Cholecystitis is inflammation of the gallbladder, which occurs most commonly due to obstruction
of the cystic duct with gallstones. Blockage of the cystic duct with gallstones causes
accumulation of bile in the gallbladder and increased pressure within the gallbladder.
Concentrated bile, pressure, and sometimes bacterial infection irritate and damage the
gallbladder wall, causing inflammation and swelling of the gallbladder. Inflammation
and swelling of the gallbladder can reduce normal blood flow to areas of the gallbladder,
which can lead to cell death due to insufficient oxygen. Not everyone who has gallstones will
go on to develop cholecystitis. Risk factors for cholelithiasis and cholecystitis
are similar and include increasing age, female sex, pregnancy, certain medications, obesity,
rapid weight loss, and Native American or Mexican American ethnicity. Females are twice
as likely to develop cholecystitis as males. Uncomplicated cholecystitis has an excellent
prognosis; however, more than 25% of patients require surgery or develop complications.
Delayed diagnosis of acute cholecystitis increases morbidity and mortality. Cholelithiasis and
cholecystitis may present as a single episode or may recur on multiple occasions.
Signs and symptoms Cholecystitis usually presents as a pain in
the right upper quadrant or epigastric region. The gallbladder may be tender and distended.
Symptomatically it differs from biliary colic by the presence of an inflammatory component.
Pain is initially intermittent, but later usually presents as constant and severe. The
pain may be referred pain that is felt in the right scapula rather than the right upper
quadrant or epigastric region. It may also correlate with eating greasy, fatty, or fried
foods. Diarrhea, vomiting, and nausea are common. The Murphy sign is sensitive, but
not specific for cholecystitis. Elderly patients and those with diabetes may have vague symptoms
that may not include fever or localized tenderness. More severe symptoms such as high fever, shock
and jaundice indicate the development of complications such as abscess formation, perforation or
ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder
perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal
obstruction. Chronic cholecystitis manifests with non-specific
symptoms such as nausea, vague abdominal pain, belching, and diarrhea.
Causes The majority of cases of cholecystitis are
caused by gallstones impacting or impinging on the flow of bile in the biliary tree. Gallstone
impaction, called cholelithiasis, most commonly occurs at the neck of the gallbladder or in
the cystic duct. This leads to inspissation of bile, bile stasis,
and secondary infection by gut organisms, predominantly E. coli and Bacteroides species.
The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture.
Inflammation often spreads to its outer covering, thus irritating surrounding structures such
as the diaphragm and bowel. Less commonly, the gallbladder may become
inflamed in the absence of a gallstone, known as acalculous cholecystitis. This is more
common in debilitated patients, such as those in intensive care units, and also in patients
with hemolytic anaemias such as sickle cell disease and diabetes mellitus.
Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient
might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where
the gallbladder is fibrotic and calcified. Diagnosis
Cholecystitis is usually diagnosed by a history of the above symptoms, as well as examination
findings: Fever
Tender right upper quadrant with or without Murphy's sign
Ortner's sign — tenderness when hand taps the edge of right costal arch. Named for Norbert
Ortner, an Austrian Surgeon. Georgievskiy-Myussi's sign — pain when press
between edges of sternocleidomastoid. Named for Konstantin Kirelei Georgievskiy and Vitali
Lev Myussi, Russian Internists. Boas' sign — Increased sensitivity below
the right scapula Subsequent laboratory and imaging tests are
used to confirm the diagnosis and exclude other possible causes.
Ultrasound is paramount in differential diagnosis. Ultrasound findings suggestive of acute cholecystitis
include pericholecystic fluid, >4 mm gallbladder wall thickening, and Murphy's sign. Visualization
of gallstones on ultrasound helps confirm the diagnosis of cholecystitis. Computed tomography
scan, magnetic resonance imaging, and hepatobiliary scintigraphy are also useful in the detection
of cholecystitis. Endoscopic retrograde cholangiopancreatography may be useful to visualize the anatomy.
