Cholecystitis


CHOLECYSTITIS

Description:

Cholecystitis is an inflammation of the gallbladder caused by obstruction of the cystic duct. A gallstone usually causes the obstruction (calculous cholecystitis). The inflammation may be sterile or bacterial. The obstruction may be acalculous or caused by sludge. This obstruction can result in gallbladder distention, gallbladder wall edema, ischemia, and necrosis. Additional inflammatory mediators, specifically prostaglandins, are released resulting in increased gallbladder inflammation.

Cholecystitis

Bacterial infection is thought to be a consequence, not a cause, of cholecystitis. In the early stages of acute cholecystitis, bile is sterile. Approximately 20-75% of bile cultures are eventually positive with the most common organisms being Escherichia coli, Klebsiella species, Enterococci, and Enterobacter. Common bile duct stones (choledocholithiasis, 10%) are either secondary (from the gallbladder) or primary (formed in bile ducts).

Types:

Acute cholecystitis: Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. 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. Treatment usually involves antibiotics and cholecystectomy.

Chronic cholecystitis: Is long-standing gallbladder inflammation almost always due to gallstones. Chronic cholecystitis almost always results from gallstones and prior episodes of acute cholecystitis (even if mild). Damage ranges from a modest infiltrate of chronic inflammatory cells to a fibrotic, shrunken gallbladder. Extensive calcification due to fibrosis is called porcelain gallbladder.

The most serious complication of acute cholecystitis is infection, which develops in about 20% of cases. It is extremely dangerous and life-threatening if it spreads to other parts of the body (septicemia), and surgery is often required. Symptoms include fever, rapid heartbeat, fast breathing, and mental confusion. Among the conditions that can lead to septicemia are the following:

    Gangrene or Abscesses: If acute cholecystitis is untreated and becomes very severe, inflammation can cause abscesses or destroy enough tissue in the gallbladder (necrosis) to lead to gangrene. Studies have reported this complication in between 2 - 30% of cases. The highest risk is in men over 50 with a history of heart disease who have high levels of infection.

  • Perforated Gallbladder: An estimated 10% of acute cholecystitis cases result in a perforated gallbladder, which is a life-threatening condition. In general, this occurs in people who wait too long to seek help or who do not respond to treatment. This condition is most common in people with diabetes. The risk for perforation increases with a condition called emphysematous cholecystitis, in which gas forms in the gallbladder. Once the gallbladder has been perforated, pain may temporarily decrease. This is a dangerous and misleading event, however, since peritonitis (widespread abdominal infection) develops afterward.

  • Empyema: Pus in the gallbladder (empyema) occurs in 2 - 3% of patients with acute cholecystitis. Patients usually experience severe abdominal pain for more than 7 days. The physical exam often fails to reveal the underlying cause. The condition can be life-threatening, particularly if infection spreads to other parts of the body.

  • Fistula: In some cases, the inflamed gallbladder adheres to and perforates nearby organs, such as the small intestine. In such cases a fistula (channel) between the organs develops. Sometimes, in these cases, gallstones can actually pass into the small intestine, which can be very serious and requires immediate surgery.

  • Gallstone Ileus: A gallstone blocking the intestine is known as gallstone ileus. It primarily occurs in patients over age 65, and can sometimes be fatal. Depending on where the stone is located, surgery to remove the stone may be required.

Symptoms:

Symptoms of acute 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 spreads to between the shoulder blades, to the right shoulder blade, or to the right shoulder. Symptoms typically start after eating.

  • Fever.

  • Shaking chills.

  • Nausea and/or vomiting.

  • Loss of appetite.

  • 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.

  • When gallstones in the common bile duct block the flow of bile from the liver to the intestine, the patient may develop a serious infection of the bile ducts called cholangitis. The typical symptoms of cholangitis are fever, right upper abdominal pain and jaundice.

Symptoms of chronic cholecystitis can include any of the above. However, some people do not have any symptoms. If you have abdominal pain, it is usually very mild, and comes and goes. You also may have indigestion or gas. These symptoms accompany so many other illnesses, so you may not be diagnosed with chronic cholecystitis until you have an episode of more severe symptoms during a sudden attack.

Causes and Risk factors:

In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Severe illness, alcohol abuse and, rarely, tumors of the gallbladder may also cause cholecystitis.

Acute cholecystitis causes bile to become trapped in the gallbladder. The build up of bile causes irritation and pressure in the gallbladder. This can lead to bacterial infection and perforation of the organ.

Gallstones occur more frequently in women than men. Gallstones become more common with age in both sexes. Native Americans have a higher rate of gallstones.

