Acute Cholecystitis – Symptoms, Causes and Treatment

Congenital Anomalies Of Gallbladder

Absence of gallbladder: Very rare other variations include:

1. Floating gallbladder: Results due to long mesentery. It is more vulnerable to torsion—a rare cause of recurrent upper abdominal pain. Such a gallbladder can be easily removed.
2. Phrygian cap: Cap which was worn by people of Phrygia (ancient Asian country, Mongolia). It is an  anomaly connected with the fundus of the gallbladder.
3. Double gallbladder: The second one is always intrahepatic (rare).
4. Absence of cystic duct: Cholecystectomy becomes difficult. There are high chances of injury to the common bile duct.
5. Low insertion of cystic duct: Cystic duct opens into the common bile duct near the ampulla. This anomaly should be kept in mind when operating on cases of obstructive jaundice.
6. An accessory or aberrant cholecystohepatic duct is present in about 10% of the patients. It may be the cause of significant bile leakage after cholecystec¬tomy. It is the segmental duct that joins biliary system outside the liver instead of within it.
7. Diverticulum of gallbladder
8. Cystic duct joining right hepatic duct
9. Anomalies of blood supply
   1. Very, very tortuous hepatic artery: Caterpillar turn or Moynihan’s hump. It runs in front of the origin of cystic duct.
   2. Cystic artery is given anteriorly from right hepatic artery.

Gallstone Disease

Aetiology

1. Aetiology Metabolic Causes: Cholesterol is produced from the liver, which gives rise to bile acids. Cholesterol is insoluble and it must be transported within the bile salt micelles and  phospholipid (lecithin) vesicles. Normal ratio of bile acids: cholesterol is 25:1.
   • This ratio is necessary to maintain the cholesterol in liquid form by forming micelles. When the ratio drops down to 13:1 (which is called critical ratio), cholesterol crystals will nucleate and stones will form.
   • Obesity, high calorie diet and medications which increase cholesterol secretion can result in stone formation.
2. Aetiology Infection: It is the most common cause responsible for a gallstone in 80% of patients. Sources of infection are tonsils, tooth, bowel, etc.
   • Organisms such as E. coli, Proteus, anaerobic organisms, streptococci, etc. reach the gallbladder wall through the bloodstream and form a focus/nidus around which cholesterol and bile salts get precipitated.
   • Over a period of many years, this results in a mixed stone. They are usually multiple and occur in infected bile.
3. Aetiology Bile Stasis and Decreased Bile Acid Pool: Pregnancy, oestrogens, following vagotomy and prolonged total parenteral nutrition are associated with bile stasis. They are prone to mixed stones as a result of bile stasis.
   • Aetiology Causes of Decreased Bile Acid Pool
     1. Cirrhosis of liver—pigment stones
     2. Gastrectomy
     3. Ileal resection
     4. Malabsorption
     5. Obesity
     6. Hypercholesterolaemia
4. Aetiology Haemolytic Anaemia
   • Examples: Hereditary spherocytosis, sickle cell anaemia.
   • Bilirubin production is increased because of increased breakdown of RBCs. Since the production is more, they cannot conjugate with glucuronic acid, which is produced at normal levels.
   • Such unconjugated bilirubin combines with calcium and is excreted in the biliary tree resulting in calcium bilirubinate stones (pigment stones) not only in the gallbladder but also in the entire ductal system.
5. Aetiology Saint’s Triad: Gallstones can occur along with two other conditions:
   • Diverticulosis of colon
   • Hiatus hernia
6. Aetiology Parasitic Infestation: In Oriental countries, Clonorchis sinensis (Chinese liver fluke) infestations can cause stone in the biliary tree. Ascaris lumbricoides in the biliary tree may produce stones the common bile duct.
7. Aetiology Due to Abnormal Mucus: It is produced in congenital cystic fibrosis. Gallstones occur in these children due to impairment of bile flow.
8. Risk Factors for Gallstone Disease
   • Female sex
   • Obesity
   • Maturity onset diabetes
   • Age >40 years

