Cholecystitis

doi:10.1016/j.suc.2008.07.008

Surgical Clinics of North America

Volume 88, Issue 6, December 2008, Pages 1241-1252

https://doi.org/10.1016/j.suc.2008.07.008 Get rights and content

Cholecystitis is the most prevalent surgical condition affecting populations in industrialized countries. Rather than a single clinical entity, cholecystitis is a class of related disease states with different causes, degrees of severity, clinical courses, and management strategies. Appropriate care of the patient who has a diseased gallbladder requires a broad understanding of the acute, chronic, and acalculous cholecystitis syndromes, and awareness of their particular clinical nuances and potential complications.

Section snippets

Overview

Cholecystitis in its varied forms is the most prevalent surgical entity afflicting populations of industrialized countries. The most common cause of cholecystitis and biliary colic is cholelithiasis. Autopsy findings show that 11% to 35% of American adults, or roughly 25 million people, have gallstones. Some 1% to 2% of people who have cholelithiasis develop symptoms or complications per year [1]. These complications include biliary colic, acute or chronic cholecystitis, choledocholithiasis,

Symptomatic cholelithiasis: gallstones

Symptomatic cholelithiasis is defined as gallbladder pain in the presence of gallstones. Gallstones arise from the precipitation of cholesterol and calcium salts in supersaturated bile. They are classified by their content of cholesterol as either cholesterol stones or pigmented stones. Pigmented stones receive their color from their concentration of calcium bilirubinate. Black stones are small and tarry and are typically found associated with cirrhosis and hemolytic disorders, such as sickle

Pathophysiology

The primary cause of obstructive cholecystitis is gallstones. Of all individuals who have gallstones, 1% to 3% develop cholecystitis. Other causes of obstructive cholecystitis include primary tumors of the gallbladder or common duct, benign gallbladder polyps, parasites, metastatic tumors to the gallbladder or the periportal lymph nodes, and even foreign bodies, such as bullets [3], [4], [5], [6]. Prolonged gallbladder outlet obstruction leads to acute cholecystitis. Obstruction at the neck of

Epidemiology

Acute inflammation of the gallbladder in the absence of cholelithiasis accounts for roughly 2% to 15% of acute cholecystitis cases and is the indication for 1% to 2% of laparoscopic cholecystectomies. Risk factors include old age, critical illness, burns, trauma, major surgical operations, long-term total parenteral nutrition, diabetes, immunosuppression, and childbirth. Acute acalculous cholecystitis occurs in 0.2% of surgical intensive care admissions and has a mortality rate as high as 40%

Pathophysiology

Chronic inflammation of the gallbladder is the indication for nearly 3% of cholecystectomies in adults. Chronic cholecystitis has many forms and the pathophysiology is poorly understood. It is believed that in most instances an evolving inflammatory process occurs with repeated episodes of low-grade gallbladder obstruction, resulting in recurrent mucosal trauma [7]. There is little correlation between the number of choleliths or their overall volume and the degree of gallbladder wall

Two complications of cholecystitis: Mirizzi syndrome and gallstone ileus

Two clinical entities result from long-term inflammation of the gallbladder and deserve mention in a discussion of cholecystitis: Mirizzi syndrome and gallstone ileus.

Summary

Rather than a single clinical entity, cholecystitis is a class of related disease states with different causes, degrees of severity, clinical courses, and management strategies. Appropriate care of the patient who has a diseased gallbladder requires a broad understanding of the acute, chronic, and acalculous cholecystitis syndromes, and awareness of their particular clinical nuances and potential complications.

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Cited by (77)

