Acute cholecystitis

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Diagnostic approach

• ABCDE survey
• Targeted clinical evaluation
• Consider biliary POCUS if available.
• CBC
• BMP
• CRP
• Coagulation studies
• Liver chemistries
• Lipase
• Amylase
• Blood cultures (2 sets)
• RUQ ultrasound
• Evaluate for predictors of choledocholithiasis.
• Severity grading of acute cholecystitis

Determine the severity of acute cholecystitis once the diagnosis is confirmed to guide management.

Diagnostic criteria

Diagnostic criteria for acute cholecystitis are based on the following:

• Clinical features of acute cholecystitis (e.g., RUQ pain, Murphy sign)
• Systemic signs of inflammation (i.e., fever, leukocytosis, and/or ↑ CRP)
• Gallbladder inflammation on imaging

Fever and tachycardia are commonly absent in acute cholecystitis; maintain a high index of clinical suspicion.

Red flag features

• Severe acute cholecystitis:
• Hypotension requiring vasopressors
• Impaired consciousness
• P_aO₂/F_iO₂ ratio < 300
• Oliguria or serum creatinine > 2 mg/dL
• INR > 1.5
• Platelet count < 100,000/mm³

Management checklist

• IV access with two large-bore peripheral lines
• Immediate hemodynamic support
• Management of sepsis and septic shock
• Start empiric antibiotic therapy for acute biliary infection.
• Consult general surgery.
• Maintain NPO status.
• Initial supportive therapy for acute biliary disease (e.g., analgesia, antiemetics)
• Consider NG tube for intractable vomiting.

All patients with acute cholecystitis require inpatient management.

Acute cholecystitis refers to the acute inflammation of the gallbladder, which is typically due to cystic duct obstruction by a gallstone (acute calculous cholecystitis). Acalculous cholecystitis is less common and seen predominantly in critically ill patients. Right upper qudrant (RUQ) pain, a positive Murphy sign, and fever are the characteristic clinical features of acute cholecystitis. RUQ ultrasound is the preferred initial imaging modality, which typically shows gallbladder distension, edema, and pericholecystic fluid. Empiric antibiotic therapy and laparoscopic cholecystectomy are the mainstays of treatment. Laparoscopic cholecystectomy should be performed as soon as possible, preferably within 72 hours of admission, unless operative and anesthesia risks outweigh the benefits of urgent surgery. In high-risk patients with severe cholecystitis, a temporizing gallbladder drainage procedure (e.g., percutaneous cholecystostomy, endoscopic gallbladder stenting) should be performed and elective interval cholecystectomy scheduled after the resolution of acute symptoms. Complications of acute cholecystitis include gangrenous cholecystitis, emphysematous cholecystitis, gallbladder perforation, biliary-enteric fistula, gallstone ileus, and pyogenic liver abscess. Chronic cholecystitis may result from chronic cholelithiasis or recurrent attacks of acute cholecystitis. Chronic gallbladder inflammation increases the risk of gallbladder carcinoma.

See also “Cholelithiasis,” “Choledocholithiasis,” and “Acute cholangitis.”

• Sex: ♀ > ♂
• Prevalence: most common complication of cholelithiasis
• Peak incidence: > 50 years

Epidemiological data refers to the US, unless otherwise specified.

• Acute calculous cholecystitis: most common form [2]
  • Cause: obstructing cholelithiasis
  • Pathophysiology
    • Cholelithiasis → passage of gallstones into the cystic duct → cystic duct obstruction → distention and inflammation of the gallbladder
    • Secondary bacterial infection may also be present (E. coli, Klebsiella, Enterobacter, Enterococcus spp. most common) but is not necessary for the development of cholecystitis.
• Acalculous cholecystitis: 5–10% of acute cholecystitis [3]
  • See ”Acalculous cholecystitis” in “Subtypes and variants” section

