Approach Considerations

Treatment of cholecystitis depends on the severity of the condition and the presence or absence of
complications. Uncomplicated cases can often be treated on an outpatient basis; complicated cases may
necessitate a surgical approach. In patients who are unstable, percutaneous transhepatic
cholecystostomy drainage may be appropriate. Antibiotics may be given to manage infection. Definitive
therapy involves cholecystectomy or placement of a drainage device; therefore, consultation with a
surgeon is warranted. Consultation with a gastroenterologist for consideration of ERCP may also be
appropriate if concern exists of choledocholithiasis.

Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery.
However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of
surgery.

For more information, see the Medscape Reference article Imaging in Cholecystitis and Biliary Colic.

Next Section: Initial Therapy and Antibiotic Treatment

Initial Therapy and Antibiotic Treatment
For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, correction of
electrolyte abnormalities, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis,
antibiotic therapy with a single broad-spectrum antibiotic is adequate. Some options include the following:

 The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV

q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h). In
severe life-threatening cases, the Sanford Guide recommends imipenem/cilastatin (Primaxin, 500 mg IV
q6h).
 Alternative regimens include a third-generation cephalosporin plus metronidazole (Flagyl, 1 g IV
loading dose followed by 500 mg IV q6h).
 Bacteria that are commonly associated with cholecystitis includeEscherichia coli and Bacteroides
fragilis and Klebsiella, Enterococcus, andPseudomonas species.
 Emesis can be treated with antiemetics and nasogastric suction.
 Because of the rapid progression of acute acalculous cholecystitis to gangrene and perforation,
early recognition and intervention are required.
 Supportive medical care should include restoration of hemodynamic stability and antibiotic
coverage for gram-negative enteric flora and anaerobes if biliary tract infection is suspected.
 Daily stimulation of gallbladder contraction with intravenous cholecystokinin (CCK) has been
shown by some to effectively prevent the formation of gallbladder sludge in patients receiving total
parenteral nutrition (TPN).
Previous
Next Section: Conservative Treatment of Uncomplicated Cholecystitis
ercutaneous Drainage
For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic
cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive
therapy.[35] Results of studies suggest that most patients with acute acalculous cholecystitis can be treated
with percutaneous drainage alone,[36, 37] but the SAGES guideline describes radiographically guided
percutaneous cholecystostomy as a temporizing measure until the patient can undergo cholecystectomy.
[30]

Conservative Treatment of Uncomplicated Cholecystitis

Outpatient treatment may be appropriate for cases of uncomplicated cholecystitis. If a patient can be
treated as an outpatient, discharge with antibiotics, appropriate analgesics, and definitive follow-up care.
Criteria for outpatient treatment include the following:

 Afebrile with stable vital signs

 No evidence of obstruction by laboratory values
 No evidence of common bile duct obstruction on ultrasonography
 No underlying medical problems, advanced age, pregnancy, or immunocompromised condition
 Adequate analgesia
 Reliable patient with transportation and easy access to a medical facility
 Prompt follow-up care
The following medications may be appropriate in this setting:

 Prophylactic antibiotic coverage with levofloxacin (Levaquin, 500 mg PO qd) and metronidazole
(500 mg PO bid), which should provide coverage against the most common organisms
 Antiemetics, such as oral/rectal promethazine (Phenergan) or prochlorperazine (Compazine), to
control nausea and to prevent fluid and electrolyte disorders
 Analgesics, such as oral oxycodone/acetaminophen (Percocet) or oxycodone/acetaminophen
(Vicodin)
Previous
Next Section: Cholecystectomy
Overview
Biliary colic and cholecystitis are in the spectrum of biliary tract disease. This spectrum ranges from
asymptomatic gallstones to biliary colic, cholecystitis, choledocholithiasis, and cholangitis.

Gallstones can be divided into 2 categories: Cholesterol stones (80%) and pigment stones (20%). Most
patients with gallstones are asymptomatic. Stones may temporarily obstruct the cystic duct or pass
through into the common bile duct, leading to symptomatic biliary colic, which develops in 1-4% of
patients with gallstones annually.

Cholecystitis occurs when obstruction at the cystic duct is prolonged (usually several hours) resulting in
inflammation of the gallbladder wall. Acute cholecystitis develops in approximately 20% of patients with
biliary colic if they are left untreated.[1] However, the incidence of acute cholecystitis is falling, likely due to
increased acceptance by patients of laparoscopic cholecystectomy as a treatment of symptomatic
gallstones.[2]

Choledocholithiasis occurs when the stone becomes lodged in the common bile duct, with the potential
sequelae of cholangitis and ascending infections.

Biliary sludge is a reversible suspension of precipitated particulate matter in bile in a viscous mucous
liquid phase. The most common precipitates are cholesterol monohydrate crystals and various calcium-
based crystals, granules, and salts.[3]A portion of biliary sludge contains comparatively large particles (1-3
mm) called microliths, the formation of which is an intermediate step in the formation of gallstones (about
12.5%).[4]

For patient education information, see eMedicineHealth's Digestive Disorders Center, as well

as Gallstones.

Go to Cholecystitis for more information on this topic.

Risk Factors
Cholelithiasis, cholecystitis, and biliary colic
Risk factors for biliary colic and cholecystitis include pregnancy, elderly population, obesity, certain ethnic
groups (Northern European and Hispanic), weight loss, and liver transplant patients. [5]

The phrase "fair, female, fat, and fertile" summarizes the major risk factors for development of gallstones.
Although gallstones and cholecystitis are more common in women, men with gallstones are more likely to
develop cholecystitis (and more severe cholecystitis) than women with gallstones. [6]

Some oral contraceptives or estrogen replacement therapy may increase the risk of gallstones. Drugs that
have been associated with cholecystitis include octreotide and ceftriaxone. [7, 8] In addition, the incidence of
sludge or stone formation during pregnancy is 5.1% in the second trimester, 7.9% in the third trimester,
and 10.2% at 4-6 weeks postpartum.[9, 10]

Age increases rates of gallstones, cholecystitis, and common bile duct stones. Elderly patients are more
likely to go from asymptomatic gallstones to serious complications of gallstones without gallbladder colic.

Acalculous cholecystitis
Risk factors for acalculous cholecystitis include diabetes, human immunodeficiency virus (HIV) infection,
vascular disease, total parenteral nutrition, prolonged fasting, or being an intensive care unit (ICU)
patient.

Children are more likely than adults to have acalculous gallstones. If stones exist, they are more likely
pigmented stones from hemolytic diseases (eg, sickle cell diseases, spherocytosis, glucose-6-phosphate
dehydrogenase [G-6-PD] deficiency) or chronic diseases (eg, total parenteral nutrition, burns, trauma).

Evaluation of Biliary Colic and Cholecystitis

Symptoms of biliary colic
Typical gallbladder colic generally includes 1-5 hours of constant pain, most commonly in the epigastrium
or right upper quadrant. Peritoneal irritation by direct contact with the gallbladder localizes the pain to the
right upper quadrant. The pain is severe, dull or boring, constant (not colicky), and may radiate to the right
scapular region or back. Patients tend to move around to seek relief from the pain. The onset of pain
develops hours after a meal, occurs frequently at night, and awakens the patient from sleep. Associated
symptoms include nausea, vomiting, pleuritic pain, and fever.

Symptoms of cholecystitis
Persistence of biliary obstruction leads to cholecystitis and persistent right upper quadrant pain. The
character of the pain is similar to gallbladder colic, except that it is prolonged and lasts hours (usually >6
h) or days. Nausea, vomiting, and low-grade fever are associated more commonly with cholecystitis. Up
to 70% of patients with cholecystitis report having experienced similar episodes in the past that
spontaneously resolved.

Symptoms of cholelithiasis
Most gallstones (60-80%) are asymptomatic at a given time. Smaller stones are more likely to be
symptomatic than larger ones. However, almost all patients develop symptoms before complications,
such as steady pain in the right hypochondrium or epigastrium, nausea, vomiting, and fever. An acute
attack often is precipitated by a large or fatty meal.

Indigestion, belching, bloating, and fatty food intolerance are thought to be typical symptoms of
gallstones; however, these symptoms are just as common in people without gallstones and frequently are
not cured by cholecystectomy.

Vital signs and appearance

Vital signs parallel the degree of illness. Patients with cholangitis are more likely to have fever,
tachycardia, and/or hypotension. Patients with gallbladder colic have relatively normal vital signs. In a
retrospective study, only 32% of patients with cholecystitis had fever. Fever may be absent, especially in
elderly patients.

Patients with cholecystitis are usually more ill appearing than simple biliary colic patients, and they usually
lie still on the examination table, as any movement may aggravate any peritoneal signs. In elderly patients
and those with diabetes, occult cholecystitis or cholangitis may be the source of fever, sepsis, or mental
status changes.

Jaundice is unusual in the early stages of acute cholecystitis and may be found in fewer than 20% of
patients. Frank jaundice should raise suspicion of concomitantcholedocholithiasis or Mirizzi
 syndrome (obstruction of the bile duct as a result of external compression of a stone in the gallbladder or
cystic duct).

Abdominal assessment
As in all patients with abdominal pain, perform a complete physical examination, including rectal and
pelvic examinations in women.

Abdominal examination in gallbladder colic and cholecystitis is remarkable for epigastric or right upper
quadrant tenderness and abdominal guarding. The Murphy sign (an inspiratory pause on palpation of the
right upper quadrant) can be found on abdominal examination. Singer et al noted that a positive Murphy
sign was extremely sensitive (97%) and predictive (positive predictive value [PPV], 93%) for cholecystitis.
[11] 
However, in elderly patients, this sensitivity may be decreased.

A palpable fullness in the RUQ may be appreciated in 20% of cases after 24 hours of symptoms, but this
finding is rarely present early in the clinical course.

