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Chronic Cholecystitis

Chronic cholecystitis denotes persistent inflammation of the gallbladder on the grounds of gallstone formation, chronic irritation and super saturation of bile. Clinical presentation includes abdominal pain, nausea and vomiting, and the disease often has an insidious onset.


Presentation

The clinical presentation of cases with chronic cholecystitis may be insidious, and a slowly progressive development of symptoms is observed. Symptoms are generally mild and patients are not significantly impaired, which is why patient history often reveals that the duration of symptoms is months or even years. Recurrent biliary colic, which occurs as a result of transient obstruction of the biliary ducts by gallstones can be manifested as either epigastric or right hypochondrial abdominal pain and is the most common manifestation. Nausea, vomiting, significant discomfort when eating fatty foods may also be reported. Fever may be present in some cases, but it usually indicates an acute process, and it is not uncommon for episodes of acute cholecystitis to occur.

Fever
  • The patient, a 69-year-old man, was admitted for epigastric pain, nausea, vomiting, and fever.[ncbi.nlm.nih.gov]
  • -intermittent jaundice reynold's pentad of acute obstructive jaundice -persistent pain -persistent fever -persistent jaundice -altered mental status -shock[cram.com]
  • Upper abdominal tenderness may be present, but usually fever is not. Fever suggests acute cholecystitis. Once episodes begin, they are likely to recur.[msdmanuals.com]
  • Sometimes there is associated low grade fever. Blood examination indicates high rise in white blood cell count. There is high risk of perforation or rupture of gallbladder in chronic cholecystitis.[tandurust.com]
Weight Loss
  • If you need to lose weight, try to do it slowly because rapid weight loss can increase your risk of developing gallstones.[healthline.com]
  • If you need to lose weight, take care to do it slowly because rapid weight loss can increase your risk of developing gallstones.[healthtools.aarp.org]
  • Classic symptoms are diarrhea and weight loss. A small percent of patient may have constipation but not severe. Common causes of severe constipation are meds induced, diet related, not drinking enough fluids, and metabolic changes.[healthtap.com]
  • Symptoms Right upper abdominal pain , nausea, vomiting , fever [1] Duration Short term or long term [2] Causes Gallstones, severe illness [1] [3] Risk factors Birth control pills , pregnancy , family history, obesity , diabetes , liver disease , rapid weight[en.wikipedia.org]
Chills
  • Signs and symptoms include: severe abdominal pains that may feel sharp or dull abdominal cramping and bloating pain that spreads to your back or below your right shoulder blade fever and chills nausea and vomiting loose, light-colored stools jaundice[healthtools.aarp.org]
  • Symptoms include: severe abdominal pains that may feel sharp or dull abdominal cramping and bloating pain that spreads to your back or below your right shoulder blade fever chills nausea vomiting loose, light-colored stools jaundice , which is when your[healthline.com]
  • Clinical Options Specialists distinguish several different clinical variants of the disease, differing in course and symptoms: cardiac - characterized by a violation of the heart rhythm; subfebrile - prolonged rise in body temperature to 37-38 degrees, chills[en.medicine-worlds.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]
Amyloidosis
  • Amyloidosis is a rare disease defined by extracellular deposits of amorphous fibrillar proteins, derived from aggregations of misfolded proteins. Localization of amyloidosis in the gallbladder is uncommon; only eight cases have been reported.[ncbi.nlm.nih.gov]
Nausea
  • The patient, a 69-year-old man, was admitted for epigastric pain, nausea, vomiting, and fever.[ncbi.nlm.nih.gov]
  • In the morning, before taking food, a frequent state of nausea and vomits of a bilious, mucous, exceptionally alimentitious type is observed.[homeoint.org]
  • Symptoms such as jaundice, urinary difficulty, nausea, bloating and more. Western conditions could be cirrhosis, gallbladder disease, alcohol toxicity and more.[theory.yinyanghouse.com]
  • The patient feels dull aches, with a locating in the right hypochondria, periodically shows complaints to nausea, vomiting, the distended abdomen, regular diarrheas after meals.[abdominal-pain-cure.com]
Vomiting
  • The patient, a 69-year-old man, was admitted for epigastric pain, nausea, vomiting, and fever.[ncbi.nlm.nih.gov]
  • A 55-year-old previously healthy male patient presented with repeated attacks of right hypochondriac pain and vomiting. On physical examination, the right upper abdomen was tender to palpation with a positive Murphy's sign.[ncbi.nlm.nih.gov]