Approximately 90% of acute cholecystitis is caused by cholelithiasis. Acalculous cholecystitis accounts for the remaining 10%. [4]

• Right upper quadrant pain
  • Typically more severe and prolonged (> 6 hours) than in biliary colic
  • Postprandial
  • Radiation to the right scapula (due to referred pain from phrenic nerve irritation)
• Positive Murphy sign: sudden pausing during inspiration upon deep palpation of the RUQ due to pain
  • Murphy sign may be falsely negative in patients > 60 years. [5][6]
• Guarding
• Fever, malaise, anorexia
• Nausea and vomiting

Acute cholecystitis should always be suspected in a patient with a history of gallstones who presents with RUQ pain, fever, and leukocytosis

Acute acalculous cholecystitis [3][7][8][9]

• Description: : an acute life-threatening necroinflammatory disorder of the gallbladder, usually seen in critically ill patients, that is not associated with gallstones
• Incidence
  • 5–10% of acute cholecystitis in adults [3]
  • > 50% of acute cholecystitis in children [10]
• Etiology: : conditions predisposing to bile stasis and reduced perfusion of the gallbladder
• Risk factors for acalculous cholecystitis [3][9]
  • Multiorgan failure (critically ill patients)
  • Severe trauma, burns
  • Surgery
  • Infection (e.g., CMV)
  • Sepsis, septic shock
  • Total parenteral nutrition
  • Prolonged fasting
  • Immunodeficiency
• Clinical features: similar to acute calculous cholecystitis
• Diagnostics
  • Laboratory studies and findings: similar to acute calculous cholecystitis
  • Imaging [9][11]
    • Abdominal ultrasound: preferred initial imaging modality [8][11]
      • Supportive findings
        • Signs of gallbladder inflammation: gallbladder wall thickening (> 3–5 mm), pericholecystic fluid
        • No evidence of cholelithiasis (sludge may be present)
    • HIDA scan: preferred confirmatory imaging modality if ultrasound is inconclusive [3][9][11]
      • Supportive findings: similar to acute calculous cholecystitis (see HIDA scan in “Diagnostics” section)
    • CT abdomen with IV contrast: an alternative to HIDA in patients with inconclusive ultrasound findings
      • Supportive findings: similar to those on ultrasound
• Treatment [7][9]
  • Initial supportive management: NPO, IV fluids, analgesics (see ''Treatment'' in ''Acute calculous cholecystitis” for details)
  • IV antibiotics: see “Empiric antibiotic therapy for acute biliary infection”
  • Source control
    • Low surgical risk: emergency laparoscopic cholecystectomy
    • High surgical risk: percutaneous cholecystostomy
      • If patients do not improve within 2–3 days, cholecystectomy should be performed.

Suspect acalculous cholecystitis in any critically ill patient with fever and RUQ tenderness.

Emphysematous cholecystitis (EC) [8][12][13]

