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Cholecystitis:PracticeEssentials,Background,Pathophysiology

Cholecystitis
Author:AlanABloom,MDChiefEditor:BSAnand,MDmore...
Updated:Apr15,2016

PracticeEssentials
Cholecystitisisinflammationofthegallbladderthatoccursmostcommonlybecause
ofanobstructionofthecysticductbygallstonesarisingfromthegallbladder
(cholelithiasis).Uncomplicatedcholecystitishasanexcellentprognosisthe
developmentofcomplicationssuchasperforationorgangrenerendersthe
prognosislessfavorable.

Signsandsymptoms
Themostcommonpresentingsymptomofacutecholecystitisisupperabdominal
pain.Thefollowingcharacteristicsmaybereported:
Signsofperitonealirritationmaybepresent,andthepainmayradiatetothe
rightshoulderorscapula
Painfrequentlybeginsintheepigastricregionandthenlocalizestotheright
upperquadrant(RUQ)
Painmayinitiallybecolickybutalmostalwaysbecomesconstant
Nauseaandvomitingaregenerallypresent,andfevermaybenoted
Patientswithacalculouscholecystitismaypresentwithfeverandsepsisalone,
withouthistoryorphysicalexamination,findingsconsistentwithacutecholecystitis.
Cholecystitismaypresentdifferentlyinspecialpopulations,asfollows:
Elderly(especiallydiabetics)Maypresentwithvaguesymptomsand
withoutmanykeyhistoricalandphysicalfindings(eg,painandfever),with
localizedtendernesstheonlypresentingsignmayprogresstocomplicated
cholecystitisrapidlyandwithoutwarning
ChildrenMaypresentwithoutmanyoftheclassicfindingsthoseathigher
riskforcholecystitisincludethosewhohavesicklecelldisease,serious
illness,arequirementforprolongedtotalparenteralnutrition(TPN),
hemolyticconditions,orcongenitalandbiliaryanomalies
Thephysicalexaminationmayrevealthefollowing:
Fever,tachycardia,andtendernessintheRUQorepigastricregion,often
withguardingorrebound
PalpablegallbladderorfullnessoftheRUQ(3040%ofpatients)
Jaundice(~15%ofpatients)
Theabsenceofphysicalfindingsdoesnotruleoutthediagnosisofcholecystitis.
SeePresentationformoredetail.

Diagnosis
Laboratorytestsarenotalwaysreliable,butthefollowingfindingsmaybe
diagnosticallyuseful:
Leukocytosiswithaleftshiftmaybeobserved
Alanineaminotransferase(ALT)andaspartateaminotransferase(AST)
levelsmaybeelevatedincholecystitisorwithcommonbileduct(CBD)
obstruction
BilirubinandalkalinephosphataseassaysmayrevealevidenceofCBD
obstruction
Amylase/lipaseassaysareusedtoassessforpancreatitisamylasemayalso
bemildlyelevatedincholecystitis
Alkalinephosphataselevelmaybeelevated(25%ofpatientswith
cholecystitis)
Urinalysisisusedtoruleoutpyelonephritisandrenalcalculi
Allfemalesofchildbearingageshouldundergopregnancytesting
Diagnosticimagingmodalitiesthatmaybeconsideredincludethefollowing:
Radiography
Ultrasonography
Computedtomography(CT)

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Magneticresonanceimaging(MRI)
Hepatobiliaryscintigraphy(seetheimagebelow)

Cholecystitis.Abnormalfindingonhepatoiminodiaceticacid(HIDA)scan.

Endoscopicretrogradecholangiopancreatography(ERCP)
TheAmericanCollegeofRadiology(ACR)makesthefollowingimaging
recommendations:
Ultrasonographyisthepreferredinitialimagingtestforthediagnosisofacute
cholecystitisscintigraphyisthepreferredalternative
CTisasecondaryimagingtestthatcanidentifyextrabiliarydisordersand
complicationsofacutecholecystitis
CTwithintravenous(IV)contrastisusefulindiagnosingacutecholecystitisin
patientswithnonspecificabdominalpain
MRI,oftenwithIVgadoliniumbasedcontrastmedium,isalsoapossible
secondarychoiceforconfirmingadiagnosisofacutecholecystitis
MRIwithoutcontrastisusefulforeliminatingradiationexposureinpregnant
womenwhenultrasonographyhasnotyieldedacleardiagnosis
Contrastagentsshouldnotbeusedinpatientsondialysisunlessabsolutely
necessary
SeeWorkupformoredetail.

