Patients with acute biliary colic display a wide range of symptoms. Location, radiation, and duration of pain are all poor discriminators of gallbladder disease. There is overlap of signs and symptoms with peptic ulcer disease, gastritis, esophageal reflux, and nonspecific dyspepsia. In addition, it has been difficult to determine which symptoms are attributable to biliary tract disease.7,8 RUQ pain is a common symptom in patients with and without gallstones.39 Up to 25 percent of postcholecystectomy patients may experience RUQ pain of unknown cause.
Biliary tract disease is an important consideration in the evaluation of dyspepsia. 10 Biliary dyskinesia or increased resting pressure of the sphincter of Oddi, or incoordination between gallbladder contraction and relaxation of the sphincter of Oddi, has been proposed as a cause of biliary tract induced dyspepsia. 10
One study has reported that epigastric pain was the predominant symptom of biliary tract disease in over 60 percent of patients studied, 9 thus accounting for the difficulty in using clinical signs and symptoms to make or exclude the diagnosis. The same study found that radiation of pain to the left upper back appears to be more commonly associated with biliary tract disease than with other upper gastrointestinal disorders, with a likelihood ratio of 4.0 for gallbladder pathology. 9
The duration and character of the pain are also nonspecific, but the pain of biliary colic is reported to persist for 2- to 6 h. Pain quality is generally persistent, not colicky, and pain episodes are infrequent, occurring at intervals greater than a week. 9 Gallstone pain is not related to meals in at least one-third of patients, 9i1 and clinical studies have not been able to identify an association with fatty food intolerance that is different from its association with a number of other upper gastrointestinal disorders.3911 Investigators have noted a circadian rhythm to biliary colic,11 with a peak of symptoms occurring around midnight to 1 a.m., and a time distribution from 9 p.m. to 4 a.m. Attacks tend to reoccur at the same time. This circadian rhythm has obvious diagnostic implications for patients who present with upper abdominal pain during the midnight shift.
Acute cholecystitis usually begins with pain similar to that of biliary colic but that persists beyond the typical 6 h. Associated nausea, vomiting, and anorexia are noted; a history of fever and/or chills is not uncommon. Patients may have either a history of similar attacks or documented gallstones. As the inflammatory process progresses, the patient's pain changes in character and location from visceral (dull and poorly localized mid-upper abdominal) to parietal (sharp and localized RUQ). The examination reveals a patient in moderate-to-severe distress with signs of systemic toxicity, including tachycardia and fever. The abdomen is tender in the RUQ, at times with evidence of localized peritoneal irritation, distention, and hypoactive bowel sounds. Generalized peritonitis with rigidity is rare and, if found, suggests perforation. The Murphy sign—worsened pain or inspiratory arrest resulting from deep, subcostal palpation on inspiration—has been estimated to be 97 percent sensitive for acute cholecystitis.3 Volume depletion is frequently found. Jaundice, usually not present, may be found in patients with prolonged biliary obstruction with late onset of inflammation or in cases of chronic intravascular hemolysis.
Acalculous cholecystitis, which occurs in 5 to 10 percent of patients with acute cholecystitis, tends to have a more rapid, malignant course. Patients frequently are elderly and have a history of diabetes mellitus. Other risk factors include multiple trauma, extensive burn injury, prolonged labor, major surgery, gallbladder torsion, systemic vasculitic states, and bacterial or parasitic infections of the biliary tract. Patients with acalculous cholecystitis are indistinguishable from those with calculous cholecystitis with two major exceptions: acalculous cholecystitis frequently occurs as a complication of another process (e.g., multiple trauma or extensive burns), and patients frequently are gravely ill on initial presentation.
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