When observed, peritoneal signs should be taken seriously. Most uncomplicated cholecystitis does not
have peritoneal signs; thus, search for complications (eg, perforation, gangrene) or other sources of pain.

Diagnosis
Differential diagnosis
When cholecystitis and biliary colic are suspected, the following conditions should also be considered:

 Aneurysm, Abdominal
 Cholangitis
 Gastroenteritis
 Hepatitis
 Mesenteric Ischemia
 Myocardial Infarction
 Obstruction, Small Bowel
 Pancreatitis
 Pregnancy, Eclampsia
 Pregnancy, Urinary Tract Infections
 Cholelithiasis and renal calculi
 Diverticular and inflammatory bowel disease
Diagnostic Tests
Cholelithiasis and biliary colic
Laboratory studies in cases of cholelithiasis and gallbladder colic should be completely normal.

Cholecystitis
White blood cell (WBC) counts and measurements of aspirate aminotransferase (AST), alanine
aminotransferase (ALT), bilirubin, and alkaline phosphate (ALP) may be helpful in the diagnosis of
cholecystitis. However, because biliary obstruction is limited to the gallbladder in uncomplicated
cholecystitis, elevation in the serum total bilirubin and ALP concentrations may not be present. Thus, the
presence of normal values does not exclude cholecystitis.

A study by Singer et al examined the utility of laboratory values in acute cholecystitis diagnosed by
hepatic 2,6-dimethyliminodiacetic acid (HIDA) scanning.[11] No difference was found in mean WBC counts
and levels of AST, ALT, bilirubin, and ALP between patients diagnosed with cholecystitis and those
without.
 Mild elevation of amylase up to 3 times normal may be found in cholecystitis, especially when gangrene is
present. A very high bilirubin should prompt the physician to pay special attention to the common bile duct
and pancreatic region.

A comprehensive metabolic panel with bicarbonate may exhibit the following:

 AST, ALT, and ALP levels may be elevated; however, as with other laboratory tests, these levels
are not sensitive for excluding cholecystitis. When the AST and ALT levels are elevated significantly, a
common bile duct stone is more likely.
 An elevation of AST, ALT, or ALP measurements should raise the possibility of other biliary
system pathology such as cholangitis, choledocholithiasis, or the Mirizzi syndrome.
 Note the calcium level (Ranson criteria) if evidence of biliary pancreatitis exists.
 Other abnormalities (eg, renal insufficiency) are not related to cholecystitis but may indicate a
comorbid condition.
An elevated WBC is expected but not reliable. In a retrospective study, only 61% of patients with
cholecystitis had a WBC count greater than 11,000 cells/µL. A WBC greater than 15,000 cells/µL may
indicate perforation or gangrene.

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are not expected to be elevated
unless sepsis or underlying cirrhosis is present. Coagulation profiles are helpful if the patient needs
operative intervention.

For febrile patients, send 2 sets of blood cultures to attempt to isolate the organism in the presence of
bacteremia from bacterial superinfection.

Although expected to be normal, urinalysis is essential in the workup of patients with abdominal pain to
exclude pyelonephritis and renal calculi.

Conduct a pregnancy test for women of childbearing age.

Imaging Considerations
Ultrasonography and nuclear medicine studies are the best imaging studies for the diagnosis of both
cholecystitis and cholelithiasis. Ultrasonography is usually favored as the initial test, whereas
hepatobiliary scintigraphy is usually reserved for the 20% of patients in whom the diagnosis is unclear
after ultrasonography has been performed.

Plain radiography, computed tomography (CT) scans, and endoscopic retrograde

cholangiopancreatography (ERCP) are diagnostic adjuncts. [12]

Ultrasonography
Ultrasonography is the most common test used in the emergency department for the diagnosis of biliary
colic and acute cholecystitis (see the image below). This imaging modality may be diagnostic for biliary
disease, help exclude biliary disease, or may reveal alternative causes of the patient's symptoms.
Ultrasonography is 90-95% sensitive for cholecystitis and has a 78-80% specificity. [13] For simple
cholelithiasis, it is 98% sensitive and specific.
 The ultrasound only shows gallstones within the gallbladder but no evidence of
cholecystitis (ie, gallbladder wall thickening, pericholecystic fluid, common bile duct dilatation, sonographic Murphy sign).

General ultrasonographic features

Findings include gallstones or sludge and one or more of the following conditions:

 Gallbladder wall thickening (>2-4 mm) - False-positive wall thickening found in hypoalbuminemia,
ascites, congestive heart failure, and carcinoma
 Gallbladder distention (diameter > 4 cm, length >10 cm)
 Pericholecystic fluid from perforation or exudate - May be seen as a hypoechoic or anechoic
region seen along the anterior surface of the gallbladder within the hepatic parenchyma
 Air in the gallbladder wall (indicating gangrenous cholecystitis)
 Ultrasonographic Murphy sign (86-92% sensitive, 35% specific) - pain when the probe is pushed
directly on the gallbladder (not related to breathing)
Ultrasonographic Murphy sign and cholelithiasis
Some ultrasonographers recommend the diagnosis of cholecystitis if both a ultrasonographic Murphy sign
and gallstones (without evidence of other pathology) are present. In a study by Ralls et al involving 497
patients with suspected acute cholecystitis, the positive predictive value of the presence of stones and a
positive ultrasonographic Murphy sign was 92% and that of stones and thickening of the gallbladder wall
was 95%. The negative predictive value of the absence of stones combined with either a normal
gallbladder wall or a negative Murphy sign was 95%.[14]

Findings with or without cholelithiasis

Additional findings in the presence or absence of gallstones may include a dilated common bile duct or
dilated intrahepatic ducts of the biliary tree, which indicate common bile duct stones. In the absence of
stones, a solitary stone may be lodged in the common bile duct, a location that is difficult to visualize
ultrasonographically.

Advantages and disadvantages of ultrasonography

Advantages of ultrasonography include imaging of other structures (eg, aorta, pancreas, liver),
identification of complications (eg, perforation, empyema, abscess), ability to be rapidly performed at the
bedside and in the emergency department, and absence of radiation (important in pregnancy). (see)

Disadvantages of ultrasonography include the fact this imaging modality is operator and patient
dependent, it is unable to image the cystic duct, and it has a decreased sensitivity for common bile duct
stones.

See Bedside Ultrasonography, Gallbladder Disease.

Biliary Scintigraphy
Depending on the clinical setting, either ultrasonography or nuclear medicine testing is the test of choice
for cholecystitis. Hepatic 2,6-dimethyliminodiacetic acid (HIDA) scans have sensitivity (94%) and
specificity (65-85%) for acute cholecystitis, and they are sensitive (65%) and specific (6%) for chronic
cholecystitis. Normal scans are characterized by normal visualization of gallbladder in 30 minutes. Oral
cholecystography is not practical for in the emergency department setting.

HIDA and diisopropyl iminodiacetic acid (DISIDA) scans are functional studies of the gallbladder.
Technetium-labeled analogues of iminodiacetic acid (IDA) or diisopropyl IDA-DISIDA are administered
intravenously (IV) and secreted by hepatocytes into bile, enabling visualization of the liver and biliary tree.

With cystic duct obstruction (cholecystitis), the HIDA scan shows nonvisualization (ie, considered positive)
of the gallbladder at 60 minutes and uptake in the intestine as the bile is excreted directly into the
duodenum. This finding has a sensitivity of 80-90% for acute cholecystitis. Obstruction of the common bile
duct causes nonvisualization of the small intestine.

The rim sign is a blush of increased pericholecystic radioactivity, tracer adjacent to the gallbladder,
present in approximately 30% of patients with acute cholecystitis and in 60% with acute gangrenous
cholecystitis.

Advantages and disadvantages of HIDA/DISIDA scanning

Advantages of HIDA/DISIDA scanning include assessment of function and simultaneous assessment of
the bile ducts. In addition, although a gallbladder may appear normal by ultrasonography, a DISIDA scan
can depict an obstructed cystic duct abnormality.

A high bilirubin (>4.4 mg/dL) can possibly decrease the sensitivity of HIDA/DISIDA scanning, and recent
eating or fasting for 24 hours may possibly affects findings. In addition, these scans do not image other
structures in the area.

False-negative and false-positive findings

False-negative results (filling in 30 min) are found in 0.5% of studies, and filling between 30-60 minutes is
associated with false-negative rates of 15-20%.

False-positive results (10-20%) occur when the gallbladder is not visualized despite a nonobstructed
cystic duct. Causes include fasting patients receiving total parenteral nutrition; severe liver disease, which
leads to abnormal uptake of the tracer; cystic-duct obstruction induced by chronic inflammation; and
biliary sphincterotomy, which decreases resistance to bile flow leading to excretion of the tracer into the
duodenum. The specificity of the test can be improved by intravenous administration of morphine, known
as morphine cholescintigraphy, which induces spasm of this sphincter, thus increasing back pressure to
fill the gallbladder.[15]

Abdominal Radiography
The advantages of abdominal radiographs include their readily availability and low cost. However,
abdominal radiographs have low sensitivity and specificity in evaluating biliary system pathology, but they
can be helpful in excluding other abdominal pathology such as renal colic, bowel obstruction, perforation.
Between 10% and 30% of stones have a ring of calcium and, therefore, are radiopaque. A porcelain
gallbladder also may be observed on plain films.

Emphysematous cholecystitis, cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation

may show air in the biliary tree. Air in the gallbladder wall indicates emphysematous cholecystitis due to
gas-forming organisms such as clostridial species and Escherichia coli.

