Cholecystitis – Causes, Symptoms, Diagnosis, Treatment

Cholecystitis is an inflammation of the gallbladder. The gallbladder is the small sac-like organ located in the upper right side of the abdomen, just below the liver. It is attached to the main duct that carries bile from the liver into the intestine. The gallbladder temporarily stores bile, which is a liquid that contains a fat-digesting substance produced in the liver. During a meal, the gallbladder contracts, and bile moves from the gallbladder through small, tube-like passages (called the cystic duct and the common bile duct) into the small intestine. Here, bile mixes with food to help break down fats.

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common.^[1] Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.^[rx][rx]

Types of Cholecystitis

The following types of  cholecystitis 

• Acute calculous cholecystitis – Gallstones blocking the flow of bile account for 90% of cases of cholecystitis (acute calculous cholecystitis). The blockage of bile flow leads to thickening and buildup of bile causing an enlarged, red, and tense gallbladder.^[rx] The gallbladder is initially sterile but often becomes infected by bacteria, predominantly E. coli, Klebsiella, Streptococcus, and Clostridium species.^[rx] Inflammation can spread to the outer covering of the gallbladder and surrounding structures such as the diaphragm, causing referred right shoulder pain.^[rx]
• Acalculous cholecystitis – In acalculous cholecystitis, no stone is in the biliary ducts.^[rx] It accounts for 5–10% of all cases of cholecystitis and is associated with high morbidity and mortality rates.^[rx] Acalculous cholecystitis is typically seen in people who are hospitalized and critically ill.^[rx] Males are more likely to develop acute cholecystitis following surgery in the absence of trauma. It is associated with many causes including vasculitis, chemotherapy, major trauma or burns.^[rx]
• Chronic cholecystitis – Chronic cholecystitis occurs after repeated episodes of acute cholecystitis and is almost always due to gallstones.^[rx] Chronic cholecystitis may be asymptomatic, may present as a more severe case of acute cholecystitis, or may lead to a number of complications such as gangrene, perforation, or fistula formation.^[rx][rx] Xanthogranulomatous cholecystitis (XGC) is a rare form of chronic cholecystitis that mimics gallbladder cancer although it is not cancerous.^[rx][rx] It was first reported in the medical literature in 1976 by McCoy and colleagues.^[rx][rx]

Causes of Cholecystitis

Cholecystitis occurs when your gallbladder becomes inflamed. Gallbladder inflammation can be caused by:

• Gallstones – Most often, cholecystitis is the result of hard particles that develop in your gallbladder (gallstones). Gallstones can block the tube (cystic duct) through which bile flows when it leaves the gallbladder. Bile builds up, causing inflammation.
• Tumor – A tumor may prevent bile from draining out of your gallbladder properly, causing bile buildup that can lead to cholecystitis.
• Bile duct blockage – Kinking or scarring of the bile ducts can cause blockages that lead to cholecystitis.
• Infection – AIDS and certain viral infections can trigger gallbladder inflammation.
• Blood vessel problems – A very severe illness can damage blood vessels and decrease blood flow to the gallbladder, leading to cholecystitis.
• Acute cholecystitis – occurs when bile becomes trapped in the gallbladder. This often happens because a gallstone blocks the cystic duct, the tube through which bile travels into and out of the gallbladder. When a stone blocks this duct, bile builds up, causing irritation and pressure in the gallbladder. This can lead to swelling and infection.
• Other causes include
  • Serious illnesses, such as HIV or diabetes
  • Tumors of the gallbladder (rare)

  Some people are more at risk for gallstones. Risk factors include:

  • Being female
  • Pregnancy
  • Hormone therapy
  • Older age
  • Being Native American or Hispanic
  • Obesity
  • Losing or gaining weight rapidly
  • Diabetes

Symptoms of Cholecystitis

Signs and symptoms of cholecystitis may include:

• Pain. You may feel this discomfort in the center of the upper abdomen, just below the breastbone, or in the upper right portion of the abdomen, near the gallbladder and liver. In some people, the pain extends to the right shoulder. Symptoms typically start after eating.
• Fever and possibly chills
• Nausea and/or vomiting
• Jaundice (yellowing of the skin or eyes), dark urine and pale, grayish bowel movements. These symptoms appear when gallstones pass out of the gallbladder and into the common bile duct, blocking the flow of bile out of the liver.
• Severe pain in your upper right or center abdomen
• Pain that spreads to your right shoulder or back
• Tenderness over your abdomen when it’s touched
• Nausea
• Vomiting
• Fever

