What Is Acute Cholecystitis?

Acute cholecystitis is inflammation of the gallbladder due to obstruction of the gallbladder duct and bacterial invasion; its typical clinical feature is paroxysmal colic in the right upper abdomen, accompanied by marked tenderness and abdominal rigidity. About 95% of patients with gallbladder stones are called calculus cholecystitis; 5% of patients without gallbladder stones are called non-calculus cholecystitis.

Basic Information

English name: acute cholecystitis
Visiting department: General Surgery, Gastroenterology
Multiple groups: female

Common causes: Gallbladder duct obstruction, bacterial infection, chemical factors, etc.
Common symptoms: Upper right abdominal pain, nausea, vomiting and fever
Contagious: no

Causes of acute cholecystitis

Mechanical inflammation

As the pressure in the gallbladder cavity is increased, the gallbladder wall and mucosa are caused by compression and ischemia;

2. Chemical inflammation

Phospholipase acts on lecithin in bile to produce lysolecithin and chemical inflammation;

3. Bacterial inflammation

Escherichia coli, Klebsiella, Streptococcus, Staphylococcus, etc. accumulate in the gallbladder, and bacterial inflammation occurs. Bacterial inflammation accounts for 50% to 80% of acute cholecystitis.

Clinical manifestations of acute cholecystitis

Symptoms

The main symptoms are right upper quadrant pain, nausea, vomiting and fever. Patients often first experience right upper quadrant pain, which diffuses to the right shoulder and back. The pain is persistent and paroxysmal, which can be accompanied by nausea and vomiting. Vomit is the contents of the stomach and duodenum. Fever in the later stage, mostly low fever, chills, high fever is not common, jaundice in the early stage, when bile duct inflammation or inflammation leading to hilar lymphadenopathy, jaundice can occur.

2. Signs

Local signs are tenderness in the right upper quadrant of the patient. About 25% of patients can touch the enlarged gallbladder. When the patient inhales or coughs, the finger placed under the right rib will touch the enlarged gallbladder. Inhalation (murphy sign), tenderness, muscle tone and rebound pain in the right upper abdomen, inflammation of the whole abdomen will occur when the gallbladder is perforated; yellowish staining of the sclera may occur in patients with systemic examination, elevated body temperature, increased pulse, and increased breathing , Blood pressure, etc., such as gallbladder perforation, increased inflammation, can show septic shock.

Acute cholecystitis examination

Laboratory inspection

(1) The total number of white blood cells and neutrophils is about 80%, and the white blood cell count increases (averagely between 10 and 15) × 10 ⁹ / L. The increase is related to the severity of the disease and the presence or absence of complications. Above 20 × 10 ⁹ / L, gallbladder necrosis or perforation should be considered.

(2) About 10% of patients with serum total bilirubin have jaundice clinically, but the total serum bilirubin is increased by about 25%. The serum total bilirubin of patients with simple acute cholecystitis generally does not exceed 34µmol / L, if it exceeds 85.5µmol The common coexistence of common bile duct stones should be considered at / L; when acute pancreatitis is combined, blood and urine amylase levels also increase.

(3) Serum transaminase is abnormal in about 40% of patients, but most of them are below 400U, rarely as high as in acute hepatitis.

2. Imaging examination

(1) B-ultrasound B-ultrasound is a fast and convenient non-traumatic examination for acute cholecystitis. Its main sonographic features are: The long and wide diameters of the gallbladder can be normal or slightly larger, and they are often oval due to increased tension; The wall of the gallbladder is thickened and the outline is blurred; sometimes most of it is double-ringed and its thickness is greater than 3mm; the sound permeability of the contents of the gallbladder is reduced, and scattered scattered echo points appear; the enhancement effect of the lower edge of the gallbladder is weakened or disappeared .

(2) X-ray examination Nearly 20% of acute gallbladder stones can be visualized on plain radiographs, purulent cholecystitis or gallbladder effusion, and can also show enlarged gallbladder or inflammatory tissue mass shadows.

(3) CT examination B ultrasound can sometimes replace CT, but patients who have complications and cannot be diagnosed must undergo CT examination. CT can show that the gallbladder wall is thicker than 3mm. If the gallbladder stones are embedded in the gallbladder duct, the gallbladder will increase significantly. The tissues and fat around the subserosal layer of the gallbladder showed a low-density ring due to secondary edema, and the gallbladder perforation showed a fluid-level abscess in the fossa of the gallbladder, such as air bubbles in the gallbladder wall or gallbladder, suggesting "emphysema cholecystitis", In such patients, the gallbladder often has gangrene, and the density of the inflammatory gallbladder wall increases significantly when the scan is enhanced.

Acute cholecystitis diagnosis

For those with sudden upper right abdominal pain and radiation to the right shoulder and back, accompanied by fever, nausea, vomiting, physical examination, right upper quadrant tenderness and muscular health, positive Murphy sign, increased white blood cell count, B-ultrasound showing gallbladder wall edema, can be confirmed This is a disease that, if you have a previous history of biliary colic, can help confirm the diagnosis. It should be pointed out that 15% to 20% of the cases have a mild clinical manifestation, or that symptoms are relieved immediately after the onset of symptoms, but when the actual condition is still progressing, it may increase the difficulty of diagnosis.