CT Scanning
Computed tomography (CT) scanning is not the test of choice and is recommended only for the
evaluation of abdominal pain if the diagnosis is uncertain. CT scans can demonstrate gallbladder wall
edema, pericholecystic stranding and fluid, and high-attenuation bile. A helical CT scan with fine cuts
through the biliary tract has not been well studied but may be useful.
 Advantages and disadvantages of CT scanning
CT scanning not only provides better information of the surrounding structures than ultrasonography and
hepatic 2,6-dimethyliminodiacetic acid (HIDA) scanning, but it is also noninvasive. For complications of
cholecystitis and cholangitis, gallbladder perforation, pericholecystic fluid, and intrahepatic ductal dilation,
CT scanning may be adequate.

However, CT scanning misses 20% of gallstones, because the stones may be of the same radiographic
density as bile. In addition, CT scanning is also more expensive; takes longer because the patient usually
has to drink oral contrast; and also, given the radiation dose, may not be ideal in the pregnant patient.

Electrocardiography
ST-segment elevations are an uncommon finding in acute cholecystitis. The pathophysiologic mechanism
of these electrocardiographic changes is unclear but has been shown to be correctable with appropriate
hepatobiliary management. Prompt recognition of cholecystitis will prevent the performance of
unnecessary diagnostic and therapeutic cardiac interventions. [16]

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) provides both endoscopic and radiographic
visualization of the biliary tract. This modality can be diagnostic and therapeutic by direct removal of
common bile duct stones.

Indications for ERCP

Ultrasonography is 50-75% sensitive for choledocholithiasis; computed tomography (CT) and hepatic 2,6-
dimethyliminodiacetic acid (HIDA) scanning are not better. Therefore, when a dilated common bile duct is
found or elevated liver function test results are present, suspicion should remain high for common bile
duct stones, and an ERCP should be considered.

Debate exists as to when an ERCP should be performed. In general, because cholecystitis is caused by
obstruction of the ducts, the risk of common bile duct stones is approximately 10%. Given its potential for
complications, ERCP should be used when there is a high potential for intervention and it should not be
used solely as a diagnostic modality.

Some studies have classified people as low risk for common bile duct stones based on (1) lack of
jaundice, (2) elevated transaminase levels, and (3) a common bile duct diameter of less than 8 mm. In
this population, the risk of common bile duct stones may be as low as 1%. In patients with any of the risk
factors, the rate of stones was 39%. Therefore, in general, people with any of the risk factors for common
bile duct stones should undergo operative or ERCP evaluation of the common bile duct.

Complications of ERCP
Major complications of ERCP include pancreatitis and cholangitis.

Prehospital Care of Cholecystitis

Patients with gallbladder colic or cholecystitis usually present in the prehospital setting with severe
abdominal pain. Transport patients with minor symptoms to the hospital with an intravenous (IV) line in
place and monitor. However, the diagnosis of cholecystitis is not a prehospital diagnosis.

In patients with severe pain (eg, differential diagnosis includes abdominal aortic aneurysm, myocardial
infarction) and in patients with hypotension and/or fever who may have cholecystitis or cholangitis,
prehospital care should include the following:

 Prioritizing and immediately assessing airway, breathing, and circulation (ABCs), as with all
emergencies
 Monitoring (pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood
glucose measurement)
 Stabilization (oxygen, placement of 2 large-bore IVs, administration of IV fluids to unstable
patients)
 Rapidly transporting
ED Management
The primary goal of emergency department care is stabilization of the patient and an expedient diagnosis.

Suspect gallbladder colic in patients with less than 4-6 hours of right upper quadrant pain that radiates to
the back. Consider acute uncomplicated cholecystitis in patients with pain of longer duration and with or
without low-grade fever. Severe cholecystitis can develop into sepsis or cholangitis, especially in patients
with diabetes or elderly patients, in whom the diagnosis may be delayed.

After assessment of the patient's airway, breathing, and circulation (ABCs), perform the standard opening
gambit of intravenous (IV) line placement, pulse oximetry measurement, oxygen administration,
electrocardiography recording, and monitoring. Send for laboratory studies when the IV line is placed;
include blood cultures if the patient is febrile.

Replace volume loss with normal saline, then maintenance fluids. Make patients nothing by mouth (NPO).
Nasogastric suction may be needed in patients with persistent vomiting or abdominal distention.

In patients who are unstable or have severe pain, consider a bedside ultrasonographic study to exclude
an abdominal aortic aneurysm and assist in the diagnosis of cholecystitis. Signs on ultrasonograms
include the presence of gallstones, an ultrasonographic Murphy sign, gallbladder wall thickening, and
pericholecystic fluid. Competent emergency physician-performed bedside ultrasonography for the
detection of acute cholecystitis has been shown to have a negative predictive value (NPV) of 95%, which
is not markedly different from radiologist-performed formal ultrasonography. [17]

Tokyo guidelines for acute cholecystitis

In 2007, the unvalidated "Tokyo guidelines" were published, a set of clinical and radiologic diagnostic
criteria for acute cholecystitis to address the controversy regarding the optimal criteria for clinical
diagnosis.[18] Patients exhibiting one of the local signs of inflammation, such as Murphy sign, or a
mass/pain/tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation,
such as fever, elevated white blood cell (WBC) count, and elevated C-reactive protein level, are
diagnosed as having acute cholecystitis.[19] Imaging findings characteristic of acute cholecystitis confirm
the diagnosis.[18]

Once the diagnosis of acute cholecystitis is made, it usually is treated by hospitalization. This may include
medical and/or surgical therapy. Some patients may be treated as outpatients.

Medical Care
Although surgical therapy is the treatment of choice for acute cholecystitis, many patients require
hospitalization for stabilization and "cooling off" of the gallbladder before surgery. However, surgical
consultation is appropriate, and depending on the institution, either medicine or surgery may admit the
patient for conservative care. In addition, obtain an urgent gastroenterology consultation for endoscopic
retrograde cholangiopancreatography (ERCP) in patients with evidence of choledocholithiasis (ie,
common bile duct stones seen on ultrasonography, dilated common bile ducts, elevated liver function test
results, pancreatitis).

Medical therapy of gallbladder colic includes antiemetics and pain control. In mild cholecystitis, in which
inflammation is the primary process, antibiotics are prophylactic but are usually used. In acute
cholecystitis, broad-spectrum antibiotic coverage is used.

Antimicrobial therapy
The guidelines of the Infectious Diseases Society of America recommend that antimicrobial therapy be
instituted if infection is suspected on the basis of laboratory and clinical findings (white blood cell count
>12,500 cells/µL; temperature >38.5°C) as well as radiographic findings (eg, air in the gallbladder or
gallbladder wall).[20]

Antibiotics are also recommended for routine use in patients who are elderly or have diabetes or
immunodeficiency and for prophylaxis in patients undergoing cholecystectomy to reduce septic
complications even when infection is not suspected.[1]

Analgesia
Several studies have shown that early pain control in the emergency department in patients with
abdominal pain does not hinder the diagnosis. Therefore, administer pain control early, without waiting for
the diagnosis or surgical consultation. However, a courtesy call to the surgical consultant before the
administration of narcotics offers the expedient opportunity to examine the patients without narcotics,
which occasionally diminishes surgical resistance to prediagnosis narcotic use.

Pain control should be with opiate analgesics such as meperidine (Demerol).[21, 22, 23] Morphine is generally
not recommended, as it can increase the tone of the sphincter of Oddi. Anticholinergic antispasmodics,
such as dicyclomine (Bentyl), are also recommended in the initial management of acute biliary colic and
cholecystitis.

Anti-inflammory and antiemetic agents

Anti-inflammatory medications such as ketorolac or indomethacin have been reported to be effective in
relieving pain from gallbladder distention. Because the release of prostaglandins results in gallbladder
distention, inhibition of these prostaglandins may help alleviate some of the symptoms. However, these
agents may not be as effective when biliary colic is complicated by infection.

Antiemetics such as metoclopramide or prochlorperazine can also be used.

Surgical Management of Cholecystitis

Historically, cholecystitis was operated on emergently, resulting in increased mortality. The current
practice is to cool off the gallbladder and perform a cholecystectomy after several days or to readmit the
patient at a later date.

Indications for urgent surgical intervention include patients with complications such as empyema,
emphysematous cholecystitis, or perforation. Emergent cholecystectomy is usually performed in 20% of
such cases.

Cholecystectomy
In approximately 30% of patients with uncomplicated cholecystitis, medical therapy is not sufficient and
these patients usually need cholecystectomy within 24-72 hours. Cholecystectomy may be performed
after the first 48 hours or after the inflammation has subsided. Unstable patients may need more urgent
intervention with endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage, or
cholecystectomy.

Laparoscopic cholecystectomy is very effective and has few complications. Approximately 5% of cases
must be converted to an open cholecystectomy; in acute cholecystectomy, the conversion rate can be as
high as 30%. The rate of conversion is higher for acute cholecystitis compared with uncomplicated
cholelithiasis, in both acute or delayed intervention. [24, 25, 26, 27] Predictors of the need for open conversion
include a white blood cell (WBC) count of more than 18,000 cells/µL at the time of presentation, a
duration of symptoms longer than 72-96 hours, and an age older than 60 years. [28]

Immediate laparoscopic cholecystectomy (within 24 h) has been increasingly performed by surgeons,

because it has been shown to be safe, is not more difficult than laparoscopic cholecystectomy performed
later, and shortens the hospital length of stay.[29, 30, 31]
 High-risk patients
Patients who are not good surgical risks but who are toxic may benefit from percutaneous gallbladder
drainage and placement of a cholecystostomy or T-tube if common bile duct stones are suspected. The
alternative is ERCP to attempt endoscopic opening of the common bile duct or cystic duct.