• Description: : a rare but life-threatening form of acute cholecystitis characterized by air within the gallbladder wall that is caused by gas-forming bacteria (e.g., Clostridium spp., E.coli)
• Epidemiology: : rare; most commonly seen in older men with diabetes (esp. 50–70 years of age) [13]
• Pathophysiology [8][13]
  • Primary vascular compromise in the gallbladder (i.e., occlusion of the cystic artery) → ischemia of the gallbladder wall → necrosis → proliferation of gas-forming bacteria within the gallbladder wall or lumen
  • Pathogens
    • Most common: Clostridium species, Escherichia coli
    • Others: Proteus vulgaris, Klebsiella aerogenes, Staphylococcus aureus, Streptococcus species, Klebsiella, Bacteroides fragilis
• Risk factors [14]
  • Hyperglycemia (e.g., diabetes mellitus)
  • Immunosuppression
  • Vascular disease (e.g., atherosclerosis, arterial embolism, vasculitis)
  • Abdominal surgery, and trauma
• Clinical features [13]
  • Similar to acute calculous cholecystitis: fever, RUQ pain, referred pain
  • Symptoms progress rapidly. [12]
  • Associated with early gangrene and gallbladder perforation
• Diagnostics
  • Laboratory studies and findings: similar to those of acute calculous cholecystitis
  • Imaging: The characteristic feature of EC on imaging is air within the gallbladder wall or lumen. [8][13]
    • RUQ ultrasound : hyperechoic air shadows within the gallbladder wall, and within bile in the gallbladder lumen [12][13]
    • Noncontrast CT abdomen : radiolucent shadows within the gallbladder wall, within bile, and within pericholecystic fluid [12]
    • MRI abdomen : hypointense (signal void) areas within the gallbladder wall
    • Abdominal x-ray : radiolucent rim outlining the gallbladder (pear-shaped radiolucency)
• Treatment [13][15]
  • Initial supportive management: NPO, IV fluids, analgesics (see ''Treatment'' section)
  • Broad-spectrum IV antibiotics with anaerobic coverage: See Grade III community-acquired infection in “Empiric antibiotic therapy for acute biliary infection.”
  • Emergency source control procedure
    • Low surgical risk: emergency laparoscopic cholecystectomy
    • High surgical risk: gallbladder drainage

The diagnosis of acute cholecystitis is based on characteristic clinical features, systemic signs of inflammation (leukocytosis, ↑ CRP),; and evidence of gallbladder inflammation on imaging.

Fever and tachycardia are commonly absent in acute cholecystitis; maintain a high index of clinical suspicion! [16]

Approach

• Initial evaluation: laboratory studies and RUQ ultrasound (consider biliary POCUS if available)
• If ultrasound findings are inconclusive, consider abdominal CT scan, abdominal MRI, MRCP, or HIDA scan to confirm the diagnosis. [17]
• Assess for choledocholithiasis (see “Diagnosis of choledocholithiasis”).
• Once the diagnosis is confirmed, determine the severity (see “Severity grading of acute cholecystitis”).

Laboratory studies [12][18]

• Tests to support the clinical diagnosis
  • CBC: Leukocytosis is most common, but WBC count may be normal in up to 40% of patients. [16]
  • CRP: elevated
  • Blood cultures: should be obtained, especially in patients with grade III acute cholecystitis (see “Severity grading of acute cholecystitis”) [19]
  • Bile cultures: should be obtained in grade II-III acute cholecystitis in patients undergoing laparoscopic cholecystectomy or gallbladder drainage [19][20]
• Tests to assess the severity of disease (see “Severity grading of acute cholecystitis”)
  • Blood gas analysis: PaO₂/F_iO₂ ratio < 300 in severely ill patients
  • BMP: AKI, electrolyte derangements may be present in patients with severe disease
  • PT/INR: coagulopathy in patients with severe disease
• Tests to rule out related biliary comorbidities: should be obtained in all patients with suspected cholecystitis
  • LFTs [18][21]
    • Mild elevations in AST and ALT are possible in acute cholecystitis.
    • Signs of cholestasis (↑ bilirubin, ↑ ALP, ↑ GGT) are uncommon in cholecystitis; if present consider biliary obstruction (see ''Diagnosis of choledocholithiasis'' and ''Cholangitis'')
  • Lipase, amylase
    • Mild elevation of amylase may be seen in acute cholecystitis [22]
    • Elevation of lipase or amylase ≥ 3 times the normal is suggestive of acute biliary pancreatitis.
• Tests to rule out differential diagnoses: See “Diagnostic workup of acute abdominal pain.”

Imaging [11][12]

RUQ transabdominal ultrasound

See also “Biliary point-of-care ultrasound.”

