Introduction

Acute cholecystitis describes inflammation of the gallbladder, typically secondary to gallstones.

Epidemiology

  • Incidence: 140.00 cases per 100,000 person-years
  • Peak incidence: 40-50 years
  • Sex ratio: more common in females 3:1
Condition Relative
incidence
Biliary colic7.14
Acute cholecystitis1
Acute appendicitis0.79
Ascending cholangitis0.36
Acute pancreatitis0.29
Perforated peptic ulcer0.05
Cholangiocarcinoma0.01
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Features
  • Right upper quadrant pain
  • Fever and signs of systemic upset
  • Murphy's sign on examination
  • Occasionally mildly deranged LFT's (especially if Mirizzi syndrome)

Investigations

Investigation
  • ultrasound is the first-line investigation of choice
  • if the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used
    • technetium-labeled HIDA (hepatobiliary iminodiacetic acid) is injected IV and taken up selectively by hepatocytes and excreted into bile
    • in acute cholecystitis there is cystic duct obstruction (secondary to odema associated with inflammation or an obstructing stone) and hence the gallbladder will not be visualised

Management

Treatment
  • intravenous antibiotics
  • NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis. Previously, surgery was delayed for several weeks until the inflammation has subsided

Complications

Complications
  • gangrenous cholecystitis
    • occurs in up to 20% of patients
  • perforation
    • occurs in up to 10% of patients
    • may result in either a pericholecystic abscess or peritonitis
  • cholecystoenteric fistula
    • usually seen with chronic cholecystitis
    • results in air in the biliary tree (pneumobilia)
    • if a gallstone passes through the fistula may result in gallstone ileus