Acute Cholecystitis
Lim Liang Yik
Definitions
• Acute cholecystitis
• Acalculous Cholecystitis
• Chronic Cholecystitis
Pathogenesis of Cholecystitis
• Does cystic duct occlusion ALONE causes acute
cholecystitis?
Not in DOGS
– Morris, CR, Hohf, RP, Ivy, AC. An experimental study
of the role of stasis in the etiology of cholecystitis.
Surgery 1952; 32:673
• Prairie dog gallstone model
• Ligation of cystic duct does not cause acute cholecystitis
• blockade of the cystic duct followed by deliberate
irritation of the gallbladder mucosa (either mechanically
with an indwelling catheter or by infusion of an irritant)
• Neither the presence of gallstones alone nor acute cystic
duct occlusion alone resulted in acute inflammation of
the gallbladder
Does the bile HAVE to be infected?
• Simultaneous bacteriologic assessment of bile from
gallbladder and common bile duct in control subjects and
patients with gallstones and common duct stones. Csendes
A; Burdiles P et al Arch Surg 1996 Apr;131(4):389-94.
– 467 Patients, 7 groups
– NO BACTERIA in samples from the gallbladder in normal subjects
– 22-46 % POSITIVE CULTURE in patients with GALLSTONES, ACUTE
CHOLECYSTITIS
– 58 % in Cholangitis
• E. Coli, Enterococcus, Klebsiella, Enterobacter
LYSOLECITHIN
Phospholipase A
LYSOLECITHIN
Present in Gall bladder
mucosa Normally absent in bile
?? Released when Present in cholecystitis
outlet obstructed??
LECITHIN
Normal in Bile
Prostaglandin released
w/w
INFECTION OF
BILE
Clinical features - Pain
Colicky to
continuation
Fatty Food and the Gallbladder
Physical Examination
Palpable Mass in RHC?
• Enlarged gallbladder
• Inflammatory mass with abscess in the gall
bladder (empyema)
• Mucocele
John Benjamin Murphy (1857 – 1916)
American Surgeon
MURPHY’S SIGN
“Palpate the the abdomen just below the tip of
the ninth costal cartilage.”
“When the liver and the attached gallbladder
descend and strike the palpating hand, the
patient will experience a sharp pain which
prevents further inspiration”
Ismar Isidor Boas (1858 – 1938)
German enterologist
“Hyperaesthesia below the right scapula may
be a sign of acute cholecystitis”
“This may be detected by lightly drawing a pin
down the back of the patient’s chest”
Less than 7 % sensitive
What if a acute cholecystitis is left
untreated?
Most will resolve
within 7 – 10 days
Complications
20 % gangrene, perforation, pericholecystic
abscess / generalized peritonitis
Clinically Septic Looking
Complications
Cholecystoenteric
fistula
Catheter cholangiogram
showing fistula between the
gallbladder and the hepatic
flexure of the colon – King
Fahad Medical City
Gallstone ileus
Emphysematous cholecystitis
Investigations and diagnosis
• Total white cell count raised
• Total bilirubin and Alkaline phosphatase
usually NOT raised
– Raised?
• Cholangitis
• Choledocholithiasis
• Mirizzi syndrome
• Mild elevations may be seen – small sludge, stones, pus
Pablo Luis Mirizzi (1893 – 1964)
Argentinean Physician
Mirizzi Syndrome
Gallstone impacted in the
distal cystic duct causing
extrinsic obstruction to the
common bile duct
ULTRASOUND
Thickening of the
gallbladder wall
(> 4 – 5 mm)
Fluid
surrounding the
distended
gallbladder
ULTRASOUND
Thickening of the gallbladder
wall
(> 4 – 5 mm)
Fluid surrounding the
distended gallbladder
Sludge
Stone with acoustic shadow
Normal Gallbladder on US
Sonographic Muphy’s sign
Sensitivity and specificity
• Revised estimates of diagnostic test sensitivity
and specificity in suspected biliary tract
disease. Shea JA; Berlin JA et al. Arch Intern
Med 1994 Nov 28;154(22):2573-81.
– 88 % sensitive
Acute cholecystitis
– 80 % specific
– 84 % sensitive Gallstones – Small (1-3 mm) stones are
– 99 % specific often missed but appear during
endoscopy
CT scan
Dilated
Gallbladder
Thickened wall
What is the normal size of the gallbladder?
What is the normal size of the gallbladder?
• Usually measures 7 – 10 cm x 2 – 3.5 cm,
usually not more than 4 x 10 cm
– But age? Contraction?
• Wall thickness is usually 2 – 3 mm, unaffected
by age
Other imaging
MRCP
HIDA
Differential diagnosis
Acute cholecystitis vs biliary Colic
Visceral
obstruction
Vs
Inflammation
Right Hypochondriac pain lasting > 6
hours should raise the suspicion of acute
cholecystitis
Differential diagnosis
Treatment of acute cholecystitis
E. Coli
Klebsiella
Enterococcus
Enterobacter
Enterococcus? Cephalosporin?
Low
pathogenicity
Surgical treatment of acute cholecystitis
• Gangrene / perforation suspected
• Emergent intervention to remove gangrenous,
perforated gall bladder
Remove the cause to Acute Cholecystitis to
prevent further attacks
• Timing of removal of gallbladder
– Papi C, et al. Am J Gastroenterol 2004;99 (1) 147 –
155 (meta-analysis of 30 trials
– Shakita S et al. Surgery 2005 35 : 553 – 560
“Early cholecystectomy (within 72
hours) for acute cholecystitis is
associated with a better outcome
than delayed cholecystectomy”
Benefits of early surgery
• Reduced hospital stay
• Reduced need for readmission
• Reduced morbidity
Acalculous cholecystitis
Presentation
•Non specific
presentation
• Fever
• Leucocytosis
• Vague abdominal
pain
Presentation
•Similar to calculous cholecystitis
Clinical features - Pain
Only in Hospital?
• The increasing prevalence of acalculous
cholecystitis in outpatients. Results of a 7-year
study. Savoca PE et al. Ann Surg 1990
Apr;211(4):433-7.
– 77 percent developed symptoms at home
without evidence of acute illness
20 %
Pathophysiology
Gall bladder Stasis,
ischemia
Inflammation,
gangrene,
perforation
E. Coli
Klebsiella
Enterococcus
Enterobacter
Surgical treatment
• Definitive – Cholecystotectomy
Critically ill –
Percutaneous
cholecystostomy