  • Bitter taste and halitosis, intense thirst, nausea or vomiting when taking warm food. The product vomited is yellowish or greenish, exceptionally alimentitious.[homeoint.org]
  • The patient feels dull aches, with a locating in the right hypochondria, periodically shows complaints to nausea, vomiting, the distended abdomen, regular diarrheas after meals.[abdominal-pain-cure.com]
Abdominal Pain
  • A 61 year old man presented with abdominal pain typical of chronic cholecystitis of one month's duration. Pallor was noted on examination and investigation uncovered myelofibrosis and a small gallstone.[ncbi.nlm.nih.gov]
  • Seventy-five patients with abdominal pain in the right upper quadrant who were subsequently confirmed operatively and histologically to have acute or chronic cholecystitis underwent radionuclide imaging of the biliary tree, ultrasonography, and/or computerized[ncbi.nlm.nih.gov]
  • A 47-year-old woman presented with a history of vague abdominal pain for several years, which worsened over the past 2 months, with pain more prominent in the right upper quadrant. She also had a history of peptic ulcer disease.[ncbi.nlm.nih.gov]
  • We report a patient who presented with colicky abdominal pain, hematemesis, and melena following a blunt abdominal injury sustained in an automobile accident.[ncbi.nlm.nih.gov]
  • The authors interviewed 269 patients who underwent either OCG, US, or both, for evaluation of chronic right upper quadrant abdominal pain.[ncbi.nlm.nih.gov]
Diarrhea
  • Constipation because of hepato-biliary, insufficiency, lack of desire to evacuate with mucous evacuations ordinarily alternating with an intensely yellow or greenish diarrhea, with ardor and tenesmus after defecation. Postprandial diarrhea.[homeoint.org]
  • Saeed 10 10 Can celiac disease cause chronic severe constipation instead of diarrhea? Dr. Imran Saeed Dr. Saeed Unlikely: Celiac disease is secondary to damage to the lining of small intestine. Classic symptoms are diarrhea and weight loss.[healthtap.com]
  • The patient feels dull aches, with a locating in the right hypochondria, periodically shows complaints to nausea, vomiting, the distended abdomen, regular diarrheas after meals.[abdominal-pain-cure.com]
  • […] cholecystitis may include Having a bitter taste on the back of the tongue (especially in the morning) – this happens as a result of the bile reflux from duodenum into the esophagus; Bitter belching, which can sometimes be followed by vomiting of bile; Diarrhea[ahealthgroup.com]
Upper Abdominal Pain
  • Upper abdominal pain is the most common symptom of cholecystitis. In acute cholecystitis, the pain is often sudden and intense. Pain can become excruciating.[rarediseases.org]
  • Specialty General surgery , gastroenterology Symptoms Right upper abdominal pain , nausea, vomiting , fever [1] Duration Short term or long term [2] Causes Gallstones, severe illness [1] [3] Risk factors Birth control pills , pregnancy , family history[en.wikipedia.org]
  • Signs and symptoms The most common presenting symptom of acute cholecystitis is upper abdominal pain.[emedicine.medscape.com]
  • The typical symptoms of cholangitis are fever, right upper abdominal pain, and jaundice. Another possible problem that may occur when gallstones pass into the common bile duct is acute pancreatitis (inflammation of the pancreas).[drugs.com]
Biliary Colic
  • Symptoms and Signs Gallstones intermittently obstruct the cystic duct and so cause recurrent biliary colic.[msdmanuals.com]
  • colic, usu. fertile fat females forty years or less Symptoms constant right upper quadrant pain after a meal (biliary colic) Prevalence very common Prognosis good, benign Chronic cholecystitis , abbreviated CC , is a very common pathology of the gallbladder[librepathology.org]
  • Patients may have a history of recurrent acute cholecystitis or biliary colic, although some may be asymptomatic. Microscopically, there is evidence of chronic inflammation within the gallbladder wall.[radiopaedia.org]
Dark Urine
  • Jaundice with mahogany-dark urine, discolored faeces due to the absence of stercobilin. Retention of biliary salts with intense pruritus all about the skin and bradycardia. Intestinal fermentation dyspepsia.[homeoint.org]
  • Symptoms of acute cholecystitis include: Pain in the upper abdomen, which can extend to the right shoulder Fever and possibly chills Nausea or vomiting Jaundice Dark urine or stool Cholecystitis treatment options and prevention Treatment of acute cholecystitis[belmarrahealth.com]
  • Fever and possibly chills Nausea and/or vomiting Jaundice (yellowing of the skin or eyes), dark urine and pale, grayish bowel movements.[drugs.com]
  • You may also develop indigestion and other digestive upset, nausea, vomiting, fever, chills, chest pain, dark urine, or clay-colored stools.[everydayhealth.com]