Management
Treatmentofcholecystitisdependsontheseverityoftheconditionandthe
presenceorabsenceofcomplications.
Inacutecholecystitis,theinitialtreatmentincludesbowelrest,IVhydration,
correctionofelectrolyteabnormalities,analgesia,andIVantibiotics.Optionsinclude
thefollowing:
SanfordguidePiperacillintazobactam,ampicillinsulbactam,or
meropeneminseverelifethreateningcases,imipenemcilastatin
AlternativeregimensThirdgenerationcephalosporinplusmetronidazole
Emesiscanbetreatedwithantiemeticsandnasogastricsuction
Becauseoftherapidprogressionofacuteacalculouscholecystitisto
gangreneandperforation,earlyrecognitionandinterventionarerequired.
Supportivemedicalcareshouldincluderestorationofhemodynamicstability
andantibioticcoverageforgramnegativeentericfloraandanaerobesif
biliarytractinfectionissuspected.
DailystimulationofgallbladdercontractionwithIVcholecystokinin(CCK)
mayhelppreventformationofgallbladdersludgeinpatientsreceivingTPN
Incasesofuncomplicatedcholecystitis,outpatienttreatmentmaybeappropriate.
Thefollowingmedicationsmaybeusefulinthissetting:
Levofloxacinandmetronidazoleforprophylacticantibioticcoverageagainst
themostcommonorganisms
Antiemetics(eg,promethazineorprochlorperazine)tocontrolnauseaand
preventfluidandelectrolytedisorders
Analgesics(eg,oxycodone/acetaminophen)
Surgicalandinterventionalproceduresusedtotreatcholecystitisincludethe
following:
Laparoscopiccholecystectomy(standardofcareforsurgicaltreatmentof
cholecystitis)
Percutaneousdrainage
ERCP
Endoscopicultrasoundguidedtransmuralcholecystostomy

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Endoscopicgallbladderdrainage
SeeTreatmentandMedicationformoredetail.