Delayed surgical intervention can be used for patients who have high-risk medical conditions and are
unstable for surgery and in patients in whom the diagnosis in doubt. Mortality may be up to 15% in
patients with acute cholecystitis who were at high risk (as per Acute Physiology and Chronic Health
Evaluation [APACHE] criteria).[32]

In patients younger than 60 years, the mortality rate for emergent cholecystectomy is approximately 3%,
whereas mortality in early or elective cholecystectomy approaches 0.5%.

Outpatient Care
Acute cholecystitis
For some patients with acute cholecystitis to be treated on an outpatient basis, the following patient
criteria must be met:

 Afebrile and normal vital signs

 Minimal amount of pain and tenderness
 No markedly abnormal laboratory results, normal common bile duct on ultrasonography, and no
pericholecystic fluid or biliary air
 No underlying medical problems (eg, diabetes, cirrhosis, vascular condition, steroids), advanced
age, or pregnancy
 Next day follow-up visit
Discharge on oral antibiotics and a small number of pain medications. In pregnancy, because symptoms
may be recurrent, refer women to their obstetrician/gynecologist as well as a surgeon. Second trimester
cholecystectomy is the safest time period, because the risk of premature labor is lower, and the uterus
does not push on the gallbladder.[33]

Biliary colic
For simple gallbladder colic, other therapies are rarely performed, because they require long-term therapy
(oral dissolution), cause complications (shock-wave therapy), and ultimately do not prevent the
recurrence of gallstones.

Oral dissolution therapy consists of bile acid therapy with ursodeoxycholic acidsometimes in combination
with chenodeoxycholic acid. With this treatment, cholesterol saturation of bile is decreased, and
dissolution of small gallstones (< 5 mm) is possible with 6-12 months of therapy; however, over 50%
recur. Oral dissolution has several disadvantages, including the time frame of up to 2 years. Fewer than
10% of patients with symptomatic gallstones are candidates for this therapy. The doses are not listed,
because this treatment option is chosen rarely.

Extracorporeal shock-wave lithotripsy is another little-used therapy due to the recurrence of stones. This
treatment is not popular, because only small (< 2 cm) stones can be fragmented, and also a recurrence of
gallstones occurs in up 30% of patients within 5 years.

Percutaneous contact dissolution therapy by injection of methyl tert-butyl ether (MTBE) into the
gallbladder to dissolve stones is rarely used.

There is evidence to support early laparoscopic cholecystectomy (< 24 h of diagnosis of biliary colic)
decreasing the morbidity during the waiting period for laparoscopic cholecystectomy, in addition to
decreasing the rate of conversion to open cholecystectomy and the hospital length of stay. [34]

Prevention of Biliary Colic

Some literature supports dietary modification of decreased fat intake to decrease occurrence of biliary
colic. Advise patients with biliary colic to refrain from eating fatty or spicy foods. They should contact their
physician for persistent recurrence of pain or fever.

Complications
Gallbladder gangrene can be a complication in up to 20% of cases of cholecystitis and usually occurs in
diabetics, the elderly, or immunocompromised persons.

Complications of cholecystitis and/or biliary colic may also include cholangitis, sepsis, pancreatitis,
hepatitis, and choledocholithiasis (10%). In addition, Gallbladder perforation occurs in 10% of patients
with cholecystitis. When perforation is localized, it may be seen as pericholecystic fluid by
ultrasonography. Abscess formation is common. Free perforation also can occur, releasing bile and
inflammatory matter intraperitoneally, causing peritonitis.

When perforation occurs next to a hollow viscus, a gallbladder enteric fistula can be formed; fistulas into
the duodenum are most common. When gallstones are passed directly through the fistula into the small
bowel, if they are greater than 2.5 cm, they can obstruct the ileocecal valve, which causes gallstone ileus.
Mortality in these cases can be up to 20%, because the diagnosis is difficult. Treatment includes
cholecystectomy, common bile duct exploration, and closure of the fistulous tract.

Outcomes
In patients with diabetes who have biliary colic, acute cholecystitis occurs more frequently compared with
the nondiabetic population. Furthermore, diabetic patients with cholecystitis are more likely experience
complications.[35]

Uncomplicated cholecystitis has a low mortality; however, mortality can be as high as 15% in
immunocompromised patients. In addition, complicated cholecystitis has up to a 25% mortality rate:
Emphysematous gallbladder of infection by gas-forming organisms (eg, Clostridium species) is more
common in patients with diabetes and men, with a 15% mortality, and gangrenous or empyema of the
gallbladder carries 25% mortality. Perforation of the gallbladder occurs in 3-15% of patients with
cholecystitis and is associated with a 60% mortality rate.

Special Considerations
Delay in diagnosis of acute cholecystitis can result in complications, such as gangrene and perforation,
and eventually, increased morbidity and mortality. Clinicians should consider this in patient populations
that may have atypical presentations, such as diabetics, the elderly, and children. Generally, all patients
with a diagnosis of acute cholecystis should be admitted to the hospital for intravenous antibiotics and
scheduled for cholecystectomy within 24-72 hours.

Gallstones are more likely to be symptomatic in pregnancy. For gallbladder colic in pregnancy, because
symptoms may be recurrent, women should be referred to their obstetrician as well as a surgeon. Second
trimester cholecystectomy is the safest time period, because the risk of premature labor is lower, and the
uterus does not push on the gallbladder.

It is uncommon for gallstone formation in children; affected children are more likely to have congenital
anomalies, biliary anomalies, or hemolytic (pigment) stones.

The incidence of gallstone increases with age. Elderly patients are more likely to go from asymptomatic
gallstones to serious complications of gallstones without gallbladder colic. Delays in diagnosis are
common, as symptoms may be limited to change in mental status or decreased food intake. Physical
examination and laboratory indexes may be normal.[36, 37]

Acalculous cholecystitis occurs in critically ill patients and localized pain and tenderness can sometimes
not be present. Patients with burns or sepsis and postoperative and trauma patients are all at risk for
acalculous cholecystitis.
 cute Cholecystitis
 Overview

 In-Depth Report
o Background
o Symptoms
o Prognosis
o Risk Factors
o Prevention
o Diagnosis
o Treatment
o Surgery
o Lithotripsy and Dissolution Therapies
o Managing Common Bile Duct Stones
o References
 News & Features
View & Print In-Depth Report »

Multimedia
 Gallbladder Removal
Web Links
 National Digestive Diseases Information Clearinghouse
 American Gastroenterological Association
 American College of Gastroenterology
 American Liver Foundation
Related Topics
 Abdominal Pain
 Gallstones
 Empyema
 Peritonitis
Illustrations

 Digestive System

 Cholecystitis, CT Scan


 Cholecystitis, Cholangiogram
  Cholecystolithiasis


 Gallstones, Cholangiogram

 Digestive System Organs


In-Depth From A.D.A.M.Treatment

Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are
performed to rule out other conditions and complications. There are 3 approaches to gallstone treatment:

 Expectant management ("wait and see")

 Nonsurgical removal of the stones
 Surgical removal of the gallbladder

EXPECTANT MANAGEMENT

Guidelines from the American College of Physicians state that when a person has no symptoms, the risks of both
surgical and nonsurgical treatment for gallstones outweigh the benefits. Experts suggest a wait-and-see approach for
such patients, which they have termed expectant management. Exceptions to this policy are those at risk for
complications from gallstones, including the following:

 People at risk for gallbladder cancer

 Pima Native Americans
 Patients with stones larger than 3 cm

One study reported that very small gallstones increase the risk for acute pancreatitis, a serious condition. Some
experts therefore believe that gallstones smaller than 5 mm warrant immediate surgery.

There are some minor risks with expectant management for asymptomatic or low-risk individuals. Gallstones almost
never spontaneously disappear, except sometimes when they are formed under special circumstances, such as
pregnancy or sudden weight loss. At some point, then, the stones may cause pain, complications, or both, and require
treatment. Some studies suggest the patient''s age at diagnosis may be a factor in the possibility of future surgery. The
probabilities are as follows:

 15% likelihood of future surgery at age 70

 20% at age 50
 30% at age 30
 The slight risk of developing gallbladder cancer might encourage young adults who are asymptomatic to have their
gallbladders removed.

GALLSTONES AND SEVERE ABDOMINAL PAIN

Gallstones are the most common cause for hospital admissions of patients with severe abdominal pain. Diagnostic
tests are performed and, depending on results, the approach may be as follows:

Normal Test Results and No Severe Pain or Complications. If the patient has no fever or underlying serious medical
problems and shows no signs of severe pain or complications, and if laboratory tests are normal, then the patients
may be discharged with oral antibiotics and pain relievers.

Gallstones and Presence of Pain (Biliary Colic) but No Infection.Patients with pain and tests that indicate gallstones
but who do not show signs of inflammation or infection have the following options:

 Intravenous painkillers are administered for severe pain. Such drugs include meperidine (Demerol) or the
potent NSAID ketorolac (Acular, Toradol). Ketorolac should not be used for patients who are likely to need surgery.
These drugs can cause nausea, vomiting, and drowsiness. Opioids such as morphine may have fewer adverse effects,
but some doctors avoid them for gallbladder disease.
 They may electively choose to have the gallbladder removed (called cholecystectomy) at their convenience.
 A minority of such patients may be candidates for a stone-breaking technique called lithotripsy. The
treatment works best on solitary stones that are less than 2 cm in diameter.
 Drug therapy for gallstones is available for some patients who are unwilling to undergo surgery or who have
serious medical problems that increase the risks of surgery. Recurrence rates are high with nonsurgical options. The
introduction of laparoscopic cholecystectomy has greatly reduced the use of nonsurgical therapies. Note: Drug
treatments are generally inappropriate for patients who have acute gallbladder inflammation or common bile duct
stones, since delaying or avoiding surgery could be hazardous.

