Cholecystitis

Cholecystitis is inflammation of the gallbladder. It is commonly due to impaction of a gallstone within the neck of the gall bladder, leading to inspisation of bile, bile stasis, and infection by gut organisms. Cholecystitis may be a cause of right upper quadrant pain. The pain may actually manifest in the right flank or scapular region at first. In severe cases, the gall bladder can rupture and form an abscess. In severe cases, it may lead to a life-threatening infection of the liver called cholangitis . In other cases, it may lead to a stable inflammatory state termed chronic cholecystitis.

Diagnosis

The classic patient with acute cholecystitis presents with acute right upper quadrant pain. On physical examination, he or she has a Murphy's sign , which is a diaphragm spasm (due to the intense pain) when the region of the gall bladder is palpated by the examiner.

Laboratory values will be notable for an elevated alkaline phosphatase and possibly an elevated bilirubin.

Radiology

sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis were 88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign . Minor criteria include gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation.

The reported sensitivity and specificity of CT scan findings are in the range of 90-95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the GB. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphy with technetium-99m bilirubin analogs is also sensitive and accurate for diagnosis of acute cholecystitis, and can differentiate between acute and chronic forms of the disease. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.

(references: Shea, JA, Berlin, JA, Escarce, JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154:2573. Fink-Bennett, D, Freitas, JE, Ripley, SD, Bree, RL. The sensitivity of hepatobiliary imaging and real time ultrasonography in the detection of acute cholecystitis. Arch Surg 1985; 120:904

Therapy

The gall bladder must be removed (cholecystectomy). This can be accomplished with an open surgery or a laparoscopic procedure. Laparoscopic procedures have less morbidity and a shorter recovery stay. An open proceudure is preferred by many surgeons if the gall bladder is so inflamed that it could fall apart with the manipulations that could be needed with a laparoscopic procedure.

In cases of severe inflammation, the gall bladder can rupture. In these cases, surgery can be impossible and can be associated with additional complications. The managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter in the ruptured gall bladder and treat the patient with antibiotics until the acute inflammation resolves.

Complications

of cholecystitis

• Rupture
• Ascending cholangitis

of cholecystectomy

• bile leak
• bile duct injury