Fact-sheet: Acute calculous cholecystitis


Updated on 04/19/2018 at 4:34 PM

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Definition

Inflammation of the gallbladder due to obstruction of the cystic duct by a calculus

Clinical features

Acute, febrile right upper quadrant pain worsened by palpation with inspiratory arrest (Murphy's sign)

Laboratory findings

Leukocytosis
Elevated CRP

Radiography

Plain abdominal radiograph (obsolete)
Radiopaque calculi (30%) in the gallbladder area.
Gallbladder distension with downward displacement of the right colic flexure

Ultrasound

- Gallbladder wall thickening >4-5 mm, layered
- Gallbladder sludge or gallstones
- Calculus impacted in the cystic duct
- Distended gallbladder
- Pericholecystic fluid
- Sonographic Murphy's sign (exquisite tenderness on pressure)
- Air bubbles in the wall: emphysematous acute cholecystitis

CT

- Gallbladder wall thickening (>4mm)
- Distended gallbladder
- Pericholecystic fat stranding
- Pericholecystic fluid
- Marked enhancement of the gallbladder wall and adjacent liver
- Gallbladder sludge
- Calculus impacted in the cystic duct (but CT sensitivity is poor for detecting gallstones)

MRI

Findings comparable to CT

Vascular intervention

Percutaneous drainage of the gallbladder (special case of inoperable patient)

Nuclear medicine

Absence of gallbladder opacification at 4 hours on biliary scintigraphy

Management

Upfront cholecystectomy or after cooling with antibiotic therapy

Classification

Calculous cholecystitis 95%
Acalculous cholecystitis 5%

Differential diagnosis

Causes of gallbladder wall thickening:
INFECTIOUS:

  • Acute calculous cholecystitis
  • Acute acalculous cholecystitis
  • Chronic cholecystitis
  • Xanthogranulomatous cholecystitis
  • Sepsis
  • Brucellosis

INFLAMMATORY:

  • AIDS cholangiopathy
  • Sclerosing cholangitis
  • Eosinophilic cholecystitis

TUMORAL:

  • Gallblaber carcinoma
  • Leukemia
  • Multiple myeloma

HEPATIC DISEASES:

  • Hepatitis
  • Cirrhosis & Ascites
  • Hepatic vein thrombosis

VOLUME OVERLOAD

OTHER:

  • Cholesterolosis of gallbladder
  • Gallbladder varices
  • Graft-versus-host disease
  • Acute pancreatitis
  • Hepatic intra-arterial chemotherapy
  • Interleukin
  • Empty, contracted gallbladder postprandially

Differential diagnoses:
- Acute pancreatitis (laboratory findings-CT)
- Gastroduodenal ulcer (endoscopy)
- Hepatic abscess (ultrasound and CT)
- Cholangitis (MR cholangiography and ultrasound)