Cholecystitis

Cholecystitis

ByDr. Mohammad Kamal Akhtar

Surgeon, Meeqat General HospitalMadina Munawwara

Cholecystitis usually presents as a pain in the right upper quadrant or epigastric region.

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Symptomatically it differs from biliary colic by the presence of an inflammatory component (fever, increased white cell count

This pain is initially intermittent, but later usually presents as constant and severe

During the initial stages, the pain may be felt in an area totally separate from the site of pathology, known as referred pain.

The pain is originally located in the right upper quadrant but the referred pain may occur in the right scapula region (Boas' sign).

This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies, and fried foods.

This is usually accompanied by diarrhea, vomiting and nausea. The gallbladder may be tender and distended.

More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.

Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, and diarrhea.

CausesCholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species.[citation needed]

The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.

Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis. This can arise in patients with anorexia nervosa, as the lack of stimulation of the gallbladder leads to an infectious process.

Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.

DiagnosisCholecystitis is usually diagnosed by a history of the above symptoms, as well as examination findings:

fever (usually low grade in uncomplicated cases)

tender right upper quadrant with or without Murphy's sign

Ortner's sign — tenderness when hand taps the edge of right costal arch

Georgievskiy — Myussi's sign (phrenic nerve sign) — pain when press between edges of sternocleidomastoid

Boas' sign — Increased sensitivity below the right scapula (also due to phrenic nerve irritation).

Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes.Ultrasound can assist in the differential

Differential diagnosis[edit] Acute cholecystitis

Differential diagnosisAcute cholecystitis Acute cholecysitis as seen on ultrasound. This should be suspected whenever there is acute right upper quadrant or epigastric pain,

other possible causes include:Perforated peptic ulcerAcute peptic ulcer exacerbationAmoebic liver abscessAcute amoebic liver colitis

Acute pancreatitisAcute intestinal obstructionRenal colicAcute retro-colic appendicitis

Chronic cholecystitisThe symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:Peptic ulcerHiatus herniaColitisFunctional bowel syndrome, is defined pathologically by the columnar epithelium reaching down to the muscular layer.

Quick DifferentialBiliary colic — Caused by obstruction of the cystic duct. It is associated with sharp and constant epigastric pain in the absence of fever, and there is usually a negative Murphy's sign. Liver function tests are within normal limits since the obstruction does not necessarily cause blockage in the common hepatic duct, thereby allowing normal bile excretion from the liver. An ultrasound scan is used to visualise the gallbladder and associated ducts, and also to determine the size and precise position of the obstruction.

Cholecystitis — Caused by blockage of the cystic duct with surrounding inflammation, usually due to infection. Typically, the pain is initially 'colicky' (intermittent), and becomes constant and severe, mostly in the right upper quadrant. Infectious agents that cause cholecystitis include E. coli, Klebsiella, Pseudomonas, B. fragilis and Enterococcus. Murphy's sign is positive, particularly because of increased irritation of the gallbladder lining, and similarly this pain radiates (spreads) to the shoulder, flank or in a band like pattern around the lower abdomen. Laboratory tests frequently show raised hepatocellular liver enzymes (AST, ALT) with a high white cell count (WBC). Ultrasound is used to visualise the gallbladder and ducts.

Choledocholithiasis — This refers to blockage of the common bile duct where a gallstone has left the gallbladder or has formed in the common bile duct (primary cholelithiasis). As with other biliary tree obstructions it is usually associated with 'colicky' pain, and because there is direct obstruction of biliary output, obstructive jaundice. Liver function tests will therefore show increased serum bilirubin, with high conjugated bilirubin. Liver enzymes will also be raised, predominately GGT and ALP, which are associated with biliary epithelium. The diagnosis is made using endoscopic retrograde cholangiopancreatography (ERCP), or the nuclear alternative (MRCP). One of the more serious complications of choledocholithiasis is acute pancreatitis, which may result in significant permanent pancreatic damage and brittle diabetes.

Cholangitis — An infection of entire biliary tract, and may also be known as 'ascending cholangitis', which refers to the presence of pathogens that typically inhabit more distal regions of the bowel[3]

Cholangitis is a medical emergency as it may be life threatening and patients can rapidly succumb to acute liver failure or bacterial sepsis. The classical sign of cholangitis is Charcot's triad, which is right upper quadrant pain, fever and jaundice. Liver function tests will likely show increases across all enzymes (AST, ALT, ALP, GGT) with raised bilirubin. As with choledocholithiasis, diagnosis is confirmed using cholangiopancreatography.

InvestigationsBloodLaboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC count. CRP (C-reactive protein) is often elevated. The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.

RadiologySonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The diagnostic criteria are gallbladder wall thickening greater than 3mm, pericholecystic fluid and sonographic Murphy's sign. Gallstones are not part of the diagnostic criteria as acute cholecystitis may occur with or without them.The reported sensitivity and specificity of CT scan findings are in the range of 90–95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.

Treatment for cholecystitis will depend on your symptoms and your general health. People who have gallstones but don't have any symptoms may need no treatment. For mild cases, treatment includes bowel rest, fluids and antibiotics given through a vein, and pain medicine.

The main treatment for acute cholecystitis is surgery to remove the gallbladder (cholecystectomy). Often this surgery can be done through small incisions in the abdomen (laparoscopic cholecystectomy), but sometimes it requires a more extensive operation

Sometimes acute cholecystitis is caused by one or more gallstones getting stuck in the main tube leading to the intestine, called the common bile duct. Treatment may involve an endoscopic procedure (endoscopic retrograde cholangiopancreatography, or ERCP) to remove the stones in the common bile duct before the gallbladder is removed.

Supportive measures are usually instituted prior to surgery. These measures include fluid resuscitation and antibiotics. Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e.g.ceftriaxone) and an antibacterial with good coverage (fluoroquinolone such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic patients, aztreonam and clindamycin may be used.

In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. A cholecystectomy may then be warranted if the patient's condition improves.

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