Cholecystitis

Template:Short description Template:Infobox medical condition (new) Cholecystitis is inflammation of the gallbladder.<ref name=NICE2014>Template:Cite report</ref> Symptoms include right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever.<ref name=NEJM2008/> Often gallbladder attacks (biliary colic) precede acute cholecystitis.<ref name=NEJM2008/> The pain lasts longer in cholecystitis than in a typical gallbladder attack.<ref name=NEJM2008/> Without appropriate treatment, recurrent episodes of cholecystitis are common.<ref name="NEJM2008" /> Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.<ref name=NEJM2008>Template:Cite journal</ref><ref name=NICE2014/>

More than 90% of the time acute cholecystitis is caused from blockage of the cystic duct by a gallstone.<ref name=NEJM2008/> Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity, diabetes, liver disease, or rapid weight loss.<ref name=NIH2013>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Occasionally, acute cholecystitis occurs as a result of vasculitis or chemotherapy, or during recovery from major trauma or burns.<ref name=Acal2015>Template:Cite book</ref> Cholecystitis is suspected based on symptoms and laboratory testing.<ref name=WS2016/> Abdominal ultrasound is then typically used to confirm the diagnosis.<ref name=WS2016/>

Treatment is usually with laparoscopic gallbladder removal, within 24 hours if possible.<ref name=Pat2015/><ref>Template:Cite journal</ref> Taking pictures of the bile ducts during the surgery is recommended.<ref name=Pat2015>Template:Cite journal</ref> The routine use of antibiotics is controversial.<ref name=WS2016/><ref name=Van2016>Template:Cite journal</ref> They are recommended if surgery cannot occur in a timely manner or if the case is complicated.<ref name=WS2016/> Stones in the common bile duct can be removed before surgery by endoscopic retrograde cholangiopancreatography (ERCP) or during surgery.<ref name=Pat2015/> Complications from surgery are rare.<ref name=NIH2013/> In people unable to have surgery, gallbladder drainage may be tried.<ref name=WS2016/>

About 10–15% of adults in the developed world have gallstones.<ref name=WS2016/> Women more commonly have stones than men and they occur more commonly after age 40.<ref name=NIH2013/> Certain ethnic groups are more often affected; for example, 48% of American Indians have gallstones.<ref name=NIH2013/> Of all people with stones, 1–4% have biliary colic each year.<ref name=WS2016/> If untreated, about 20% of people with biliary colic develop acute cholecystitis.<ref name=WS2016>Template:Cite journal</ref> Once the gallbladder is removed outcomes are generally good.<ref name=NIH2013/> Without treatment, chronic cholecystitis may occur.<ref name=Sle2010>Template:Cite book</ref> The word is from Greek, cholecyst- meaning "gallbladder" and -itis meaning "inflammation".<ref>Template:Cite book</ref> Template:TOC limit

Signs and symptoms

File:Blausen 0428 Gallbladder-Liver-Pancreas Location.png

Location of the gallbladder

Most people with gallstones do not have symptoms.<ref name=NEJM2008/> However, when a gallstone temporarily lodges in the cystic duct, they experience biliary colic.<ref name=NEJM2008/> Biliary colic is abdominal pain in the right upper quadrant or epigastric region. It is episodic, occurring after eating greasy or fatty foods, and leads to nausea and/or vomiting.<ref name=":1">Greenberger N.J., Paumgartner G (2012). Chapter 311. Diseases of the Gallbladder and Bile Ducts. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), Harrison's Principles of Internal Medicine, 18e</ref> People with cholecystitis most commonly have symptoms of biliary colic before developing cholecystitis. The pain becomes severe and constant in cholecystitis. Nausea is common and vomiting occurs in 75% of people with cholecystitis.<ref name=":2">Friedman L.S. (2015). Liver, Biliary Tract, & Pancreas Disorders. In Papadakis M.A., McPhee S.J., Rabow M.W. (Eds), Current Medical Diagnosis & Treatment 2015</ref> In addition to abdominal pain, right shoulder pain can be present.<ref name=":1" />

On physical examination, an inflamed gallbladder is almost always tender to the touch and palpable (~25-50% of cases) in the midclavicular right lower rib margin.<ref name=":1" /> Additionally, a fever is common.<ref name=":2" /> Pain with deep inspiration leading to termination of the breath while pressing on the right upper quadrant of the abdomen usually causes severe pain (Murphy's sign).<ref>Template:Cite journal</ref> Yellowing of the skin (jaundice) may occur but is often mild. Severe jaundice suggests another cause of symptoms such as choledocholithiasis.<ref name=":2" /> People who are old, have diabetes, chronic illness, or who are immunocompromised may have vague symptoms that may not include fever or localized tenderness.<ref name=":4">Template:Cite journal</ref>