Background
Cholecystitisisdefinedasinflammationofthegallbladderthatoccursmost
commonlybecauseofanobstructionofthecysticductfromcholelithiasis.Ninety
percentofcasesinvolvestonesinthegallbladder(ie,calculouscholecystitis),with
theother10%ofcasesrepresentingacalculouscholecystitis. [1]
Riskfactorsforcholecystitismirrorthoseforcholelithiasisandincludeincreasing
age,femalesex,certainethnicgroups,obesityorrapidweightloss,drugs,and
pregnancy.Althoughbileculturesarepositiveforbacteriain5075%ofcases,
bacterialproliferationmaybearesultofcholecystitisandnottheprecipitating
factor.
Acalculouscholecystitisisrelatedtoconditionsassociatedwithbiliarystasis,
includingdebilitation,majorsurgery,severetrauma,sepsis,longtermtotal
parenteralnutrition(TPN),andprolongedfasting.Othercausesofacalculous
cholecystitisincludecardiaceventssicklecelldiseaseSalmonellainfections
diabetesmellitusandcytomegalovirus,cryptosporidiosis,ormicrosporidiosis
infectionsinpatientswithAIDS.(SeeEtiology.)Formoreinformation,seethe
MedscapeReferencearticleAcalculousCholecystopathy.
Uncomplicatedcholecystitishasanexcellentprognosis,withaverylowmortality
rate.Oncecomplicationssuchasperforation/gangrenedevelop,theprognosis
becomeslessfavorable.Some2530%ofpatientseitherrequiresurgeryordevelop
somecomplication.(SeePrognosis.)
Themostcommonpresentingsymptomofacutecholecystitisisupperabdominal
pain.Thephysicalexaminationmayrevealfever,tachycardia,andtendernessinthe
RUQorepigastricregion,oftenwithguardingorrebound.However,theabsenceof
physicalfindingsdoesnotruleoutthediagnosisofcholecystitis.(SeeClinical
Presentation.)
Delaysinmakingthediagnosisofacutecholecystitisresultinahigherincidenceof
morbidityandmortality.ThisisespeciallytrueforICUpatientswhodevelop
acalculouscholecystitis.Thediagnosisshouldbeconsideredandinvestigated
promptlyinordertopreventpooroutcomes.(SeeDiagnosis.)
Initialtreatmentofacutecholecystitisincludesbowelrest,intravenoushydration,
correctionofelectrolyteabnormalities,analgesia,andintravenousantibiotics.For
mildcasesofacutecholecystitis,antibiotictherapywithasinglebroadspectrum
antibioticisadequate.Outpatienttreatmentmaybeappropriateforuncomplicated
cholecystitis.Ifsurgicaltreatmentisindicated,laparoscopiccholecystectomy
representsthestandardofcare.(SeeTreatmentandManagement.)
Patientsdiagnosedwithcholecystitismustbeeducatedregardingcausesoftheir
disease,complicationsifleftuntreated,andmedical/surgicaloptionstotreat
cholecystitis.Forpatienteducationinformation,seetheLiver,Gallbladder,and
PancreasCenter,aswellasGallstonesandPancreatitis.
Forfurtherclinicalinformation,seetheMedscapeReferencetopicCholecystitisand
BiliaryColic.

Pathophysiology
Ninetypercentofcasesofcholecystitisinvolvestonesinthegallbladder(ie,
calculouscholecystitis),withtheother10%ofcasesrepresentingacalculous
cholecystitis. [1]
Acutecalculouscholecystitisiscausedbyobstructionofthecysticduct,leadingto
distentionofthegallbladder.Asthegallbladderbecomesdistended,bloodflowand
lymphaticdrainagearecompromised,leadingtomucosalischemiaandnecrosis.
Althoughtheexactmechanismofacalculouscholecystitisisunclear,several
theoriesexist.Injurymaybetheresultofretainedconcentratedbile,anextremely
noxioussubstance.Inthepresenceofprolongedfasting,thegallbladdernever
receivesacholecystokinin(CCK)stimulustoemptythus,theconcentratedbile
remainsstagnantinthelumen. [2,3]
AstudybyCullenetaldemonstratedtheabilityofendotoxintocausenecrosis,
hemorrhage,areasoffibrindeposition,andextensivemucosalloss,consistentwith
anacuteischemicinsult. [4]Endotoxinalsoabolishedthecontractileresponseto
CCK,leadingtogallbladderstasis.

Etiology
Riskfactorsforcalculouscholecystitismirrorthoseforcholelithiasisandincludethe
following:
Femalesex
Certainethnicgroups
Obesityorrapidweightloss
Drugs(especiallyhormonaltherapyinwomen)

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Pregnancy
Increasingage
Acalculouscholecystitisisrelatedtoconditionsassociatedwithbiliarystasis,and
includethefollowing:
Criticalillness
Majorsurgeryorseveretrauma/burns
Sepsis
Longtermtotalparenteralnutrition(TPN)
Prolongedfasting
Othercausesofacalculouscholecystitisincludethefollowing:
Cardiacevents,includingmyocardialinfarction
Sicklecelldisease
Salmonellainfections
Diabetesmellitus[5]
PatientswithAIDSwhohavecytomegalovirus,cryptosporidiosis,or
microsporidiosis
Patientswhoareimmunocompromisedareatanincreasedriskofdeveloping
cholecystitisfromanumberofdifferentinfectioussources.Idiopathiccasesexist.

