Edit concept Create issue ticket

Cholecystitis

Cholecystitis is the inflammation of the gallbladder, most commonly caused by the presence of gallstones.


Presentation

Patients with acute cholecystitis usually present with the following symptoms:

Chills
  • Symptomatology: —Among the first symptoms are chill and fever. Usually the fever does not exceed 101.5 or 102 F., except in the suppurative forms, when it becomes remittent in character, and in the exacerbations may reach 104 or 104.5 F.[henriettes-herb.com]
  • Symptoms include right upper quadrant pain and tenderness, sometimes accompanied by fever, chills, nausea, and vomiting. Abdominal ultrasonography detects the gallstone and sometimes the associated inflammation.[merckmanuals.com]
  • The patient also experiences nausea , vomiting , and chills. In chronic cholecystitis the gallbladder often is contracted rather than swollen; its wall is grayish white, tough, and thickened.[britannica.com]
Dyspepsia
  • Flatulent dyspepsia: Diagnosis: Ultrasonography is usually the only investigation needed to show gallstones. A bile duct 8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation.[en.wikibooks.org]
  • Biliary colic (colicky RUQ pain ) Especially postprandial May radiate to the epigastrium, right shoulder, and back Nausea , vomiting , feelings of satiety Bloating , dyspepsia Choledocholithiasis Colicky RUQ/epigastric pain Nausea , vomiting Extrahepatic[amboss.com]
  • Other findings, such as fever, nausea, vomiting, diarrhea, dyspepsia, fatigue, altered mental status and jaundice may be present, but they are very nonspecific sysmptoms [ 55 , 63 ].[pancreas.imedpub.com]
Abdominal Mass
  • On physical examination, he presented fatigue, diffuse abdominal pain to superficial and deep palpation, and no abdominal masses or signs of peritoneal irritation.[scielo.br]
Jaundice
  • A 61-year-old man presented with upper abdominal pain and jaundice.[ncbi.nlm.nih.gov]
  • We placed a plastic stent of 8.5Fr and 12 cm in length in the hepatic duct, and after biliary plastic stent placement, jaundice was rapidly reduced and liver function was improved significantly.[ncbi.nlm.nih.gov]
  • Jaundice: Mild jaundice with dark urine and pale stools may also be present. Other symptoms: These include anorexia, nausea, vomiting, sweating and abdominal bloating.[symptoma.com]
  • Jaundice: The inability to dispose of bile properly can lead to a build up of bilirubin in the body. This causes jaundice, which is when your skin and the whites of your eyes turn yellow.[doctorshealthpress.com]
  • Watch for increasing jaundice, which may be a sign of ongoing CBD obstruction or acute cholangitis.[clinicaladvisor.com]
Shoulder Pain
  • Constant right upper quadrant pain that can radiate to the right shoulder. Pain typically persists for more than six hours, in contradistinction to the intermittent right upper quadrant pain of biliary colic.[radiopaedia.org]
  • For example, sometimes a patient may not realize that their stomach pain may be related to their recent onset of shoulder pain.[physio-pedia.com]
  • Nausea is common and vomiting occurs in 75% of people with cholecystitis. [14] In addition to abdominal pain, right shoulder pain can be present. [13] On physical examination, fever is common. [14] A gallbladder with cholecystitis is almost always tender[en.wikipedia.org]
Hyperesthesia
  • Boas sign It is hyperesthesia of the skin below the scapula. Laboratory investigations Leukocytosis: Leukocytosis with a left shift may be observed in cholecystitis . Ultrasonography: Ultrasonography is the most useful investigation.[symptoma.com]

Workup

Cholecystitis is diagnosed clinically by history and physical examination. The following signs are specific for cholecystitis.

Murphy’s sign

It is inspiratory arrest during deep palpation of right upper quadrant. It occurs due to touching of the inflammed gallbladder with parietal peritoneum. When parietal peritoneum touches the gallbladder, severe pain is felt and patient immediately withholds the breath by reflex mechanism.

Boas sign

It is hyperesthesia of the skin below the scapula.

Laboratory investigations

  • Leukocytosis: Leukocytosis with a left shift may be observed in cholecystitis .
  • Ultrasonography: Ultrasonography is the most useful investigation [7]. Acute cholecystitis is indicated by features such as thick walled (>3mm) gallbladder, pericholecystic fluid and sonographic Murphy's sign.
  • CT scan: It might not be helpful for detecting gallstones, but usually provides an excellent view of the gallbladder, plus the surrounding structures such as liver, bile duct and pancreas.
  • Radionuclide Scan: A hepatobiliary iminodiacetic acid scan will show non filling of gallbladder even after 24 hours of injection. It involves injecting a radioactive chemical in body. The chemical binds to the bile producing-cells, so it can be clearly seen as it travels with the bile through the bile ducts.
Liver Biopsy
  • Because of the symptoms, laboratory findings, results of a drug-induced lymphocyte stimulation test, and pathological findings of liver biopsy, we diagnosed her with drug-induced liver injury.[ncbi.nlm.nih.gov]

Treatment

The treatment of choice for acute cholecystitis is cholecystectomy; however, patient should be resuscitated and prepared before this operation can be performed. Cholecystectomy can be performed laparoscopically or by open surgery. Laparoscopic cholecystectomy is the better option of the two [8]. Cholecystectomy can be performed within 2-3 days of illness or after 6-10 weeks of initial attack.

