What provokes chronic cholecystitis?

Bacterial infection

Bacterial infection is one of the most important etiologic factors of chronic acalculous cholecystitis. Sources of infection may be diseases of the nasopharynx and paranasal sinuses (chronic tonsillitis, sinusitis); oral cavity (stomatitis, gingivitis, periodontosis); urinary system (cystitis, pyelonephritis); reproductive system (prostatitis, urethritis); gynecological diseases (adnexitis, endometritis); infectious bowel diseases; viral liver damage.

Infection enters the gallbladder in three ways:

• hematogenous (from the systemic circulation through the hepatic artery, from which the cystic artery branches off);
• ascending (from the intestine); the penetration of infection by this route is facilitated by insufficiency of the sphincter of Oddi, gastric hyposecretion, maldigestion and malabsorption syndromes);
• lymphogenous (along the lymphatic pathways from the intestines, genital area, liver and intrahepatic pathways).

The most common pathogens causing chronic cholecystitis are Escherichia coli and Enterococcus (mainly with ascending infection of the gallbladder); Staphylococcus and Streptococcus (with hematogenous and lymphatic routes of infection); very rarely Proteus, typhoid and paratyphoid bacilli, yeast fungi. In 10% of cases, chronic cholecystitis is caused by hepatitis B and C viruses, as evidenced by clinical observations and morphological examination of the gallbladder, confirming the possibility of developing chronic cholecystitis after acute viral hepatitis B and C. Quite often, the cause of chronic acalculous cholecystitis is the penetration of mixed microflora into the gallbladder.

[ 1 ], [ 2 ], [ 3 ]

Parasitic infestation

Some researchers point to the possible role of opisthorchiasis in the development of chronic acalculous cholecystitis. Opisthorchiasis can affect both the gallbladder and liver tissue with the development of intrahepatic cholestasis and reactive inflammation. In rare cases, chronic acalculous cholecystitis is caused by ascariasis.

There is still no consensus on the role of Giardia in the development of chronic acalculous cholecystitis. A. L. Myasnikov, N. L. Dehkan-Khodzhaeva considered giardiasis a possible cause of chronic acalculous cholecystitis. It is believed that giardiasis is a disease that occurs at the subclinical level. Giardia can cause a decrease in the body's defenses, functional disorders of the biliary tract, and increase the pathogenic properties of E. coli by 4-5 times. Many researchers believe that the role of Giardia in the etiology of chronic cholecystitis is questionable, since Giardia cannot exist in bile for a long time, they die. It is possible that Giardia found in gallbladder and liver bile originate from the duodenum. It is believed that giardiasis cholecystitis does not exist. There is no convincing morphological data on the penetration of lamblia into the wall of the gallbladder, and this is the main argument against lamblia-induced cholecystitis.

But this does not mean that Giardia do not play a role in the development of chronic acalculous cholecystitis. It is probably more correct to consider that Giardia contribute to the development of chronic cholecystitis.

Duodenobiliary reflux

Duodenobiliary reflux develops in chronic duodenal stasis with increased pressure in the duodenum, sphincter of Oddi insufficiency, and chronic pancreatitis. With the development of duodenobiliary reflux, duodenal contents with activated pancreatic enzymes are thrown back, which leads to the development of non-bacterial "enzymatic", "chemical" cholecystitis.

In addition, duodenobiliary reflux contributes to bile stagnation and the penetration of infection into the gallbladder.

[ 4 ], [ 5 ], [ 6 ]

Allergy

It is known that food and bacterial allergens can cause the development of chronic cholecystitis, which is confirmed by the morphological detection of signs of inflammation and eosinophils in the wall of the gallbladder in the absence of a bacterial infection (toxic-allergic cholecystitis).

[ 7 ], [ 8 ]

Chronic inflammatory diseases of the digestive system

Chronic hepatitis, liver cirrhosis, chronic bowel and pancreatic diseases are often complicated by the development of chronic cholecystitis, since they contribute, firstly, to the penetration of infection into the gallbladder, and secondly, to the inclusion of pathogenetic factors of chronic cholecystitis. Diseases of the choledochoduodenopancreatic zone play a particularly important role.

[ 9 ], [ 10 ], [ 11 ], [ 12 ]

Acute cholecystitis

Previously suffered acute cholecystitis can in some cases lead to the further development of chronic cholecystitis.

[ 13 ], [ 14 ]

Predisposing factors

The following factors contribute to the development of chronic cholecystitis:

1. Stagnation of bile, which can be caused by:
   • dyskinesia of the biliary tract, primarily the hypomotor-hypotonic variant;
   • obesity and pregnancy (in these conditions, intra-abdominal pressure increases and the outflow of bile from the gallbladder becomes more difficult);
   • psycho-emotional stressful situations (in which case biliary dyskinesia develops);
   • violation of the diet (eating promotes emptying of the gallbladder, infrequent meals predispose to stagnation of bile in the bladder); abuse of fatty and fried foods causes spasms of the sphincters of Oddi and Lutkens and hypertonic dyskinesia of the biliary tract;
   • the absence or insufficient content of plant fiber (coarse fibers) in food, which is known to help thin bile and empty the gallbladder;
   • hypokinesia;
   • congenital anomalies of the gallbladder.
2. Reflex influences from the abdominal organs during the development of an inflammatory process in them (chronic pancreatitis, colitis, gastritis, peptic ulcer, etc.). This leads to the development of biliary dyskinesia and stagnation of bile in the gallbladder.
3. Intestinal dysbacteriosis. Intestinal dysbacteriosis creates favorable conditions for the penetration of infection in an ascending manner into the gallbladder.
4. Metabolic disorders that contribute to changes in the physicochemical properties and composition of bile (obesity, diabetes mellitus, hyperlipoproteinemia, gout, etc.).
5. Hereditary predisposition to chronic cholecystitis.