Cholecystitis, the inflammation of the gallbladder, is a condition that can present a range of clinical manifestations and complications. It is primarily associated with gallstone disease, but other etiologies also contribute to its development.
The gallbladder is a small organ situated beneath the liver, responsible for storing bile produced by the liver. Bile aids in the digestion of fats and is released into the small intestine through the bile ducts. Cholecystitis commonly results from the obstruction of the cystic duct, usually by gallstones (cholelithiasis), leading to bile stasis, increased pressure, and subsequent inflammation. This condition is termed acute calculous cholecystitis.
However, cholecystitis can also occur in the absence of gallstones, known as acalculous cholecystitis. This form is often seen in critically ill patients or those with systemic conditions such as diabetes, severe trauma, or prolonged fasting. Acalculous cholecystitis is believed to result from bile stasis, ischemia, and secondary infection. Other rare causes include bacterial infections, particularly from organisms such as Salmonella or Helicobacter species, and neoplasms obstructing the cystic duct.
Patients with cholecystitis typically present with right upper quadrant (RUQ) abdominal pain, which may radiate to the right shoulder or back. The pain often starts abruptly, following a meal rich in fats, and is accompanied by nausea and vomiting. Fever is a common symptom, reflecting the inflammatory process. On physical examination, RUQ tenderness is evident, and a positive Murphy’s sign—pain elicited on palpation of the gallbladder during deep inspiration—can be a crucial diagnostic clue.
In severe cases, particularly with complications such as gallbladder perforation or empyema, patients may exhibit signs of peritonitis or sepsis, including hypotension and tachycardia. Chronic cholecystitis, resulting from repeated episodes of acute inflammation, may present with more subtle, intermittent RUQ discomfort, bloating, and indigestion.
The diagnosis of cholecystitis begins with a thorough history and physical examination, followed by laboratory and imaging studies. Laboratory tests often reveal leukocytosis with a left shift, indicating an inflammatory response. Liver function tests may show elevated levels of bilirubin, alkaline phosphatase, and transaminases if the common bile duct is involved.
Imaging plays a pivotal role in confirming the diagnosis. Ultrasound is the preferred initial modality due to its high sensitivity and specificity for detecting gallstones and signs of inflammation, such as gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy’s sign. In more complex cases or when ultrasound findings are inconclusive, further imaging with hepatobiliary iminodiacetic acid (HIDA) scan, computed tomography (CT), or magnetic resonance imaging (MRI) may be warranted. The HIDA scan, in particular, is useful in assessing cystic duct obstruction and gallbladder function.
The management of cholecystitis depends on the severity and the patient’s overall condition. Initial treatment typically involves hospitalization, fasting (nil per os, NPO), intravenous fluid resuscitation, and antibiotics to cover common biliary pathogens like E. coli, Klebsiella, and Enterococcus. Pain management is also crucial, with nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids often being administered.
Surgical intervention, specifically cholecystectomy (removal of the gallbladder), is the definitive treatment for most cases of acute calculous cholecystitis. The timing of surgery depends on the severity of the disease and the patient’s risk factors. Early cholecystectomy, performed within 72 hours of symptom onset, is generally preferred as it reduces complications and shortens hospital stay. In patients who are poor surgical candidates due to comorbid conditions or advanced age, percutaneous cholecystostomy—a procedure to drain the gallbladder—may be performed as a temporizing measure.
For patients with chronic cholecystitis, elective cholecystectomy is usually indicated to prevent recurrent episodes and complications. In cases of acalculous cholecystitis, the approach may vary, often requiring more aggressive supportive care and careful consideration of surgical risks.
Cholecystitis can lead to several serious complications if not promptly treated. These include gallbladder gangrene, perforation, abscess formation, and biliary peritonitis. Such complications increase the risk of sepsis and significantly elevate morbidity and mortality. Chronic cholecystitis may result in a contracted, fibrotic gallbladder, sometimes referred to as a porcelain gallbladder, which carries a higher risk of gallbladder cancer.
Preventive strategies for cholecystitis primarily focus on reducing the risk of gallstone formation. These include maintaining a healthy weight through balanced diet and regular exercise, as obesity is a significant risk factor for gallstones. A diet high in fiber and low in refined carbohydrates and fats can also decrease the likelihood of gallstone formation. For those with a history of gallstones but no symptoms, regular monitoring and lifestyle modifications are advised.
In conclusion, cholecystitis is a common and potentially serious condition characterized by inflammation of the gallbladder, most often due to gallstones. It presents with acute abdominal pain and systemic signs of inflammation, requiring prompt diagnosis and management to prevent complications. The cornerstone of treatment is cholecystectomy, with supportive measures and antibiotics playing critical roles in initial management. Understanding the nuances of cholecystitis, from its pathophysiology to its clinical management, is essential for effective patient care and improved outcomes.
Leave a Reply