Acute cholecystitis

Acute cholecystitis is an acute inflammation of the gallbladder wall that develops over several hours, usually as a result of obstruction of the cystic duct by a gallstone. Symptoms of cholecystitis include pain in the right hypochondrium and weakness, sometimes accompanied by fever, chills, nausea, and vomiting. Detection of stones and associated inflammation is performed using abdominal ultrasound. Treatment usually includes antibiotic therapy and cholecystectomy.

In the vast majority of cases, acute cholecystitis develops when the cystic duct is obstructed by a stone, which causes an increase in intravesical pressure. Thus, acute cholecystitis is the most common complication of gallstone disease.

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Epidemiology of acute cholecystitis

Women over 40 who are obese are more likely to get sick. Acalculous cholecystitis develops more often in men.

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What causes acute cholecystitis?

Acute cholecystitis is the most common complication of cholelithiasis. Conversely, >95% of patients with acute cholecystitis have cholelithiasis. Acute inflammation results from impaction of a stone into the cystic duct, thereby causing its complete obstruction. Stagnation of bile provokes the production of inflammatory enzymes (eg, phospholipase A transforms lecithin into lysolecithin, which causes inflammation). The damaged mucosa secretes more fluid into the gallbladder. As a result of bladder dilation, even more inflammatory mediators (eg, prostaglandins) are released, causing more significant damage to the mucosa and ischemia, which contributes to chronic inflammation. If bacterial infection develops, necrosis and perforation may develop. If the process resolves, fibrosis of the gallbladder wall develops, disruption of its concentrating and contractile functions, leading to incomplete emptying.

Five to 10% of cholecystectomies performed for acute cholecystitis are for acute acalculous cholecystitis (ie, cholecystitis without stones). Risk factors include critical illness (recurrent surgery, burns, sepsis, or severe trauma), prolonged fasting or TPN (predisposes to bile stasis), shock, and vasculitis (eg, systemic lupus erythematosus, polyarteritis nodosa). The mechanism is likely related to the release of inflammatory mediators in response to ischemia, infection, or bile stasis. Occasionally, a concomitant infection (eg, Salmonella or cytomegalovirus in immunocompromised patients) may be identified. In children, acute acalculous cholecystitis may occur after febrile illnesses without verification of a specific infection.

What causes acute cholecystitis?

Symptoms of acute cholecystitis

Most patients have a history of attacks of biliary colic or acute cholecystitis. In the nature and localization of pain, cholecystitis resembles biliary colic, but it is more severe and lasts longer (i.e., more than 6 hours). Vomiting usually occurs, as does pain in the right side and in the right upper quadrant of the abdomen. Within a few hours, Murphy's sign appears (when palpated, increased pain in the right hypochondrium with deep inspiration and holding the exhalation) with tension of the abdominal muscles on the right. Fever usually appears, but it is usually not pronounced. In elderly people, fever may be absent or the manifestations of the disease may be only general and vague (e.g., anorexia, vomiting, malaise, weakness, fever).

If untreated, 10% of patients develop limited perforation, and 1% develop perforation into the free abdominal cavity and peritonitis. Increased abdominal pain, significant increase in body temperature, chills, muscle rigidity, peritoneal symptoms or signs of intestinal obstruction indicate the development of empyema (pus in the gallbladder), gangrene or perforation of the gallbladder. If acute cholecystitis is accompanied by jaundice or cholestasis, partial obstruction of the common bile duct by a calculus or as a result of inflammation is possible. Common bile duct stones that have migrated from the gallbladder can block, cause narrowing or inflammation of the pancreatic duct, leading to pancreatitis (biliary pancreatitis). Mirizzi syndrome is a rare complication in which a gallstone located in the cystic duct or Hartmann's pouch compresses and blocks the common bile duct. Sometimes a large stone erodes the wall of the gallbladder, forming a cystoenteric fistula; the stone may fall through and cause obstruction of the small intestine (cholelith ileus). Acute cholecystitis usually regresses within 2-3 days and resolves within 1 week.

