cholecystitis

Cholecystitis is inflammation of the gallbladder. The most common form is acute calculous cholecystitis, caused by obstruction of the cystic duct by gallstones. Acalculous cholecystitis occurs without stones and is more common in critically ill patients. Chronic cholecystitis refers to long-standing inflammation often related to recurrent gallstone disease and may be less painful but persistent.

Pathophysiology and risk factors: Cystic duct obstruction leads to gallbladder distension, ischemia, and an inflammatory response. Bacterial infection may accompany the inflammation, most often Escherichia coli, Klebsiella, and Enterococcus. Risk factors include gallstones, female sex, older age, obesity, rapid weight loss, pregnancy, and prolonged fasting or total parenteral nutrition.

Clinical presentation and diagnosis: Acute cholecystitis presents with right upper quadrant or epigastric pain, fever, nausea, and vomiting. A positive Murphy sign may be detected on examination. Ultrasound is the initial imaging test and typically shows gallstones, gallbladder wall thickening, pericholecystic fluid, and sometimes a positive sonographic Murphy sign. Laboratory tests often show leukocytosis; liver tests may be mildly abnormal. If ultrasound is nondiagnostic, a hepatobiliary iminodiacetic acid (HIDA) scan can confirm cystic duct obstruction.

Management and prognosis: Initial treatment includes intravenous fluids, analgesia, and broad-spectrum antibiotics. For most patients with acute calculous cholecystitis, prompt cholecystectomy is recommended, usually by laparoscopy, within 24 to 72 hours. High-risk patients may require percutaneous cholecystostomy. Chronic cholecystitis may be managed with elective cholecystectomy after symptoms resolve. Complications can include gallbladder perforation, gangrene, empyema, fistula, and biliary sepsis; prognosis improves with timely intervention.