Differential diagnosis Acute cholecystitis
This should be suspected whenever there is acute right upper quadrant or epigastric pain,
other possible causes include: Perforated peptic ulcer
Acute peptic ulcer exacerbation Amoebic liver abscess
Acute amoebic liver colitis Acute pancreatitis
Acute intestinal obstruction Renal colic
Acute retro-colic appendicitis Chronic cholecystitis
The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may
be mistaken for other common disorders: Peptic ulcer
Hiatus hernia Colitis
Functional bowel syndrome, is defined pathologically by the columnar epithelium reaching down to
the muscular layer. Quick Differential
Biliary colic — Caused by obstruction of the cystic duct. It is associated with sharp
and constant epigastric pain in the absence of fever, and there is usually a negative
Murphy's sign, although it can be positive in some instances. Liver function tests are
within normal limits since the obstruction does not necessarily cause blockage in the
common hepatic duct, thereby allowing normal bile excretion from the liver. An ultrasound
scan is used to visualise the gallbladder and associated ducts, and also to determine
the size and precise position of the obstruction. Cholecystitis — Caused by blockage of the
cystic duct with surrounding inflammation, usually due to infection. Typically, the pain
is initially 'colicky', and becomes constant and severe, mostly in the right upper quadrant.
Infectious agents that cause cholecystitis include E. coli, Klebsiella, Pseudomonas,
B. fragilis and Enterococcus. Murphy's sign is positive, particularly because of increased
irritation of the gallbladder lining, and similarly this pain radiates to the shoulder,
flank or in a band like pattern around the lower abdomen. Laboratory tests frequently
show raised hepatocellular liver enzymes with a high white cell count. Ultrasound is used
to visualise the gallbladder and ducts. Choledocholithiasis — This refers to blockage
of the common bile duct where a gallstone has left the gallbladder or has formed in
the common bile duct. As with other biliary tree obstructions it is usually associated
with 'colicky' pain, and because there is direct obstruction of biliary output, obstructive
jaundice. Liver function tests will therefore show increased serum bilirubin, with high
conjugated bilirubin. Liver enzymes will also be raised, predominately GGT and ALP, which
are associated with biliary epithelium. The diagnosis is made using endoscopic retrograde
cholangiopancreatography, or the nuclear alternative. One of the more serious complications of choledocholithiasis
is acute pancreatitis, which may result in significant permanent pancreatic damage and
brittle diabetes. Cholangitis — An infection of entire biliary
tract, and may also be known as 'ascending cholangitis', which refers to the presence
of pathogens that typically inhabit more distal regions of the bowel
Cholangitis is a medical emergency as it may be life-threatening and patients can rapidly
succumb to acute liver failure or bacterial sepsis. The classical sign of cholangitis
is Charcot's triad, which is right upper quadrant pain, fever and jaundice. Liver function tests
will likely show increases across all enzymes with raised bilirubin. As with choledocholithiasis,
diagnosis is confirmed using cholangiopancreatography. It is worth noting that bile is an extremely
favorable growth medium for bacteria, and infections in this space develop rapidly and
may become quite severe. Xanthogranulomatous cholecystitis
Xanthogranulomatous cholecystitis is a rare form of gallbladder disease which mimics gallbladder
cancer although it is not cancerous. It was first discovered and reported in the medical
literature in 1976 by J.J. McCoy, Jr., and colleagues.
Investigations Blood
Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated
bilirubin, and possibly an elevation of the WBC count. CRP is often elevated. The degree
of elevation of these laboratory values may depend on the degree of inflammation of the
gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal
laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.
Radiology Sonography is a sensitive and specific modality
for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis
of acute cholecystitis are 88% and 80%, respectively. The diagnostic criteria are gallbladder wall
thickening greater than 3mm, pericholecystic fluid and sonographic Murphy's sign. Gallstones
are not part of the diagnostic criteria as acute cholecystitis may occur with or without
them. The reported sensitivity and specificity of
CT scan findings are in the range of 90–95%. CT is more sensitive than ultrasonography
in the depiction of pericholecystic inflammatory response and in localizing pericholecystic
abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot
see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.