Workup

Patients with recurrent abdominal pain and suspected development of gallstones should be evaluated through various imaging techniques [10]. Abdominal ultrasonography is the initial diagnostic procedure of choice, as it can clearly show the presence of gallstones, while changes in gallbladder shape can be detected by this method as well. Other imaging techniques, such as, computed tomography (CT), magnetic resonance imaging (MRI) or hepatobiliary scintigraphy (HIDA) may be used as well if ultrasound shows inconclusive results. 

In addition to imaging techniques, blood levels of amylase, lipase, bilirubin, liver transaminases (including ALT and AST), lactate dehydrogenase, alkaline phosphatase (ALP) should be determined, together with a complete blood count (CBC). Because recurrent abdominal pain may resemble pyelonephritis, urinalysis should be performed, and abdominal ultrasound should include examination of the kidneys, to rule out infection of the renal system as a possible cause of symptoms.

Nonvisualization of the Gallbladder
  • Using nonvisualization of the gallbladder for up to 4 h as the criterion for acute cholecystitis, the sensitivity and specificity for acute cholecystitis were 97 and 66%, respectively.[ncbi.nlm.nih.gov]
  • Cholescintigraphy may show nonvisualization of the gallbladder but is less accurate. Treatment Laparoscopic cholecystectomy Laparoscopic cholecystectomy is indicated to prevent symptom recurrence and further biliary complications.[msdmanuals.com]

Treatment

Surgical treatment is the method of choice for chronic cholecystitis, primarily because of the complications it may cause, but also to prevent recurrent development of symptoms [11]. Laparoscopic cholecystectomy is recommended over open cholecystectomy primarily because mortality rates were shown to be significantly higher when performing open cholecystectomy [12], but also because patients with additional comorbidities may not be suitable for open surgery [13]. Moreover, early surgical treatment was established to provide significantly better recovery rates, reduced mortality rates, and shorter duration of hospital stay [14]. Additional procedures may include endoscopic retrograde cholangiopancreatography (ERCP), which is used to remove gallstones from the biliary ducts.

Prognosis

Having in mind its slowly progressive course, which can present as a significant challenge for the physician, this disorder may cause significant morbidity to patient. Numerous complications may arise [9]:

  • Super infection by bacterial organisms, which may lead to cholangitis or life-threatening sepsis.
  • Gallbladder perforation, local abscess formation, or rupture that may lead to peritonitis.
  • Formation of cholecystenteric fistulas, that consequently drain bile into adjacent organs, or may present as a mean of bacterial entry into the biliary tree.
  • Further progression of pre-existing conditions, such as liver cirrhosis, heart failure and chronic kidney disease.

For these reasons, it is imperative to obtain a diagnosis while chronic cholecystitis is in its early stages, to prevent these complications and provide significant benefit to the patient.

Etiology

Presumably, chronic cholecystitis almost exclusively occurs because of gallstone formation, while preceding acute cholecystitis plays a minor role in its development. In rare cases, chronic cholecystitis may also develop without the presence of gallstones (acalculous cholecystitis), in which case other causes may be responsible. Bacterial pathogens, primarily Helicobacter pylori [2], but also Escherichia coli and enterococcal species have been associated with disorders of the biliary system and are supposedly involved in both acute and chronic inflammation of the gallbladder. 