• Indications: preferred initial imaging modality in suspected acute cholecystitis [11][12]
• Characteristic findings [12]
  • Sonographic features of gallbladder inflammation
    • Gallbladder wall thickening > 3–5 mm [8]
    • Gallbladder distention (8–10 x 4 cm) [12][23]
    • Gallbladder wall edema (double-wall sign): The innermost and outermost layers appear hyperechoic; edematous tissue appears as a hypoechoic layer in between.
    • Sonographic Murphy sign: Tenderness upon compression of the gallbladder with the ultrasound transducer
    • Pericholecystic free fluid
  • Presence of gallstones and/or biliary sludge (see “Cholelithiasis” for details)
  • In emphysematous cholecystitis, mural air appears as hyperechoic shadows within the gallbladder wall. [8]
• Important consideration: The CBD should be assessed for choledocholithiasis (see ''Diagnosis of choledocholithiasis” for further details).

Cholescintigraphy [3][11][24]

Commonly referred to as hepatobiliary iminodiacetic acid scintigraphy or a HIDA scan.

• Indications: : preferred confirmatory test for suspected uncomplicated acute cholecystitis if ultrasound findings are inconclusive [11]
• Procedure: The radioactive tracer 99mTc-hepatic iminodiacetic acid is injected intravenously → selective uptake by hepatocytes → subsequent excretion into bile → bile with radiotracer enters the gallbladder if the cystic duct is patent → visualization of tracer within the gallbladder via a gamma camera [3]
• Advantages
  • High sensitivity (96%) and specificity (90%); considered the gold standard test to diagnose acute cholecystitis [24][25]
  • Can differentiate between acute and chronic cholecystitis
• Disadvantages
  • Time-consuming
  • Cannot identify complications of acute cholecystitis, if present
  • Cannot be used to evaluate for potential differential diagnoses
  • May not be widely available
• Characteristic findings
  • Normal: gallbladder visualized within 4 hours of administration of radioactive tracer
  • Acute cholecystitis: gallbladder is not visualized within 4 hours [3]

MRI abdomen without and with IV contrast [11][23][26]

• Indications
  • Alternative to CT or HIDA scan in suspected acute cholecystitis with inconclusive ultrasound findings
  • Either of the following in patients with contraindications to CT: [8][21]
    • Suspected complications of cholecystitis
    • Clinical diagnosis of acute cholecystitis unclear
  • Suspected choledocholithiasis (MRCP) [21]
• Characteristic findings: Similar to ultrasound findings
  • Hyperintensity (T2) of the gallbladder wall and pericholecystic region, indicating inflammation
  • Evidence of choledocholithiasis, if present (see ''Diagnosis of choledocholithiasis” for further details)
  • Evidence of complications, such as emphysematous cholecystitis, empyema gallbladder, and gallbladder perforation (see ''Complications'' section)

CT abdomen with IV contrast [3][8]

• Indications
  • An alternative to MRI or HIDA scan in suspected acute cholecystitis with inconclusive ultrasound findings [11][26]
  • Suspected emphysematous cholecystitis [12]
  • Suspected complications of acute cholecystitis [8][12]
  • Clinical diagnosis of acute cholecystitis unclear [3][8]
• Characteristic findings: similar to those on ultrasound and MRI

• See “Differential diagnosis of acute abdominal pain.”
• See “Overview of biliary disease.”
• RUQ pain with fever
  • Acute cholangitis
  • Liver abscess
  • Acute hepatitis
  • Acute necrotizing pancreatitis
  • Acalculous cholecystitis
  • Chronic cholecystitis
  • Bile leak (Iatrogenic)
• RUQ pain without fever
  • Biliary colic
  • PUD
  • Acute gastritis
  • Acute pancreatitis
  • Chronic pancreatitis
  • Acute GERD
  • Sphincter of Oddi dysfunction
  • Congestive hepatopathy
  • Nephrolithiasis
  • Malignancy
    • HCC
    • Cholangiocarcinoma
    • Gallbladder cancer
    • Pancreatic cancer

The differential diagnoses listed here are not exhaustive.

