Constant right upper quadrant pain that can radiate to the right shoulder. Cholecystitis pain typically persists for more than six hours compared to the intermittent right upper quadrant pain of biliary colic. Nausea, vomiting, and fevers are also often reported.
Approximately 90-95% of cases are due to gallstones. The development of acute calculous cholecystitis follows a sequence of events:
- gallstone obstruction of the gallbladder neck or cystic duct
- inflammation from chemical injury of the mucosa by bile salts
- reactive production of mucus, leading to increased intraluminal pressure and distention
- increased luminal distention restricting blood flow to the gallbladder wall (gallbladder hydrops)
- increasing wall thickness from edema and inflammatory changes
- secondary bacterial infection in ~66% of patients
Ultrasound (US) is the preferred initial modality in the investigation of right upper quadrant pain. It is more sensitive than HIDA scintigraphy 4 and CT in the diagnosis of acute cholecystitis, and more readily available.
The most sensitive US finding in acute cholecystitis is the presence of cholelithiasis in combination with the sonographic Murphy sign. Both gallbladder wall thickening (>3 mm) and pericholecystic fluid are secondary findings.
Every effort should be made to demonstrate the obstructing stone in the gallbladder neck or cystic duct.
HIDA cholescintigraphy in acute cholecystitis will demonstrate nonvisualization of the gallbladder.
Cholescintigraphy is unable to demonstrate many complications of cholecysitis, nor the alternative diagnoses which may be found with US. It is therefore reserved for the evaluation of sonographically equivocal cases.
Although less sensitive than ultrasound, CT findings include 3:
- gallbladder distension
- gallbladder wall thickening
- mural or mucosal hyperenhancement
- pericholecystic fluid and inflammatory fat stranding
- enhancement of the adjacent liver parenchyma due to reactive hyperaemia
tensile gallbladder fundus sign 7
- fundus bulging the anterior abdominal wall
- ~75% sensitivity and ~95% specificity for acute cholecystitis in the absence of any other CT features
- useful sign in making early diagnosis
Diagnostic criteria on CT as proposed by Mirvis et al. include 6:
- major criteria
- thickened gallbladder wall
- pericholecystic fluid collections
- subserosal edema.
- minor criteria
- gallbladder distention
- diagnosis of acute cholecystitis can be supported if 1 major and 2 minor criteria are present refs
MRI is sensitive in the detection of acute cholecystitis, with findings similar to those seen on ultrasound and CT 3. MR cholangiopancreatography (MRCP) may show an impacted stone in the gallbladder neck or cystic duct.
Treatment and prognosis
Urgent surgical removal of the gallbladder is the treatment of choice for uncomplicated disease. Gallbladder ischemia and transmural necrosis may occur if the obstruction persists.
- gangrenous cholecystitis
- emphysematous cholecystitis
- gallbladder perforation
- pericholecystic abscess
- cholecystoenteric fistula
Differential diagnosis for acute cholecystitis is extensive and includes:
For a more extensive differential, please refer to the article on differential diagnosis of diffuse gallbladder wall thickening.
- chronic cholecystitis
- acute acalculous cholecystitis
- Mirizzi syndrome
- xanthogranulomatous cholecystitis
Ultrasound - gallbladder
- ultrasound (introduction)
- gallbladder ultrasound
- diffuse gallbladder wall thickening (differential)
- focal gallbladder wall thickening (differential)
- gallbladder sludge
- acute cholecystitis
- chronic cholecystitis
- gallbladder polyp
- porcelain gallbladder
- gallbladder carcinoma
- gallbladder metastases
- gallbladder lymphoma
- gallbladder volvulus / torsion
- variants and anomalies
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