Acute cholecystitis

Acute cholecystitis is an acute inflammation of the wall of the gallbladder, which develops within a few hours, usually as a result of obturation of the cystic duct with a gallstone. Symptoms of cholecystitis include pain in the right upper quadrant and weakness, sometimes accompanied by fever, chills, nausea and vomiting. Detection of stones and associated inflammation is carried out using ultrasound of the abdominal cavity. Treatment usually includes antibiotic therapy and cholecystectomy.

In the overwhelming majority of cases, acute cholecystitis develops when the bladder duct becomes obstructed with a stone, which provokes an increase in intravesical pressure. Thus, acute cholecystitis is the most common complication of cholelithiasis.

[1], [2], [3], [4], [5], [6]

Epidemiology of acute cholecystitis

Most often, women over 40 who suffer from obesity are ill. Acid-free cholecystitis often develops in men.

[7], [8], [9], [10], [11], [12], [13], [14]

What causes acute cholecystitis?

Acute cholecystitis is the most common complication of cholelithiasis. Conversely,> 95% of patients with acute cholecystitis have cholelithiasis. Acute inflammation is the result of wedging the stone into the bladder duct, thereby causing it to become completely obstructed. Bile stasis provokes the production of inflammatory enzymes (for example, phospholipase A transforms lecithin into lysolecithin, which causes inflammation). Damaged mucous membrane secrets more fluid into the gallbladder. As a result of the dilatation of the bladder, an even greater yield of inflammatory mediators (for example, prostaglandins) occurs, causing more damage to the mucosa and ischemia, which contributes to chronic inflammation. In the case of bacterial infection, necrosis and perforation may develop. If the process resolves, the fibrosis of the gallbladder wall develops, its concentrating and contractile functions are violated, leading to incomplete emptying.

From 5 to 10% of cholecystectomies performed with acute cholecystitis are carried out for acute acalculous cholecystitis (i.e., cholecystitis without stones). Risk factors include critical conditions (frequent surgical interventions, burns, sepsis or severe trauma), prolonged fasting or PPP (predispose to bile stasis), shock and vasculitis (eg SLE, nodular polyarteritis). The mechanism is most likely associated with the release of inflammatory mediators in response to ischemia, infection, or bile congestion. Sometimes a concomitant infection (eg, Salmonella or cytomegalovirus in immunocompromised patients) can be detected . In children, acute acalculous cholecystitis can occur after diseases accompanied by fever, without verification of a certain infection.

What provokes acute cholecystitis?

Symptoms of acute cholecystitis

Most patients have a history of biliary colic or acute cholecystitis. By the nature and localization of pain, cholecystitis resembles biliary colic, but it is more pronounced and prolonged (i.e., more than 6 hours). Usually there is vomiting, as well as pain in the right side and in the upper right quadrant of the abdomen. Within a few hours, Murphy's symptom appears (with palpation pain in the right upper quadrant with deep inhalation and exhalation delay) with the tension of the abdominal muscles on the right. As a rule, there is a fever, but it is usually not expressed. In elderly people, fever may not be present or the manifestations of the disease can only be general and indeterminate (eg, anorexia, vomiting, malaise, weakness, fever).

In the absence of treatment, 10% of patients develop limited perforation, and 1% have perforation in the free abdominal cavity and peritonitis. Increased abdominal pain, a significant increase in body temperature, chills, muscle stiffness, peritoneal symptoms or signs of intestinal obstruction indicate the development of empyema (pus in the gallbladder), gangrene or perforation of the bladder. If acute cholecystitis is accompanied by jaundice or cholestasis, partial obturation of the common bile duct by concrement or as a result of inflammation is possible. Choledocha stones migrating from the gallbladder can block, cause constriction or inflammation of the pancreatic duct, leading to pancreatitis (biliary pancreatitis). Mirizzi syndrome is a rare complication in which the bile calculus localized in the bladder duct or Hartmann's pocket compresses and blocks the common bile duct. Sometimes a large stone destroys the wall of the gallbladder, forming a vesicouteral fistula; the stone can fail and cause an obstruction of the small intestine (cholelithiasis intestinal obstruction). Acute cholecystitis usually regresses in 2-3 days and is resolved within 1 week.

Acute galloping cholecystitis is manifested by the same signs as calculous cholecystitis, but the symptoms can be masked in severe patients, contact with which is difficult. The only sign may be bloating or an unexplained fever. Without treatment, the disease can quickly lead to gall bladder gangrene 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 is common in men with diabetes mellitus, and is manifested by a picture of severe acute cholecystitis with toxemia, sometimes a palpable formation in the abdominal cavity is detected.

