Cholecystitis Clinical Presentation_ History, Physical Examination

10/15/2015 CholecystitisClinicalPresentation:History,PhysicalExamination

http://emedicine.medscape.com/article/171886clinical 1/4

CholecystitisClinicalPresentationAuthor:AlanABloom,MDChiefEditor:JulianKatz,MDmore...

Updated:Apr01,2014

HistoryThemostcommonpresentingsymptomofacutecholecystitisisupperabdominalpain.Signsofperitonealirritationmaybepresent,andinsomepatients,thepainmayradiatetotherightshoulderorscapula.Frequently,thepainbeginsintheepigastricregionandthenlocalizestotherightupperquadrant(RUQ).Althoughthepainmayinitiallybedescribedascolicky,itbecomesconstantinvirtuallyallcases.Nauseaandvomitingaregenerallypresent,andpatientsmayreportfever.

Mostpatientswithacutecholecystitisdescribeahistoryofbiliarypain.Somepatientsmayhavedocumentedgallstones.Acalculousbiliarycolicalsooccurs,mostcommonlyinyoungtomiddleagedfemales.Thepresentationisalmostidenticaltocalculousbiliarycolicwiththeexceptionofreferencerangelaboratoryvaluesandnofindingsofcholelithiasisonultrasound.Cholecystitisisdifferentiatedfrombiliarycolicbythepersistenceofconstantseverepainformorethan6hours.

Patientswithacalculouscholecystitismaypresentsimilarlytopatientswithcalculouscholecystitis,butacalculouscholecystitisfrequentlyoccurssuddenlyinseverelyillpatientswithoutapriorhistoryofbiliarycolic.Often,patientswithacalculouscholecystitismaypresentwithfeverandsepsisalone,withouthistoryorphysicalexaminationfindingsconsistentwithacutecholecystitis.

Cholecystitisinelderlypersons

Elderlypatients(especiallypatientswithdiabetes)maypresentwithvaguesymptomsandwithoutmanykeyhistoricalandphysicalfindings.Painandfevermaybeabsent,andlocalizedtendernessmaybetheonlypresentingsign.Elderlypatientsmayalsoprogresstocomplicatedcholecystitisrapidlyandwithoutwarning.

Cholecystitisinchildren

Thepediatricpopulationmayalsopresentwithoutmanyoftheclassicfindings.Childrenwhoareathigherriskfordevelopingcholecystitisincludepatientswithsicklecelldisease,seriouslyillchildren,thoseonprolongedTPN,thosewithhemolyticconditions,andthosewithcongenitalandbiliaryanomalies.[8]Formoreinformation,seetheMedscapeReferencearticlePediatricCholecystitis.

Complications

Bacterialproliferationwithintheobstructedgallbladderresultsinempyemaoftheorgan.Patientswithempyemamayhaveatoxicreactionandmayhavemoremarkedfeverandleukocytosis.[9,10]Thepresenceofempyemafrequentlyrequiresconversionfromlaparoscopictoopencholecystectomy.[11]

Inrareinstances,alargegallstonemayerodethroughthegallbladderwallintoanadjacentviscus,usuallytheduodenum.Subsequently,thestonemaybecomeimpactedintheterminalileumorintheduodenalbulband/orpylorus,causingagallstoneileus.

Emphysematouscholecystitisoccursinapproximately1%ofcasesandisnotedbythepresenceofgasinthegallbladderwallfromtheinvasionofgasproducingorganisms,suchasEscherichiacoli,Clostridiaperfringens,andKlebsiellaspecies.Thiscomplicationismorecommoninpatientswithdiabetes,hasamalepredominance,andisacalculousin28%ofcases.Becauseofahighincidenceofgangreneandperforation,emergencycholecystectomyisrecommended.Perforationoccursinupto15%ofpatients.[12,10]Formoreinformation,seetheMedscapeReferencearticleEmphysematousCholecystitis.

Othercomplicationsincludesepsisandpancreatitis.[13]

PhysicalExaminationThephysicalexaminationmayrevealfever,tachycardia,andtendernessintheRUQorepigastricregion,oftenwithguardingorrebound.TheMurphysign,whichisspecificbutnotsensitiveforcholecystitis,isdescribedastendernessandaninspiratorypauseelicitedduringpalpationoftheRUQ.ApalpablegallbladderorfullnessoftheRUQispresentin3040%ofcases.Jaundicemaybenotedinapproximately15%ofpatients.

Theabsenceofphysicalfindingsdoesnotruleoutthediagnosisofcholecystitis.ManypatientspresentwithdiffuseepigastricpainwithoutlocalizationtotheRUQ.PatientswithchroniccholecystitisfrequentlydonothaveapalpableRUQmasssecondarytofibrosisinvolvingthegallbladder.