Hepatobiliary scintigraphy with technetium-99m DISIDA analog is also sensitive and accurate
for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall
bladder to expel bile, and low gall bladder ejection fraction has been linked to chronic
cholecystitis. However, since most patients with right upper quadrant pain do not have
cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose
other causes, as well. Management
For most patients diagnosed with acute cholecystitis, the definitive treatment is surgical removal
of the gallbladder, cholecystectomy. Until the late 1980s surgical removal was usually
accomplished by a large incision in the upper right quadrant of the abdomen under the rib
cage. Since the advent of laparoscopic surgery in the early 1990s, laparoscopic cholecystectomy
has become the treatment of choice for acute cholecystitis. Laparoscopic cholecystectomy
is performed using several small incisions located at various points across the abdomen.
Several studies have demonstrated the superiority of laparoscopic cholecystectomy when compared
to open cholecystectomy. Patient undergoing laparoscopic surgery report less incisional
pain postoperatively as well as having fewer long term complications and less disability
following the surgery. Additionally, laparoscopic surgery is associated with a lower rate of
surgical site infection. During the days prior to laparoscopic surgery,
studies showed that outcomes were better following early removal of the gallbladder, preferably
within the first week. Patients receiving early intervention had shorter hospital stays
and lower complication rates. In the era of laparoscopic surgery, a similar approach is
still advocated. In a 2006 Cochrane review, early laparoscopic cholecystectomy was compared
to delayed treatment. The review consisted of 5 trials with 451 patients randomized to
either early or delayed surgical management. There was no statistically significant difference
in terms of negative outcomes including bile duct injury or conversion to open cholecystectomy.
However, the early group was found to have shorter hospital stays. For early cholecystectomy,
the most common reason for conversion to open surgery is inflammation obscuring Calot's
triangle. For delayed surgery, the most common reason was fibrotic adhesions.
Supportive measures are usually instituted prior to surgery. These measures include fluid
resuscitation and antibiotics targeting enteric organisms, such as E coli and Bacteroides.
Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam,
ampicillin-sulbactam, ticarcillin-clavulanate, or a cephalosporin and an antibacterial with
good coverage and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic
patients, aztreonam and clindamycin may be used. Parenteral narcotics can be used for
pain control. In cases of severe inflammation, shock, or
if the patient has higher risk for general anesthesia, the managing physician may elect
to have an interventional radiologist insert a percutaneous drainage catheter into the
gallbladder and treat the patient with antibiotics until the acute inflammation resolves. A cholecystectomy
may then be warranted if the patient's condition improves.
Homeopathic approaches to treating cholecystitis have not been validated by evidence and should
not be used in place of surgery. Complications
Perforation or rupture Ascending cholangitis
Rokitansky-Aschoff sinuses Cholecystectomy
emphysematous cholecystitis bile leak
bile duct injury abscess
wound infection bleeding
hernia organ injury
deep vein thrombosis/pulmonary embolism fatty acid and fat-soluble vitamin malabsorption
Gall bladder perforation Gall bladder perforation is a rare but life-threatening
complication of acute cholecystitis. The early diagnosis and treatment of GBP are crucial
to decrease patient morbidity and mortality. Approaches to this complication will vary
based on the condition of an individual patient, the evaluation of the treating surgeon or
physician, and the facilities' capability. Perforation can happen at the neck from pressure
necrosis due to the impacted calculus, or at the fundus. It can result in a local abscess,
or perforation into the general peritoneal cavity. If the bile is infected, diffuse peritonitis
may occur readily and rapidly and may result in death A retrospective study looked at 332
patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis.
Patients were treated with analgesics and antibiotics within the first 36 hours after
admission, and proceeded to surgery for a cholecystectomy. Two patients died and 6 patients
had further complications. The morbidity and mortality rates were 37.5% and 12.5%, respectively
in the present study. The authors of this study suggests that early diagnosis and emergency
surgical treatment of gallbladder perforation are of crucial importance.
See also gallstone
Boas' sign Murphy's sign
References