Acute Cholecystitis (Gallbladder Inflammation). The first step if there are signs of acute cholecystitis is to "rest" the
gallbladder in order to reduce inflammation. This involves the following treatments:

 Fasting
 Intravenous fluids and oxygen therapy
 Intravenous painkillers, usually meperidine (Demerol). Potent NSAIDs, usually indomethacin, may be
particularly useful. Indomethacin, for example, can reduce pain and inflammation and improve emptying actions of
the gallbladder. Some doctors believe morphine should be avoided for gallbladder disease.
 Intravenous antibiotics. These are administered if the patient shows signs of infection, including fever or an
elevated white blood cell count, or in patients without such signs who do not improve after 12 - 24 hours.

Surgery to remove the gallbladder (called cholecystectomy) is nearly always indicated in people with acute
cholecystitis. The most common procedure is now laparoscopy, a less invasive technique than open cholecystectomy
(which involves a wide abdominal incision). Timing can be within hours to weeks after the acute episode, depending
on the severity of the condition.
 SLIDE SHOW:Gallbladder removal - series

Gallstone-Associated Pancreatitis. Patients who have developed gallstone-associated pancreatitis almost always

require surgery with either laparoscopic or open cholecystectomy.

Common Duct Stones. If noninvasive diagnostic tests suggest obstruction from common duct stones, the doctor will
perform a procedure called endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis and
remove stones. This technique is used urgently along with antibiotics if infection is present in the common duct
(cholangitis). In most cases, common duct stones are discovered during or after gallbladder removal.

Definition
By Mayo Clinic Staff

Multimedia

Gallbladder and bile duct

Cholecystitis (ko-luh-sis-TIE-tis) is inflammation of the gallbladder. Your gallbladder is a

small, pear-shaped organ on the right side of your abdomen, just beneath your liver.
The gallbladder holds a digestive fluid called bile that's released into your small
intestine.

In most cases, cholecystitis is caused by gallstones that block the tube leading out of
your gallbladder. This results in a buildup of bile that can cause inflammation. Other
causes of cholecystitis include bile duct problems and tumors.
 If left untreated, cholecystitis can lead to serious complications, such as a gallbladder
that becomes enlarged or that ruptures. Once diagnosed, cholecystitis requires a
hospital stay. Treatment for cholecystitis often eventually includes gallbladder removal.

Symptoms
By Mayo Clinic Staff

Signs and symptoms of cholecystitis may include:

 Severe, steady pain in the upper right part of your abdomen

 Pain that radiates from your abdomen to your right shoulder or back
 Tenderness over your abdomen when it's touched
 Sweating
 Nausea
 Vomiting
 Fever
 Chills
 Abdominal bloating
Cholecystitis signs and symptoms usually occur after a meal, particularly a large meal
or a meal high in fat.

When to see a doctor

Make an appointment with your doctor if you have any signs or symptoms that worry
you. Abdominal pain that is so severe you can't sit still or find a comfortable position is
an emergency, so have someone drive you to the emergency room in this situation.

Causes
By Mayo Clinic Staff

Multimedia


Gallbladder and bile duct

Cholecystitis occurs when your gallbladder becomes inflamed. Gallbladder inflammation

can be caused by:

 Gallstones. The vast majority of cholecystitis cases are the result of gallstones that
block the cystic duct — the tube through which bile flows when it leaves the gallbladder —
causing bile to build up and resulting in gallbladder inflammation.
 Tumor. A tumor may prevent bile from draining out of your gallbladder properly, causing
bile buildup that can lead to cholecystitis.
 Bile duct blockage. Kinking or scarring of the bile ducts can cause blockages that lead
to cholecystitis.

Risk factors
By Mayo Clinic Staff

The following factors may increase your risk of cholecystitis:

 Gallstones. Most cases of cholecystitis are linked to gallstones. If you have

gallstones, you're at high risk of developing cholecystitis.
 Being female. Women have a greater risk of gallstones than men do. This
makes women more likely to develop cholecystitis.
 Increasing age. As you get older, your risk of gallstones increases, as does your
risk of cholecystitis.

Complications
By Mayo Clinic Staff

Cholecystitis can lead to a number of serious complications, including:

 Enlarged gallbladder. If your gallbladder becomes inflamed due to bile buildup,

it may stretch and swell beyond its normal size, which can cause pain and increase
the risk of a tear (perforation) in your gallbladder, as well as infection and tissue
death.
 Infection within the gallbladder. If bile builds up within your gallbladder,
causing cholecystitis, the bile may become infected.
 Death of gallbladder tissue. Untreated cholecystitis can cause tissue in the
gallbladder to die (gangrene), which in turn can lead to a tear in the gallbladder, or it
may cause your gallbladder to burst.
 Torn gallbladder. A tear (perforation) in your gallbladder may be caused by an
enlarged or infected gallbladder that occurs as a result of cholecystitis.

Preparing for your appointment

By Mayo Clinic Staff

Make an appointment with your doctor if you have any signs or symptoms that worry
you. If your doctor suspects you have cholecystitis, you may be referred to a doctor who
specializes in the digestive system (gastroenterologist), or your doctor may refer you
directly to the hospital.

Because appointments can be brief, and because there's often a lot of ground to cover,
it's a good idea to be well prepared. Here's some information to help you get ready, and
what to expect from your doctor.

What you can do

 Be aware of any pre-appointment restrictions. At the time you make the appointment,
ask if there's anything you need to do in advance, such as restrict your diet.
 Write down any symptoms you're experiencing, including any that may seem
unrelated to the reason for which you scheduled the appointment.
 Write down key personal information, including any major stresses or recent life
changes.
 Make a list of all medications, as well as any vitamins or supplements, that you're
taking.
 Consider taking a family member or friend along.Sometimes it can be difficult to
remember all the information provided during an appointment. Someone who accompanies
you may remember something that you missed or forgot.
 Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions will help you make
the most of your time together. List your questions from most important to least
important in case time runs out. For cholecystitis, some basic questions to ask your
doctor include:

 Is cholecystitis the likely cause of my abdominal pain?

 What are other possible causes for my symptoms?
 What kinds of tests do I need?
 Do I need gallbladder removal surgery (cholecystectomy)?
 When do I need gallbladder surgery?
 What are the risks of surgery?
 How long does it take to recover from gallbladder surgery?
 Are there other treatment options for cholecystitis?
 Should I see a specialist? What will that cost, and will my insurance cover it?
 Are there any brochures or other printed material that I can take with me? What websites
do you recommend?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask
additional questions.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may
allow more time to cover other points you want to address. Your doctor may ask:

 When did you first begin experiencing symptoms?

 Have you had bouts of pain similar to this before?
 Do you have a fever?
 Have your symptoms been continuous or occasional?
 How severe are your symptoms?
 What, if anything, seems to improve your symptoms?
 What, if anything, appears to worsen your symptoms?

Tests and diagnosis

By Mayo Clinic Staff

Tests and procedures used to diagnose cholecystitis include:

 Blood tests. Your doctor may order blood tests to look for signs of an
infection or signs of gallbladder problems.
 Imaging tests that show your gallbladder. Imaging tests, such as abdominal
ultrasound or a computerized tomography (CT) scan, can be used to create pictures
of your gallbladder that may reveal signs of cholecystitis.
  A scan that shows the movement of bile through your body. A hepatobiliary
iminodiacetic acid (HIDA) scan tracks the production and flow of bile from your liver
to your small intestine and shows if bile is blocked at any point along the way. A
HIDA scan involves injecting a radioactive chemical into your body. The chemical
binds to the bile-producing cells, so it can be clearly seen as it travels with the bile
through the bile ducts.

Treatments and drugs

By Mayo Clinic Staff

Multimedia

Laparoscopic cholecystectomy

Treatment for cholecystitis usually involves a stay in the hospital to stabilize the
inflammation in your gallbladder. Once your cholecystitis is under control, your doctor
may recommend surgery to remove your gallbladder, since cholecystitis frequently
recurs. In emergency situations, such as a ruptured gallbladder, surgery may be
required right away.

Hospitalization
If you're diagnosed with cholecystitis, you'll be admitted to the hospital. Your doctor will
work to control your signs and symptoms and to control the inflammation in your
gallbladder. Treatments may include:

 Fasting. You may not be allowed to eat or drink at first in order to take stress off your
inflamed gallbladder. So that you don't become dehydrated, you may receive fluids through
a vein in your arm.
 Antibiotics to fight infection. If your cholecystitis is caused by an infection or has
caused an infection in your gallbladder, your doctor may recommend antibiotics to treat the
infection.
 Pain medications. You may receive pain medications to help control pain until the
inflammation in your gallbladder is relieved.
Your symptoms may begin to go away in a day or two after being hospitalized.

Surgery to remove the gallbladder

Because cholecystitis frequently recurs, most people diagnosed with cholecystitis
eventually require gallbladder removal surgery (cholecystectomy). When you're feeling
better, your doctor may recommend cholecystectomy. When you'll undergo surgery
depends on your situation. If you have complications of cholecystitis, such as gangrene
or perforation of your gallbladder, you may need to have surgery immediately.

Cholecystectomy is most commonly performed using a tiny video camera mounted at

the end of a flexible tube. This allows your surgeon to see inside your abdomen and to
use special surgical tools to remove the gallbladder (laparoscopic cholecystectomy).
The tools and camera are inserted through four incisions in your abdomen, and the
surgeon watches a monitor while guiding the tools during surgery.

Once your gallbladder is removed, bile flows directly from your liver into your small
intestine, rather than being stored in your gallbladder. You don't need your gallbladder
to live, and gallbladder removal doesn't affect your ability to digest food, although it can
cause diarrhea that is usually temporary.

