Cholecystitis

Patients with acute cholecystitis usually present with the following symptoms:

• Pain: Patients with cholecystitis usually present with right upper quadrant pain which radiates to the tip of right shoulder. There may be tenderness in right hypochondrium.
• Symptoms typically start after eating.
  Fever: Patient may present with fever and possibly chills [5].
• Jaundice: Mild jaundice with dark urine and pale stools may also be present.
• Other symptoms: These include anorexia, nausea, vomiting, sweating and abdominal bloating.
• More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, ascending cholangitis or perforation. Sepsis or pancreatitis may also develop [6].

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.

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.

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%.

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.

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.

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].

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.

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.

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.

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