Complications

A number of complications may occur from cholecystitis if not detected early or properly treated. Signs of complications include high fever, shock and jaundice. Complications include the following:<ref name=":1" />

• Gangrene
• Gallbladder rupture
• Empyema
• Fistula formation and gallstone ileus
• Rokitansky-Aschoff sinuses

Gangrene and gallbladder rupture

Cholecystitis causes the gallbladder to become distended and firm. Distension can lead to decreased blood flow to the gallbladder, causing tissue death and eventually gangrene.<ref name=":1" /> Once tissue has died, the gallbladder is at greatly increased risk of rupture (perforation), which can cause sharp pain. Rupture can also occur in cases of chronic cholecystitis.<ref name=":1" /> Rupture is a rare but serious complication that leads to abscess formation or peritonitis.<ref name=":2" /> Massive rupture of the gallbladder has a mortality rate of 30%.<ref name=":1" />

Empyema

Untreated cholecystitis can lead to worsened inflammation and infected bile that can lead to a collection of pus inside the gallbladder, also known as empyema.<ref name=":1" /> The symptoms of empyema are similar to uncomplicated cholecystitis but greater severity: high fever, severe abdominal pain, more severely elevated white blood count.<ref name=":1" />

Fistula formation and gallstone ileus

The inflammation of cholecystitis can lead to adhesions between the gallbladder and other parts of the gastrointestinal tract, most commonly the duodenum.<ref name=":1" /> These adhesions can lead to the formation of direct connections between the gallbladder and gastrointestinal tract, called fistulas.<ref name=":1" /> With these direct connections, gallstones can pass from the gallbladder to the intestines. Gallstones can get trapped in the gastrointestinal tract, most commonly at the connection between the small and large intestines (ileocecal valve). When a gallstone gets trapped, it can lead to an intestinal obstruction, called gallstone ileus, leading to abdominal pain, vomiting, constipation, and abdominal distension.<ref name=":1" />

Causes

Cholecystitis occurs when the gallbladder becomes inflamed.<ref name=":1" /> Gallstones are the most common cause of gallbladder inflammation but it can also occur due to blockage from a tumor or scarring of the bile duct.<ref name=":1" /><ref name=":3">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The greatest risk factor for cholecystitis is gallstones.<ref name=":3" /> Risk factors for gallstones include female sex, increasing age, pregnancy, oral contraceptives, obesity, diabetes mellitus, ethnicity (Native North American), rapid weight loss.<ref name=":1" />

Acute calculous cholecystitis

Gallstones blocking the flow of bile account for 90% of cases of cholecystitis (acute calculous cholecystitis).<ref name=NEJM2008/><ref name=":2" /> Blockage of bile flow leads to thickening and buildup of bile causing an enlarged, red, and tense gallbladder.<ref name=NEJM2008/> The gallbladder is initially sterile but often becomes infected by bacteria, predominantly E. coli, Klebsiella, Streptococcus, and Clostridium species.<ref name=":1" /> Inflammation can spread to the outer covering of the gallbladder and surrounding structures such as the diaphragm, causing referred right shoulder pain.<ref name=":1" />

Acalculous cholecystitis

In acalculous cholecystitis, no stone is in the biliary ducts.<ref name=":1" /> It accounts for 5–10% of all cases of cholecystitis and is associated with high morbidity and mortality rates.<ref name=":1" /> Acalculous cholecystitis is typically seen in people who are hospitalized and critically ill.<ref name=":1" /> Males are more likely to develop acute cholecystitis following surgery in the absence of trauma.<ref name=":2" /><ref>Barie PS. Acalculous and postoperative cholecystitis. In: Surgical intensive care, Barie PS, Shires GT. (Eds), Little Brown & Co, Boston 1993. p.837.</ref> It is associated with many causes including vasculitis, chemotherapy, major trauma or burns.<ref name="Acal2015"/>

The presentation of acalculous cholecystitis is similar to calculous cholecystitis.<ref>Template:Cite journal</ref><ref name=":1" /> Patients are more likely to have yellowing of the skin (jaundice) than in calculous cholecystitis.<ref name=":0">Template:Cite book</ref> Ultrasonography or computed tomography often shows an immobile, enlarged gallbladder.<ref name=":1" /> Treatment involves immediate antibiotics and cholecystectomy within 24–72 hours.<ref name=":0" />