Epidemiology
Anestimated1020%ofAmericanshavegallstones,andasmanyasonethirdof
thesepeopledevelopacutecholecystitis.Cholecystectomyforeitherrecurrentbiliary
colicoracutecholecystitisisthemostcommonmajorsurgicalprocedureperformed
bygeneralsurgeons,resultinginapproximately500,000operationsannually.

Agedistributionforcholecystitis
Theincidenceofcholecystitisincreaseswithage.Thephysiologicexplanationfor
theincreasingincidenceofgallstonediseaseintheelderlypopulationisunclear.
Theincreasedincidenceinelderlymenhasbeenlinkedtochangingandrogento
estrogenratios.
GotoPediatricCholecystitisformorecompleteinformationonthistopic.

Sexdistributionforcholecystitis
Gallstonesare23timesmorefrequentinfemalesthaninmales,resultingina
higherincidenceofcalculouscholecystitisinfemales.Elevatedprogesteronelevels
duringpregnancymaycausebiliarystasis,resultinginhigherratesofgallbladder
diseaseinpregnantfemales.Acalculouscholecystitisisobservedmoreoftenin
elderlymen.

Prevalenceofcholecystitisbyraceandethnicity
Cholelithiasis,themajorriskfactorforcholecystitis,hasanincreasedprevalencein
peopleofScandinaviandescent,PimaIndians,andHispanicpopulations,whereas
cholelithiasisislesscommonamongindividualsfromsubSaharanAfricaandAsia.
[6,7]IntheUnitedStates,whitepeoplehaveahigherprevalencethanblackpeople.

Prognosis
Uncomplicatedcholecystitishasanexcellentprognosis,withaverylowmortality.
Mostpatientswithacutecholecystitishaveacompleteremissionwithin14days.
However,2530%ofpatientseitherrequiresurgeryordevelopsomecomplication.
Oncecomplicationssuchasperforation/gangrenedevelop,theprognosisbecomes
lessfavorable.Perforationoccursin1015%ofcases.Patientswithacalculous
cholecystitishaveamortalityrangingfrom1050%,whichfarexceedstheexpected
4%mortalityobservedinpatientswithcalculouscholecystitis.Inpatientswhoare
criticallyillwithacalculouscholecystitisandperforationorgangrene,mortalitycan
beashighas5060%.
Theseverityofacutecholecystitisalsohasanimpactontheriskofiatrogenicbile
ductinjuryduringcholecystectomy. [8]Tornqvistetalreportedadoublingoftherisk
forsustainingabiliarylesioninpatientswithongoingacutecholecystitiscompared
tothosewithoutacutecholecystitis.PatientswithTokyogradeII(moderate)acute
cholecystitisandthosewithTokyogradeIII(severe)cholecystitishad,respectively,
overdoubleandmorethaneighttimestheriskofbileductinjurycomparedtothose
withoutacutecholecystitis.Theriskofbiliaryinjurywasreducedby52%with
intentiontouseintraoperativecholangiography. [8]
ClinicalPresentation

ContributorInformationandDisclosures
Author
AlanABloom,MDAssociateClinicalProfessorofMedicine,AlbertEinsteinCollegeofMedicineAttending
Physician,DepartmentofGastroenterology,VeteransAffairsHospital,Bronx
AlanABloom,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,American

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Cholecystitis:PracticeEssentials,Background,Pathophysiology

GastroenterologicalAssociation,AmericanMedicalAssociation,AmericanSocietyforGastrointestinal
Endoscopy,NewYorkAcademyofMedicine,NewYorkAcademyofSciences

