hepatic and biliary disorders
Acute Cholecystitis
Symptoms and Signs of Acute Cholecystitis
Most patients have had prior attacks of biliary colic or acute cholecystitis. The pain of cholecystitis is similar in quality and location to biliary colic but lasts longer (ie,>6 hours) and is more severe. Vomiting is common, as is right subcostal tenderness. Within a few hours, the Murphy sign (deep inspiration exacerbates the pain during palpation of the right upper quadrant and halts inspiration) develops along with involuntary guarding of upper abdominal muscles on the right side. Fever, usually low grade, is common. In older patients, the first or only symptoms may be systemic and nonspecific (eg, anorexia, vomiting, malaise, weakness, fever). Sometimes fever does not develop. Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. Without treatment, patients can develop localized or free perforation and peritonitis. Increasing abdominal pain, high fever, and rigors with rebound tenderness or ileus suggest empyema (pus) in the gallbladder, gangrene, or perforation. When acute cholecystitis is accompanied by Jaundice or cholestasis, partial common duct obstruction is likely, usually due to stones or inflammation. Other complications include the following: Mirizzi syndrome: Rarely, a gallstone becomes impacted in the cystic duct and compresses and obstructs the common bile duct, causing cholestasis. Gallstone pancreatitis: Gallstones pass from the gallbladder into the biliary tract and block the pancreatic duct. Cholecystoenteric fistula: Infrequently, a large stone erodes the gallbladder wall, creating a fistula into the small bowel (or elsewhere in the abdominal cavity); the stone may pass freely or obstruct the small bowel (gallstone ileus). The symptoms are similar to those of acute cholecystitis with gallstones but may be difficult to identify because patients tend to be severely ill (eg, in an intensive care unit) and may be unable to communicate clearly. Abdominal distention or unexplained fever may be the only clue. Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. Closely monitor patients at risk of acalculous cholecystitis (eg, critically ill, fasting, or immunocompromised patients) for subtle signs of the disorder (eg, abdominal distention, unexplained fever). 