Pancreatitis aguda

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The

n e w e ng l a n d j o u r na l

of

m e dic i n e

clinical practice

Acute Calculous Cholecystitis
Steven M. Strasberg, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinicalrecommendations.

A previously well 42-year-old woman presents with severe pain in the right upper quadrant, which started 15 hours earlier. She has previously noted episodic pain in that location that lasted for up to 2 hours but has not sought medical advice. She has had one episode of vomiting with the current attack. On physical examination, her temperature is 38.5°C, and the heart rate is 95beats per minute. She has tenderness and guarding in the right upper quadrant. How should her condition be evaluated and treated?

The Cl inic a l Probl e m
From the Section of Hepatobiliary–Pancreatic Surgery, Washington University in St. Louis and Barnes–Jewish Hospital, St. Louis. Address reprint requests to Dr. Strasberg at Box 8109, 660 Euclid Ave., St. Louis, MO 63110, or at strasbergs@wustl.edu. N Engl J Med 2008;358:2804-11.
Copyright © 2008 Massachusetts Medical Society.

Acute calculous cholecystitis is a complication of cholelithiasis, a condition that afflicts more than 20 million Americans annually1 and results in direct costs of more than $6.3 billion.2 Most patients with gallstones are asymptomatic. Of such patients, biliary colic develops in 1 to 4% annually,3-5 andacute cholecystitis eventually develops in about 20% of these symptomatic patients if they are left untreated.6 Such patients tend to be somewhat older than those with uncomplicated symptomatic cholelithiasis. Most patients with acute cholecystitis have had attacks of biliary colic, but some have had no previous biliary symptoms.3-5 After an initial attack of acute cholecystitis, additional attacksof pain or inflammation are common.7 In a small proportion of patients, acute cholecystitis may coexist with choledocholithiasis, cholangitis, or gallstone pancreatitis. About 120,000 cholecystectomies are performed for acute cholecystitis annually in the United States. However, the incidence of acute cholecystitis seems to be falling because of the greater acceptance by patients of laparoscopiccholecystectomy as a treatment for symptomatic gallstones.8 About 60% of patients with acute cholecystitis are women. However, acute cholecystitis develops in men more frequently than would be expected from the relative prevalence of gallstones (about half that in women),1 and cholecystitis tends to be more severe in men.9 In patients with diabetes who have symptomatic gallstones, acutecholecystitis seems to develop more frequently than in patients without diabetes, and such patients are more likely to have complications of acute cholecystitis when it occurs.10
Pathogenetic Features

More than 90% of cases of acute cholecystitis are associated with cholelithiasis (acute calculous cholecystitis). The key elements in pathogenesis seem to be an obstruction of the cystic duct in thepresence of bile supersaturated with cholesterol.11 Brief impaction may cause pain only, but if impaction is prolonged over many hours, inflammation can result. With inflammation, the gallbladder becomes enlarged, tense, and reddened, and wall thickening and an exudate of pericholecystic fluid may develop. The inflammation is initially sterile in most cases, but sec2804

n engl j med 358;26www.nejm.org

june 26, 2008

The New England Journal of Medicine Downloaded from www.nejm.org on October 18, 2010. For personal use only. No other uses without permission. Copyright © 2008 Massachusetts Medical Society. All rights reserved.

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