Chronic cholecystitis is usually caused by repeated attacks of acute cholecystitis. This leads to thickening of the gallbladder walls. The gallbladder begins to shrink and eventually loses the ability to perform its function, which is concentrating, storing, and releasing bile.

The disease occurs more often in women than in men. The incidence increases after age 40. The main risk factors include the presence of gallstones (in which case, the symptoms are due to gallstones).

Diagnosis:

The diagnostic challenge posed by gallstones is to verify that abdominal pain is caused by stones and not by some other condition. Ultrasound or other imaging techniques can usually detect gallstones. Nevertheless, because gallstones are common and most cause no symptoms, simply finding stones does not necessarily explain a patient's pain, which may be caused by any number of ailments.

Laboratory Studies: Labs with cholelithiasis and gallbladder colic should be completely normal. WBC, aspirate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and alkaline phosphate may be helpful in the diagnosis of cholecystitis. However, presence of normal lab values does not exclude cholecystitis.Because biliary obstruction is limited to the gallbladder in uncomplicated cholecystitis, elevation in the serum total bilirubin and alkaline phosphatase concentrations may not be present. A study by Singer et al examined the utility of laboratory values in acute cholecystitis diagnosed by hepatic 2,6-dimethyliminodiacetic acid (HIDA) scan.1 No difference was found in mean WBC, AST, ALT, bilirubin, and alkaline phosphate between patients diagnosed with cholecystitis and those without.

An elevated WBC is expected but not reliable. In a retrospective study, only 61% of patients with cholecystitis had a WBC greater than 11,000. A WBC greater than 15,000 may indicate perforation or gangrene.

Comprehensive metabolic panel with bicarbonate may exhibit the following:

AST, ALT, and alkaline phosphate levels may be elevated; however, as with other laboratory tests, these levels are not sensitive for excluding cholecystitis. When the AST and ALT are elevated significantly, a common bile duct stone is more likely.

An elevation of AST, ALT, or alkaline phosphate should raise the possibility of other biliary system pathology such as cholangitis, choledocholithiasis, or the Mirizzi syndrome (obstruction of the common bile duct by an impacted stone in the distal cystic duct).

Note calcium level (Ranson criteria) if evidence of biliary pancreatitis exists.

Other abnormalities (eg, renal insufficiency) are not related to cholecystitis but may indicate a comorbid condition.

Imaging Studies:

Ultrasonography and nuclear medicine studies are the best imaging studies for the diagnosis of both cholecystitis and cholelithiasis. Plain radiography, CT scans, and endoscopic retrograde cholangiopancreatography (ERCP) are diagnostic adjuncts.

Abdominal radiographs

  • The advantages of abdominal radiographs include their readily availability and low cost. However, abdominal radiographs have low sensitivity and specificity in evaluating biliary system pathology, but they can be helpful in excluding other abdominal pathology such as renal colic, bowel obstruction, perforation. Between 10 and 30% of stones have a ring of calcium and, therefore, are radiopaque. A porcelain gallbladder also may be observed on plain films.

  • Emphysematous cholecystitis, cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation may show air in the biliary tree. Air in the gallbladder wall indicates emphysematous cholecystitis due to gas-forming organisms such as clostridial species and Escherichia coli.

Computed tomography scan

  • CT scan is not the test of choice and is recommended only for the evaluation of abdominal pain if the diagnosis is uncertain. CT scan can demonstrate gallbladder wall edema, pericholecystic stranding and fluid, and high-attenuation bile.

  • A helical CT scan with fine cuts through the biliary tract has not been well studied and may be useful.

  • Advantages: For complications of cholecystitis and cholangitis, gallbladder perforation, pericholecystic fluid, and intrahepatic ductal dilation, CT scan may be adequate. CT scan provides better information of the surrounding structures than sonogram and HIDA. CT scan is also noninvasive.

  • Disadvantages: CT scan misses 20% of gallstones because the stones may be of the same radiographic density as bile. CT scan is also more expensive and takes longer since the patient usually has to drink oral contrast. Also, given the radiation dose, it may not be ideal in the pregnant patient.

Ultrasonography

  • Ultrasonography is the most common test used in the ED for the diagnosis of biliary colic and acute cholecystitis. It is 90-95% sensitive for cholecystitis and 78-80% specific. For simple cholelithiasis, it is 98% sensitive and specific.

  • Ultrasonography may be diagnostic for biliary disease, help exclude biliary disease, or may reveal alternative causes of the patient's symptoms.

