The fever and its pattern may be helpful in the diagnostic work-up. A fever above 38.1 °C must be observed on at least three occasions over 3 weeks. In elderly patients, because of a blunted febrile response, it is suggested that the temperature criterion should be any increase of 1. 3°C from the baseline temperature or a persistent rectal temperature greater than 37.5°C.
The fever pattern may occasionally point to the diagnosis, and a number of fever patterns have been described. Cyclical fevers due to malaria can occur at 48-hour intervals (tertian fevers) in the case of Plasmodium vivax or Plasmodium ovale infection and at 72-hour intervals (quartan fevers) in the case of Plasmodium malariae infection. The Pel-Ebstein fever pattern of Hodgkin’s disease is characterized by 3 to 10 days of fever followed by 3 to 10 afebrile days. The relapsing fever pattern due to Borrelia species is characterized by 2 to 3 days of fever followed by a 7- to 9-day afebrile interval before symptoms recur.
The duration of the fever may also be helpful. Although a prolonged fever (occurring over months to years) without other concomitant symptoms is less suggestive of infection or malignancy, chronic “smoldering” osteomyelitis, an occult abscess, parasitic infections, or Whipple’s disease can have indolent courses and should be considered. Still’s disease, Crohn’s disease, hereditary fever syndromes, and Behget’s disease may also have long recurrent courses of fever interspersed with afebrile periods.
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Pathogenesis
Acute inflammation of the gallbladder wall usually follows obstruction of the infundibulum or cystic duct by a stone. This obstruction of bile leads to an increase in pressure in the gallbladder that damages the mucosa and causes release of inflammatory mediators. Continued distention of the gallbladder wall can lead to a compromise of its blood supply, resulting in gangrene or perforation. Bacteria can proliferate in the inflamed gallbladder, and infection develops in up to one half of cases.
Clinical Manifestations
Initial obstruction of the infundibulum or cystic duct may be accompanied only by mild epigastric pain, nausea, and anorexia. Vomiting may occur and contribute to intravascular volume depletion. As the episode continues, the pain of acute cholecystitis becomes more localized to the right upper quadrant (RUQ) of the abdomen and may radiate о the right scapula or shoulder.
On physical examination, low-grade fevers, rigors, hypoactive bowel sounds, and RUQ abdominal tenderness may be present. Murphy’s sign, characterized by the sudden cessation of inspiration due to the pain inked by RUQ palpation, may also be identified. Approximately 20% of patients have a palpable mass in the RUQ due to irritation of the omentum overlying the inflamed gallbladder. Localized rebound tenderness and guarding may also be found if gallbladder perforation and early peritonitis have occurred. Jaundice, it should be noted, is unusual early in the course of acute cholecystitis but may occur when inflammation involves the adjacent bile ducts.
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ACUTE CALCULOUS CHOLECYSTITIS : PATHOGENESIS AND CLINICAL MANIFESTATIONSPathogenesisAcute inflammation of the gallbladder wall usually follows obstruction of the infundibulum or cystic duct by a stone. This obstruction of bile leads to an increase in pressure in the gallbladder that damages the mucosa and causes release of inflammatory mediators. Continued distention of the gallbladder wall can lead to a compromise of its blood supply, resulting in gangrene or perforation. Bacteria can proliferate in the inflamed gallbladder, and infection develops in up to one half of cases.
Clinical ManifestationsInitial obstruction of the infundibulum or cystic duct may be accompanied only by mild epigastric pain, nausea, and anorexia. Vomiting may occur and contribute to intravascular volume depletion. As the episode continues, the pain of acute cholecystitis becomes more localized to the right upper quadrant (RUQ) of the abdomen and may radiate о the right scapula or shoulder.On physical examination, low-grade fevers, rigors, hypoactive bowel sounds, and RUQ abdominal tenderness may be present. Murphy’s sign, characterized by the sudden cessation of inspiration due to the pain inked by RUQ palpation, may also be identified. Approximately 20% of patients have a palpable mass in the RUQ due to irritation of the omentum overlying the inflamed gallbladder. Localized rebound tenderness and guarding may also be found if gallbladder perforation and early peritonitis have occurred. Jaundice, it should be noted, is unusual early in the course of acute cholecystitis but may occur when inflammation involves the adjacent bile ducts.*101/348/5*
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