Disclosure:Nothingtodisclose.
ChiefEditor
BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeof
Medicine
BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,AmericanSociety
forGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
AdditionalContributors
JulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine
JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,
Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocial
Responsibility
Disclosure:Nothingtodisclose.
Acknowledgements
ClintonSBeverly,MDClinicalAssistantProfessor,DepartmentofSurgery,MercerUniversitySchoolof
Medicine
ClintonSBeverly,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeonsand
SocietyofAmericanGastrointestinalandEndoscopicSurgeons
Disclosure:Nothingtodisclose.
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,Program
DirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserveUniversity
SchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracic
Society,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
JackADiPalma,MDDirector,DivisionofGastroenterology,Professor,DepartmentofInternalMedicine,
UniversityofSouthAlabamaCollegeofMedicine
JackADiPalma,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterologyand
AmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
DonGladden,DOStaffPhysician,DepartmentofEmergencyMedicine,SetonMedicalCenterWilliamson
DonGladden,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
SamuelMKeim,MDAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofArizonaCollegeof
Medicine
SamuelMKeim,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,AmericanPublicHealth
Association,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AlexandreFMigala,DOStaffPhysician,DepartmentofEmergencyMedicine,DentonRegionalMedicalCenter
AlexandreFMigala,DOisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,AmericanOsteopathicAssociation,AssociationofMilitary
OsteopathicPhysiciansandSurgeons,andTexasMedicalAssociation
Disclosure:Nothingtodisclose.
AnilMinocha,MD,FACP,FACG,AGAF,CPNSSProfessorofMedicine,DirectorofDigestiveDiseases,
MedicalDirectorofNutritionSupport,MedicalDirectorofGastrointestinalEndoscopy,InternalMedicine
Department,UniversityofMississippiMedicalCenterClinicalProfessor,UniversityofMississippiSchoolof
Pharmacy
AnilMinocha,MD,FACP,FACG,AGAF,CPNSSisamemberofthefollowingmedicalsocieties:American
AcademyofClinicalToxicology,AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeof

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ForensicExaminers,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,American
FederationforClinicalResearch,AmericanGastroenterologicalAssociation,andAmericanSocietyof
GastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
TusharPatel,MB,ChBProfessorofMedicine,OhioStateUniversityMedicalCenter
TusharPatel,MB,ChBisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyof
LiverDiseasesandAmericanGastroenterologicalAssociation
Disclosure:Nothingtodisclose.
RahulSharma,MD,MBA,FACEPMedicalDirectorandAssociateChiefofService,NYULangoneMedical
Center,TischHospitalEmergencyDepartmentAssistantProfessorofEmergencyMedicine,NewYorkUniversity
SchoolofMedicine
RahulSharma,MD,MBA,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicianExecutives,PhiBetaKappa,andSocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
PeterADSteel,MA,MBBSAttendingPhysician,DepartmentofEmergencyMedicine,JoanandSanfordI
WeillCornellMedicalCenter,NewYorkPresbyterianHospital
PeterADSteel,MA,MBBSisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,BritishMedicalAssociation,EmergencyMedicineResidentsAssociation,andSocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
AlanBRThomson,MDProfessorofMedicine,DivisionofGastroenterology,UniversityofAlberta,Canada
AlanBRThomson,MDisamemberofthefollowingmedicalsocieties:AlbertaMedicalAssociation,American
CollegeofGastroenterology,AmericanGastroenterologicalAssociation,CanadianAssociationof
Gastroenterology,CanadianMedicalAssociation,CollegeofPhysiciansandSurgeonsofAlberta,andRoyal
CollegeofPhysiciansandSurgeonsofCanada
Disclosure:Nothingtodisclose.
JefferyWolff,DOConsultingStaff,DepartmentofGastroenterology,BrookeArmyMedicalCenterStaff
Gastroenterologist,LandstuhlRegionalMedicalCenter
JefferyWolff,DO,isamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanGastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.