Implications and Limitations of Point-of-Care Ultrasound in Diagnosing Acute Cholecystitis
2024, Annals of Emergency Medicine
External validation of the bedside score for the diagnosis of acute cholecystitis
2024, Heliyon
Objective: Acute cholecystitis usually presents with right upper quadrant (RUQ) abdominal pain. However, there are other conditions with similar findings which make the diagnosis difficult. The objective of this study is to prospectively validate the performance of the bedside score for the diagnosis of cholecystitis in patients presenting to the emergency department (ED) with possible acute cholecystitis.
We performed a prospective observational study of a convenience sample of patients with RUQ pain admitted to the ED of three academic hospitals. Symptoms (post prandial symptoms), physical signs (RUQ tenderness, murphy's sign) and ultrasound findings (Murphy's sign, gallstone, and gallbladder thickening) were scoring system items. The final diagnosis of cholecystitis was confirmed with a surgical pathology and/or discharge diagnosis of the patient in a 30-day follow-up. The treating physicians' clinical gestalt of acute cholecystitis was also assessed by 5-point Likert scale.
One hundred thirty patients were followed up and were included in the analysis. 42 patients (32 %) had cholecystitis. The bedside clinical score of less than 4 had a sensitivity of 100 % (CI95 %: 91.60 %–100 %), negative predictive value (NPV) of 100 % (CI 95 %: 41.35 %–63 %), and negative likelihood ratio (-LR) of 0. Score of 6 and above had a specificity of 90.91 % (CI 95 %: 82.87 %–95.99 %), positive predictive value (PPV) of 83.67 % (CI 95 %: 72.55 %–90.86 %), and positive likelihood ratio (+LR) of 10.74 (CI95 %: 5.54–20.83). Physicians’ clinical gestalt at the scale of 4 and 5 showed a specificity of 95.45 % (CI 95 %: 88.77 %–98.75 %), PPV of 90.91 % (CI 95 %: 79.29 %–96.31 %), and +LR of 20.95 (CI95 %: 8.02–54.71). At the same time at the scale of 1 and 2, the sensitivity was 95.24 % (CI 95 %: 83.84 %–99.42 %), NPV was 97.22 % (CI 95 %: 90.01 %–99.27 %), and the –LR was 0.06 (CI 95 %: 0.02–0.423). The area under the curve of bedside clinical score was not significantly higher than clinical gestalt (97.58 (CI 95 %: 95.31–99.85) vs. 95.37 (CI 95: 99.24–100))(p-value = 0.35)
This study showed while the bedside score would be helpful to rule out and rule in acute cholecystitis, physicians’ gestalt had similar diagnostic performance.
Gallbladder Disorders: A Comprehensive Review
2021, Disease-a-Month
Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.
Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients
2021, American Journal of Emergency Medicine
Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients.
This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points.
153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%–96.9%), and a specificity of 67.5% (95% CI 58.2%–75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%–100%) and specificity of 35% (95% CI 26.5%–44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%–61.9%) and specificity of 95.7% (95% CI 90.3%–98.6%).
A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.
Derivation and validation of a practical Bedside Score for the diagnosis of cholecystitis
2019, American Journal of Emergency Medicine
Citation Excerpt :
Cholelithiasis is estimated to affect approximately 20 million Americans, or roughly 7% of men and 11% of women [1,2]. While the majority of patients with cholelithiasis are asymptomatic, biliary colic develops at a rate of 1%–2% annually [3,4]. If untreated, cholecystitis eventually develops in about 20% of symptomatic patients [2].
We sought to develop a practical Bedside Score for the diagnosis of cholecystitis and test its accuracy against the Tokyo Guidelines (TG13).
We conducted a retrospective study of 438 patients undergoing urban, academic Emergency Department (ED) evaluation of RUQ pain. Symptoms, physical signs, ultrasound signs, and labs were scoring system candidates. A random split-sample approach was used to develop and validate a new clinical score. Multivariable regression analysis using development data was conducted to identify predictors of cholecystitis. Cutoff values were chosen to ensure positive/negative predictive values (PPV, NPV) of at least 0.95. The score was externally validated in 80 patients at a different hospital undergoing RUQ pain evaluation.
230 patients (53%) had cholecystitis. Five variables predicted cholecystitis and were included in the scores: gallstones, gallbladder thickening, clinical or ultrasonographic Murphy's sign, RUQ tenderness, and post-prandial symptoms. A clinical prediction score was developed. When dichotomized at 4, overall accuracy for acute cholecystitis was 90% for the development cohort, 82% and 86% for the internal and external validation cohorts; TG13 accuracy was 62%–79%.