Acute cholecystitis - Classification

[15], [16], [17]

Complications of acute cholecystitis

1. The 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. Aubianus abscess.
3. Perforation of the gallbladder. Acute calculous cholecystitis can lead to transmural necrosis of the gallbladder wall and its perforation. Perforation occurs due to the pressure of the stone on the necrotic wall or the rupture of dilated infected Rokitansky-Ashot sines.

Acute cholecystitis - Complications

[18], [19], [20], [21],

Diagnosis of acute cholecystitis

Suspicion of acute cholecystitis occurs in patients with characteristic symptoms. Diagnosis is usually based on ultrasound, in which gallstones can be identified, local tenderness in the projection of the gallbladder (Murphy's ultrasonographic sign). Peripuzyrnoe fluid accumulation or thickening of the gallbladder wall indicates acute inflammation. If the results are doubtful, then cholescintigraphy is used; the absence of radioactivity with an increase in the gallbladder suggests an obstruction of the cystic duct. False positive symptoms can be in severe patients or patients with fasting receiving PPP, in patients with severe liver disease or in patients who have undergone sphincterotomy. CT of the abdominal cavity can reveal cholecystitis, as well as perforation of the gallbladder or pancreatitis. Magnetic resonance cholangiography is an informative, but more expensive, study than ultrasound. Usually a general blood test, functional liver tests are performed, the level of amylase and lipase is determined, but they rarely help in diagnosis. Characterized by leukocytosis with a shift of the formula to the left. In acute uncomplicated cholecystitis, as a rule, no specific biochemical abnormalities of the liver function or an increase in the level of lipase are observed.

In acute acalculous cholecystitis, laboratory abnormalities are nonspecific. Typically, leukocytosis and changes in biochemical parameters characterizing liver function are observed. Manifestations of cholestasis can be a consequence of directly sepsis, choledocholithiasis or cholangitis. Ultrasonography can be performed directly in the ward. Gallstones are not visualized. Murphy's sonographic sign and the congestion of the peripuzary fluid suggest gallbladder disease, while the dilated gallbladder, bile 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 informative and can reveal extrabiliary disorders. Cholescintigraphy is a more useful study; the lack of filling the bladder can point to the bladder duct block due to swelling. However, congestion in the gallbladder itself may be the cause of a violation of its filling. The use of morphine, which increases the tone of the sphincter of Oddi, strengthens the filling and thus can differentiate the false positive result.

Acute cholecystitis - Diagnosis

[22], [23], [24]

Screening of acute cholecystitis

Specific activities have not been developed. Nevertheless, in the presence of discomfort in the right hypochondrium or epigastric region, an ultrasound of the abdominal cavity organs is desirable for the timely detection of concrements in the gallbladder and / or biliary tract.

Treatment of acute cholecystitis

Treatment includes hospitalization, intravenous fluid transfusion and opiates. Food intake is excluded, nasogastric probing and aspiration are indicated in case of vomiting. Parenterally, antibiotics are prescribed for the prevention of a possible infection, but there is no conclusive evidence of the effectiveness of antibiotic therapy. Empirical treatment is directed to Gram-negative intestinal microorganisms such as Escherichia coli Enterococcus Klebsiella and Enterobacter, this can be achieved by a different combination of drugs, for example 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 a method of treatment of acute cholecystitis and eliminates biliary pain. If the diagnosis is established and the surgical risk for the patient is small, a cholecystectomy is best performed within the first 24-48 hours. In patients with high risk and severe chronic pathology (eg, cardiopulmonary), cholecystectomy should be delayed, drug therapy administered until the patient's condition is stabilized or cholecystitis manifestations regress. If cholecystitis regresses, cholecystectomy can be performed after more than 6 weeks. Empyema, gangrene, perforation and acuminate cholecystitis require urgent surgical treatment. In patients with very high surgical risk, percutaneous cholecystostomy can be performed as an alternative to cholecystectomy.

Acute cholecystitis - Treatment

Prevention of acute cholecystitis

With the development of clinical manifestations associated with the presence of stones in the gallbladder, it is necessary to consider the possibility of conducting cholecystectomy (optimally with the help of endoscopic techniques) in a planned manner to prevent the development of bile colic and acute cholecystitis.

Prognosis of acute cholecystitis

In the natural course of acute cholecystitis due to the presence of calculus (concrements) in the gallbladder, 85% of the cases come to an independent recovery, but in 1/3 of patients within 3 months a new attack develops. In 15% of patients the disease progresses and often leads to serious complications, which dictates the need for early resolution of the question of surgical treatment in each case of acute cholecystitis. Possible rapid progression of cholecystitis to gangrene or empyema of the gallbladder, the formation of fistulas, intrahepatic abscesses, the development of peritonitis. Mortality with complicated cholecystitis reaches 50-60%. Lethality in the absence of cholecystitis is 2 times higher than in calculosa, and gangrene and perforation develop more often.