Depending on the ED, either sonography or nuclear medicine testing is the test of choice for cholecystitis. HIDA scans have sensitivity (94%) and specificity (65-85%) for acute cholecystitis. They are sensitive (65%) and specific (6%) for chronic cholecystitis. Oral cholecystography is not practical for the ED.

HIDA and DISIDA scans are functional studies of the gallbladder. Technetium-labeled analogues of iminodiacetic acid (IDA) or diisopropyl IDA-DISIDA are administered intravenously (IV) and secreted by hepatocytes into bile, enabling visualization of the liver and biliary tree.

Advantages of HIDA/DISIDA scans include the following:

  • Assessment of function.

  • Normal-appearing gallbladder (by ultrasound); obstructed cystic duct abnormal on DISIDA scan but not ultrasound.

  • Simultaneous assessment of bile ducts.

Disadvantages of HIDA/DISIDA scans include the following:

    High bilirubin (>4.4 mg/dL) possibly decreases sensitivity.

  • Recent eating or fasting for 24 hours also possibly affects study.

  • No imaging of other structures in the area.

Other Tests:

  • Endoscopic retrograde cholangiopancreatography.

  • ERCP provides both endoscopic and radiographic visualization of the biliary tract. It can be diagnostic and therapeutic by direct removal of common bile duct stones.

  • Ultrasound is 50-75% sensitive for choledocholithiasis. CT and HIDA scans are not better. Therefore, when a dilated common bile duct is found or elevated LFTs are present, suspicion should remain high for common bile duct stones, and an ERCP should be considered.

  • Debate exists as to when an ERCP should be performed. In general, since cholecystitis is caused by obstruction of the ducts, the risk of common bile duct stones is approximately 10%. Given its potential for complications, ERCP should be used when there is a high potential for intervention and it should not be used solely as a diagnostic modality.

  • Some studies have classified people as low risk for common bile duct stones based on (1) lack of jaundice, (2) elevated transaminases, and (3) a common bile duct diameter of less than 8 mm. In this population, the risk of common bile duct stones may be as low as 1%. In patients with any of the risk factors, the rate of stones was 39%. Therefore, in general, people with any of the risk factors for common bile duct stones should undergo operative or ERCP evaluation of the common bile duct.

  • Major complications of ERCP include pancreatitis and cholangitis.

Treatment:

Treatment for cholecystitis will depend on your symptoms and your general health. People who have gallstones but don't have any symptoms may need no treatment. For mild cases, treatment includes bowel rest, fluids and antibiotics given through a vein, and pain medicine.

The main treatment for acute cholecystitis is surgery to remove the gallbladder (cholecystectomy). Often this surgery can be done through small incisions in the abdomen (laparoscopic cholecystectomy), though sometimes it requires a more extensive operation. Your doctor may try to reduce swelling and irritation in the gallbladder before removing it. Occasionally acute cholecystitis is caused by one or more gallstones becoming stuck in the main tube leading to the intestine, called the common bile duct. Treatment may involve an endoscopic procedure (endoscopic retrograde cholangiopancreatography, or ERCP) to remove the stones in the common bile duct before the gallbladder is removed.

In rare cases of chronic cholecystitis, you may also receive medicine that dissolves gallstones over a period of time.

Medicine and medications:

Medical treatment of cholecystitis remains inadequate, especially in the pediatric population. The only treatments approved for use in children are open cholecystectomy (OC), laparoscopic cholecystectomy (LC), cholecystotomy, and endoscopic retrograde cholangiopancreatography (ERCP). The 2 oral medications that have been used with some success are chenodiol (chenodeoxycholic acid) and ursodiol (ursodeoxycholic acid). Both medications selectively inhibit hydroxymethylglutaryl-coenzyme A reductase (HMG-CoA reductase), thereby decreasing bile cholesterol supersaturation and lithogenicity. Chenodiol was shown to achieve complete dissolution of pure cholesterol gallstones in 15% of adult patients and partial dissolution in 28% of adult patients. However, the medications are expensive and cause adverse effects, including diarrhea and hepatotoxicity.

Combination treatment may be more effective and allow lower doses of each medication, causing fewer adverse effects. Although ursodiol was found to be unsuccessful in dissolving radiolucent gallstones in 10 children with cystic fibrosis (CF), it has been shown to increase hepatobiliary excretion and may be useful in a cytoprotective and preventative role.

Bile acids: Bile acids are used for the medical dissolution of cholesterol gallstones. Ursodiol and chenodiol both are orphan drugs and have been approved by the US Food and Drug Administration (FDA) for the dissolution of gallstones.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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