Gallstones Other Diseases Associated

• Diabetes mellitus
• Type 4 hyperlipoproteinaemia
• Cirrhosis of liver
• Fistulae on treatment with total parenteral nutrition
• Gastric surgery

Gallstones Types

1. Cholesterol stones
   • Constitutes about 10% of the gallstones.
   • Occur in patients with increased cholesterol levels.
   • Fatty women are commonly affected.
   • It is single, solitary, occurs in aseptic bile. Sometimes they can be multiple. Precipitation of cholesterol gives rise to stone.
   • Such stones can be silent for many years. They are radiolucent.
   • Pigment can also get precipitated along with cholesterol.
2. Brown pigment stones
   • Rare in gallbladder, occurs in bile duct.
   • Composed of calcium bilirubinate, calcium palmitate and calcium stearate + cholesterol.
   • Occur due to bile stasis caused by foreign bodies, endoprosthesis, Clonorchis sinensis and Ascaris lumbricoides.
3. Mixed stones
   • They constitute about 80% of gallstones.
   • They contain alternating layers of cholesterol and pigment with epithelial debris or vegetations, from infective organisms.
   • They are multiple, small, faceted by mutual pressure.
4. Pigment stones
   • They are found in 5 to 10% of patients.
   • They are calcium bilirubinate stones.
   • Commonly occur due to haemolysis. Hence, they are black, multiple, small, irregular concretions or sludge particles.
   • For reasons not clear, cirrhotic patients have increased incidence of black pigment stones.
   • Bacteria also have a major role to play in the formation of pigment stones. Patients with pigment stones have more sepsis than patients with cholesterol stones.

Gallstones Clinical Features (Complications of Gallstones): Clinical presentation of these patients vary from dyspepsia to severe forms such as pancreatitis and perforation of the gallbladder. Complications are classified as in the gallbladder, in the CBD and in the intestines.

In the Gallbladder

• Silent stones
• Flatulent dyspepsia
• Gallstone colic
• Acute cholecystitis—Murphy’s sign positive
• Chronic cholecystitis
• Mucocele—enlarged gallbladder without jaundice
• Empyema
• Perforation
• Carcinoma of the gallbladder
• Mirizzi’s syndrome

In the Bile Duct

• Obstructive jaundice
• Cholangitis
• White bile
• Acute pancreatitis

In the Intestine: Acute intestinal obstruction (gallstone ileus)

Complications In The Gallbladder

1. Silent Stones
   • This is usually a single, silent, cholesterol stone which is symptomless.
   • It is accidentally discovered, may be by an ultrasound or plain X-ray abdomen (since calcium content is low in a cholesterol stone, it is very rarely visible in a plain X-ray).
   • This stone rarely causes obstructive jaundice.
   • Hence, it is left alone without treatment.
2. Flatulent Dyspepsia: If an obese woman (fatty, fertile, flatulent, female in forties) complains of gaseous distention, intolerance to fatty food discomfort in the abdomen, heartburn and belching, she probably has gallstones. These patients benefit from cholecystectomy.
3. Gallstone Colic; It usually occurs at night wherein a stone tends to block the cystic duct or neck of gallbladder in the supine position.
   • It is a severe colicky upper abdominal pain felt in the right hypochondrium, may shoot to the back or between shoulder blades. The pain is continuous and lasts for a few hours. Pain may radiate to chest also.
     • The pain is due to spasm of gallbladder.
     • It is associated with vomiting due to reflex pylorospasm, restlessness and sweating.
     • There is tenderness in the right hypochondrium.
   • Pain may last for a few minutes to a few hours.
   • Differential diagnoses include:
     • Chronic duodenal ulcer
     • Reflux oesophagitis (some causes can present as precordial chest pain)
     • Pancreatitis
     • Myocardial infarction

Acute Cholecystitis

Acute Cholecystitis Definition: Acute bacterial inflammation of the gallbladder with or without stone.

