Cholecystitis

Cholecystitis is inflammation of the gallbladder. It is commonly due to impaction (sticking) of a gallstone within the neck of the gall bladder, leading to inspissation of bile, bile stasis, and infection by gut organisms. Cholecystitis may be a cause of right upper quadrant pain. The pain may actually manifest in the right flank or scapular region at first. In severe cases, the gall bladder can rupture and form an abscess. In severe cases, it may lead to a life-threatening infection of the liver called ascending cholangitis. In other cases, it may lead to a stable inflammatory state termed chronic cholecystitis.

Diagnosis

Acute cholecystitis classically presents with acute pain in the right upper quadrant of the abdomen, nausea or vomiting, and fever. On physical examination, the pain may have Murphy's sign, spasm of the diaphragm (due to the intense pain) when the region of the gallbladder is palpated by the examiner.

Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC count. The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.

Radiology

Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign. Minor criteria include gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation.

The reported sensitivity and specificity of CT scan findings are in the range of 90-95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.

References

Shea, JA, Berlin, JA, Escarce, JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154:2573.
Fink-Bennett, D, Freitas, JE, Ripley, SD, Bree, RL. The sensitivity of hepatobiliary imaging and real time ultrasonography in the detection of acute cholecystitis. Arch Surg 1985; 120:904.

Therapy

Although antibiotics will often help reduce the inflammation of the gallbladder, acute cholecystitis is an indication for gallbladder removal (cholecystectomy). This can be accomplished with an open surgery or a laparoscopic procedure. Laparoscopic procedures can have less morbidity and a shorter recovery stay. An open procedure is preferred by many surgeons if the gallbladder is so inflamed that it could fall apart with the manipulations that could be needed with a laparoscopic procedure. A laparoscopic procedure may also be 'converted' to an open procedure during the operation if the surgeon feels that further attempts at laparoscopic removal might harm the patient.

In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. The patient may later warrant cholecystectomy if their condition improves. Gallbladder rupture is a possible but an unusual complication of cholecystitis. Approaches to this complication will vary based on the condition of an individual patient, the evaluation of the treating surgeon or physician, and the facilities' capability.

Complications

of cholecystitis

Rupture
Ascending cholangitis

of cholecystectomy

bile leak ("biloma")
bile duct injury (about 5-7 out of 1000 operations. Open and laparoscopic surgeries have essentially equal injuries, but the recent trend is towards fewer injuries with laparoscopy, probably because the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
abscess
wound infection
bleeding (liver surface and cystic artery most common sites)
hernia
organ injury (intestine and liver at highest risk, especially if gallbladder through inflammation has become adherent/scarred to other organstransverse colon)
deep vein thrombosis/pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)

Gastroenterology | Hepatology | Inflammations | General surgery

Colecistite | 胆嚢炎 | Zapalenie pęcherzyka żółciowego | Colecistite | Cholecystit