References
1.HuffmanJL,SchenkerS.Acuteacalculouscholecystitisareview.ClinGastroenterolHepatol.2009Sep
9.[Medline].
2.DonovanJM.Physicalandmetabolicfactorsingallstonepathogenesis.GastroenterolClinNorthAm.1999
Mar.28(1):7597.[Medline].
3.SitzmannJV,PittHA,SteinbornPA,etal.Cholecystokininpreventsparenteralnutritioninducedbiliary
sludgeinhumans.SurgGynecolObstet.1990Jan.170(1):2531.[Medline].
4.CullenJJ,MaesEB,AggrawalS,etal.Effectofendotoxinonopossumgallbladdermotility:amodelof
acalculouscholecystitis.AnnSurg.2000Aug.232(2):2027.[Medline].
5.ForbesLE,BajajM,McGinnT,etal.Perihepaticabscessformationindiabetes:acomplicationofsilent
gallstones.AmJGastroenterol.1996Apr.91(4):7868.[Medline].
6.HuangJ,ChangCH,WangJL,KuoHK,LinJW,ShauWY,etal.Nationwideepidemiologicalstudyof
severegallstonediseaseinTaiwan.BMCGastroenterol.2009Aug22.9:63.[Medline].[FullText].
7.LeeSW,YangSS,ChangCS,YehHJ.ImpactoftheTokyoguidelinesonthemanagementofpatients
withacutecalculouscholecystitis.JGastroenterolHepatol.2009Aug3.[Medline].
8.TornqvistB,WaageA,ZhengZ,YeW,NilssonM.Severityofacutecholecystitisandriskofiatrogenicbile
ductinjuryduringcholecystectomy,apopulationbasedcasecontrolstudy.WorldJSurg.2016May.40
(5):10607.[Medline].
9.McEvoyCF,SuchyFJ.Biliarytractdiseaseinchildren.PediatrClinNorthAm.1996Feb.43(1):7598.
[Medline].
10.GruberPJ,SilvermanRA,GottesfeldS,etal.Presenceoffeverandleukocytosisinacutecholecystitis.
AnnEmergMed.1996Sep.28(3):2737.[Medline].
11.NidimusiliAJ,AlraiesMC,EisaN,AlraiyesAH,ShaheenK.Leukocytosisofunknownorigin:gangrenous
cholecystitis.CaseRepMed.2013.2013:418014.[Medline].[FullText].