Acute Cholecystitis Types

1. Calculous: Obstructive cholecystitis. It is the commonest variety. Calculi cause bile stasis.
2. Acalculous: Nonobstructive cholecystitis. It is not uncommon and is seen in patients who are recovering from major illness.
3. Acute emphysematous cholecystitis.

Acalculous Cholecystitis-Percutaneous Cholecystostomy

• In life-threatening situations with severe sepsis due to gallstones, percutaneous cholecystostomy seems to be a very good alternative to save the life of the patient.
• Indicated in acalculous cholecystitis in which the patient’s condition is serious with sepsis with comorbid conditions.
• Using ultrasound or CT guidance, a pigtail catheter can be inserted into the gallbladder, ideally transperitoneally.
• It is the treatment of choice for acalculous cholecystitis.
• 3-4 days later, when sepsis improves, laparoscopic/ open cholecystectomy can be done.

Acute Cholecystitis Bacteriology

• Majority of the cases of calculous cholecystitis are due to organisms such as E. coli, streptococci, Salmonella, Klebsiella, etc.
• Typhoid fever can also cause typhoid cholecystitis around 2nd week of infection.
• Clostridial infection of the gallbladder produces acute cholecystitis with toxaemia.

Acute Cholecystitis Typhoid Infection Of Gallbladder

• Salmonella typhi or S. typhimurium are the organisms.
• Acute cholecystitis can occur in the 2nd week of typhoid fever.
• Long-lasting infections—chronic cholecystitis can occur.
• Bacilli can be present in the bile for a long time.
• Obstruction by a pre-existing stone or any other cause.
• Necrosis of GB, ulceration, perforation can be dangerous.
• Local tenderness, on the right side of abdomen, guarding can occur.
• Antibiotics against Salmonella must be given.

Acute Cholecystitis Pathogenesis

• Acute calculous cholecystitis appears to be caused by obstruction to bile flow from gallbladder by stone or oedema formed as a result of local mucosal erosion and inflammation caused by stone. Once mucosa is eroded, tissue planes are exposed to bile salts. Toxic bile salts destroy cells by their detergent action leading to necrosis and perforation of gallbladder.
• At the same time, bacterial infection adds to the morbi¬dity of acute cholecystitis. Positive bile cultures are found in 70% of cases of acute calculous cholecystitis.

Acute Cholecystitis Pathology

1. Inflammation: Entire gallbladder is inflamed, swollen and is friable. When the inflammatory exudate surrounding the gallbladder collects under the diaphragm, it results in pain radiating to the right shoulder (C3, C4) due to phrenic nerve irritation. It may undergo complete resolution with antibiotic therapy but such recurrent attacks are common at a later date.
2. Perforation: Extensive ulcerations of gallbladder may result in perforation with biliary peritonitis and carries a very high mortality rate. Perforation can occur when the stone is impacted in the Hartmann’s pouch.
3. Obstruction to the neck of gallbladder results in mucocele or pyocele (empyema). Empyema of the gallbladder can occur in diabetic patients and is associated with high grade fever, chills, rigors and even septicaemia.
4. Gangrene of gallbladder can occur, if the blood vessels get thrombosed. All these features are more in an obstructive variety. If there is clostridial infection as can occur in diabetics because of extensive gas production in biliary tree and associated toxicity, perforation is likely even without a stone.
5. Jaundice as in hereditary spherocytosis.

Acute Cholecystitis Clinical Features

• A fatty, fertile, female is the typical victim who pre-sents with severe upper abdominal pain. The pain is colicky in nature and more prolonged because of inflammation. Severe nausea and vomiting are present. In the initial phase, there is low grade fever, except in clostridial infection where there is high grade fever.
• Right shoulder pain is due to inflammatory exudate irritating under surface of the diaphragm (supplied by phrenic nerves C4-C5—shoulder region is supplied by supraclavicular nerves.

