Review Question - QID 104810

This patient's presentation is consistent with a diagnosis of acute cholecystitis. Estrogen increases cholesterol levels in bile, and hormonal replacement therapy are risk factors for the development of acute cholecystitis.

Cholecystitis is caused by prolonged blockage of the cystic duct (typically by a lodged gallstone) that leads to distension, inflammation, and ultimately superinfection of the gallbladder. Additional risk factors include female gender, age > 40, overweight/obese, diabetic, total parental nutrition, rapid fluctuations in body weight, and Native American ancestry.
Abdominal ultrasound is the gold-standard imaging study for the diagnosis of cholelithiasis and acute cholecystitis. Cholecystitis manifests on ultrasound with a thickened gallbladder wall and pericholecystic fluid with or without gallstones. Acalculous cholecystitis, cholecystitis in the absence of gallstones, is often seen in critically ill patients or those receiving prolonged parenteral nutrition.

Abraham et al. discusses the management of gallstones. Biliary colic, intermittent obstruction of the cystic duct, may precede the development of acute cholecystitis. The development of cholecystitis is heralded by persistent pain, fever, and elevated white blood cell count. In addition to cholecystitis, other complications of gallstones can include pancreatitis or ascending cholangitis.

Jick and Pennap examine the commonly held belief that oral contraceptives increase risk of gallbladder disease. They found that women taking drospirenone- or levonorgestrel-containing oral contraceptives do NOT have an elevated risk of gallbladder disease compared to women who are not taking any oral contraceptive. It appears that these progesterone-containing derivatives may not have an effect on gallbladder disease, whereas medications containing estrogen alone may have an association. Additional and ongoing research needs to be conducted in order to further elucidate and confirm these findings.

Figure A shows an ultrasound demonstrating findings consistent with acute cholecystitis. Note the thickened gallbladder wall and hyper-echoic gallstones with associated acoustic shadowing.

Illustration A summarizes risk factors for the development of cholecysitis.

Incorrect Answers:
Answer 2: Meperidine is not known to increase the risk of acute cholecystitis. Some other opiate medications such as morphine can affect tone at the Sphincter of Oddi and may increase the risk of acute cholecystitis.

Answer 3: Naproxen, like other non-steroidal anti-inflammatory (NSAID) medications, increases the risk of gastric ulcer development and renal insufficiency. However, it is does not increase risk of acute cholecystitis.

Answer 4: Prednisone, like other steroid medications, may increase the risk of infection, particularly with prolonged courses. However, it does not increase the risk of acute cholecystitis particularly.

Answer 5: Trimethoprim-sulfamethoxazole is classically associated with a variety of side effects including hyperkalemia, Steven Johnson syndrome, and others. However, it does not increase the risk of acute cholecystitis.

Bullet Summary:
Estradiol and other estrogen supplements increase cholesterol saturation in bile and thereby predispose to the development of cholelithiasis and cholecystitis.