Chronic cholecystitis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Cholecystitis must be differentiated from other conditions that affect the gallbladder and biliary tract such as biliary colic, choledocholithiasis, and cholangitis. Acute cholecystitis must be differentiated from other diseases that cause epigastric pain such as acute intestinal obstruction, acute pancreatitis, acute peptic ulcer exacerbation, acute retrocolic appendicitis, amoebic liver abscess, and myocardial infarction. Chronic cholecystitis must be differentiated from colitis, functional bowel syndrome, hiatal hernia, and peptic ulcer.

Differentiating Cholecystitis from other Diseases

• Biliary colic
  • Caused by obstruction of the cystic duct
  • Sharp and constant epigastric pain without fever
  • Murphy's sign is negative
  • Liver function tests are normal

• Choledocholithiasis
  • Blockage of the common bile duct
  • Associated with 'colicky' pain
  • Obstructive jaundice
  • Liver function tests - increase in serum bilirubin, high conjugated bilirubin, raised GGT and ALP

• Cholangitis
  • An infection of entire biliary tract.
  • It may involve pathogens of distal bowels and is also known as 'ascending cholangitis.
  • The classical sign of cholangitis is Charcot's triad - which is right upper quadrant pain, fever and jaundice.
  • Liver function tests - increase if enzymes (AST, ALT, ALP, GGT) with raised bilirubin.
  • Bile is an extremely favorable growth medium for bacteria and infections develop rapidly and become quite severe.

Acute Cholecystitis

• This should be suspected whenever there is acute right upper quadrant or epigastric pain.
  • Other possible causes include:
    • Acute intestinal obstruction
    • Acute pancreatitis
    • Acute peptic ulcer exacerbation
    • Acute retrocolic appendicitis
    • Amoebic liver abscess
    • MI
    • Perforated peptic ulcer
    • Renal colic

Chronic Cholecystitis

• The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:
  • Colitis
  • Functional bowel syndrome
  • Hiatus hernia
  • Peptic ulcer

Classification of acute abdomen based on etiology Presentation Symptoms Signs Diagnosis Comments Fever Abdominal Pain Jaundice Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Primary Peritonitis Spontaneous bacterial peritonitis + Diffuse - - - Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Secondary Peritonitis Perforated gastric and duodenal ulcer + Diffuse - + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute cholangitis + RUQ + - - N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + - - Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric +/- - - N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ - + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ +/- + - Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Acute salpingitis + LLQ/ RLQ - +/- +/- N Leukocytosis Pelvic ultrasound Vaginal discharge Hollow Viscous Obstruction Small intestine obstruction - Diffuse - + +/- Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia +/- Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis +/- Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Ovarian Cyst Complications Torsion of the cyst - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding References Template:WH Template:WS