Acute Cholecystitis Signs

1. Murphy’s sign: Keep the fingers in the right hypochondrium and ask the patient to take a deep inspiration.
   • At the height of inspiration, there is a sudden catch in the inspiration.
   • It is due to inflamed gallbladder coming in contact with the abdo¬minal wall under the fingers and producing pain. This is called Murphy’s sign positive. It is a diagnostic sign of acute chole¬cystitis
2. Boas’ sign: An area of hyperaesthesia between 9th and 11th ribs posteriorly on the right side is a feature.
3. Upper abdominal guarding, rigidity.
4. Vague mass consisting of inflamed gallbladder, omentum, inflammatory exudate can be felt at times. Hence, even if a perforation occurs, generalised peritonitis is uncommon.

Acute Cholecystitis Differential Diagnosis (DD)

1. Perforated peptic ulcer: Severe sudden pain, severe tenderness in the right hypochondrium, guarding and rigidity caused by perforated peptic ulcer, can mimic acute cholecystitis. Obliteration of liver dullness, coffee ground vomitus, generalised guarding and rigidity clinches the diagnosis of perforated duodenal ulcer.
2. Acute pancreatitis: A severe pain in upper abdomen, tenderness in the right hypochondrium and epigastrium mimic cholecystitis. One should remember that pain of pancreatitis is more severe and classically radiates to back.
3. High retrocaecal appendicitis: Especially when appendix is in the subhepatic position. Once inflammatory fluid spreads in the general peritoneal cavity, there will be more difficulty in diagnosing clinically.
4. Amoebic liver abscess: Can also mimic very closely. It is more common in male alcoholics. Liver is enlarged and one can feel the round lower border of liver very closely. Liver will be extremely tender.
5. Lobar pneumonia (basal): It can give rise to referred pain in the right hypochondrium with guarding and rigidity.

Acute Cholecystitis Investigations

1. Total WBC count is always raised.
2. Blood and urine sugar estimation to rule out diabetes
   mellitus.
3. Emergency ultrasonography
   • To demonstrate stones, which cast posterior acoustic shadow.
   • Success rate is >95%.
   • It can demonstrate inflamed, thickened organ, in cases of acalculous cholecystitis.
   • More than 5-6 mm thickness of gallbladder suggests significant thickening.
   • Pericholecystic oedema may be present.
   • Demonstration of Murphy’s sign, with the help of ultrasonography is possible which adds to the diagnosis.
   • Ultrasound can also measure gallbladder function by using ultrasonic dimensions of the gallbladder.
   • It can detect gallbladder polyps.
4. Plain X-ray abdomen erect position
   • Gallstones can be demonstrated in 10% of the patients as radio-opaque shadows in the right hypochondrium. In lateral view, the stone is seen in front of vertebral bodies.
   • To rule out other causes such as perforated peptic ulcer (air under diaphragm).
   • Rarely, it may show a calcified gallbladder (porcelain gallbladder).
     10% gallstones are radio-opaque, 90% gallstones are radiolucent. Centre of stones may contain radiolucent gas, either triradiate (Mercedes-Benz sign) or biradiate (Sea Gull sign).
5. CT scan
   • It is done when ultrasound findings are not clear
   • It not only diagnoses gallstones, but also detects other complications such as perforation, stones in the CBD, etc.
   • Renal halo sign is due to fluid around.
   • Obliteration of psoas shadow can be seen.
   • Air fluid level in duodenum are the features.

Acute Cholecystitis Treatment

1. Conservative Treatment (60 to 70%) Followed by Cholecystectomy: Basically there are two types of cholecystectomy—one is early cholecystectomy and other is elective cholecystectomy. Elective cholecystectomy is followed by many surgeons because many patients are elderly often diabetic or may be having cardiac comorbidity. Also inflammation would have resulted in so-called frozen or difficult ‘Calot’s triangle’ dissection.

During surgery, dissection may result in injuries to CBD, hepatic artery, portal vein, etc. Hence, these are managed conservati¬vely till pain inflammation settles down. Principles of conservative treatment are given below.