Stratify the severity of acute cholecystitis to determine the best approach to treatment. [12][27]

Empiric antibiotic therapy and cholecystectomy are the mainstays of treatment for acute cholecystitis after initial supportive therapy.

Initial management [19][27][28]

• Screen patients for signs of sepsis or shock.
• Provide immediate hemodynamic support (e.g., IV fluid resuscitation) and respiratory support (e.g., oxygen therapy) if necessary.
• Start empiric antibiotic therapy for acute biliary infection.
• Provide initial supportive therapy for acute biliary disease: e.g., analgesia, antiemetics, electrolyte repletion, consider NG tube insertion.
• Maintain NPO status.
• Consult general surgery to determine:
  • Surgical risk using the ASA-PS or Charlson comorbidity index (CCI).
  • Definitive management and disposition based on severity grading of acute cholecystitis and risk of complications (see “Disposition”).
• Identify and treat concurrent choledocholithiasis (see “Diagnosis of choledocholithiasis”).
• Monitoring and reevaluation
  • Adjust monitoring level to individual patient needs.
  • If there is early deterioration, perform ABCDE assessment.
    • Consider the development of complications (e.g., gallbladder perforation) or other differential diagnoses (e.g., acute cholangitis).
    • Consider ICU consult.

Definitive management [27][28][29][30]

The initial procedure and duration of antibiotic therapy depend on severity grading of acute cholecystitis, patient's individual surgical risk, and presence of complications.

• Laparoscopic cholecystectomy
  • Preferred approach if expertise is available
  • Perform as soon as possible, unless operative and anesthesia risks outweigh the benefits of urgent surgery.
  • Conversion to open cholecystectomy may be required depending on intraoperative findings [27]
• Gallbladder drainage procedures (e.g., percutaneous cholecystostomy) typically performed as a temporizing measure for:
  • Unstable or clinically deteriorating patients: e.g., grade II–III acute cholecystitis [30][31]
  • Frail patients or those at high risk of surgical complications
• Postprocedural antibiotics
  • Consider prolonging the duration of therapy (beyond the standard recommendation) in patients with:
    • Signs of sepsis (e.g., persistent fever, stable or increasing leukocytosis)
    • Evidence of biliary tract obstruction
    • Complications (e.g., pericholecystic abscess).
  • Tailor agent to bile and/or blood cultures as soon as available.

Perform preoperative or postoperative stone extraction in patients with concurrent choledocholithiasis.

Grade I acute cholecystitis

• Low surgical risk
  • Early laparoscopic cholecystectomy
  • Postoperative antibiotics not required
• High surgical risk
  • Early intervention
    • Early laparoscopic cholecystectomy
    • Discontinue antibiotics 24 hours after surgery.
  • OR conservative approach
    • Continue antibiotics until symptomatic improvement [27][28]
    • Arrange interval cholecystectomy

Grade II acute cholecystitis

• Improvement with initial management
  • Low surgical risk
    • Early laparoscopic cholecystectomy
    • Discontinue antibiotics 24 hours after surgery.
  • High surgical risk :
    • Continue antibiotics until symptomatic improvement.
    • Arrange interval cholecystectomy
• Deterioration despite initial management
  • Urgent gallbladder drainage followed by interval cholecystectomy
  • Continue antibiotics for a total of 7 days. [32]

Grade III acute cholecystitis

• Low surgical risk
  • Early laparoscopic cholecystectomy if there is an adequate response to initial supportive care
  • Continue antibiotics for 4–7 days after surgery. [33]
• High surgical risk
  • Urgent gallbladder drainage, followed by:
    • Interval cholecystectomy
    • OR observation
  • Continue antibiotics for a total of 7 days. [32]