Epidemiology

Chronic cholecystitis occurs in the setting of cholelithiasis in the vast majority of cases, and it is described as the most important risk factor for the development of this disease. Both genetic and geographic factors are deemed to be important determinants for the development of gallstones [3]. Prevalence of gallstones has been established to be very high in certain ethnic groups such as Native and Mexican Americans, and people living in Northern Europe, while lowest prevalence rates are observed in the African populations [4]. Epidemiological studies indicate that between 10-20% of people living in the United States have gallstones and are at increased risk for chronic cystitis, while similar rates are observed in Central Europe and Asia. Significant gender predilection toward females has been established, with a 2:1 or 3:1 ratio. Additional risk factors for gallstone formation, thereby chronic cholecystitis include advanced age, hyperlipidemic syndromes (either metabolic defects or dietary habits), obesity and bile stasis [5].

Sex distribution
Age distribution

Pathophysiology

The pathogenesis of chronic cholecystitis generally starts with gallstone formation and they exert significant damage to the gallbladder epithelium [6]. However, other factors are also involved in the onset of inflammation and its persistence throughout time, such as bile super saturation, while infections have been hypothesized to contribute as well. Various bacterial pathogens have been cultured in patients suffering from cholecystitis, including Helicobacter pylori, Escherichia coli and other species that are known to reside in bile ducts, implying that they also play a role in the pathogenesis of this condition [7]. 

All of these factors result in structural and morphological changes in the gallbladder wall, including extensive fibrosis and development of calcifications ("porcelain gallbladder"), while chronic inflammatory cells have been identified in many patients. Still, the exact mechanism of its occurrence remains incompletely understood.

Additionally, cholecystitis has implications in the development of preneoplastic lesions, and eventual development of gallbladder cancer [8].

Prevention

The burden of chronic cholecystitis may be significantly reduced on a global basis through several preventive measures. Since hyperlipidemia and obesity have been brought into connection with this disease, proper dietary habits should be instated. Additionally, patients in whom a diagnosis of cholelithiasis (gallstones) has been established, proper therapeutic regimens should be carried out and regular follow-ups should be conducted to prevent the onset of chronic and irreversible damage to the gallbladder, especially if symptoms are present.

Summary

Chronic cholecystitis is a term that describes persistent, long-standing inflammation of the gallbladder, which almost always occurs on pre-existing gallstone formation and sometimes recurrent bouts of acute cholecystitis. Additionally, bacterial pathogens such as Helicobacter pylori, and gram-negative bacteria have also been found associated with the condition in a significant number of patients, implying an infectious component in the disease pathogenesis [1]. Changes that are observed include extensive calcification and fibrosis (termed "porcelain gallbladder"), while absence of acute inflammatory infiltrates distinguishes this condition from acute cholecystitis. Cholecystitis is one of the most common indications for abdominal surgery throughout the world and several risk factors have been established. Significant predilection toward female gender has been observed, due to much more common rates of cholelithiasis among females, and this ratio is the largest among middle-aged adults. Additionally to gender, obesity, hyperlipidemia, pregnancy, but also genetic and geographic factors may contribute to development of this disorder. Chronic forms of cholecystitis tend to have a very slow progression and may be without symptoms in its early stages. Symptoms, when present, include nausea, vomiting, epigastric and right upper quadrant pain. The diagnosis is made through various laboratory tests and abdominal ultrasonography. Because numerous complications may arise from chronic cholecystitis, some of them even life-threatening, such as bacterial superinfection, perforation or rupture of gallbladder, or formation of biliary enteric fistulas, surgical treatment is indicated. In most cases, laparoscopic cholecystectomy is recommended.

Patient Information

Chronic cholecystitis implies prolonged inflammation of the gallbladder, which most commonly occurs in patients with gallstones. The main function of the gallbladder is to store bile and release it into the gastrointestinal tract to facilitate food digestion.

