Cholecystitis is often caused by cholelithiasis (the Cholecystitis is usually diagnosed by a history of the
presence of choleliths, or gallstones, in the above symptoms, as well examination findings:
gallbladder), with choleliths most commonly
blocking the cystic duct directly. This leads to fever (usually low grade in uncomplicated
inspissation (thickening) of bile, bile stasis, and cases)
secondary infection by gut organisms, predominantly tender right upper quadrant +/- Murphy's
E. coli and Bacteroides species. sign
Ortner's sign - tenderness when hand taps
The gallbladder's wall becomes inflamed. Extreme the edge of right costal arch.
cases may result in necrosis and rupture. Georgievskiy-Myussi's sign (phrenic nerve
Inflammation often spreads to its outer covering, thus sign) - pain when press between edges of
irritating surrounding structures such as the sternocleidomastoid muscle. [1]
diaphragm and bowel.
Subsequent laboratory and imaging tests are used to
Less commonly, in debilitated and trauma patients, confirm the diagnosis and exclude other possible
the gallbladder may become inflamed and infected in causes.
the absence of cholelithiasis, and is known as acute
acalculous cholecystitis.
Ultrasound can assist in the differential.[2][3]
Stones in the gallbladder may cause obstruction and
Differential diagnosis
the accompanying acute attack. The patient might
develop a chronic, low-level inflammation which
leads to a chronic cholecystitis, where the gallbladder Acute cholecystitis
is fibrotic and calcified.
This should be suspected whenever there is
[ acute right upper quadrant or epigastric pain.
o Other possible causes include:
Cholecystitis usually presents as a pain in the right Perforated peptic ulcer
upper quadrant. This is usually a constant, severe Acute peptic ulcer exacerbation
pain. The pain may be felt to 'refer' to the right flank Amoebic liver abscess
or right scapular region at first. Acute amoebic liver colitis
Acute pancreatitis
Acute intestinal obstruction
This may also present with the above mentioned pain Renal colic
after eating greasy or fatty foods such as pastries, Acute retrocolic appendicitis
pies and fried foods.
Chronic cholecystitis
This is usually accompanied by a low grade fever,
diarrhea, vomiting and nausea.
The symptoms of chronic cholecystitis are non-
specific, thus chronic cholecystitis may be mistaken
More severe symptoms such as high fever, shock and for other common disorders:
jaundice indicate the development of complications
such as abscess formation, perforation or ascending
cholangitis. Another complication, gallstone ileus, Peptic ulcer
occurs if the gallbladder perforates and forms a Hiatus hernia
fistula with the nearby small bowel, leading to Colitis
symptoms of intestinal obstruction. Functional bowel syndrome
Chronic cholecystitis manifests with non-specific It is defined pathologically by the columnar
symptoms such as nausea, vague abdominal pain, epithelium has reached down the muscular layer.
belching, and diarrhea.
Quick Differential Choledocholithiasis - This refers to blockage
of the common bile duct where a gallstone
Biliary colic - Caused by obstruction of the has left the gallbladder or has formed in the
cystic duct. It is associated with sharp and common bile duct (primary cholelithiasis).
constant epigastric pain in the absence of As with other biliary tree obstructions it is
fever and usually there is a negative usually associated with 'colicky' pain, and
Murphy's sign. Liver function tests are because there is direct obstruction of biliary
within normal limits since the obstruction output, obstructive jaundice. Liver function
does not necessarily cause blockage in the tests will therefore show increased serum
common hepatic duct, thereby allowing bilirubin, with high conjugated bilirubin.
normal bile excretion from the liver. An Liver enzymes will also be raised,
ultrasound scan is used to visualise the predominately GGT and ALP, which are
gallbladder and associated ducts, and also to associated with biliary epithelium. The
determine the size and precise position of diagnosis is made using endoscopic
the obstruction. retrograde cholangiopancreatography
Cholecystitis - Caused by blockage of the (ERCP), or the nuclear alternative (MRCP).
cystic duct with surrounding inflammation, One of the more serious complications of
usually due to infection. Typically, the pain choledocholithiasis is acute pancreatitis,
is initially 'colicky' (intermittent), and which may result in significant permanent
becomes constant and severe, mostly in the pancreatic damage and brittle diabetes.
right upper quadrant. Infectious agents that Cholangitis - An infection of entire biliary
cause cholecystitis include E. coli, tract, and may also be known as 'ascending
Klebsiella, Pseudomonas, B. fragilis and cholangitis', which refers to the presence of
Enterococcus. Murphy's sign is positive, pathogens that typically inhabit more distal
particularly because of increased irritation of regions of the bowel[4]
the gallbladder lining, and similarly this pain
radiates (spreads) to the shoulder, flank or in Cholangitis is a medical emergency as it may be life
a band like pattern around the lower threatening and patients can rapidly succumb to acute
abdomen. Laboratory tests frequently show liver failure or bacterial sepsis. The classical sign of
raised hepatocellular liver enzymes (AST, cholangitis is Charcot's triad, which is right upper
ALT) with a high white cell count (WBC). quadrant pain, fever and jaundice. Liver function
Ultrasound is used to visualise the tests will likely show increases across all enzymes
gallbladder and ducts. (AST, ALT, ALP, GGT) with raised bilirubin. As
with choledocholithiasis, diagnosis is confirmed
using cholangiopancreatography.
Cholelithiasis is the presence of stones in the gallbladder.
Cholecystitis is acute or chronic inflammation of the gallbladder.
Choledocholithiasis is the presence of stones in the common bile
duct.
Most gallstones result from supersaturation of cholesterol in the
bile, which acts as an irritant, producing inflammation in the
gallbladder, and which precipitates out of bile, causing stones. Risk
factors include gender (women four times as like to develop
cholesterol stones as men), age (older than age 40), multiple parity,
obesity, use of estrogen and cholesterol-lowering drugs, bile acid
malabsorption with GI disease, genetic predisposition, rapid weight
loss. Pigment stones occur when free bilirubin combines with
calcium. These stones occur primarily in patients with cirrhosis,
hemolysis, and biliary infections.
Acute cholecystitis is caused primarily by gallstone obstruction of
the cystic duct with edema, inflammation, and bacterial invasion. It
may also occur in the absence of stones, as a result of major
surgical procedures, severe trauma, or burns.
Chronic cholecystitis results from repeated attacks of cholecystitis,
presence of stones, or chronic irritation. The gallbladder becomes
thickened, rigid, fibrotic, and functions poorly.
Complications of gallbladder disease include cholangitis; necrosis,
empyema, and perforation of gallbladder; biliary fistula through
duodenum; gallstone ileus; and adenocarcinoma of the gallbladder.