Procedures

Laparoscopic cholecystectomy

• Indication: gold standard of treatment for acute calculous cholecystitis [27]
• Timing: depends on surgical and anesthesia risks, disease severity, and symptom duration
  • Early laparoscopic cholecystectomy: performed within 10 days of symptom onset; preferably within the initial 24–72 hours [27][29]
    • Indication: symptom duration of ≤ 10 days in patients with low surgical and anesthesia risk(s) [27]
    • Contraindications
      • High surgical or anesthesia risks
      • Symptom duration > 10 days
  • Interval laparoscopic cholecystectomy (delayed lap. chole)
    • Performed 45 days after resolution of symptoms [27]
    • Indications
      • High surgical or anesthesia risk
      • Symptom duration > 10 days

Gallbladder drainage

• Indication: temporizing, minimally invasive measures in high surgical-risk patients not responding to conservative management [34]
• Contraindication: uncontrolled bleeding diathesis
• Options
  • Percutaneous cholecystostomy: image-guided placement of a catheter (cholecystostomy tube) into the gallbladder under local anesthesia through the abdominal wall to provide biliary drainage [34][35]
  • Endoscopic gallbladder stenting: may be preferred over percutaneous cholecystostomy if endoscopy operator expertise is available as it is less invasive. [36][37][38]

Disposition [28]

All patients with acute cholecystitis require inpatient management.

• Grade I acute cholecystitis: healthcare facility with the ability to perform laparoscopic cholecystectomy
• Grade II acute cholecystitis: advanced healthcare facility with access to urgent gallbladder drainage and surgical expertise to handle a difficult laparoscopic cholecystectomy.
• Grade III acute cholecystitis: same as for grade II PLUS access to intensive care.

General principles [19]

• Important considerations
  • Obtain blood cultures prior to administering antibiotics, especially in patients with severe biliary infection.
  • Obtain bile cultures at the beginning of any drainage procedure.
  • Tailor antibiotic therapy to sensitivity reports as early as possible. [33]
  • Switch to oral antibiotics, if feasible, once improvement is evident. [39]
• Required coverage
  • Gram-negative coverage: Escherichia coli (most common), Klebsiella spp., Enterobacter spp., Pseudomonas spp.
  • Anaerobic coverage is recommended if biliary-enteric anastomosis is suspected or identified.
  • Consider Enterococcus spp. coverage in grade III community-acquired and healthcare-associated infection.
• Choice of empiric antibiotic: should be determined by the following parameters
  • Community-acquired or healthcare-associated infection
  • Severity of infection (see “Severity grading of acute cholecystitis” or “Severity grading of acute cholangitis” for details on grading)
  • Local resistance patterns (local antibiogram)
  • If a biliary-enteric anastomosis is suspected
• Timing of antibiotic administration
  • Septic shock: within one hour of presentation
  • Other patients: within six hours of presentation
• Duration of therapy
  • Grade I acute cholecystitis, grade II acute cholecystitis: up to 24 hours after early lap. chole.
  • Grade III acute cholecystitis and all grades of community-acquired acute cholangitis: 4–7 days after early lap. chole or until symptomatic improvement (if patient is managed conservatively).
  • For patients who undergo urgent gallbladder drainage: continue antibiotics for a total of 7 days. [32]
  • All grades of healthcare-associated cholangitis and cholecystitis with gram-positive bacteremia known to cause infective endocarditis : consider 14 days of treatment.

Recommended empiric regimen [19]

Many ESBL-producing gram-negative organisms are resistant to fluoroquinolones.

Resistance of E. coli to ampicillin-sulbactam is becoming more common, especially in North America. Consider local resistance rates carefully before choosing an empiric antibiotic regimen.

