Chapter 2 Acute cholecystitis

Acute cholecystitis is nonspecific inflammation of gallbladder. By frequency this disease takes second place after acute appendicitis and makes about 10% in relation to all acute surgical diseases of abdominal cavity organs.

Acute cholecystitis occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Ninety percent of cases involve stones in the cystic duct (i.e., calculous cholecystitis), with the other 10% representing acalculous cholecystitis.

Acalculous acute cholecystitis is associated with biliary stasis, including debilitation, major surgery, severe trauma, sepsis, long-term total parenteral nutrition and prolonged fasting. Other causes of acalculous cholecystitis include cardiovascular attacks; sickle cell disease; Salmonella infections; diabetes mellitus; and cytomegalovirus, cryptosporidiosis or microsporidiosis infections in patients with AIDS.

Although bile cultures are positive for bacteria in 50–75% of cases, bacterial proliferation may be a result of cholecystitis and not the precipitating factor.

Risk factors for cholecystitis include increasing age, female sex, certain ethnic groups, obesity or rapid weight loss, drugs and pregnancy.

As a result inflammatory process develops from simple (catarrhal or superficial) cholecystitis till destructive cholecystitis (phlegmonous, gangrenous) and complicated cholecystitis.

Classification. Acute cholecystitis is divided into:

I. Acute calculous cholecystitis.

II. Acute non-calculous cholecystitis:

1. Catarrhal.

2. Phlegmonous.

3. Gangrenous.

4. Complicated:

a) hydropsy;

b) empyema;

c) biliary pancreatitis;

d) choledocholithiasis;

e) hepatitis;

f) cholangitis;

g) mass;

h) abscess;

i) hepatorenal insufficiency;

j) peritonitis (local, general).

Clinical diagnostic of acute cholecystitis

Most patients with acute cholecystitis describe a history of biliary pain. Some patients may have documented gallstones.

The disease, as a rule, begins after violation of diet: intake of much of fatty foods.

Pain syndrome. Frequently, the pain begins in the epigastric region and then localizes to the right upper quadrant.

Although the pain may initially be described as colicky, it becomes constant in virtually all cases. The pain may radiate to the right shoulder or scapula.

Dyspepsia syndrome. Frequent symptoms which disturb a patient are nausea, vomiting, at first by gastric content, and later – with a part of bile. Afterwards feelings of swelling of stomach, delay of emptying and gases often join to them.

Examination. During examination almost in all patients subicterus of sclera even at the normal passage of bile can be observed. Patients complain of dryness in mouth. In difficult cases the tongue is usually dry, assessed by white stratification with a yellow spot in the center.

The temperature of body of most patients rises (37.2 С in patients with catarrhal cholecystitis, 38.0–39.0  С at its destructive forms and cholangitis).

At first hours of disease the pulse rate usually is relevant to the temperature, and at progress of process, especially with development of peritonitis, it becomes frequent and weak.

During palpation painfulness in the place of crossing of right costal arc with the external edge of direct muscle of abdomen can be observed (the Kehr’s point). By superficial and deep palpation of right hypochondrium, as a rule, painfulness and increased gallbladder are exposed.

Murphy’s sign – a delay of breathing during palpation of gallbladder on inhalation because of pain increasing.

Kehr’s sign – strengthening of pain at pressure on the region of gallbladder.

Ortner’s sign – painfulness at the easy pattering on right costal arc by the edge of palm.

Mussy’s sign – increasing of pain after palpation between the legs of right nodding muscle.

Blumberg’s sign may be positive in patients with peritonitis. In elderly patients, pain and fever may be absent, and localized tenderness may be the only present sign.

Patients with acalculous cholecystitis may present similarly to patients with calculous cholecystitis, but acalculous cholecystitis frequently occurs suddenly in severely ill patients without a prior history of biliary colic.