Eur J Surg. Nov 1994;160(11):627-31. [Medline].
27. Yusoff IF, Barkun JS, Barkun AN. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin North Am. Dec 2003;32(4):1145-68. [Medline].
28. Zeman RK, Garra BS. Gallbladder imaging. The state of the art. Gastroenterol Clin North Am. Mar 1991;20(1):127-56. [Medline].

Article Last Updated: Nov 19, 2007