Elderlypatientsandpatientswithdiabetesfrequentlyhaveatypicalpresentations,includingabsenceoffeverandlocalizedtendernesswithonlyvaguesymptoms.

DifferentialDiagnoses

ContributorInformationandDisclosuresAuthor



AlanABloom,MDAssociateClinicalProfessorofMedicine,AlbertEinsteinCollegeofMedicineAttendingPhysician,DepartmentofGastroenterology,VeteransAffairsHospital,Bronx

AlanABloom,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,NewYorkAcademyofMedicine,NewYorkAcademyofSciences

Disclosure:Nothingtodisclose.

ChiefEditorJulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine

JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocialResponsibility


AcknowledgementsClintonSBeverly,MDClinicalAssistantProfessor,DepartmentofSurgery,MercerUniversitySchoolofMedicine

ClintonSBeverly,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeonsandSocietyofAmericanGastrointestinalandEndoscopicSurgeons


BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserveUniversitySchoolofMedicine

BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,andSocietyforAcademicEmergencyMedicine


JackADiPalma,MDDirector,DivisionofGastroenterology,Professor,DepartmentofInternalMedicine,UniversityofSouthAlabamaCollegeofMedicine

JackADiPalma,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterologyandAmericanSocietyforGastrointestinalEndoscopy


DonGladden,DOStaffPhysician,DepartmentofEmergencyMedicine,SetonMedicalCenterWilliamson

DonGladden,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians


EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergencyMedicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,MartinLutherKingJr/DrewMedicalCenter


SamuelMKeim,MDAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofArizonaCollegeofMedicine

SamuelMKeim,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,AmericanPublicHealthAssociation,andSocietyforAcademicEmergencyMedicine


AlexandreFMigala,DOStaffPhysician,DepartmentofEmergencyMedicine,DentonRegionalMedicalCenter

AlexandreFMigala,DOisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanOsteopathicAssociation,AssociationofMilitaryOsteopathicPhysiciansandSurgeons,andTexasMedicalAssociation


AnilMinocha,MD,FACP,FACG,AGAF,CPNSSProfessorofMedicine,DirectorofDigestiveDiseases,MedicalDirectorofNutritionSupport,MedicalDirectorofGastrointestinalEndoscopy,InternalMedicineDepartment,UniversityofMississippiMedicalCenterClinicalProfessor,UniversityofMississippiSchoolofPharmacy

AnilMinocha,MD,FACP,FACG,AGAF,CPNSSisamemberofthefollowingmedicalsocieties:AmericanAcademyofClinicalToxicology,AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeofForensicExaminers,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanFederationforClinicalResearch,AmericanGastroenterologicalAssociation,andAmericanSocietyofGastrointestinalEndoscopy


TusharPatel,MB,ChBProfessorofMedicine,OhioStateUniversityMedicalCenter

TusharPatel,MB,ChBisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiverDiseasesandAmericanGastroenterologicalAssociation


RahulSharma,MD,MBA,FACEPMedicalDirectorandAssociateChiefofService,NYULangoneMedicalCenter,TischHospitalEmergencyDepartmentAssistantProfessorofEmergencyMedicine,NewYorkUniversity



SchoolofMedicine

RahulSharma,MD,MBA,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicianExecutives,PhiBetaKappa,andSocietyforAcademicEmergencyMedicine


PeterADSteel,MA,MBBSAttendingPhysician,DepartmentofEmergencyMedicine,JoanandSanfordIWeillCornellMedicalCenter,NewYorkPresbyterianHospital

PeterADSteel,MA,MBBSisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,BritishMedicalAssociation,EmergencyMedicineResidentsAssociation,andSocietyforAcademicEmergencyMedicine


FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeSalaryEmployment

AlanBRThomson,MDProfessorofMedicine,DivisionofGastroenterology,UniversityofAlberta,Canada

AlanBRThomson,MDisamemberofthefollowingmedicalsocieties:AlbertaMedicalAssociation,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,CanadianAssociationofGastroenterology,CanadianMedicalAssociation,CollegeofPhysiciansandSurgeonsofAlberta,andRoyalCollegeofPhysiciansandSurgeonsofCanada


JefferyWolff,DOConsultingStaff,DepartmentofGastroenterology,BrookeArmyMedicalCenterStaffGastroenterologist,LandstuhlRegionalMedicalCenter

JefferyWolff,DO,isamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy


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Cholecystitis Clinical Presentation_ History, Physical Examination