Fever and leukocytosis in acute cholecystitis - adapted from the Annals of Emergency Medicine 1996;2

Author: Richard Sadovsky
Date: Nov 15, 1996

Acute cholecystitis is a common abdominal condition resulting from chemical or bacterial inflammation of the gallbladder. It is generally related to gallstones and subsequent unresolved obstruction. Early surgery is the treatment of choice because of the greater mortality and morbidity associated with treatment delay. The clinical presentation is most commonly characterized by abdominal pain, anorexia, nausea and vomiting. Some studies have also demonstrated the presence of fever and leukocytosis as typical findings. Gruber and associates retrospectively reviewed the medical charts of patients presenting to an emergency department to determine the frequency of fever and leukocytosis associated with acute cholecystitis.

Patients were included in the study if they had a positive hepato-iminodiacetic acid (HIDA) scan establishing the diagnosis of acute cholecystitis. All of the patients underwent surgery, and pathologic diagnosis of acute cholecystitis was made if neutrophils were present and there was no evidence of chronicity. A total of 198 patients were identified (median age: 59 years). Pathologic examination revealed acute cholecystitis in 154 subjects (78 percent) and chronic cholecystitis in 44 subjects (22 percent). Of the 154 patients with acute cholecystitis, 51 (34 percent) were found to have gangrenous cholecystitis.

During the first eight hours following arrival in the emergency department, 32 percent of the patients had fever (defined as an oral temperature of 37.7[degrees]C 100.0[degrees]F or greater or a rectal temperature of 38.0[degrees]C [100.4[degrees]F], and 61 percent had leukocytosis (defined as a white blood cell count of 11,000 per mL [11.0 x [10.sup.9] per L] or greater). Thirty-one percent of the patients did not have fever or leukocytosis. The presence of fever or leukocytosis was not related to the duration of symptoms, time elapsed before surgery, or the sex of the patient. The occurrence of fever was not related to the occurrence of leukocytosis. The maximum temperature and white blood cell count during the first 24 hours in the hospital were also recorded; fever developed in 66 percent of the patients and leukocytosis developed in 76 percent.

The authors conclude that typical clinical presentations of acute cholecystitis include abdominal pain or pain on examination, and history of nausea and vomiting. Most patients with nongangrenous cholecystitis did not have fever, and 32 percent of all patients with acute cholecystitis lacked leukocytosis. The clinician should not depend on the presence of these signs to make the diagnosis of acute cholecystitis.

Gruber PJ, et al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med 1996;28:273-7.

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