Acute cholecystitis refers to acute right subcostal pain and tenderness resulting from obstruction of the cystic duct and subsequent distention, inflammation, and secondary infection of the gallbladder. Acalculous cholecystitis, accounting for 5% of cases, is associated with the triad of "prolonged fasting, im-mobility, and hemodynamic instability", such as occurs in critically ill patients (especially patients with burns, trauma, and sepsis) and with parenteral hyperalimentation. Acute cholecystitis usually begins with epigastric or right upper quad-rant pain that gradually increases in severity and usually local. izes to the area of the gallbladder. Unlike biliary pain, the pain of acute cholecystitis does not subside spontaneously. Low. grade fever, anorexia, nausea, vomiting, and right subcostal tenderness are commonly present, as is Murphy's sign (in-creased subhepatic tenderness and inspiratory arrest during a deep breath). In approximately one third of patients, a ten-der, enlarged gallbladder may be felt. Mild jaundice occurs in about 20 % of patients as a result of concomitant common duct stones or bile duct edema. Complications of acute cholecystitis include emphysematous cholecystitis (especially in diabetics with bacterial gas present in the gallbladder lumen and wall), empyema of the gallbladder, gangrene, and perforation. Pro-found jaundice may result from Mirizzi's syndrome, in which extrinsic common bile duct compression occurs from an impact-ed stone in the gallbladder neck. Approximately 10% of pa-tients present with or develop one of these complications and require emergency surgery. The onset of severe fever, shaking chills, increased leukocytosis, increased abdominal pain or ten-derness, or persistent severe symptoms, alone or incombina-tion, indicates progression of disease and suggests development of one of these complications.

Radionuclide scanning after intravenous administration of 99mTc-DISIDA or HIDA is the most accurate test with which to confirm the clinical impression of acute cholecystitis (cystic duct obstruction). If the gallbladder fills with the isotope, acute cholecystitis is unlikely, whereas if the bile duct is visu-alized but the gallbladder is not, the clinical diagnosis is strongly supported. An ultrasonographic examination that shows the presence of gallstones (or sludge in acalculous chole-cystitis), along with localized tenderness over the gallbladder (ultrasonographic Murphy' s sign), pericholecystic fluid, and gallbladder wall thickening, provides strong supportive evi-dence for acute cholecystitis. Oral cholecystograms are of no value in this clinical setting, because they are unreliable in the acutely ill patient.

Patients with acute cholecystitis may improve over 1 to 7 days with conventional expectant management, which includes nasogastric suction for patients with profound vomiting and/or abdominal distention, intravenous fluids, antibiotics, and analgesics. Because of the high risk of recurrent acute cho1e-cystitis, most patients need to undergo cholecystectomy, often performed within the first 24 to 48 hours or, less often, 4 to8 weeks after an acute episode, as either conventional or laparo. scopic cholecystectomy.

Emergency surgery is performed on patients with ad-vanced disease and complications, usually associated with in-fection and sepsis. Cholecystostomy (either operative or percu-taneous), rather than cholecystectomy, may be a useful tech. nique in patients in whom there is a high operative risk. Pa-tients who are good operative risks and in whom the diagnosis is certain are scheduled for prompt cholecystectomy within 24 to 48 hours. Antibiotics are used in patients with suppurative complications. Expectant management is reserved for those with uncomplicated disease who are not good operative candi-dates or those in whom the diagnosis is not clear.

The mortality of acute cholecystitis of 5 % to 10% is al-most entirely confined to patients older than age 60 with seri-ous associated diseases and to those with suppurative complica-tions. Complications of acute cholecystitis include infectious complications and cholecystoenteric fistula resulting in gall-stone ileus.

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