Acute acalculous cholecystitis presents with the same symptoms as calculous cholecystitis, but the symptoms may be masked in severely ill patients, with whom contact is difficult. The only sign may be abdominal distension or unexplained fever. Without treatment, the disease can quickly lead to gangrene of the gallbladder and perforation, leading to sepsis, shock, and peritonitis with a mortality rate of about 65%. Choledocholithiasis and cholangitis may also develop.

Acute Cholecystitis - Symptoms

Classification of acute cholecystitis

Gas cholecystitis usually occurs in men with diabetes mellitus and is manifested by a picture of severe acute cholecystitis with toxemia, sometimes a palpable formation is found in the abdominal cavity.

Acute Cholecystitis - Classification

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Complications of acute cholecystitis

1. Empyema of the gallbladder is a purulent inflammation of the gallbladder, accompanied by the accumulation of a significant amount of pus in its cavity;
2. Perivesical abscess.
3. Gallbladder perforation. Acute calculous cholecystitis may lead to transmural necrosis of the gallbladder wall and its perforation. Perforation occurs due to pressure of the stone on the necrotic wall or rupture of dilated infected Rokitansky-Aschoff sinuses.

Acute Cholecystitis - Complications

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Diagnosis of acute cholecystitis

Acute cholecystitis is suspected in patients with characteristic symptoms. Diagnosis is usually based on ultrasound, which may reveal gallstones and local tenderness in the projection of the gallbladder (Murphy's ultrasonographic sign). Pericholecystic fluid accumulation or thickening of the gallbladder wall indicate acute inflammation. If the results are doubtful, cholescintigraphy is used; the absence of radioactivity with an enlarged gallbladder suggests obstruction of the cystic duct. False-positive symptoms may occur in seriously ill or fasting patients receiving TPN, in patients with severe liver disease, or in patients who have undergone sphincterotomy. Abdominal CT may reveal cholecystitis, as well as gallbladder perforation or pancreatitis. Magnetic resonance cholangiography is an informative but more expensive study than ultrasound. A complete blood count, liver function tests, amylase and lipase levels are usually performed, but they are rarely helpful in diagnosis. Leukocytosis with a left shift in the formula is characteristic. In acute uncomplicated cholecystitis, as a rule, no specific biochemical abnormalities of liver function or increased lipase levels are observed.

In acute acalculous cholecystitis, laboratory abnormalities are nonspecific. Leukocytosis and changes in liver function tests are common. Cholestasis may be due directly to sepsis, choledocholithiasis, or cholangitis. Ultrasonography can be performed in the ward. Gallstones are not visualized. Murphy's sonographic sign and pericystic fluid accumulation suggest gallbladder disease, while a distended gallbladder, biliary sludge, and thickened gallbladder wall (due to low albumin or ascites) may simply be the result of the patient's severe condition. CT is also useful and may reveal extrabiliary abnormalities. Cholescintigraphy is more useful; failure to fill the bladder may indicate cystic duct blockage due to edema. However, gallbladder congestion itself may be the cause of impaired filling. The use of morphine, which increases the tone of the sphincter of Oddi, enhances filling and can thus differentiate a false-positive result.

Acute Cholecystitis - Diagnosis

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Screening for acute cholecystitis

No specific measures have been developed. However, if there is discomfort in the right hypochondrium or epigastric region, it is advisable to conduct an ultrasound of the abdominal organs for the timely detection of stones in the gallbladder and/or bile ducts.

