Rethinking the Spectrum of Biliary Disease: Incipient Cholecystitis, an Intermediate Clinical Entity Between Biliary Colic and Acute Cholecystitis – A Case Series

Biliary disease is among the commonest and costliest diseases of the digestive system with an estimated 15% prevalence of gallstones in the United States population. While cholelithiasis may often remain asymptomatic, some patients eventually progress to biliary colic and acute cholecystitis. Both biliary colic and acute cholecystitis present with right upper quadrant pain, with pain persisting for greater than six hours in acute cholecystitis. Acute cholecystitis is thought to be an inflammatory process, with the development of fever and leukocytosis. In addition, acute cholecystitis is also characterized by typical findings of inflammatory processes on ultrasonography and cystic duct obstruction on cholecystography. However, a subset of patients presents with an intermediate clinical picture, with prolonged abdominal pain suggestive of acute cholecystitis, but a negative ultrasonography exam. This case series presents three patients with such a clinical presentation, who had abdominal pain with tenderness and a negative ultrasound but where cholecystography revealed cystic duct obstruction. The authors therefore propose a new hypothetical clinical entity, “incipient cholecystitis,” to characterize these individuals. We suggest that patients with similar intermediate clinical presentation should not be labeled as biliary colic alone, as they may have an accelerated rate of progression to acute cholecystitis. We suggest that future studies are needed in this specific subset of the population, to further investigate this accelerated progression which is not seen in the “typical” or “classic” indolent biliary colic. This will enable clinicians to characterize their risk of progression, as we feel that these patients may benefit from aggressive initial management and early surgical intervention, in stark contrast to “benign” biliary colic, which can be managed conservatively, with an interval cholecystectomy.