More than 90% of uncomplicated cases of acute cholecystitis resolve spontaneously with conservative measures. Conservative measures in this group of patients include the following:

  • Nil per oral (i.e. oral intake of food is ceased).
  • Antibiotics: Antibiotic regimen in cholecystitis usually consist of broad spectrum antibiotics such as cephalosporins, clindamycin and metronidazole [9] [10].
  • Analgesics: Parenteral narcotics can be used to control pain until the inflammation in gall bladder is relieved.
  • Intravenous fluids.
  • Patient is monitored with blood pressure, pulse and temperature.

Emergency cholecystectomy should be performed in these conditions.

  • Worsening of symptoms despite of conservative management.
  • Detection of gas in biliary tract.
  • Empyema of gallbladder.
  • Established generalized peritonitis.
  • Gangrene or perforation of gallbladder.

In patients who are severly ill and cannot tolerate general anesthesia, a percutaneous cholecystectomy can be performed under ultrasound guidance.

Patients with chronic cholecystitis require the removal of gallbladder surgically. Moreover, removal of gallstones in common bile duct can be done with newer techniques such as endoscopic retrograde cholangiopancreatography.

Prognosis

Uncomplicated cholecystitis has an excellent prognosis. Most cases of acute cholecystitis recover within a few days to a few weeks. However, 25-30% of patients either require surgery or develop some serious complications such as gangrene, perforation, empyema or rupture of gallbladder. In patients with acalculous cholecystitis, mortality rate can be as high as 50-60%.

Etiology

The following factors increase the risk of cholecystitis [2] [3].

  • Gallstones: As much as 90% of the cases of acute cholecystitis are caused by gallstones obstructing the flow of bile in the biliary tree. Gallstone impaction (called cholelithiasis) mostly occurs at the neck of the gallbladder.
  • Female gender: Women have a greater risk of gallstones as compared to men. This makes women more likely to develop cholecystitis.
  • Increasing age: The risk of gallstones increases with age.
  • Obesity: The incidence of cholecystitis is higher in obese women.
  • Drugs: Drugs especially hormonal therapy in women increases the risk of develoing gallstones.
  • Bile duct obstruction: This can lead to obstruction of bile flow, thus causing cholecystitis.
  • Tumor: A tumor may also prevent bile draining out of gallbladder properly, causing bile buildup that can lead to cholecystitis.

Epidemiology

Cholecystectomy performed due to cholecystitis is one of the most common major surgical procedures worldwide. The incidence of cholecystitis increases with age. Gallstones are 2-3 times more common in females than in males. In the United States, the prevalence of gallstones is higher in white people than black people.

Sex distribution
Age distribution

Pathophysiology

In acute calculous cholecystitis, blockage of cystic duct with gallstones causes accumulation of bile in the gallbladder. This can lead to bacterial infection, causing inflammation and distention of the gallbladder. As a result, blood flow and lymphatic drainage are compromised leading to mucosal ischemia, necrosis and cell death.

In acute acalculous cholecystitis, concentrated bile remains stagnant in the lumen causing inflammation of gallbladder and bile duct [4].

Prevention

Since most of the cases of cholecystitis are caused by gallstones, the risk of cholecystitis can be reduced by controlling the risk factors that lead to the formation of gallstones. These include reduction of weight by regular exercise and avoiding a high fat diet.

Summary

Cholecystitis is inflammation of the gallbladder which most commonly occurs due to impaction of gallstones at its neck causing obstruction of the cystic duct. This is known as acute calculous cholecystitis. It results in a buildup of bile in the gallbladder causing it to become inflamed, hyperemic, edematous, tense and distended.

Cholecystitis may also occur in the absence of gallstones in around 10% of the cases [1]. In this case, it is known as acalculous cholecystitis. It critically develops in the patients who are admitted in intensive care units and also in those with extensive burns, sepsis, multiple traumas and hemolytic anemias.
If left untreated, cholecystitis can lead to serious complications, such as gangrene and rupture of gallbladder.

Patient Information

Cholecystitis is the pain and swelling of the gallbladder which occurs most commonly due to stones. The patients usually present with pain in the upper abdomen, fever, vomiting and yellowing of the skin or eyes. The disease is more common in women as compared to men. With proper treatment, the disease has an excellent prognosis.

References

Article

  1. Huffman JL, Schenker S. Acute acalculous cholecystitis: a review. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. Jan 2010;8(1):15-22.
  2. Soustek Z, Dyrhonova V. [Etiology and therapy of cholecystitis and cholelithiasis]. Zeitschrift fur die gesamte innere Medizin und ihre Grenzgebiete. Nov 1 1981;36(21):824-829.
  3. Velikoretskii AN. [Cholelithiasis and cholecystitis (etiology, pathogenesis and classification)]. Fel'dsher i akusherka. Apr 1979;44(4):16-19.
  4. Donovan JM. Physical and metabolic factors in gallstone pathogenesis. Gastroenterology clinics of North America. Mar 1999;28(1):75-97.
  5. Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Annals of emergency medicine. Sep 1996;28(3):273-277.
  6. Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emergency medicine clinics of North America. Nov 1996;14(4):719-737.
  7. Roe J. Evidence-based emergency medicine. Clinical assessment of acute cholecystitis in adults. Annals of emergency medicine. Jul 2006;48(1):101-103.
  8. Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RT, Toouli J. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Annals of surgery. Nov 1993;218(5):630-634.
  9. Kittisupamongkol W. Role of antibiotics in the severity of cholecystitis. American journal of surgery. May 2010;199(5):723; author reply 722-723.
  10. Lishchenko AN. [Is it necessary to use antibiotics in acute cholecystitis?]. Khirurgiia. Jul 1986(7):51-53.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 11:46