Introduction
Cholecystitis is the inflammation of the gallbladder and is a complication that occurs in 10% of patients with gallstones (also known as cholelithiasis). This is usually caused by a complete blockage of the cystic duct or neck of the gallbladder which causes the inflammation. However, a minority of cholecystitis do happen in the absence of gallstones (referred to as acalculous cholecystitis). Patients can present with upper right quadrant pain, fever and general malaise.
Epidemiology
Most patients with gallstones do not develop symptoms and only about 1-2% become symptomatic every year. This condition is more common in women than in men of all ages.
Causes
Most cases of cholecystitis develop due to gallstones, so its risk factors are very similar to gallstone formation.
| Modifiable risk factors | Non-modifiable risk factors |
|---|---|
| 1. Rapid weight loss 2. Obesity 3. Sedentary behaviour 4.Smoking 5. Total parenteral nutrition 6. Diet: – High calorie – Low fibre – Highly absorbable sugars 7. Medication: – Oestrogen – Octreotide – Ceftriaxone 8.Medical conditions: – Haemolytic conditions – Hypertriglyceridaemia – Cirrhosis – Cystic fibrosis – Ileal diseases – Bacterial or parasitic infections – Neoplasms | 1.Older age 2. Female 3. Genetic factors/family history |
A commonly used aide memoire for remembering the main risk factors for gallstones is ‘5 Fs’:
- Female sex
- Fair: Caucasian ethnicity
- Fat: BMI >30
- Fertile: had one or more children
- Forty: age over 40 years
More rarely, acalculous cholecystitis can develop and has been linked to several risk factors, including:
- Starvation
- Total parenteral nutrition
- Narcotic analgesics
- Immobility
- Viral and bacterial infections
Pathophysiology
Cholecystitis occurs as a result of obstruction of the gallbladder neck or cystic duct, leading to inflammation. This may subsequently result in infections and gallbladder perforation.
Gallstones
Most cases are due to a gallstone which becomes trapped, increasing pressure and irritation of the gallbladder. As the gallbladder continues to distend with glandular secretions, its vascular supply can become compromised and leads to inflammation and potential for developing infection.
Biliary Sludge
Biliary sludge may similarly obstruct the pathway when a patient is dehydrated or has other conditions causing bile stasis. This leads to increased pressure, irritation and inflammation.
Bacterial & Helminth Infection
Bacterial infections in the gall bladder leading to inflammation occur in about 20% of cases. Helminth infections leading to cholecystitis are more commonly seen in Asia, South Africa and Latin America.
Clinical features
Patients presenting with acute cholecystitis are often known to have a history of gallstones and biliary colic. A typical presentation can include the following symptoms and signs:
- Upper right quadrant pain and tenderness
- Longer-lasting than biliary colic
- Severe and constant pain
- Referred pain can present as pain in the right shoulder tip/interscapular area
- Nausea and vomiting
- Fever
- Mild jaundice
- The gallbladder may be distended on palpation and present as a mass
- Positive Murphy’s sign (sensitive and specific for cholecystitis):
- Apply pressure with your hands in the right and left upper quadrants while the patient breathes out. Then ask the patient to breathe in and observe for signs of pain.
- Murphy’s sign is positive if only right upper quadrant causes the patient to pause when breathing in
- This occurs as inspiration pushes against the abdominal contents and patient with cholecystitis will pause due to a tender gallbladder
While some symptoms are common to both biliary colic and cholecystitis, the presence of fever, prolonged pain and a positive Murphy’s sign are suggestive of cholecystitis.
Investigations
First-line investigations for suspected acute cholecystitis include baseline blood tests and abdominal ultrasound scan. Further imaging investigations can be done using Computer Tomography (CT) and Magnetic Resonance Imaging (MRI) to look for other intra-abdominal complications.
Blood tests
| Investigation | Findings |
| Full Blood Count | Leukocytosis indicates active inflammation and is suggestive of cholecystitis |
| C Reactive Protein (CRP) | Elevated CRP indicates inflammation and infection |
| Liver Function Test | Mostly normal or slightly elevated alkaline phosphatase (ALP)/ bilirubin/alanine aminotransferase (ALT). Bilirubin can be raised in biliary obstruction. |
| Serum Amylase or Lipase | If elevated above 3x normal amounts, suggests acute pancreatitis rather than cholecystitis |
| Blood Cultures | Can identify infective organisms |
Imaging
| Investigation | Findings |
| Abdominal Ultrasound | Detects presence of gallstones, gallbladder wall, distended gallbladder and pericholecystic fluid |
| Abdominal Computed Tomography or Magnetic Resonance Imaging | To detect gangrenous cholecystitis or gallbladder perforation if present. Can also detect if there is gallbladder wall thickening, poor contrast enhancement of gallbladder wall, increased fatty tissue around the gallbladder or gas and abscesses the gallbladder |
Management
Initially, offer analgesics to control pain (such as paracetamol, NSAIDs and opioids) and start antibiotics to cover for potential infections. Assess fluid status and determine if IV fluid resuscitation is required; otherwise, provide maintenance fluids as indicated. Consider intensive care admission if there is severe organ dysfunction.
Laparoscopic cholecystectomy should be offered to patients fit enough for surgery. Note that there has been debate over ‘hot’ and ‘cold’ cholecystectomy. Hot cholecystectomy refers to performing the operation during an acute admission, as opposed to a delayed operation. A Cochrane evidence review has shown no significant differences between the timing of the approaches, although early surgery appears to be safe and may shorten total hospital stay. For patients unfit for surgery (such as in cases of extensive infection), consider percutaneous cholecystostomy to manage complications of cholecystitis. Subsequent cholecystectomy can then be performed several weeks after recovery from the acute event to reduce risk of recurrence.
Complications
Cholecystitis and inflammation of the gallbladder region can cause subsequent issues, including:
- Suppurative cholecystitis/gallbladder empyema: gallbladder lumen becomes filled with pus
- Cholecystoenteric fistula: inflammation leading to abnormal connection between the biliary tree and the gastrointestinal tract
- Gallstone ileus: gallstone passing into the intestinal tract and causing intestinal obstruction
- Risk of iatrogenic injury during surgery
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