Chronic cholecystitis

Chronic cholecystitis occurs after repeated episodes of acute cholecystitis and is almost always due to gallstones.<ref name=":1" /> Chronic cholecystitis may be asymptomatic, may present as a more severe case of acute cholecystitis, or may lead to a number of complications such as gangrene, perforation, or fistula formation.<ref name=":1" /><ref name=":2" />

Xanthogranulomatous cholecystitis (XGC) is a rare form of chronic cholecystitis which mimics gallbladder cancer although it is not cancerous.<ref name="Makino09">Template:Cite journal</ref><ref name="Rao05">Template:Cite journal</ref> It was first reported in the medical literature in 1976 by McCoy and colleagues.<ref name="Makino09" /><ref name="McCoy76">Template:Cite journal</ref>

Mechanism

Blockage of the cystic duct by a gallstone causes a buildup 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.<ref name=NEJM2008/> Inflammation and swelling of the gallbladder can reduce normal blood flow to areas of the gallbladder, which can lead to cell death due to inadequate oxygen.<ref name=":1" />

Diagnosis

The diagnosis of cholecystitis is suggested by the history (abdominal pain, nausea, vomiting, fever) and physical examinations in addition to laboratory and ultrasonographic testing. Boas's sign, which is pain in the area below the right scapula, can be a symptom of acute cholecystitis.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Blood tests

In someone suspected of having cholecystitis, blood tests are performed for markers of inflammation (e.g. complete blood count, C-reactive protein), as well as bilirubin levels in order to assess for bile duct blockage.<ref name=":2" /> Complete blood count typically shows an increased white blood count (12,000–15,000/mcL).<ref name=":2" /> C-reactive protein is usually elevated although not commonly measured in the United States.<ref name=NEJM2008/> Bilirubin levels are often mildly elevated (1–4 mg/dL).<ref name=":2" /> If bilirubin levels are more significantly elevated, alternate or additional diagnoses should be considered such as gallstone blocking the common bile duct (common bile duct stone).<ref name=NEJM2008/> Less commonly, blood aminotransferases are elevated.<ref name=":1" /> The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder.<ref>Template:Cite book</ref>

Imaging

Right upper quadrant abdominal ultrasound is most commonly used to diagnose cholecystitis.<ref name=NEJM2008 /><ref name="pmid7979854">Template:Cite journal</ref><ref name="pmid3893388">Template:Cite journal</ref> Ultrasound findings suggestive of acute cholecystitis include gallstones, pericholecystic fluid (fluid surrounding the gallbladder), gallbladder wall thickening (wall thickness over 3 mm),<ref name="van Breda VriesmanEngelbrecht2007">Template:Cite journal</ref> dilation of the bile duct, and sonographic Murphy's sign.<ref name=":1" /> Given its higher sensitivity, hepatic iminodiacetic acid (HIDA) scan can be used if ultrasound is not diagnostic.<ref name=":1" /><ref name=":2" /> CT scan may also be used if complications such as perforation or gangrene are suspected.<ref name=":2" />

• Ultrasonography of cholecystitis.jpg

  Abdominal ultrasonography showing gallstones, wall thickening and fluid around the gall bladder

• Ultrasonography of sludge and gallstones, annotated.jpg

  Gallstones and biliary sludge, but the gallbladder wall is not clearly thickened, with no edema in the pericholecystic fat, thus not cholecystitis.

• Pacutecholecystitits.png

  Acute cholecystitis as seen on ultrasound. The closed arrow points to gallbladder wall thickening. Open arrow points to stones in the GB

• GBthick,GS,largeMark.png

  Acute cholecystitis with gallbladder wall thickening, a large gallstone, and a large gallbladder

• UOTW 30 - Ultrasound of the Week 1.webm

  CitationClass=web }}</ref>

• UOTW 30 - Ultrasound of the Week 2.webm

  Significant gallbladder wall thickening<ref name=UOTW30/>

Histopathology

Histopathology is indicated if preoperative imaging and/or gross examination gives a suspicion of gallbladder cancer.<ref name="TalrejaAli2016">Template:Cite journal</ref>

• Gross pathology of gallbladder carcinoma.jpg

  Gross examination of gallbladder carcinoma, with a prominent nodule.

• Histopathology of gallbladder carcinoma.jpg

  Histopathology of gallbladder carcinoma, with marked nuclear pleomorphism.