Prevention
By Mayo Clinic Staff

Because most cases of cholecystitis are caused by gallstones, you can reduce your risk
of cholecystitis by taking the following steps to prevent gallstones:

 Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can
increase the risk of gallstones. Aim to lose 1 or 2 pounds (0.5 to about 1 kilogram) a
week.
 Maintain a healthy weight. Obesity and being overweight increase the risk of
gallstones. Work to achieve a healthy weight by reducing the number of calories you
eat and increasing the amount of physical activity you get. Once you achieve a
healthy weight, work to maintain that weight by continuing your healthy diet and
continuing to exercise.
 Choose a healthy diet. Diets high in fat and low in fiber may increase the risk of
gallstones. To reduce your risk of gallstones, choose a diet that's full of fruits,
vegetables and whole grains.
Cholecystitis
Original Editors - David Martin as part of theBellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - David Martin, Laura Ritchie,Dave Pariser and Elaine Lonnemann

Contents
[hide]

 1 Definition/Description
 2 Prevalence
 3 Pathology[3]

 4 Clinical Presentation
 5 Associated Co-morbidities [7][8]

 6 Medications
 7 Diagnostic Tests/Lab Tests/Lab Values
 8 Causes [7], [8], [6]

 9 Systemic Involvement [6]

 10 Medical Management (current best evidence)[7],[8]

o 10.1 Surgical Treatment
o 10.2 Nonsurgical Treatment
 11 Physical Therapy Management (current best evidence) [4][3]

 12 Alternative/Holistic Management (current best evidence)

12.1 Herbs[18]
o
12.2 Accupuncture [18]
o
12.3 Homeopathy [18]
o
12.4 Physical Medicine [18]
o
 13 Differential Diagnosis[6]

 14 Prognosis
 15 Case Reports
 16 Resources
 17 Recent Related Research (from Pubmed)
 18 References

Definition/Description

Cholecystitis is inflammation of the gallbladder and can  

[1]

be acute or chronic ( ).  This occurs most offten as a

[2]

result of impaction of the gallstones in the systic duct,

leading to obstruction of bile flow and painful distention of the gallbladder  [3]

Acute Cholecystitis

Inflammation of the gallbladder that develops over hours, usually resulting from a cystic duct
obstruction by a gallstone  . This form of gallbladder disease usually subsides within 1 to 7 days
[2]

with a conservative plan of treatment  [4]

Chronic Cholecystitis

Chronic Cholecystitis is long standing gall bladder inflammation almost always caused by
gallstones  l.  This can also be called cystic duct
[2]
 
[5]

inflammation.  A cholecstectomy, or removal of the

gallbladder, is required when symptoms do not resolve
with conservative treatment, or may be indicated if a person has chronic cholecystitis  .
[4]

Cholecystitis often occurs due to untreated gallstones.  Cholelithiasis, or gallstones, are small,
pebble-like substances that develop in the gallbladder called calculi  . Gallstones occur when
[6]

liquid stored in the gallbladder is not secreted properly and hardens into pieces of stone-like
material. The liquid—called bile—helps the body digest fats. Bile is made in the liver, then
stored in the gallbladder until the body needs it. The gallbladder contracts and pushes the bile
into a tube—called the common bile duct—that carries it to the small intestine, where it helps
with digestion  .  Gallstones can also be collection of cholesterol, bile pigment or a combination
[7]

of the two, which can form in the gallbladder or within the bile ducts of the liver.  Cholesterol
stones form due to an imbalance in the production of cholesterol or the secretion of bile. 80
percent of all gallstones diagnosed are of cholesterol form  .  Pigmented stones are primarily
[3]

composed of bilirubin, which is a chemical produced as a result of the normal breakdown of red
blood cells  .  The bilirubin stones account for 20 percent of the stones being diagnosed  . 
[8] [3]

Someone can develop what is called acholelithiasis cholecystitis, or inflammation of the

gallbladder without gallstones  .   [4]

Prevalence

In the United States, the most common type of gallstones is made of cholesterol.  Bilirubin
gallstones are more common in Asians and Africans, but are seen in diseases that damage red
blood cells such as sickle cell anemia.  American Indians have the highest rate of gallstones in
the United States. The majority of American Indian men have gallstones by age 60. Among the
Pima Indians of Arizona, 70 percent of women have gallstones by age 30  . [7][8]

Gallstones, occur increasingly with advancing age, so 20% of men and 35% of women have
gallstones present by the age of 75.  It is estimated that 15-20 million people in the United States
have gallstones  .  Cholelithiasis is the fifth leading cause of hospitalization among adults.  They
[4][6]

also account for 90% of all gallbladder and duct diseases  .

[6]
Cholelithiasis is the most common gastrointestinal disease in the United States.  25 percent of all
cases, symptoms and complications develop secondary to the the presence of gallstones.  These
cases will require surgery or other forms of treatment  .  
[3]

Pathology [3]

Cholesterol that is needed to form cholesterol gallstones mainly comes from the diet. 
Cholesterol is then absorbed into the liver from the blood by receptors. Each lipoprotein has its
own receptor.  Low density lipoproteins are removed from the blood by the binding of the apo
B,E receptor. The B1 receptor travels around looking for high density lipoproteins and removes
them.  Through a series of reactions and protein interactions helps keep this process moving. 

The bile that is produced in the liver helps aid in the excretion of excess cholesterol. Biliary
lipids that are secreted from the liver help compose bile. Each of the lipids secreted into bile has
a specific transporter. Once the lipids are secreted into the bile, the phospholipids and cholesterol
form vesicles while the bile salts form micelles. The vesicles and micelles interact and pass
through the gallbladder. 

Cholesterol needs detergent properties of the phospholipids and bile salts to remain a liquid
solution. If there is a larger presence of cholesterol in bile, the bile will become oversaturated
with cholesterol and then crystals will form. 

Common mechanisms associated with cholesterol stone formation are:

1. Stasis of bile in the gallbladder- this may occur when insoluble or supersaturated cholesterol is
absorbed into the wall of the gallbladder.  This leads to difficulty contracting the smooth
muscles.  This commonly seen in pregnancy, after a period of weight loss, RA patients, and
patients receiving total parenteral nutrition (TPN). 
2. Changes in mucin glycoproteins- there are several proteins that interact with the miced micelles
during the tranport process from the liver to the gallbladder, mucin glycoproteins are shown to
form cholesterol stones.  Patients who experience rapid weight loss may have an increase in
mucin glycoprotein production
3. Processses that may increase the amount of cholesterol or reduce the amount of bile salts or
phospholipids that are secreted into bile

Pigemented stones:

Black stones are caused by an increase in the production of unconjugated bilirubin.  This type of
stone occurs in the patient population who have chronic hemolysis (i.e. sickle cell anemia) or
have end-stage liver disease.

Bronw stones are less common.  These occure in geographic arease where biliary infections are
prevelant.  Brown stones can form in the gallbladder or in the ducts and form secondary to
anaerobic bacterial infections. 
Clinical Presentation

 Right Upper Quadrant Pain and tenderness especially near the right subcostal region
 Low grade fever to high grade fever  [2][6]

 Chills  [2][6]

 Nausea  [6]

 Vomiting  [2]

 Abdominal Pain- may be intermittent or steady  [4]

 Rigors with rebound tenderness or ileus

 Interscapular pain  [4]

 Heartburn, belching, flatulence, epigastric discomfort, and food intolerance (especially to fats
and cabbage)  .  [4][6]

 Jaundice- this is a result of blockage of the common bile duct  . [6]

 Green hued skin

 Persistent pruritis, or skin itching  [6]

 Anterior rib pain (tip of 10th rib; can also affect ribs 11 and 12)  . [6]

 Dark Urine, Light Stools

 Bleeding from skin and mucous membranes and weight loss- late signs of gallbladder cancer
 Feeling of fullness

If a patient presents with any of the following they should be advised to see their doctor
immediately:

 prolonged pain—more than 5 hours

 nausea and vomiting
 fever—even low-grade—or chills
 yellowish color of the skin or whites of the eyes
 clay-colored stools  [7]

Most gallstones are asymptomatice: approximately 30% cause symptoms of cholecystitis. 

Gallstones in the older population may not cause pain, fever, or jaundice.  Mental confusion and
shakiness may be the only symptoms the elderly patient may present with  .  [4]

Associated Co-morbidities  [7][8]

The development of pigmented stones is not fully understood. People who develop pigmented
stones often have liver cirrhosis, biliary tract infections, or hereditary blood disorders—such as
sickle cell anemia—in which the liver makes too much bilirubin.  If a person already has
gallstones present this may lead to the formation of more gallstones. 
Medications

Actigall-

 can be used for gallstone dissolution and should be used for radiolucent stones <20 mm. 
Patients need to be monitored every 6 months with ultrasound. This should also be used for 3
months after dissolution and must be given with food.  It is not recommended for children.  If a
patient has gallstone pancreatitis, calcified cholesterol stones, radiolucent bile pigment stones,
and radiopaque stones should not use this drug.  Patients should avoid or use alternative
methods for estrogen hormone replacement therapy, oral contraceptives, and antacids.  Actigall
may cause diarrhea, dyspepsia, abdominal pain, nausea, vommiting, dizziness, and constipation. 
Actigall woks by decreasing cholesterol synthesis, secretion, and absorption.  It also works by
altering bile cholesterol composition .[9]

Diagnostic Tests/Lab Tests/Lab Values

Cholecystitis is usually diagnosed with the use of ultrasound.  An abdominal ultrasound

examination is a quick, sensitive, and relatively inexpensive method of detecting gallstones in
the gallbladder or common bile duct. This is the test most often used  [8]

Murphy's Sign is a screening test performed by clinicians to assess for cholecystitis. [10][11][12][13]