1. Admission
2. Aspiration with Ryle’s tube: Aspiration of HCl decreases the stimulus to the secretion of bile. Spasm of gallbladder may come down.
3. Antispasmodics: Injection tramadol 50 mg IV/IM is given and if necessary repeated.
4. Antibiotics: Broad spectrum antibiotics are given against gram +ve, gram -ve and anaerobic organisms. Cefazolin, cefuroxime or amikacin are the drugs of choice. The patient is kept nil orally for 2-3 days and during this time, 4 fluids are given.

After 2-3 days, pain comes down, signs (tenderness) disappear and abdomen becomes soft. Ryle’s tube is removed, clear oral fluid is given for 2-3 days followed by soft diet. After 6 weeks, the patient is advised to undergo elective cholecystectomy. Reason for conservative treatment is in majority of cases, inflammation will settle down.

2. Early Cholecystectomy

• Patients in the first group need two admissions, cost is increased and return to work is also delayed.
• Hence, if a surgeon is experienced and the set up is good, one can proceed to early cholecystectomy from 2nd day to 7th day.
• It has been proved that even though gallbladder is inflamed, complications are no way more than elective cholecystectomy in the hands of experienced surgeon while performing laparoscopic cholecystectomy.
• Thus, if a firm preoperative diagnosis is established and some of the comorbid conditions are corrected (diabetes, hypertension, etc.), surgery can be done safely. This is called early cholecystectomy done within 48 to 72 hours.

3. Emergency Cholecystostomy: About 5% of cases of acute cholecystitis require emergency cholecystostomy.

• In these patients, high grade fever, sepsis, shock, high leukocyte count are the deciding factors.
• Acalculous cholecystitis and perforated gallbladder with peritonitis are definitely strong indications for emergency cholecystostomy.
• This is an attempt to decrease toxicity, fever and improve general condition.
• Either by open-laparoscopic method, a tube is inserted into gallbladder (Pigtail catheter/Malecot’s) and the pus/necrotic tissue is drained out. Only an experienced surgeon can attempt cholecystectomy. Otherwise tube is inserted and fixed and brought outside.
• After 6-8 days later, cholecystectomy is done.

Acute Cholecystitis Prognosis

• Overall death rate is 3-5%.
• Contributing factors for death are diabetes, age above 60 years, cardiovascular or pulmonary disease.
• Uncontrolled sepsis, intra-abdominal abscess.

What is prophylactic cholecystectomy?: It means removal of gallbladder with stones without symptoms. It is indicated in:

• Congenital haemolytic anaemia
• Patients undergoing bariatric surgery
• Porcelain gallbladder

Congenital Anomalies Of Gallbladder

Absence of gallbladder: Very rare other variations include:

1. Floating gallbladder: Results due to long mesentery. It is more vulnerable to torsion—a rare cause of recurrent upper abdominal pain. Such a gallbladder can be easily removed.
2. Phrygian cap: Cap which was worn by people of Phrygia (ancient Asian country, Mongolia). It is an  anomaly connected with the fundus of the gallbladder.
3. Double gallbladder: The second one is always intrahepatic (rare).
4. Absence of cystic duct: Cholecystectomy becomes difficult. There are high chances of injury to the common bile duct.
5. Low insertion of cystic duct: Cystic duct opens into the common bile duct near the ampulla. This anomaly should be kept in mind when operating on cases of obstructive jaundice.
6. An accessory or aberrant cholecystohepatic duct is present in about 10% of the patients. It may be the cause of significant bile leakage after cholecystec¬tomy. It is the segmental duct that joins biliary system outside the liver instead of within it.
7. Diverticulum of gallbladder
8. Cystic duct joining right hepatic duct
9. Anomalies of blood supply
   1. Very, very tortuous hepatic artery: Caterpillar turn or Moynihan’s hump. It runs in front of the origin of cystic duct.
   2. Cystic artery is given anteriorly from right hepatic artery.