Cholecystitis overview: Difference between revisions
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Revision as of 19:15, 2 June 2015
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Cholecystitis is inflammation of the gall bladder.
Historical Perspective
Xanthogranulomatous cholecystitis (XGC) is a rare form of gall bladder disease which mimics gallbladder cancer although it is not cancerous. It was first discovered and reported in the medical literature in 1976 by J.J. McCoy, Jr., and colleagues.[1]. Eosinophilic cholecystitis was first described in 1949.[2].
Diagnosis
History and Symptoms
Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first. This is usually accompanied by a low grade fever, vomiting and nausea. More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.
Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, and diarrhea.
Physical Examination
Cholecystitis is usually diagnosed by a history of the symptoms, as well as examination findings like fever (usually low grade in uncomplicated cases) and a tender right upper quadrant +/- Murphy's sign. Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes.
Laboratory Findings
Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC. CRP (C-reactive protein) is often elevated. The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.
Electrocardiogram
Acute cholecystitis presents as pain in the epigastrium, which can be confused with an acute myocardial infarction. ECG can be useful in excluding an MI.
CT
The reported sensitivity and specificity of CT scan findings are in the range of 90-95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder.
Ultrasound
Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign. Minor criteria includes gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation. [3] [4]
Other Diagnostic Studies
Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gallbladder to expel bile (gallbladder ejection fraction), and a low gallbladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes as well. [3] [4]
Diagnostic Criteria
The diagnostic criteria for acute cholecystitis according to Tokyo guidelines is as follows.[5][6]
| Clinical Manifestations | |
|---|---|
| Local symptoms and signs | Murphy’s sign Pain or tenderness in the right upper quadrant Mass in the right upper quadrant |
| Systemic signs | Fever Leukocytosis Elevated C-reactive protein level |
| Imaging findings | A confirmatory finding on ultrasonography or hepatobiliary scintigraphy |
Diagnosis: The presence of one local sign or symptom, one systemic sign, and a confirmatory finding on an imaging test.
Severity Grading
The severity grading for acute cholecystitis according to Tokyo guidelines is as follows.[6]
| Grade | Criteria |
|---|---|
| Mild (grade 1) | Acute cholecystitis that does not meet the criteria for a more severe grade Mild gallbladder inflammation without any organ dysfunction |
| Moderate (grade 2) | The presence of one or more of the following: Elevated white-cell count (>18,000 cells per cubic millimeter) Palpable, tender mass in the right upper quadrant Duration >72 hr Marked local inflammation including biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis |
| Severe (grade 3) | The presence of one or more of the following: Cardiovascular dysfunction (hypotension requiring treatment with dopamine at ≥5 μg per kg of body weight per minute or any dose of dobutamine) Neurologic dysfunction (decreased level of consciousness) Respiratory dysfunction (ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300) Renal dysfunction (oliguria; creatinine level, >2.0 mg/deciliter) Hepatic dysfunction (prothrombin time–international normalized ratio, >1.5) Hematologic dysfunction (platelet count, <100,000 per cubic millimeter) |
References
- ↑ Makino I, Yamaguchi T, Sato N, Yasui T, Kita I (2009). "Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET". World Journal of Gastroenterology : WJG. 15 (29): 3691–3. PMC 2721248. PMID 19653352. Retrieved 2012-08-20. Unknown parameter
|month=ignored (help) - ↑ Dabbs DJ (1993). "Eosinophilic and lymphoeosinophilic cholecystitis". The American Journal of Surgical Pathology. 17 (5): 497–501. PMID 8470764. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ 3.0 3.1 Shea, JA, Berlin, JA, Escarce, JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154:2573.
- ↑ 4.0 4.1 Fink-Bennett, D, Freitas, JE, Ripley, SD, Bree, RL. The sensitivity of hepatobiliary imaging and real time ultrasonography in the detection of acute cholecystitis. Arch Surg 1985; 120:904.
- ↑ Takada, T.; Kawarada, Y.; Nimura, Y.; Yoshida, M.; Mayumi, T.; Sekimoto, M.; Miura, F.; Wada, K.; Hirota, M. (2007). "Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis". J Hepatobiliary Pancreat Surg. 14 (1): 1–10. doi:10.1007/s00534-006-1150-0. PMID 17252291.
- ↑ 6.0 6.1 Hirota, M.; Takada, T.; Kawarada, Y.; Nimura, Y.; Miura, F.; Hirata, K.; Mayumi, T.; Yoshida, M.; Strasberg, S. (2007). "Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 78–82. doi:10.1007/s00534-006-1159-4. PMID 17252300.