 Patient lies supine with relaxed abdomen

 Therapist places one hand on the right, posterior, inferior costal margin.
 Therapist places the other hand on the right upper abdominal quadrant (subcostal).
 Therapist applies slight pressure (palpates deeply) while patient inspires
+ sign if pain is reproduced or client stops inspiration

                     Sensitivity: 86%, 63%, 97%   [10]

                     Specificity: 35%, 94%, 48%

                     +LR (1.32, 9.84, 1.88)
                      -LR (.4, .4, .06)
                     Quadas Scores (9, 9, 10)

The following are also tests that can be used to diagnose cholecystitis:

Cholescintigraphy  -  the patient is injected with a small amount of radioactive material and is
[2]

absorbed by the gallbladder.  Then the gall bladder is stimulated to see how well it contracts or if
there is an obstruction within the bile ducts  . [7]

Abdominal CT scan

Magnetic Resonance Cholangiography

Complete Blood Cell Count (CBC):  the presence of an elevated white blood count to 12,000-
15,000 per microL.   
Liver Function Test  - total serum bilirubin levels, serum amniotransferase, and alkaline
[2]

phosphotase levels are commonly elevated in acute cholecystitis, but normal or minimally
elevated in the chronic form  . [4]

X-Rays of the abdomen may show radiopaque gallstones in only 15% of all cases  . [3]

The diagnosis of gallstones is suspected when symptoms of right upper quadrant abdominal pain,
nausea or vomiting occur. The location, duration and “character” (stabbing, gnawing, cramping)
of the pain help to determine the likelihood of gallstone disease. Abdominal tenderness and
abnormally high liver function blood tests may be present.

Causes  ,  , 
[7] [8] [6]

 [14]

The following are other risk factors that may contribute

to the formation of gallstones, particularly cholesterol
stones:

 Sex: Women are twice as likely to develop gallstones as men. This is due to an excess amount of
estrogen from pregnancy, hormone replacement therapy, and birth control pills appears to
increase cholesterol levels in bile.  This then decreases the motility in the gallbladder, which 
then can lead to gallstones.
 Family history: Other family members tend to develop gall stones, which leads researchers to
believe that people are genetically inclined to develop gall stones.
  Weight: People who are moderately overweight have an increased risk for developing
gallstones. The most likely reason is that the amount of bile salts in the bile is reduced, leading
to an increase in cholesterol. The increase in cholesterol reduces the gallbladders ability to
empty. Obesity is a major risk factor for gallstones, especially in women.
  Diet: Diets that are high in fat and cholesterol and low in fiber increases the risk of gallstones
due to increased cholesterol in the bile and reduced gallbladder emptying.
  Rapid weight loss: As the body metabolizes fat during prolonged fasting and rapid weight loss—
such as “crash diets" leads to the liver secreting extra cholesterol into the bile, which then can
cause gallstones. In addition, the gallbladder does not empty properly.  If a patient has had
gastric bypass surgery to help loose weight this puts them at risk for developing gallstones.  
  Age: People over the age 60 are more likely to develop gallstones than younger people. As
people age, the body tends to secrete more cholesterol into bile.  With this increase in secretion
of cholesterol there is a simulatneous decrease in bile salt production.  
  Ethnicity: American Indians are genetically predisposed to secrete high levels of cholesterol in
bile.  Mexican American men and women of all ages also have high rates of gallstone formation.
  Cholesterol-lowering drugs: Drugs that lower cholesterol levels in the blood actually increase
the amount of cholesterol secreted into bile.  This then leads to an increased risk of gallstones.
  Diabetes: People with diabetes generally have high levels of fatty acids called triglycerides.
These fatty acids may increase the risk of gallstone formation.
  Drugs: Estrogen is one of the most common studied drug that leads to gallstones.  Other drugs
that have been shown to cause the formation of gallstones are ceftriaxone, clofibrate, and
octreotide.

Systemic Involvement  [6]

Shoulder pain can be from any of the following:

Cancer-metastases to nodes of axilla or mediastinum, metastases to lungs from the bone, breast,
kidney, colorectal, pancreas, and uterus, metastases to thoracic spine from breast, lung, and
thyroid, Breast Cancer, Pancreatic Cancer.

Cardiovascular- Thoracic Outlet Syndrome, Myocardial Infarct, Post CABG, Bacterial

Endocarditis, Aortic Aneurysm, Empyema and lung abscess, Dissecting aortic aneurysm.

Pulmonary- Pulmonary TB, PE, Spontaneous Pneumothorax, Pancoast's tumor, Pneumonia.

Renal/urologic- Kidney stones, Obstruction, inflammation or infection of the upper urinary tract.

Gastrointestinal/Hepatic- Hiatal Hernia, Peptic/duodenal ulcer, Ruptured Spleen,

Liver/gallbladder disease, Pancreatic Disease, Ectopic pregnancy.

Gynecologic- Mastodynia, Subphrenic abscess.

Other- Mononucleosis, Osteomyelitis, Syphillis, Herpes Zoster, Diabetes, Sickle Cell Anemia,
Hemophilia, Diaphragmatic hernia, Anterior spinal surgery.

Medical Management (current best evidence) , [7] [8]

Surgical Treatment

If a patient comes to you and has been diagnosed with gallstones comes they may not be
receiving treatment.  This is because the patient is not having a gallbladder attack or no
symptoms are present.  However, if a patient has had several frequent attacks, they need to see
their doctor.  The doctor may recommend removing the gallbladder, an operation called
cholecystectomy.  In the United States cholecystectomys are the most common surgeries being
performed.  Most all of the procedures are performed laproscopically.
Recovery after the surgery usually involves only one night in the hospital, and normal ADL's can
be resumed a few days later.  Due to the abdominal muscles not being cut during the surgery,
their is less pain and fewer complications than after an “open” surgery.  This type of surgery
requires a 5- to 8-inch incision across the abdomen.
If the tests ordered by the physician show an abnormal amount of inflammation, infections and
or scarring secondary to other operations, the physician may choose to do an "open surgery" for
removal of the gallbladder.  If during the laproscopic procedure the surgeon finds the above
mentioned problems a larger incision is made.   Recovery from the open procedure requires a 3-5
day stay in the hospital.  This type of surgery is onle needed in about five percent of all
gallbladder operations performed.
One of the most common complications with gallbladder surgery is that there is an increased risk
for injury to the bile ducts.  Injury to the common bile duct will cause bile to leak out and cause
and extreme amount of pain and a potentially dangerous infection. Mild injuries to the bile ducts
can sometimes be treated without surgery. However, major injuries, are more serious and leads
to more surgery.

If gallstones are found to be in the bile ducts, the gastroenterologist may use endoscopic
retrograde cholangiopancreatography (ERCP) to locate and remove the stones before or during
gallbladder surgery.  A person on occasion, who has had
a cholecystectomy, may be dianosed with gallstones in   [15]

the bile ducts weeks or years after.  The ERCP procedure

is successful in removing the stone in these cases.  If
performing an ERCP the surgeon finds gallstones in the gallbladder itself a choleycystectomy
has to be performed.  This procedure does not remove stones from the gallbladder.

Nonsurgical Treatment

Nonsurgical approaches are mainly used when a patient has serious medical conditions that
prevent surgery.  Nonsurgical treatments are used also only on cholesterol stones. Stones can
reocur within 5 years if a patient has been treated nonsurgically.

Some types of nonsurgical treatment are:

1. Oral dissolution therapy. This is where drugs made from bile acids are used to help dissolve the
gallstones. The most common drugs used for small stones are ursodiol (Actigall) and chenodiol
(Chenix). However, this type of treatment take a really long time for the stone to completely
dissolve.
2. Contact dissolution therapy. This is an experimental procedure that involves injecting a drug
directly into the gallbladder that will help dissolve cholesterol stones. The most common drug
that is used in this tupe of treatmnet is, methyl tert-butyl ether.  This is a fast acting treatment
that dissolves the stone in 1-3 days.

Physical Therapy Management (current best evidence)  [4][3]

Usual postoperative exercises for any surgical procedure apply, especially in cases where
complications may occur.  Early activity assists with the return of intestinal motility, so the
patient is encouraged to begin progressive movement and ambulation as soon as possible.

Some examples of postoperative exercises include:

 breathing exercises
 positioning changes
 coughing
  wound splinting
 compressive stockings
 lower extremity exercises

Alternative/Holistic Management (current best evidence)

An alternative remedy for getting rid gallstones in the body is a gallbladder cleanse.  There is no
research or evidence that this is useful in preventing or treating gallstones.  A gallbladder cleanse
involves a person eating or drinking a combination of olive oil, herbs and some type of fruit juice
over several hours. The theory behind the gallbladder
cleanse is that it helps break up gallstones and stimulates   [16]

the gallbladder to release them into stool.  Olive oil can

act as a laxative, there's no evidence that it is an effective
treatment for gallstones. People who try this may see what appears as stones in the stool, but
what they are seeing is globs of oil, juice and other materials.  Some people who have tried this
have experienced nausea, vomiting, diarrhea and abdominal pain during the flushing or cleansing
period. Individual components of the herbal mixtures used in a gallbladder cleanse may present
their own health hazards  .
[17]

Herbs [18]

Some herbal supplements have been found safe to help strengthen the body's systems.  Before
beginning any herbal regimen one should talk their health care provider to get your problem
diagnosed.  Herbs can be used as dried extracts (capsules, powders, teas), glycerites (glycerine
extracts), or tinctures (alcohol extracts). People with a history of alcoholism should not take
tinctures. Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink two to four
cups per day. You may use tinctures singly or in combination as noted.

 Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant effects.
You may also prepare teas from the leaf of this herb.
 Milk thistle (Silybum marianum) seed standardized extract, 80 - 160 mg two to three times daily,
for liver and galbladder detoxification support.
 Globe artichoke (Cynara scolymus) standardized extract, 250 - 500 mg two to three times daily,
for support of galbladder and liver function.
 Turmeric (Curcuma longa) standardized extract, 300 mg three times daily for support of liver
function.
Accupuncture  [18]

Acupuncture has been proven to be helpful in pain relief, reducing spasms, and easing bile flow
and proper liver and gallbladder function.

Homeopathy  [18]

Few clinical studies have proven the effectiveness of certain homeopathic remedies. However, a
professional homeopath may recommend one or more of the following treatments for menstrual
pain based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths
take into account a person's constitutional type -- your physical, emotional, and intellectual
makeup. An experienced homeopath assesses all of these factors when determining the most
appropriate remedy for a particular individual.

Some of the most common remedies are listed below. A common dose is three to five pellets of a
12X to 30C remedy every 1 - 4 hours until your symptoms improve.

 Colocynthis for colicky abdominal pains that are lessened by pressure or bending double
 Chelidonium for abdominal pain that moves to the right shoulder area
 Lycopodium for abdominal pain that is worse with deep breaths

Physical Medicine  [18]

A castor oil pack may be applied to the abdominal area or to the gallbladder region to help
reduce swelling.  To make a castor oil pack apply oil to a clean, soft cloth and place on the
abdomen abdomen. Cover with plastic wrap and place a heating source over the pack. Let the
heat source sit for 30 - 60 minutes and for best results, use for 3 consecutive days. 

Differential Diagnosis [6]

Obstruction of the gallbladder can lead to:

 biliary stasis
 delayed gallbladder emptying
 These two combined can occur with any pathological condition of the liver, hormonal
influencse, and pregnancy.

Cholangitis- this is where the gallstone get lodged further down into the common bile duct.  If
bile flow is blocked at the biliare tree this can lead to jaundice.
Primary Biliary Cirrhosis- this is a chronic progressive, inflammatory disease of the liver that
involves primarily the intrahepatic bile duct and results in the impairement of bile secretion.  

Gallbladder Cancer- this is closely associated with gallstone disease.  If this is diagnosed it is
usually in later stages and often has a poor outcome. 

Gallstone Pacreatitis- this is the inflammation of the pancrease secondary to blockage of the
pancreatic duct via a gallstone.  The blockage occurs at the sphincter of Oddi.  If a stone from the
gallbladder travels down the common bile duct and gets stuck in the sphincter, it will block the
flow of all material from the liver and pancreas. This leads to inflammation of the pancreas and
can be quite severe. Gallstone pancreatitis can be a life-threatening disease and evaluation by a
physician urgently is needed if someone with gallstones suddenly develops severe abdominal
pain [8]

Sphincter of Oddi Dysfunction-  Sphincter of Oddi Dysfunction (SOD) is a symptom complex of

intermittent upper abdominal pain and may be accompanied by nausea and vommitting.  This is
thought to be caused from scarring or spasm of the sphincter of Oddi muscle. This is a small
circular muscle that is a ½ inch in length, located at the end of the bile duct and pancreas duct.
This muscle works to keep the bile duct and pancreatic duct muscles closed; this prevents reflux
of intestinal contents into the bile duct and pancreas duct. If this muscle should spasm or scar,
drainage of the bile duct and/or pancreas duct may be hindered. Abnormal dilation of the bile
duct and/or pancreas duct is often associated with an increase in the products and enzymes made
by the liver, gallbladder and pancreas, which can be tested for with blood tests (serum liver tests,
amylase, lipase). If the ducts are blocked this may result in pain  [8]

Peptic Ulcer Disease- characterized by burning, epigastric pain that occurs after meals.  This
often wakes patients up at night and pain improves with eating  . [9]

Acute Pacreatitis- this is characterized by epigastric or periumbilical abdominal pain radiating to

the back  .[9]

Scickle Cell Crises- this is typically associated with gallstone disease.  A patient may experience
pain anywhere in the body, which can be unrelated to the formation of gallstones  . [9]

Appendicitis- a patient may experience pain in the right lower quadrant near the iliac crest.  To
rule this out look for rebound tenderness at McBurneys point.  Pain a patient experiences with
appendicities may complain that it started in the periumbilical region  . [9]

Right Lower Lobe Pneumonia-  a patient who presents with this will have a productive cough
and fever.  Listen to a patients breath sounds to help rule this out, in doing so one will hear
bronchial breath sounds  .  
[9]

Acute Coronary Syndrome- a person will typically experience central chest pain that radiates to
the left arm or jaw.  A patient may experience pain the epigastrum region.  One thing to be
listening for in the history is previous history of chest pain and or look for risk factors for
coronary artery disease  .
[9]
GERD- a patient who presents with thsi will have a burning sensation in chest after meals.  This
sensation is made worse on bending over or lying down. A patient may also have acid reflux and
dysphagia  .   [9]

Prognosis

The prognosis for acute and chronic cholecystitis is good if the patient seeks medical treatment. 
Acute attacks should resolve spontaneously, but a person may experience reoccurences.  This
may lead to the patient having their gallbladder removed.  Mortality secondary to acute
cholecystitis is 5 to 10 percent for clients that are older than 60 and have serious associated
diseases  .
[3]

Case Reports

add links to case studies here (case studies should be added on new pages using the case study
template)

Resources 

The American College of Gastroenterology-www.acg.gi.org

National Digestive Disease International Clearinghouse-digestive.niddk.nih.gov

Recent Related Research (from Pubmed)

 Early Cholecystectomy for Acute Cholecystitis: How Early Should It Be?
 Long-term outcomes after endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis.
 Eosinophilic cholangitis coexisted with idiopathic thrombocytopenic purpura: report of a case.
 Acalculous cholecystitis with multiple organ failure and disseminated intravascular coagulation in a patient with adult onset
Still's disease.

References
1. ↑ WashingtonDeceit. Histopathology Gallbladder--Acute cholecystitis . Available
from:http://www.youtube.com/watch?v=9qVg4OQTXMA[last accessed 09/03/13]
2. ↑                 Beers M, et al. The Merck Manual of Diagnosis and Therapy Eighteenth Edition.
2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7

Merck Research Laboratories: Whitehouse Station; 2006; 240-244,

3. ↑                 Goodman CC, Fuller K. Pathology Implications for the Physical Therapist Third
3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7

Edition. Saunders Elsevier: St. Louis; 2009.

4. ↑                     Goodman CC, Boissonnault W. Pathology Implications for the Physical
4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9

Therapist. Saunders: Philadelphia; 1998.

5. ↑ WashingtonDeceit. Histopathology Gallbladder--Chronic cholecystitis. Available
from:http://www.youtube.com/watch?v=gxGvP3GV_1E[last accessed 09/03/13]
6. ↑                           Goodman CC, Snyder T. Differential Diagnosis for Physical Therapists
6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12

Screening for Referral Fourth Edition. Saunders Elsevier: St. Louis; 2007.
7. ↑               National Digestive Diseases Information
7.0 7.1 7.2 7.3 7.4 7.5 7.6

Clearinghouse. http://digestive.niddk.nih.gon. Last accessed April 11, 2010

 8. ↑                 The American College of
8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7

Gastroenterology.http://www.acg.gi.org/patients/gihealth.asp#GI. Last accessed April 11, 2010.

9. ↑                 Epocrates Online. https://online.epocrates.com/noFrame/showPage.do?
9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7

method=diseases&amp;amp;MonographId=78&amp;amp;ActiveSectionId=35. Accessed April

10, 2010.
10. ↑     Cook C., Hegedus E. Orthopaedic Physical Examination Tests: an evidence based
10.0 10.1

approach. 2nd ed. Upper Saddle River NJ, Pearson Education Inc. 2013
11. ↑ Bree RL. Further observations on the usefullness of the sonographic Murphy Sign in the
evaluation of suspected acute cholecystitis. J Clin Ultrasound. 1995; 23: 169-172
12. ↑ Singer AJ. McCracken G, Henry Mc, et al. Correlation among clinical , laboratory and
hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med.
1996; 28; 267-272
13. ↑ Ralls PW, Halls J, Lapin Sa, et al. Prospective evaluation of the sonographic Murphy Sign in
supspected acute cholectystis. J Clin Ultrasound. 1982; 10; 113-115
14. ↑ livestrong. Gallstones Health Byte. Available from: http://www.youtube.com/watch?
v=WmcOAb9e-5Y[last accessed 09/03/13]
15. ↑ emedtv. ERCP with Balloon Dilation. Available from: http://www.youtube.com/watch?
v=qFM6j-RkESA[last accessed 09/03/13]
16. ↑ fishman2002. Liver & Gall Bladder Body Cleanse Testimony - (Natural Recipe to Remove
Gallstones and Liver Stones). Available from: http://www.youtube.com/watch?v=qbrNbGl1-
vA[last accessed 09/03/13]
17. ↑ Picco M. Mayo Clinic. http://www.mayoclinic.com/health/gallbladder-cleanse/AN01283.
Updated February 26, 2010. Accessed April 10, 2010.
18. ↑         University of Maryland Medical
18.0 18.1 18.2 18.3

Center. http://www.umm.edu/altmed/articles/gallbladder-disease-000066.htm. Updated
February 12, 2008. Accessed April 10, 2010.
Categories: Bellarmine Student Project | Videos

ACHILLES TENDINOPATHY

In this month's Members topic we are exploring the foot and ankle with a
focus on achilles tendinopathy. This month we have exclusive access to:
1. 2 FREE chapters from text books Maitland's Peripheral
Manipulation by Hengeveld & Banks 2014 and A Practical
Approach to Orthopaedic Medicine by Atkins, Kerr and Goodlad.
2010
2. 4 FREE journal articles from The Foot
3. An interview with Maitland expert Elly Hengeveld