• Histopathology of eosinophilic cholecystitis.jpg

  Histopathology of eosinophilic cholecystitis

• Gross pathology of cholesterolosis.jpg

  Gross examination of gallbladder cholesterolosis, with yellow streaks of cholesterol deposition.

• Histopatholgoy of acute gangrenous cholecystitis.jpg

  Histopathology of acute gangrenous cholecystitis, showing necrosis, neutrophils and partially sloughed off mucosa.

Differential diagnosis

Many other diagnoses can have similar symptoms as cholecystitis. Additionally the symptoms of chronic cholecystitis are commonly vague and can be mistaken for other diseases. These alternative diagnoses include but are not limited to:<ref name=":2" />

• Perforated peptic ulcer
• Acute pancreatitis
• Liver abscess
• Pneumonia
• Myocardial ischemia
• Hiatal hernia
• Biliary colic
• Choledocholithiasis
• Cholangitis
• Appendicitis
• Colitis
• Acute peptic ulcer exacerbation
• Amoebic liver abscess
• Acute intestinal obstruction
• Kidney stone
• Biliary ascariasis<ref>Template:Cite journal</ref>

Treatment

File:Laprascopy-Roentgen.jpg

X-ray during laparoscopic cholecystectomy

Surgery

For most people with acute cholecystitis, the treatment of choice is surgical removal of the gallbladder, laparoscopic cholecystectomy.<ref name="Strasberg,2006">Template:Cite journal</ref> 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 (using a large incision in the right upper abdomen under the rib cage). People undergoing laparoscopic surgery report less incisional pain postoperatively as well as having fewer long-term complications and less disability following the surgery.<ref name="Velanovich,2000">Template:Cite journal</ref><ref name="Chen,2005">Template:Cite journal</ref> Additionally, laparoscopic surgery is associated with a lower rate of surgical site infection.<ref name="Richards,2003">Template:Cite journal</ref>

During the days prior to laparoscopic surgery, studies showed that outcomes were better following early removal of the gallbladder, preferably within the first week.<ref name="Banz,2011">Template:Cite journal</ref> Early laparoscopic cholecystectomy (within 7 days of visiting a doctor with symptoms) as compared to delayed treatment (more than 6 weeks) may result in shorter hospital stays and a decreased risk of requiring an emergency procedure.<ref name=Gurusamy2013 /> There is no difference in terms of negative outcomes including bile duct injury or conversion to open cholecystectomy.<ref name=Gurusamy2013>Template:Cite journal</ref> For early cholecystectomy, the most common reason for conversion to open surgery is inflammation that hides Calot's triangle. For delayed surgery, the most common reason was fibrotic adhesions.<ref name=Gurusamy2013 />

Other

File:X-ray with contrast of a percutaneous gallbladder drain.jpg

Radiography of a percutaneous drainage catheter (yellow arrow). In this control, the instilled radiocontrast is filling out the gallbladder (red arrow), where the filling defects are gallstones. The cystic duct (blue arrow) is tortuous, the common bile duct (green arrow) is mildly dilated but patent, with tapering at ampulla Vateri (white arrow), but without obstruction. Contrast was seen extending into the duodenum (orange arrows), demonstrating open passage through the bile ducts.<ref>Template:Cite journal</ref>

Supportive measures may be instituted prior to surgery. These measures include fluid resuscitation. Intravenous opioids can be used for pain control.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Antibiotics are often not needed.<ref>Template:Cite journal</ref>

In cases of severe inflammation, shock, or if the person has higher risk for general anesthesia (required for cholecystectomy), an interventional radiologist may insert a percutaneous drainage catheter into the gallbladder (percutaneous cholecystostomy tube) and treat the person with antibiotics until the acute inflammation resolves. A cholecystectomy may then be warranted if the person's condition improves.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Homeopathic approaches to treating cholecystitis have not been validated by evidence and should not be used in place of surgery.<ref>Template:Cite book</ref>

Epidemiology

Cholecystitis accounts for 3–10% of cases of abdominal pain worldwide.<ref name=":12">Template:Cite journal</ref> Cholecystitis caused an estimated 651,829 emergency department visits and 389,180 hospital admissions in the US in 2012.<ref name=":02">Template:Cite journal</ref> The 2012 US mortality rate was 0.7 per 100,000 people.<ref name=":02" /> The frequency of cholecystitis is highest in people age 50–69 years old.<ref name=":12" />