Acute calculous cholecystitis

Acute calculous cholecystitis is one manifestation of complicated gallstone disease characterised by inflammation of the gallbladder secondary to cystic duct obstruction by a gallstone. It's not necessarily infected by bacteria, but it may be.

Acute calculous cholecystitis may be complicated by gallbladder gangrene, perforation, or emphysema.

Clinical features

Cholecystitis usually presents with right upper quadrant pain which lasts longer than biliary colic, fever, nausea/vomiting, and positive Murphy sign (may be negative in elderly). The patient usually appears ill and may have abnormal vital signs.

Diagnosis and evaluation

Laboratory tests show elevated inflammatory parametres. Ultrasound shows gallbladder wall thickening or oedema, and it will likely show gallstones as well. There is usually no evidence of cholestasis, unless there is concomitant choledocholithiasis.

Treatment

Left untreated, most symptoms of cholecystitis are self-limiting. However, the risk of developing complications is high, so treatment is indicated.

Even though the infection is not necessarily bacterial, antibiotics are used in the acute phase (in Norway ampicillin + gentamycin + metronidazole is used). If the patient is really ill or antibiotics are insufficient to clear the infection, we must achieve source control by gallbladder drainage or emergency surgery. Gallbladder drainage can be achieved percutaneously or endoscopically (with ERCP).

The definitive treatment for acute calculous cholecystitis is laparoscopic subtotal cholecystectomy, to prevent both complications and recurrence. There are two approaches to the timing of cholecystectomy, early surgery (during the same hospital admission) and delayed surgery (elective surgery after 6+ weeks).

In most cases, we opt for early surgery. In complicated cases, one may opt for delayed surgery. This allows the inflammation to heal, making surgery less risky.

Complications

Gangrenous cholecystitis

Some people (around 20% of cholecystitides) develop gangrenous cholecystitis, which is more severe than "regular" acute cholecystitis and which may cause sepsis.

Gallbladder perforation

10% of cholecystitis cases are complicated by gallbladder perforation, which may form an abscess or cause peritonitis.

Emphysematous cholecystitis

Cholecystitis complicated by secondary infection with gas-forming bacteria like clostridium may cause cholecystitis with gas in the gallbladder wall. This increases the risk for gangrene or perforation. It's difficult to distinguish from "regular" acute cholecystitis, but crepitus in the abdominal wall may be present.