Gangrenous cholecystitis [8][40][41]

• Definition: ischemic necrosis of the gallbladder
• Etiology: most common complication of acute cholecystitis [8]
• Clinical features: difficult to distinguish from uncomplicated acute cholecystitis
• Imaging
  • Ultrasound: features of acute cholecystitis plus echogenic membranes floating within the gallbladder lumen
  • CT with IV contrast: nonenhancement of the gallbladder wall
• Treatment: emergency laparoscopic cholecystectomy and empiric antibiotic therapy for biliary infection

Gallbladder perforation [8][41][42]

• Definition: break in the continuity of the gallbladder wall, typically as a consequence of ischemic necrosis
• Clinical features: variable; symptoms typically progress rapidly
  • May be indistinguishable from uncomplicated acute cholecystitis
  • Potentially accompanied by a palpable RUQ mass and/or signs of generalized peritonitis
• Imaging : focal defect in the gallbladder wall; extraluminal stone may be visualized
• Treatment: emergency laparoscopic cholecystectomy and empiric antibiotic therapy for biliary infection

Cholecystoenteric fistula

• See “Cholecystoenteric fistula” in “Fistula.”

Gallbladder empyema (suppurative cholecystitis) [8]

• Definition: distended pus-filled gallbladder
• Clinical features: similar to uncomplicated acute cholecystitis
• Imaging: gallbladder distention with hyperechoic (on ultrasound) or hyperdense (on CT abdomen with IV contrast) material within its lumen
• Treatment [43]
  • Empiric antibiotic therapy for biliary infection
  • Emergency source control procedure
    • Low surgical risk: laparoscopic cholecystectomy
    • High surgical risk: image-guided percutaneous drainage of empyema followed by interval laparoscopic cholecystectomy

Chronic cholecystitis [4][8][44]

• Definition: chronic inflammation of the gallbladder
• Etiology
  • Chronic irritation of gallbladder mucosa by cholelithiasis
  • Recurrent attacks of acute cholecystitis
• Clinical features: recurrent symptoms similar to acute cholecystitis but typically less severe and often self-limiting
• Diagnostics
  • Laboratory studies: may be normal [44]
  • Ultrasound abdomen or CT abdomen with IV contrast:
    • Thickened gallbladder wall
    • No evidence acute inflammatory changes (e.g., pericholecystic fluid);
    • Cholelithiasis commonly present
  • HIDA scan: delayed visualization of the gallbladder [45]
  • All patients should also be evaluated for choledocholithiasis before treatment (see ''Imaging'' in “Choledocholithiasis”).
• Treatment: elective laparoscopic cholecystectomy [8][46]
• Complications [8]
  • Porcelain gallbladder [8][45][47]
    • Definition: calcification of the gallbladder wall due to chronic inflammation
    • Imaging (x-ray or noncontrast CT abdomen): focal or diffuse hyperdensity (radiopaque appearance) of the gallbladder wall
    • Clinical significance: a risk factor for gallbladder cancer [48]
    • Treatment: conservative management or laparoscopic cholecystectomy based on symptoms, pattern of gallbladder calcification, and comorbidities [49][50]
  • Gallbladder cancer [51]
  • Cholecystoenteric fistula and gallstone ileus

Chronic gallbladder inflammation increases the risk of gallbladder carcinoma, especially when porcelain gallbladder is present.

Other [8]

• Gallstone ileus
• Pericholecystic abscess
• Subhepatic abscess
• Pyogenic liver abscess
• Hemorrhagic cholecystitis [8]
• Gallbladder cancer

We list the most important complications. The selection is not exhaustive.

Acute cholecystitis in pregnancy [52][53]

• Acute cholecystitis is the second most common indication for nonobstetric surgery in pregnant individuals after acute appendicitis. [52][53]
• Clinical features are largely similar to those in nonpregnant individuals; Murphy sign may be absent in pregnant individuals. [53][54]
• Additional differential diagnoses of acute cholecystitis to consider in pregnant individuals include: [55]
  • HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
  • Acute fatty liver of pregnancy
  • Pyelonephritis
  • Appendicitis

Depending on the size and position of the uterus, Murphy sign may be absent in pregnant patients with acute cholecystitis. [53]

Diagnostic evaluation and treatment of cholecystitis should not be delayed during pregnancy as the condition can have negative maternal and fetal outcomes. [52][56]

Diagnostics [53]

The diagnostic approach for cholecystitis during pregnancy is similar to that for nonpregnant individuals, with the following additional considerations.

