Cholecystitis refers to a painful inflammation of the gallbladder's wall. The disorder can occur a single time (acute), or can recur multiple times (chronic).
The gallbladder is a small, pear-shaped organ in the upper right hand corner of the abdomen. It is connected by a series of ducts (tube-like channels) to the liver, pancreas, and duodenum (first part of the small intestine). To aid in digestion, the liver produces a substance called bile, which is passed into the gallbladder.
The gallbladder concentrates this bile, meaning that it reabsorbs some of the fluid from the bile to make it more potent. After a meal, bile is squeezed out of the gallbladder by strong muscular contractions, and passes through a duct into the duodenum. Due to the chemical makeup of bile, the contents of the duodenum are kept at an optimal pH level for digestion. The bile also plays an important part in allowing fats within the small intestine to be absorbed.
Gallstone formation is seen in twice as many women as men, particularly those between the ages of 20 and 60. Pregnant women or those on birth control pills or estrogen replacement therapy have a greater risk of gallstones, as do Native Americans and Mexican Americans.
People who are overweight, or who lose a large amount of weight quickly, are at greater risk for developing gallstones. Not all individuals with gallstones go on to have cholecystitis, since many people never have any symptoms from their gallstones and never know they exist. However, the vast majority of people with cholecystitis are found to have gallstones. Rare causes of cholecystitis include severe burns or injury, massive systemic infection, severe illness, diabetes, obstruction by a tumor of the duct leaving the gallbladder, and certain uncommon infections of the gallbladder (including bacteria and worms).
In about 95% of all cases of cholecystitis, the gallbladder contains gallstones. Gallstones are solid accumulations of the components of bile, particularly cholesterol, bile pigments, and calcium. These solids may occur when the components of bile are not in the correct proportion to each other. If the bile becomes overly concentrated, or if too much of one component is present, stones may form. When these stones block the duct leaving the gallbladder, bile accumulates within the gallbladder. The gallbladder continues to contract, but the bile cannot pass out of the gallbladder in the normal way. Back pressure on the gallbladder, chemical changes from the stagnating bile trapped within the gallbladder, and occasionally bacterial infection result in damage to the gallbladder wall. As the gallbladder becomes swollen, some areas of the wall do not receive adequate blood flow, and lack of oxygen causes cells to die.
When the stone blocks the flow of bile from the liver, certain normal byproducts of the liver's processing of red blood cells (called bilirubin) build up. The bilirubin is reabsorbed into the bloodstream, and over time this bilirubin is deposited in the skin and in the whites of the eyes. Because bilirubin contains a yellowish color, it causes a yellowish cast to the skin and eyes that is called jaundice.
Although there are rare reports of patients with chronic cholecystitis who never experience any pain, nearly 100% of the time cholecystitis is diagnosed after a patient has experienced a bout of severe pain in the region of the gallbladder and liver. The pain may be crampy and episodic, or it may be constant. The pain is often described as pushing through to the right upper back and shoulder. Because deep breathing increases the pain, breathing becomes shallow. Fever is often present, and nausea and vomiting are nearly universal. Jaundice occurs when the duct leaving the liver is also obstructed, although it may take a number of days for it to become apparent. When bacterial infection sets in, the patient may begin to experience higher fever and shaking chills.
Diagnosis of cholecystitis involves a careful abdominal examination. The enlarged, tender gallbladder may be felt through the abdominal wall. Pressure in the upper right corner of the abdomen may cause the patient to stop breathing in, due to an increase in pain. This is called Murphy's sign. Physical examination may also reveal an increased heart rate and an increased rate of breathing.
Blood tests will show an increase in the white blood count and bilirubin. Ultrasound is used to look for gallstones and to measure the thickness of the gallbladder wall (a marker of inflammation and scarring). A scan of the liver and gallbladder, with careful attention to the system of ducts throughout (called the biliary tree) is used to demonstrate obstruction of ducts.
Rare complications of cholecystitis include:
Initial treatment of cholecystitis usually requires hospitalization. The patient is given fluids, salts, and sugars through a needle placed in a vein (intravenous or IV). No food or drink is given by mouth. A tube, called a nasogastric or NG tube, may need to be passed through the nose and down into the stomach to drain out the excess fluids. Medications for pain and IV administration of broad spectrum antibiotics are initiated.
Treatment almost always involves removal of the gallbladder, a surgery called cholecystectomy. It is not usually recommended that the patient have surgery while acutely ill, however, patients with complications may require emergency surgery (immediately following diagnosis) because the death rate increases in these cases. Similarly, patients who have cholecystitis with no gallstones have a 50% chance of death if the gallbladder is not quickly removed.Most patients do best if surgery is performed after they have been stabilized with fluids, possibly an NG tube, and administration of antibiotics. Results of recent research indicate that early operation (laparoscopic cholecystectomy) by an experienced surgeon within 72 hours of admission results in the best outcomes for the patient. In patients who have other serious medical problems that may increase the risks of gallbladder removal surgery, the surgeon may decide to leave the gallbladder in place. In this case, the operation may involve removing obstructing gallstones and draining infected bile (called cholecystotomy).
Both cholecystectomy and cholecystotomy may be performed via the classical open abdominal operation (laparotomy). Tiny, "keyhole" incisions, a flexible scope, and a laser device that shatters the stones (a laparoscopic laser) can be used to destroy the gallstones. The laparoscopic procedure can also be used to remove the gallbladder through one of the small incisions. Because of the smaller incisions, laparoscopic cholecystectomy is a procedure that is less painful and promotes faster healing.
Hospital management of cholecystitis ends the symptoms for about 75% of all patients. Of these patients, 25% will have another attack of cholecystitis within a year, and 60% will have another attack within six years. Each attack of cholecystitis increases a patient's risk of developing life-threatening complications, requiring emergency surgery. Therefore, early removal of the gallbladder, rather than a "wait-and-see" approach, is usually recommended. Cure is complete in those patients who undergo cholecystectomy.
Prevention of cholecystitis is best attempted by maintaining a reasonable ideal weight. Some studies have suggested that eating a diet high in fiber, vegetables, and fruit is also protective.