In most cases, gallstones contribute to chronic irritation and inflammation of the gallbladder by mechanical irritation of its wall and bile ducts and induce scarring and fibrosis of the gallbladder wall (in which case the term "porcelain gallbladder" is used). Certain bacterial microorganisms, such as Helicobacter pylori, which are the cause of acute gastritis, and other pathogens such as Escherichia coli, have been implicated in the development of chronic cholecystitis. Chronic cholecystitis almost universally occurs in patients with gallstones. The common risk factors associated with cholecystitis are obesity, increased amount of fat in circulation and a female gender predilection predisposing individuals to this disorder. Pregnancy and use of oral contraceptives have been associated with gallstone formation in females.

Chronic cholecystitis is characterized by a slow onset of symptoms that are usually recurrent, which include abdominal pain, usually below the ribs or in the right upper corner, in the projection of gall bladder and most commonly occurs due to transient passage of gallstones through the bile ducts (known as biliary colic). Other symptoms include nausea, vomiting and intolerance to foods that are rich in fat, while patients who report fever are more likely suffering from acute cholecystitis. The diagnosis of this condition can be made by performing abdominal ultrasonography, which can provide a clear view into the contents of the gallbladder and its wall, while additional tests that evaluate liver and gallbladder function should be performed as well.

Because various complications can arise in patients suffering from cholecystitis, such as sepsis, gallbladder perforation or rupture and subsequent leakage of bile into other organs, surgical removal of gallbladder, known as cholecystectomy, is indicated in all patients. More specifically, laparoscopic cholecystectomy is recommended, because this method is less invasive than open cholecystectomy, and shows much better results in terms of lower mortality rates and shorter time of recovery. It is established that surgical treatment of this disease significantly improves outcomes in patients, which is why an early diagnosis of chronic cases of cholecystitis may be life-saving. Significant steps in prevention of this disease can be made, such as restriction of food that is high in fat and regular monitoring of fat content in blood. Patients in whom gallstones are already diagnosed should be regularly followed-up, while symptoms should be reported immediately after their appearance.

References

Article

  1. Chen DF, Hu L, Yi P, et al. H. pylori exist in the gallbladder mucosa of patients with chronic cholecystitis. World J Gastroenterol. 2007;13:1608-1611. 
  2. Lee JW, Lee DH, Lee JI, et al. Identification of Helicobacter pylori in Gallstone, Bile, and Other Hepatobiliary Tissues of Patients with Cholecystitis. Gut Liver. 2010;4:60-67.
  3. Sarin SK, Negi VS, Dewan R, et al. High familial prevalence of gallstones in the first-degree relatives of gallstone patients. Hepatology. 1995;22:138–141.
  4. Stinton LM, Shaffer EA. Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut and Liver. 2012;6(2):172-187.
  5. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J. 2011. 
  6. Kimura Y, Takada T, Kawarada Y, et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. Journal of Hepato-Biliary-Pancreatic Surgery. 2007;14(1):15-26. 
  7. Zhou D, Zhang Y, Gong W, et al. Are Helicobacter pylori and other Helicobacter species infection associated with human biliary lithiasis? A meta-analysis. PLoS One. 2011;6 (11):e27390.
  8. Hsing AW, Gao YT, Han TQ, et al. Gallstones and the risk of biliary tract cancer: a population-based study in China. Br J Cancer. 2007;97:1577–1582.
  9. Andreotti G, Liu E, Gao YT, et al. Medical history and the risk of biliary tract cancers in Shanghai, China: implications for a role of inflammation. Cancer Causes Control. 2011; 22: 1289-1296.
  10. Bennett GL. Evaluating Patients with Right Upper Quadrant Pain. Radiol Clin North Am. 2015;53(6):1093-1130.
  11. Dolan JP, Diggs BS, Sheppard BC, et al. The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: 1997-2006. J Gastrointest Surg. 2009;13(12):2292-2301.
  12. Huang J, Chang CH, Wang JL, et al. Nationwide epidemiological study of severe gallstone disease in Taiwan. BMC Gastroenterol. 2009;9:63.  
  13. Keus F, de Jong JA, Gooszen HG, et al. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006;4:CD006231.
  14. Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin N Am. 2014;94:455-470.

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Last updated: 2018-06-22 02:06