Snap Shot A 45-year-old obese woman presents in the ER with steady, severe, aching pain in the upper right quadrant that radiates to the right scapula. The onset was acute and occurred 30 minutes after lunch. She had nausea with vomiting. On physical exam, she noted that she stops breathing on deep palpation of the right quadrant. Laboratory studies show an absolute neutrophillic leukocytosis with a left shift. Introduction Prolonged blockage of the cystic duct leading to distention inflammation superinfection of the gallbladder 90% due to stone in cystic duct Risk factors include Fat Female Forty Flatulent Fertile TPN oral contraceptives North American Indian ancestry debilitated patients trauma burn victims Caused by EEEK bugs Escherichia coli Enterobacter cloacae Enterococcus Klebsiella Acalculous cholecystitis is cholecystitis in the absence of gallstones seen most commonly in critically and chronically ill patients ...Presentation Symptoms RUQ pain sudden onset 15-30 minutes after eating steady and aching radiates to the right scapula nausea vomiting Physical exam RUQ tenderness inspiratory arrest during deep palpation of the RUQ (Murphy's sign) low grade fever mild icterus may be present Gallbladder palpable in 30-40% of patients Evaluation Ultrasound stones thickened gallbladder wall pericholecystic fluid Labs absolute neutrophillic leukocytosis with left shift elevated AST / ALT elevated bilirubin elevated amylase Obtain HIDA scan when ultrasound equivocal Absence of gallbladder suggest cholecystiits Differential Biliary colic , cholangitis, GERD, hepatitis, acute pancreatitis, MI, acute appendicitis, renal colic, Fitz-Hugh-Curtis Syndrome, PUD, pneumonia Treatment IV antibiotics Fluids Electrolytes Perform early cholecystectomy (within 72 hours) if patient in good health with intra-operative cholangiogram to rule out common bile duct stones gallstones discovered incidentally that are asymptomatic do not need to be treated Patients are too acutely ill (e.g. acalculous cholecystitis) for cholecystectomy can be stabilized with percutaneous cholecystostomy prior to cholecystectomy Ursodeoxycholic acid can be used as prophylaxis Prognosis, Prevention, and Complications Gangrene Fistulas Perforation Sepsis Repeat episodes increase the risk for adenocarcinoma of the gallbladder