A clinical prediction score for cholecystitis demonstrates accuracy equivalent to TG13. Use of this score may streamline work-up by decreasing the need for comprehensive ultrasound evaluation and CRP measurement and may shorten ED length of stay.
Eosinophilic cholecystitis: a retrospective study spanning a fourteen-year period
2018, Revista de Gastroenterologia de Mexico
La colecistitis eosinofílica es una entidad rara que se describió por primera vez en 1949 y es clínicamente indistinguible de la colecistitis litiásica. Histológicamente, hay infiltración inflamatoria transmural de la pared de la vesícula biliar con más del 90% de eosinófilos. El objetivo del presente trabajo es revisar la prevalencia y analizar las características clínico-quirúrgicas de los pacientes con diagnóstico de colecistitis eosinofílica operados en nuestro hospital.
Se trata de un estudio retrospectivo (de enero del 2000 a agosto del 2014) en el que se incluyeron pacientes postoperados de colecistectomía con diagnóstico histopatológico de colecistitis eosinofílica. Se describen variables demográficas, clínicas, paraclínicas, quirúrgicas e histopatológicas.
Se encontraron un total de 7,494 pacientes postoperados de colecistectomía en un período de 14 años, de los cuales 12 pacientes tuvieron el diagnóstico postoperatorio histopatológico de colecistitis eosinofílica. La edad media de presentación fue de 39 años (± 11 años), y predominó el sexo femenino con 7 casos. Todos los pacientes tenían colelitiasis concomitante y 10 de ellos se presentaron con colecistitis aguda, que requirió colecistectomía de urgencia. Todos los casos se consideraron idiopáticos. Encontramos una prevalencia del 0.16%, que corresponde a un caso por cada 625 colecistectomías llevadas a cabo en nuestra institución.
Encontramos una prevalencia baja de colecistitis eosinofílica (0.16%) en nuestra población de estudio. Las manifestaciones clínicas se asemejan a las que se presentan en colecistitis litiásica. La colecistectomía es el tratamiento adecuado en pacientes con esta entidad de etiología idiopática.
Eosinophilic cholecystitis is a rare entity that was first described in 1949 and is clinically indistinguishable from calculous cholecystitis. Histologically, there is transmural inflammatory infiltration of the gallbladder wall, more than 90% of which is composed of eosinophils. The aim of the present article was to review the prevalence of eosinophilic cholecystitis and analyze the clinical and surgical characteristics of patients diagnosed with the disease that were operated on at our hospital.
A retrospective study was conducted on patients that underwent cholecystectomy and whose postoperative histopathologic diagnosis was eosinophilic cholecystitis, within the time frame of January 2000 and August 2014. The demographic, clinical, paraclinical, surgical, and histopathologic variables were described.
Over a period of 14 years, a total of 7,494 patients underwent cholecystectomy. Of those patients, 12 had a postoperative histologic diagnosis of eosinophilic cholecystitis. Mean patient age for disease presentation was 39 years (± 11 years), and female sex was predominant, with 7 cases. All the patients had concomitant gallstones and 10 patients presented with acute cholecystitis that required urgent cholecystectomy. All the cases were considered idiopathic. We found a prevalence of 0.16%, corresponding to 1 case for every 625 cholecystectomies performed at our hospital.
We found a low prevalence of eosinophilic cholecystitis (0.16%) in our study population. The clinical manifestations were similar to those of calculous cholecystitis. Cholecystectomy is adequate treatment in patients with idiopathic disease.

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Cholecystitis

Section snippets

Overview

Symptomatic cholelithiasis: gallstones

Pathophysiology

Epidemiology

Pathophysiology

Two complications of cholecystitis: Mirizzi syndrome and gallstone ileus

Summary

Lancet

J Gastrointest Surg

The spectrum and cost of complicated gallstone disease in California

Arch Surg

Cholecystectomy through a 5 cm incision

Br J Surg

Acalculous cholecystitis: ascariasis as an unusual cause

J Gastroenterol

Acute cholecystitis from metastatic melanoma to the gall-bladder in a patient with a low-risk melanoma

Br J Dermatol

Gunshot cholecystitis

J Clin Gastroenterol

Massive hemobilia and acalculous cholecystitis due to benign gallbladder polyp

Dig Dis Sci

Gallbladder and extrahepatic biliary ducts

Infections of the liver and biliary system

Prospective evaluation of 99m TC-IDA cholescintigraphy in the diagnosis of acute cholecystitis

Radiology

Gallstones, cholecystitis and diabetes

Surg Gynecol Obstet