acute cholecystitis
Summary
Acute cholecystitis is inflammation of the gallbladder wall, most commonly caused by gallstone obstruction of the cystic artery (95% of cases). It presents with RUQ pain, fever, and positive Murphy's sign, and can progress to gangrene, perforation, or empyema if untreated.
Detail
Acute cholecystitis involves inflammation of the gallbladder wall, typically triggered by cystic duct obstruction by gallstones (cholelithiasis), leading to increased intraluminal pressure, ischemia, and bacterial superinfection. The pathophysiology begins with mechanical obstruction causing gallbladder distension, followed by release of inflammatory mediators (phospholipase A2, prostaglandins) that damage the mucosa. This creates an environment for bacterial overgrowth, commonly E. coli, Klebsiella, and Enterococcus. Clinical presentation includes steady RUQ or epigastric pain radiating to the right shoulder/scapula, fever, nausea, and vomiting. Physical exam reveals RUQ tenderness with positive Murphy's sign (inspiratory arrest during deep palpation of RUQ). Laboratory findings show leukocytosis, elevated alkaline phosphatase, and mild hyperbilirubinemia. Ultrasound is the initial imaging modality showing gallbladder wall thickening (>3mm), pericholecystic fluid, and gallstones. HIDA scan can confirm cystic duct obstruction. Complications include gangrene, perforation, empyema, and Mirizzi syndrome. Treatment involves IV antibiotics, pain control, and cholecystectomy (preferably laparoscopic within 72 hours of symptom onset).
Sources
- First Aid for the USMLE Step 1
- Harrison's Principles of Internal Medicine
- Robbins Basic Pathology
- UpToDate Clinical Decision Support
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