EXAM
■ RUQ tenderness, inspiratory arrest during deep palpation to the RUQ
(Murphy’s sign), fever, leukocytosis, mild icterus, and possibly guarding or
rebound tenderness may be present on examination.
DIAGNOSIS
■ CBC, amylase, lipase, and LFT panel should be obtained.
■ Ultrasound may demonstrate stones, biliary sludge, pericholecystic fluid, a
thickened gallbladder wall ( ≥3 mm), gas in the gallbladder, and an ultra-
sonic Murphy sign (see Figure 11.9).
■ Obtain HIDA scan when ultrasound is equivocal (see Figure 11.10).
■ Nonvisualization of the gallbladder on HIDA scan suggests acute chole-
cystitis.
■ AXR or CT may demonstrate a fluid-filled gallbladder with gas in the gall-
bladder wall indicative of emphysematous cholecystitis, a rare but life-
threatening complication found in older men classically with associated
diabetes.
TREATMENT
■ Early surgical consultation is indicated especially if the patient is febrile,
septic, or has an emphysematous or gangrenous gallbladder.
■ Hospitalize patients, administer IV pain medications, antibiotics, and fluids,
and replete electrolytes.
■ Perform early cholecystectomy (within 72 hours of symptom onset) along
with either a preoperative ERCP or an intraoperative cholangiogram to
rule out common bile duct stones.
■ Since 50% of cases resolve spontaneously, hemodynamically stable patients
with significant medical problems, eg, diabetes, can initially be managed
medically with a 4- to 6-week delay in surgical treatment.
COMPLICATIONS
■ Gangrene, empyema, perforation, gallstone ileus, fistulization, sepsis, abscess
formation
ABDOMINAL AND GASTROINTESTINALEMERGENCIESFIGURE 11.9. Acute cholecystitis. The arrowheads indicate the thickened gallbladder
wall. There are several stones in the gallbladder (arrows) throwing acoustic shadows. Also
seen is pericholecystic fluid.
(Reproduced, with permission, from Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter
JG, Pollock RE. Schwartz’s Principles of Surgery,8th ed. New York: McGraw-Hill, 2004:1200.)