Treatment of acute cholecystitis

Treatment includes hospitalization, intravenous fluids, and opioids. Fasting is avoided, nasogastric intubation is indicated, and aspiration is done in case of vomiting. Parenteral antibiotics are usually given to prevent possible infection, but there is no convincing evidence of the effectiveness of antibiotic therapy. Empirical treatment is directed at gram-negative enteric organisms such as Escherichia coli, Enterococcus Klebsiella, and Enterobacter, this can be achieved with various combinations of drugs, such as piperacillin/tazobactam 4 g intravenously every 6 hours, ampicillin/sulbactam 3 g intravenously every 6 hours, or ticarcillin/clavulanate 4 g intravenously every 6 hours.

Cholecystectomy is the treatment of acute cholecystitis and relieves biliary pain. If the diagnosis is established and the surgical risk to the patient is low, cholecystectomy is best performed within the first 24 to 48 hours. In high-risk patients with severe chronic pathology (eg, cardiopulmonary), cholecystectomy should be delayed and medical therapy administered until the patient's condition is stabilized or the manifestations of cholecystitis regress. If cholecystitis regresses, cholecystectomy can be performed after more than 6 weeks. Empyema, gangrene, perforation, and acalculous cholecystitis require urgent surgical treatment. In patients with very high surgical risk, percutaneous cholecystostomy may be performed as an alternative to cholecystectomy.

Acute Cholecystitis - Treatment

Clinical guidelines for the management of acute cholecystitis

Acute cholecystitis is an inflammation of the gallbladder, most often caused by blockage of the bile ducts by gallstones. Treatment of acute cholecystitis requires medical attention and may require surgery. The following are clinical guidelines for acute cholecystitis:

1. See a doctor: If you have severe upper abdominal pain, especially in the right upper quadrant, accompanied by nausea, vomiting, and possibly fever, it is important to see a doctor as soon as possible. Diagnosis and treatment of acute cholecystitis require medical evaluation.
2. Prescribing medications: Your doctor may prescribe antibiotics to fight any infection that may develop as a result of the inflammation. He or she may also prescribe analgesics to relieve pain and antiemetics.
3. Do not eat or drink anything: If you suspect acute cholecystitis, it is important to refrain from eating or drinking anything to avoid further irritating the gallbladder and reduce the risk of gallstones.
4. Fasting: Your doctor may recommend fasting, in which you abstain from food for a certain amount of time (usually 12 to 24 hours). This can help reduce the strain on your gallbladder.
5. Surgery: In cases of severe symptoms or complications, such as gallbladder perforation or bile duct obstruction, surgical removal of the gallbladder (cholecystectomy) may be necessary. This is usually performed after the patient's condition has stabilized.
6. Post-operative recommendations: After surgery, it is important to follow your doctor's recommendations regarding post-operative care, diet, and physical activity.
7. Doctor's examination: After discharge from the hospital, you should visit your doctor and follow the recommendations for treatment and monitoring of the condition.

It is important to understand that acute cholecystitis is a serious condition and should be treated under the supervision of a physician. Do not attempt to treat acute cholecystitis on your own. If you have symptoms that suggest acute cholecystitis, see a physician for professional evaluation and treatment.

Prevention of acute cholecystitis

In the event of development of clinical manifestations associated with the presence of stones in the gallbladder, it is necessary to consider the possibility of performing cholecystectomy (optimally using endoscopic techniques) on a planned basis to prevent the development of biliary colic and acute cholecystitis.

Prognosis of acute cholecystitis

In the natural course of acute cholecystitis caused by the presence of a calculus (calculi) in the gallbladder, spontaneous recovery occurs in 85% of cases, but a new attack develops in 1/3 of patients within 3 months. In 15% of patients, the disease progresses and often leads to serious complications, which dictates the need for an early decision on surgical treatment in each case of acute cholecystitis. Rapid progression of cholecystitis to gangrene or empyema of the gallbladder, formation of fistulas, intrahepatic abscesses, and development of peritonitis is possible. Mortality in complicated cholecystitis reaches 50-60%. Mortality in acalculous cholecystitis is 2 times higher than in calculous cholecystitis, and gangrene and perforation develop more often.