Differential diagnosis of acute cholecystitis

Duodenal ulcer perforation

Most patients have a history of ulcers. The degree of abdominal pain is severe, with continuous slash-like pain, which can sometimes cause the patient to be in shock. The abdominal wall is rigid, often "plate-like," with tenderness and rebound pain. The bowel sounds disappear. X-ray examination of the abdomen can find free gas under the iliac crest, but a few cases have no history of typical ulcers, small perforations or atypical symptoms of chronic perforations, which can cause diagnostic difficulties.

2. Acute pancreatitis

Abdominal pain is mostly located in the middle or left of the upper abdomen, the signs are not as obvious as acute cholecystitis, and Murphy sign is negative; the serum amylase is significantly increased; B-ultrasounds show pancreatic enlargement and unclear borders without signs of acute cholecystitis; The diagnosis of acute pancreatitis is more reliable than that of the B-ultrasound, because the B-ultrasound often shows unclear pancreas due to abdominal flatulence.

3. High acute appendicitis

For metastatic abdominal pain, abdominal wall tenderness, and abdominal muscle rigidity can be confined to the right upper quadrant, which is easy to be misdiagnosed as acute cholecystitis, but the B-ultrasonography has no signs of acute cholecystitis and Rovsing (Luo Fu benzene) signs (pressing the left lower abdomen can cause the appendix site Pain) helps to distinguish. In addition, the history of recurrent cholecystitis and the characteristics of pain are also valuable for differential diagnosis.

4. Acute intestinal obstruction

Intestinal obstruction colic is mostly located in the lower abdomen, often accompanied by hyperactive bowel sounds, "metallic sounds" or the sound of gas passing through water, abdominal pain is not radioactive, and the abdominal muscles are not tense. X-ray examination shows a liquid level in the abdomen

5. Right Kidney Stones

Fever is rare, and patients are often accompanied by low back pain, radiating to the perineum, knocking pain in the kidney area, gross hematuria or microscopic hematuria, plain radiographs on the X-ray abdomen can show positive stones, renal stones can be seen on B-ultrasonography or with renal pelvis dilation .

6. Right lobar pneumonia and pleurisy

Patients may also have right upper quadrant pain, tenderness, and muscle health, which are mixed with acute cholecystitis, but the disease often has symptoms such as high fever, cough, and chest pain in the early stage, chest breathing lung sounds are reduced, snoring or pleural friction sounds can be heard, X A chest radiograph helps diagnosis.

7. Coronary artery disease

When angina pectoris, the pain can often involve the middle of the upper abdomen or the right upper quadrant. If anesthesia or surgery is misdiagnosed as acute cholecystitis, sometimes it can cause immediate death. Therefore, patients over 50 years of age have symptoms of abdominal pain and tachycardia, heart rhythm Patients with irregularities or hypertension must undergo an electrocardiogram to identify them.

8. Acute viral hepatitis

Acute severe jaundice hepatitis can have right upper abdominal pain and muscular health similar to cholecystitis, fever, increased white blood cell count, and jaundice, but patients with hepatitis often have prodromes such as loss of appetite, fatigue, and low fever; physical examination can often find general tenderness in the liver area , White blood cells generally do not increase, liver function is significantly abnormal, it is generally not difficult to identify.

Acute cholecystitis complications

1. Gallbladder pus and hydrops

When cholecystitis is accompanied by persistent obstruction of the gallbladder duct, gallbladder empyema may occur. At this time, the symptoms worsen, the patient shows high fever, severe right upper quadrant pain, and perforation is prone to occur, requiring emergency surgery. If the gallbladder tube is blocked for a long time, and there is no bacterial infection in the gallbladder, it may be accompanied by hydrocystic or mucinous cysts, and the gallbladder may be enlarged. In the right upper abdomen, an enlarged or painless gallbladder may be touched, which should be treated surgically.

2. Gallbladder perforation

The gallbladder is perforated on the basis of gangrene. The perforation is often surrounded by the omentum, and the death rate of those who are not surrounded is up to 30%.

3. Bile fistula

Gallbladder inflammation can cause local perforation, forming gallbladder duodenal fistula, gallbladder colon fistula, gallbladder gastric fistula, jejunal fistula, gallbladder bile duct fistula and so on.

Acute cholecystitis treatment

Surgery is the main treatment for acute cholecystitis, but fasting, gastrointestinal decompression, correction of water and electrolyte abnormalities, and antibiotics should be routinely performed before surgery. Surgical treatment should be used when the following cases occur: cholecystitis with severe biliary tract infection; complications of cholecystitis, such as gallbladder gangrene inflammation, empyema, perforation, etc .; patients preparing for surgery, complicated by acute cholecystitis For surgery, cholecystectomy and cholecystostomy can be used.