Acute cholecystitis (see Chap.i..81) is the most common surgical emergency in older patients with abdominal pain. Fortunately, physicians have a record of high diagnostic accuracy for this condition in the elderly.6 The presenting features of acute cholecystitis in the older population are similar to those in younger patients. Right-upper-quadrant or epigastric pain is present in most patients, while radiation to the back or shoulder area occurs in about one-third. Roughly half will report nausea or vomiting, and jaundice will occur in 10 to 30 percent. Fever may be absent in over half of these patients. Laboratory testing may be misleading, as 30 to 40 percent can have a normal white blood cell count. Plain radiographs are of little value; the diagnostic study of choice is ultrasonography. Computed tomography is generally of limited usefulness. -I..0,!5
Conservative management is generally unsuccessful and operative delay increases the complication rate. The older patient can appear deceptively well with acute cholecystitis; however, the overall mortality rate approximates 10 percent.16 Additionally, a clinical picture of fever, jaundice, and altered mental status without significant abdominal findings has been described in a subset of elderly patients with acute cholecystitis.
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