Diagnosis of Cholecystitis

• Computed Tomography (CT) – In a CT scan, a rotating x-ray device moves around the patient and takes multiple detailed images of organs and body parts.^[rx] Sometimes patients are injected with a contrast agent before images are taken, for better visualization of the body part being examined.^[rx] CT findings consistent with acute cholecystitis include gallbladder wall thickening, gallbladder distention, pericholecystic fluid, and pericholecystic fat.
• Magnetic Resonance Cholangiopancreatography (MRCP) – An MRCP is a magnetic resonance imaging (MRI) test that produces detailed images of the hepatobiliary and pancreatic systems. Images are created using a magnetic field and radiofrequency pulses. Patients undergoing MRI are placed on to a table that is moved into the center of the MRI machine. Some patients are given contrast material before the MRI. MRCP findings indicative of acute cholecystitis include gallbladder stones, wall thickening, and pericholecystic fluid.^[rx]
• Ultrasound (U/S) – During a U/S, a transducer is placed over the organ of interest. The transducer generates sound waves that pass through the body and produce echoes that are analyzed by a computer to produce images of the body part being analyzed.^[rx] U/S findings consistent with acute cholecystitis include the visualization of gallstones, intraluminal sludge, thickening of the gallbladder wall, pericholecystic fluid, increased blood flow in the gallbladder wall, and sonographic Murphy’s sign.^[rx] Murphy’s sign of cholecystitis refers to pain felt by the patient on taking a deep breath while pressure is placed in the right upper quadrant of the abdomen.^[rx]
• Abdominal CT – Computed tomography (CT) uses x-rays to produce detailed pictures of the abdomen, liver, gallbladder, bile ducts and intestine to help identify inflammation of the gallbladder or blocked bile flow. Sometimes (but not always) it can also show gallstones.
• Magnetic resonance cholangiopancreatography (MRCP) – MRCP is a type of MRI exam that makes detailed images of the liver, gallbladder, bile ducts, pancreas and pancreatic duct. It is very good at showing gallstones, gallbladder or bile duct inflammation, and blocked bile flow.
• Hepatobiliary nuclear imaging – This nuclear medicine test uses an injected radiotracer to help evaluate disorders of the liver, gallbladder and bile duct (biliary system). In acute cholecystitis, it can detect blockage of the cystic duct (the duct that is always blocked with acute cholecystitis).

Treatment of Cholecystitis

Initial treatment

Initial treatment will usually involve

• not eating or drinking (fasting) to take the strain off your gallbladder
• receiving fluids through a drip directly into a vein (intravenously) to prevent dehydration
• taking medicine to relieve your pain

You’ll also be given antibiotics if it’s thought you have an infection. These often need to be continued for up to a week, during which time you may need to stay in the hospital, or you may be able to go home.

After initial treatment, any gallstones that may have caused acute cholecystitis usually fall back into the gallbladder and the inflammation will often settle down.

Your doctor may suggest

• Fasting to rest the gallbladder
• A special, low-fat diet
• Pain medication
• Antibiotics to treat the infection

Surgery

About 20% of patients with acute cholecystitis need emergency surgery. Such surgery is indicated if the patient’s condition deteriorates or when generalized peritonitis or emphysematous cholecystitis is present. These features suggest gangrene or perforation of the gall bladder.

• Cholecystectomy – The timing of surgery for 80% of patients without evidence of gangrene or perforation is under debate. Open cholecystectomy traditionally has been performed 6-12 weeks after the acute episode to allow the inflammatory process to resolve before the procedure (interval surgery).[^rx] Patients with acute cholecystitis who undergo early laparoscopic cholecystectomy (before symptoms have lasted 72-96 hours) have lower complication rates and lower conversion rates than open cholecystectomy and shorter hospital stays than those undergoing interval surgery.
• Laparoscopic surgery – The surgeon uses the belly button and several small cuts to insert a laparoscope to see inside the abdomen and remove the gallbladder. You will be asleep for the surgery. Early laparoscopic surgery is safe and feasible in patients with acute cholecystitis. If early intervention—less than 72 hours after symptoms started—can be achieved, “edema planes” present during this period allow the gall bladder to be dissected laparoscopically.
• Open surgery – The surgeon makes a cut in the abdomen and removes the gallbladder. You will be asleep for the surgery.

If you cannot have surgery, your doctor may drain bile from the gallbladder. This may be done by:

• Percutaneous cholecystostomy – This procedure is done by a radiologist. It places a tube through the skin directly into the gallbladder using ultrasound or CT guidance. Blocked or infected bile is removed to reduce inflammation. This procedure is typically done in patients who are too sick to have their gallbladder removed. You will be sedated for this procedure. The tube typically has to stay in for at least a few weeks.
• Endoscopic retrograde cholangiopancreatography (ERCP) – This procedure is typically done by a doctor who specializes in abdominal disorders (a gastroenterologist). A camera on a flexible tube is passed from the mouth through the stomach and into the beginning of the small bowel. This is where the common bile duct meets the small intestine. The valve mechanism (called the sphincter) at the end of the bile duct can be examined and opened to clear blocked bile and stones, if necessary. Doctors can also insert a small tube into the main bile duct and inject contrast material to better see the duct. They also may use a laser fiber to destroy small gallstones or use a basket or balloon to retrieve stones or stone fragments. All of this may be done without making any incisions in the abdomen. This procedure poses a small, but real risk of pancreas inflammation or injury. You will be sedated for this procedure.
• Percutaneous transhepatic cholangiography (PTC) – This procedure is done by a radiologist. A needle is placed in the bile ducts within the liver using imaging guidance. Contrast material is injected to help locate gallstones that may be blocking bile flow. Some stones can be removed during a PTC. Others may be bypassed by leaving a small stent in place to allow bile to get around the area of blockage. This helps reduce inflammation. You will be sedated for this procedure.
• Percutaneous cholecystostomy – is a minimally invasive procedure that can benefit patients with serious comorbidity who are at high risk from major surgery. Percutaneous cholecystostomy can be performed at the bedside under local anesthetic and is suitable for patients in intensive care units and those with burns. It is the definitive treatment in patients with acalculous cholecystitis (see below), or it may be used as a temporizing measure—to drain infected bile and delay the need for definitive treatment.
• Single-incision laparoscopic cholecystectomy – where the gallbladder is removed through a single cut, which is usually made near the bellybutton.

References

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