• Preferred imaging modalities: RUQ ultrasound or MRI abdomen without contrast [17][57]
• Obtain additional diagnostics as indicated by clinical examination and imaging findings (e.g., for suspected choledocholithiasis and/or biliary obstruction).
  • MRCP [53]
  • ERCP [54][58]
  • Intraoperative cholangiography during cholecystectomy [53]
• See “Diagnostic criteria for acute cholecystitis.”

If a diagnostic or therapeutic procedure involving ionizing radiation is deemed necessary during pregnancy, implement strategies to minimize fetal radiation exposure, such as shielding the pelvis and reducing fluoroscopy time. [53][54][57]

Management [52][53][59]

Treatment of acute cholecystitis is similar in pregnant and nonpregnant individuals, with the following considerations.

• Early laparoscopic cholecystectomy is the preferred treatment for all trimesters. [52][54][59]
• For patients at high surgical risk, consider percutaneous or endoscopic gallbladder drainage. [54][60]
• Consider corticosteroids to induce fetal lung maturity if indicated. [56]
• Assess for risk factors for venous thromboembolism and provide appropriate VTE prophylaxis. [56]

Conservative management of acute cholecystitis in pregnancy is associated with a higher risk of recurrence and complications than laparoscopic cholecystectomy. [59]

Acute cholecystitis in children [10][17][61]

Epidemiology

• Uncommon in children [17][61]
• Incidence increases with age [62]

Etiology [10][17][62][63]

• Acalculous cholecystitis (most common) [10][62]
  • Risk factors for acalculous cholecystitis are similar to those in adults.
  • Additional risk factors in children include:
    • Infection (e.g., Epstein-Barr virus, hepatitis A virus, Ascaris lumbricoides)
    • Systemic disease (e.g., Kawasaki disease, malignancy)
    • Anatomical anomalies
    • Genetic conditions (e.g., cystic fibrosis, galactosemia)
• Cholelithiasis (uncommon in children): often caused by an underlying condition, including [61][62]
  • Metabolic disease (e.g., diabetes, pediatric obesity) [10][64]
  • Hemolytic disease (e.g., sickle cell, hereditary spherocytosis)
  • Cystic fibrosis
  • Treatment of pediatric malignancies [65]

Acaclulous cholecystitis is the most common cause of acute cholecystitis in children. In contrast, cholelithiasis is the most common cause of acute cholecystitis in adults. [10][62]

Clinical features [63][64]

• Clinical features of acute cholecystitis are similar in adults and children
• Features of the underlying condition may mask features of acute cholecystitis. [10]

Consider acaclulous cholecystitis in all children with acute RUQ pain, especially those with a concurrent severe illness or recent history of trauma or surgery. [66]

Diagnosis [10][17]

• Diagnosis of calculous cholecystitis and acalculous cholecystitis is the same in children and adults.
• Identify the underlying etiology: Order additional diagnostics based on clinical suspicion.

Treatment [64][66][67]

• Urgent consult or referral to a specialist (e.g., pediatric surgery, gastroenterology, critical care) for management
• Initial management [64]
  • Bowel rest
  • Initial supportive therapy of acute biliary disease
  • Broad spectrum IV empiric antibiotic therapy for acute biliary infection
• Further management depends on the type of cholecystitis.
  • Acalculous cholecystitis: Treat the underlying condition. [64][66][67]
  • Acute calculous cholecystitis: cholecystectomy [68][69]

Acalculous cholecystitis is often managed conservatively in children, while cholecystectomy is typically recommended in adults.. [66][67]

Prognosis

Acute acalculous cholecystitis may progress to chronic cholecystitis if untreated. [62][64]