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Radiology

Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The diagnostic criteria are gallbladder wall thickening greater than 3mm, pericholecystic fluid and sonographic Murphy's sign. Gallstones are not part of the diagnostic criteria as acute cholecystitis may occur with or without them.

The reported sensitivity and specificity of CT scan findings are in the range of 90–95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.

Management

X-Ray during laparoscopic cholecystectomy

For most patients diagnosed with acute cholecystitis, the definitive treatment is surgical removal of the gallbladder, cholecystectomy. Until the late 1980s surgical removal was usually accomplished by a large incision in the upper right quadrant of the abdomen under the rib cage. Since the advent of laparoscopic surgery in the early 1990s, laparoscopic cholecystectomy has become the treatment of choice for acute cholecystitis^[4]. Laparoscopic cholecystectomy is performed using several small incisions located at various points across the abdomen. Several studies have demonstrated the superiority of laparoscopic cholecystectomy when compared to open cholecystectomy. Patient undergoing laparoscopic surgery report less incisional pain postoperatively as well as having fewer long term complications and less disability following the surgery^[5][6]. Additionally, laparoscopic surgery is associated with a lower rate of surgical site infection.^[7]

During the days prior to laparoscopic surgery, studies showed that outcomes were better following early removal of the gallbladder, preferably within the first week.^[8] Patients receiving early intervention had shorter hospital stays and lower complication rates. In the era of laparoscopic surgery, a similar approach is still advocated. In a 2006 Cochrane review, early laparoscopic cholecystectomy was compared to delayed treatment. The review consisted of 5 trials with 451 patients randomized to either early (223 patients) or delayed (228) surgical management.^[9] There was no statistically significant difference in terms of negative outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) or conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34).^[9] However, the early group was found to have shorter hospital stays.^[9] For early cholecystectomy, the most common reason for conversion to open surgery is inflammation obscuring Calot's triangle. For delayed surgery, the most common reason was fibrotic adhesions.^[9]

Supportive measures are usually instituted prior to surgery. These measures include fluid resuscitation and antibiotics. Antibiotic regimens usually consist of a broad spectrum antibiotic such aspiperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e.g.ceftriaxone) and an antibacterial with good coverage (fluoroquinolone such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic patients, aztreonam and clindamycin may be used.

In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. Acholecystectomy may then be warranted if the patient's condition improves.

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