http://emedicine.medscape.com/article/171886overview

6/8

4/19/2016

Cholecystitis:PracticeEssentials,Background,Pathophysiology

12.LioliosA,OropelloJM,BenjaminE.Gastrointestinalcomplicationsintheintensivecareunit.ClinChest
Med.1999Jun.20(2):32945,viii.[Medline].
13.ChiuHH,ChenCM,MoLR.Emphysematouscholecystitis.AmJSurg.2004Sep.188(3):3256.[Medline].
14.MoscatiRM.Cholelithiasis,cholecystitis,andpancreatitis.EmergMedClinNorthAm.1996Nov.
14(4):71937.[Medline].
15.OzekiM,TakedaY,MoritaH,etal.Acutecholecystitismimickingoraccompanyingcardiovasculardisease
amongJapanesepatientshospitalizedinaCardiologyDepartment.BMCResNotes.2015Dec19.8
(1):805.[Medline].
16.YatesMR3rd,BaronTH.Biliarytractdiseaseinpregnancy.ClinLiverDis.1999.3:131147.
17.SingerAJ,McCrackenG,HenryMC,etal.Correlationamongclinical,laboratory,andhepatobiliary
scanningfindingsinpatientswithsuspectedacutecholecystitis.AnnEmergMed.1996Sep.28(3):26772.
[Medline].
18.[Guideline]KatzDS,RosenMP,BlakeMA,etalandExpertPanelonGastrointestinalImaging.ACR
AppropriatenessCriteriarightupperquadrantpain.[onlinepublication].Reston(VA):AmericanCollegeof
Radiology(ACR)2010.[FullText].
19.TowfighS,McFaddenDW,CortinaGR,etal.Porcelaingallbladderisnotassociatedwithgallbladder
carcinoma.AmSurg.2001Jan.67(1):710.[Medline].
20.StephenAE,BergerDL.Carcinomaintheporcelaingallbladder:arelationshiprevisited.Surgery.2001
Jun.129(6):699703.[Medline].
21.BingenerJ,SchwesingerWH,ChopraS,etal.Doesthecorrelationofacutecholecystitisonultrasound
andatsurgeryreflectamirrorimage?.AmJSurg.2004Dec.188(6):7037.
22.JangT,AubinC,NaunheimR.Minimumtrainingforrightupperquadrantultrasonography.AmJEmerg
Med.2004Oct.22(6):43943.[Medline].
23.RoeJ.Evidencebasedemergencymedicine.Clinicalassessmentofacutecholecystitisinadults.Ann
EmergMed.2006Jul.48(1):1013.[Medline].
24.RosenCL,BrownDF,ChangY,etal.Ultrasonographybyemergencyphysiciansinpatientswithsuspected
cholecystitis.AmJEmergMed.2001Jan.19(1):326.[Medline].
25.RubensDJ.Hepatobiliaryimaginganditspitfalls.RadiolClinNorthAm.2004Mar.42(2):25778.
[Medline].
26.ShahK,WolfeRE.Hepatobiliaryultrasound.EmergMedClinNorthAm.2004Aug.22(3):66173,viii.
[Medline].
27.KawaiR,HataJ,ManabeN,etal.ContrastenhancedultrasonographywithSonazoidfordiagnosisof
gangrenouscholecystitis.JMedUltrason(2001).2016Apr.43(2):1939.[Medline].
28.PereiraJ,AfonsoAC,ConstantinoJ,etal.Accuracyofultrasoundinthediagnosisofacutecholecystitis
withcoexistentacutepancreatitis.EurJTraumaEmergSurg.2015Dec22.[Medline].
29.KimYK,KwakHS,KimCS,HanYM,JeongTO,KimIH,etal.CTfindingsofmildformsorearly
manifestationsofacutecholecystitis.ClinImaging.2009JulAug.33(4):27480.[Medline].
30.WangA,ShanbhogueAK,DunstD,HajduCH,RosenkrantzAB.UtilityofdiffusionweightedMRIfor
differentiatingacutefromchroniccholecystitis.JMagnResonImaging.2015Dec22.[Medline].
31.SahaiAV,MauldinPD,MarsiV,etal.Bileductstonesandlaparoscopiccholecystectomy:adecision
analysistoassesstherolesofintraoperativecholangiography,EUS,andERCP.GastrointestEndosc.1999
Mar.49(3Pt1):33443.[Medline].
32.SiddiquiT,MacDonaldA,ChongPS,etal.Earlyversusdelayedlaparoscopiccholecystectomyforacute
cholecystitis:ametaanalysisofrandomizedclinicaltrials.AmJSurg.2008Jan.195(1):407.[Medline].
33.CoxMR,WilsonTG,LuckAJ,etal.Laparoscopiccholecystectomyforacuteinflammationofthe
gallbladder.AnnSurg.1993Nov.218(5):6304.[Medline].
34.LoCM,LiuCL,FanST,etal.Prospectiverandomizedstudyofearlyversusdelayedlaparoscopic
cholecystectomyforacutecholecystitis.AnnSurg.1998Apr.227(4):4617.[Medline].
35.IkumotoT,YamagishiH,IwatateM,SanoY,KotakaM,ImaiY.Feasibilityofsingleincisionlaparoscopic
cholecystectomyforacutecholecystitis.WorldJGastrointestEndosc.2015Dec25.7(19):132733.
[Medline].
36.ZafarSN,ObiriezeA,AdesibikanB,CornwellEE3rd,FullumTM,TranDD.Optimaltimeforearly
laparoscopiccholecystectomyforacutecholecystitis.JAMASurg.2015Feb.150(2):12936.[Medline].
37.[Guideline]OverbyDW,ApelgrenKN,RichardsonW,FanelliR.SAGESguidelinesfortheclinical
applicationoflaparoscopicbiliarytractsurgery.SurgEndosc.2010Oct.24(10):236886.[Medline].
38.WilsonE,GurusamyK,GluudC,DavidsonBR.Costutilityandvalueofinformationanalysisofearly
versusdelayedlaparoscopiccholecystectomyforacutecholecystitis.BrJSurg.2010Feb.97(2):2109.
[Medline].
39.TarragunAV,AzagraJS,LensV,ManzoniD,FabianoP,GoergenM.TwoStagedMinimallyInvasive
TreatmentforAcuteCholecystitisinHighRiskPatients.Hepatogastroenterology.2013May1.60(123):
[Medline].
40.BinenbaumSJ,TeixeiraJA,ForresterGJ,HarveyEJ,AfthinosJ,KimGJ,etal.Singleincision
laparoscopiccholecystectomyusingaflexibleendoscope.ArchSurg.2009Aug.144(8):7348.[Medline].

