Acute cholecystitis
Updates to Article Attributes
Acute cholecystitis refers to the acute inflammation of the gallbladder. It is the primary complication of cholelithiasis and the most common cause of acute pain in the right upper quadrant (RUQ).
Clinical presentation
Constant right upper quadrant pain that can radiate to the right shoulder. Cholecystitis pain typically persists for more than 6 hours compared to the intermittent right upper quadrant pain of biliary colic. Nausea, vomiting, and fevers are also often reported.
Pathology
Approximatemy 90 to 95% of cases are due to calculous obstruction of the gallbladder neck or cystic duct, leading to increased intraluminal pressure and distention. Inflammation may result from chemical injury of the mucosa by bile salts and/or superimposed infection.
Radiographic features
Ultrasound
Ultrasound (US) is the preferred initial modality in the investigation of right upper quadrant pain. It is more sensitive than HIDA scintigraphy4 and CT in the diagnosis of acute cholecystitis, and more readily available.
The most sensitive US finding in acute cholecystitis is the presence of cholelithiasis in combination with the sonographic Murphy sign. Both gallbladder wall thickening (>3 mm) and pericholecystic fluid are secondary findings.
Other less specific imaging findings include gallbladder distension and sludge.
Every effort should be made to demonstrate the obstructing stone in the gallbladder neck or cystic duct.
Nuclear medicine
99mTc-HIDA scintigraphy
HIDA cholescintigraphy in acute cholecystitis will demonstrate nonvisualization of the gallbladder.
Cholescintigraphy is unable to demonstrate many complications of cholecysitis, nor the alternative diagnoses which may be found with US. It is therefore reserved for the evaluation of sonographically equivocal cases.
CT
Although less sensitive than ultrasound, CT findings include 3:
- cholelithiasis
- gallbladder distension
- gallbladder wall thickening
- mural or mucosal hyperenhancement
- pericholecystic fluid and inflammatory fat stranding
- enhancement of the adjacent liver parenchyma due to reactive hyperaemia
- Mirvis CT Crieteria for diagnosis of acute cholecystitis:
- Major Crieteria 1. Gallstones 2.Thickened Gall Bladder wall 3. Pericholecystic fluid collection 4. Subserosal edema.
- Minor crieteria : 1. Gall Bladder distention 2. Sludge.
- Diagnosis of acute cholecystitis can be made if 1 major and 2 minor crieteias are present.
MRI
MRI is sensitive in the detection of acute cholecystitis, with findings similar to those seen on ultrasound and CT 3. MR cholangiopancreatography may show an impacted stone in the gallbladder neck or cystic duct.
Treatment and prognosis
Urgent surgical removal of the gallbladder is the treatment of choice for uncomplicated disease. Gallbladder ischemia and transmural necrosis may occur if the obstruction persists.
Complications
- gangrenous cholecystitis
- emphysematous cholecystitis
- gallbladder perforation
- pericholecystic abscess
- cholecystoenteric fistula
Differential diagnosis
Differential diagnosis for acute cholecystitis is extensive and includes:
For a more extensive differential, please refer to the article on differential diagnosis of diffuse gallbladder wall thickening.
See also
- +<li>Mirvis CT Crieteria for diagnosis of acute cholecystitis:</li>
- +<li>Major Crieteria 1. Gallstones 2.Thickened Gall Bladder wall 3. Pericholecystic fluid collection 4. Subserosal edema.</li>
- +<li>Minor crieteria : 1. Gall Bladder distention 2. Sludge.</li>
- +<li>Diagnosis of acute cholecystitis can be made if 1 major and 2 minor crieteias are present.</li>
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