Diagnosis and treatment of acute cholecystitis

Abstract

Acute cholecystitis is a common emergency presentation of gallstone disease. The improvements in diagnosis and treatment can lead to reduce rates of morbidity, mortality and costs. Clinical findings are usually diagnostic of acute cholecystitis. However, imaging studies play an important role in the confirmation of the diagnosis and detection of associated complications. On physical examination patients typically present severe right upper quadrant pain with positive Murphy sign associated with nausea, vomits and fever. Leukocytosis with neutrophilia is the most common laboratory finding, while elevated liver enzymes are related with worse outcome. Imaging studies allow clinicians to establish diagnosis in suspected individuals and to detect complications. Right upper quadrant ultrasound is the imaging modality of choice due to its sensitivity (82%), specificity (81%), availability, low cost and lack of radiation exposure. Computed Tomography (CT) is currently recommended when other intraabdominal pathologies are suspected and Magnetic Resonance Imaging (MRI) is useful for pregnant patients and to identify choledocholithiasis. Once the diagnosis of acute cholecystitis is achieved, we must take decisions in order to provide patients the best management available. Despite of overtime controverses about the optimal treatment, early laparoscopic cholecystectomy is currently accepted as the best option. Surgery should be performed as soon as possible after diagnosis, because it reduces total hospital stay and does not increase complication or conversion rates. Percutaneous cholecystostomy is indicated in the advanced form of inflammation or in patients with severe comorbidities increasing surgical risk.