http://emedicine.medscape.com/article/171886overview

7/8

4/19/2016

Cholecystitis:PracticeEssentials,Background,Pathophysiology

41.WuCH,ChenCC,WangCJ,etal.Discriminationofgangrenousfromuncomplicatedacutecholecystitis:
AccuracyofCTfindings.AbdomImaging.2011Apr.36(2):1748.[Medline].
42.JulliardO,HautersP,PossozJ,MalvauxP,LandenneJ,GherardiD.Incisionalherniaaftersingleincision
laparoscopiccholecystectomy:incidenceandpredictivefactors.SurgEndosc.2016Feb19.[Medline].
43.SilberfeinEJ,ZhouW,KougiasP,etal.Percutaneouscholecystostomyforacutecholecystitisinhighrisk
patients:experienceofasurgeoninitiatedinterventionalprogram.AmJSurg.2007Nov.194(5):6727.
[Medline].
44.MutignaniM,IacopiniF,PerriV,etal.Endoscopicgallbladderdrainageforacutecholecystitis:technical
andclinicalresults.Endoscopy.2009Jun.41(6):53946.[Medline].
45.LiM,LiN,JiW,QuanZ,WanX,WuX,etal.PercutaneousCholecystostomyIsaDefinitiveTreatmentfor
AcuteCholecystitisinElderlyHighriskPatients.AmSurg.2013May.79(5):5247.[Medline].
46.LeeSS,ParkdoH,HwangCY,etal.EUSguidedtransmuralcholecystostomyasrescuemanagementfor
acutecholecystitisinelderlyorhighriskpatients:aprospectivefeasibilitystudy.GastrointestEndosc.2007
Nov.66(5):100812.[Medline].
47.LawR,BaronTH.Endoscopicultrasoundguidedbiliaryinterventions:anupdateonrecentdevelopments.
CurrOpinGastroenterol.2016May.32(3):2327.[Medline].
48.AnderloniA,BudaA,VieceliF,KhashabMA,HassanC,RepiciA.Endoscopicultrasoundguided
transmuralstentingforgallbladderdrainageinhighriskpatientswithacutecholecystitis:asystematic
reviewandpooledanalysis.SurgEndosc.2016Apr8.[Medline].
49.GreenwaldJA,McMullenHF,CoppaGF,etal.Standardizationofsurgeoncontrolledvariables:impacton
outcomeinpatientswithacutecholecystitis.AnnSurg.2000Mar.231(3):33944.[Medline].
50.GuttCN,EnckeJ,KningerJ,HarnossJC,WeigandK,KipfmllerK,etal.Acutecholecystitis:early
versusdelayedcholecystectomy,amulticenterrandomizedtrial(ACDCstudy,NCT00447304).AnnSurg.
2013Sep.258(3):38593.[Medline].
51.LowenfelsA.Isearlysurgerybetterforacutecholecystitis?MedscapeMedicalNews.November6,2013.
Availableathttp://www.medscape.com/viewarticle/813363.Accessed:December2,2013.
52.KhasawnehMA,ShampA,HellerS,etal.Successfullaparoscopiccholecystectomyafterpercutaneous
cholecystostomytubeplacement.JTraumaAcuteCareSurg.2015Jan.78(1):1004.[Medline].
53.KnabLM,BollerAM,MahviDM.Cholecystitis.SurgClinNorthAm.2014Apr.94(2):45570.[Medline].
54.vanDijkAH,deReuverPR,TasmaTN,vanDierenS,HughTJ,BoermeesterMA.Systematicreviewof
antibiotictreatmentforacutecalculouscholecystitis.BrJSurg.2016Mar30.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/171886overview

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