Acute cholecystitis - Symptoms.

Acute cholecystitis against the background of cholelithiasis (calculous cholecystitis).

Symptoms of acute cholecystitis are determined by the severity of the pathological process, which varies from mild inflammation to fulminant gangrene of the gallbladder wall. Often, an attack of the disease is an exacerbation of chronic cholecystitis.

People of any constitution, gender and age can get sick, although women over 40 who are obese are more likely to get sick.

The main symptoms of acute cholecystitis are:

Pain (biliary colic) is localized in the epigastric or right hypochondrium, radiates to the back below the angle of the right scapula, the right shoulder, less often to the left half of the body and may resemble an attack of angina. The pain occurs at night or early in the morning, increases to a certain intensity and persists for 30-60 minutes. The onset of pain may be preceded by the consumption of fatty, spicy, spicy food, alcohol, emotional experiences.

Characteristic features include increased sweating, a grimace of pain, and a motionless position on the side with legs tucked up to the stomach. Patients often apply a heating pad to the right hypochondrium.

Pain from gallbladder distension occurs due to obstruction of the cystic duct and increased contraction of the gallbladder. The pain is localized deep, more centrally, is not accompanied by tension in the abdominal wall muscles, and does not increase with superficial or deep palpation.

Pain from peritoneal irritation is localized superficially, increases when touching the skin, and is accompanied by hyperesthesia and tension of the abdominal wall muscles. The bottom of the gallbladder is in contact with the diaphragmatic peritoneum, which is innervated by the diaphragmatic and six lower intercostal nerves. Irritation of the anterior branches of the intercostal nerves causes pain in the right upper quadrant of the abdomen, and irritation of the posterior cutaneous branch causes characteristic pain under the right shoulder blade.

The spinal nerves innervate a small area of the mesentery and gastrohepatic ligament around the large bile ducts. Irritation of these nerves is perceived as pain in the back and right upper quadrant of the abdomen, which explains the pain associated with common bile duct stones and cholangitis.

Digestive system. Acute cholecystitis is characterized by flatulence and nausea; the addition of vomiting makes one think of concomitant choledocholithiasis.

Fever - often subfebrile, rarely reaches febrile values (in destructive forms of cholecystitis or due to complications). Hectic temperature curve, accompanied by pronounced sweating, severe chills, often indicates purulent inflammation (empyema of the gallbladder, abscess). In weakened patients and elderly people, body temperature even with purulent cholecystitis can remain subfebrile, and sometimes even normal due to decreased reactivity.

Other symptoms include belching with bitterness or a constant bitter taste in the mouth; a feeling of distension in the upper abdomen, bloating, bowel movements, nausea, and vomiting of bile are possible.

Jaundice is not typical, but is possible if the outflow of bile is obstructed due to the accumulation of mucus, epithelium, obstruction of the common bile duct by stones, or if cholangitis has developed.

When collecting anamnesis, it is necessary to ask the patient especially carefully about the following points:

• nature, duration, localization and irradiation of pain;
• associated symptoms such as fever, chills, nausea, vomiting;
• history of episodes of biliary colic; age of the patient (since complications occur more often in the elderly and old age);
• the presence of diabetes mellitus (with this disease, gangrenous cholecystitis more often develops).

During a physical examination it is necessary to carry out:

• assessment of the general condition;
• examination of the skin and visible mucous membranes (especially carefully examine the sclera, conjunctiva and frenulum of the tongue) and skin for timely detection of jaundice;
• determination of muscle tension in the anterior abdominal wall, especially in the right hypochondrium and epigastric regions;
• palpation of the right hypochondrium to detect an enlarged gallbladder while simultaneously checking for symptoms of gallbladder inflammation (the sensitivity of a positive Murphy's sign in acute cholecystitis is 92%, specificity is 48%);
• body temperature measurement.

The following signs can be found in patients with acute cholecystitis.

Symptoms of inflammation of the gallbladder, which include the following:

• Murphy's symptom - sharp pain when pressing on the right hypochondrium at the height of inhalation (in another interpretation: involuntary holding of breath during inhalation due to sharp pain when pressing on the right hypochondrium);
• Kerr's symptom - pain on palpation of the right hypochondrium;
• Ortner's symptom - pain when tapping on the right costal arch;
• de Mussy-Georgievsky's symptom (phrenicus symptom) - pain when pressing with a finger between the legs of the right sternocleidomastoid muscle.
• Shchetkin-Blumberg's symptom becomes positive when the peritoneum is involved in the inflammatory process (peritonitis).

Acute cholecystitis in the absence of gallstone disease (acalculous cholecystitis) is characterized by more frequent development of complications and higher mortality.

Acute cholecystitis should be considered in critically ill patients.

It is important to remember that in this case the clinical picture may be blurred: pain syndrome is often absent.

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