Cholecystitis

What is Cholecystitis?

Cholecystitis is defined as an inflammation of the gallbladder. Located at the right side of our abdomen, the gallbladder is a small organ that helps in digestion and stores the product produced by the liver called bile.

Cholecystitis is normally caused by the formation of gallstones (calculous cholelithiasis) that interfere with or totally obstruct the bile duct, causing irritation and inflammation of the surrounding area. Gallstones are very common in the Western society, affecting about 10% of the population.

Inflammation of the gallbladder might also occur in the absence of gallstones (acalculous cholecystitis) due to other inflammation, injury or a tumor near the gallbladder. Acalculous cholecystitis accounts for 10% of all cholecystitis cases.

What Causes Cholecystitis?

The development of cholecystitis can be abrupt or slow depending on its cause. Some of the conditions or factors associated with cholecystitis include:

• Gallstones (cholelithiasis)
• Obesity - excessive dietary cholesterol intake and sedentary lifestyle
• Sudden weight loss
• Older age (over 60 years old)
• Type-1 diabetes
• Prolonged trauma or surgery
• Infection
• Long term fasting
• Tumors
• Pregnancy
• Hormone replacement therapy
• Cardiac events
• Sickle cell disease
• Prolonged total parenteral nutrition
• AIDS/HIV

Symptoms of Cholecystitis

The symptoms of cholecystitis often occur after a meal rich in fat. Patients frequently have a pain on the right upper region of the abdomen that may radiate to the right shoulder.

Other symptoms include:

• Diarrhea
• Nausea and vomiting
• Loss of appetite
• Abdominal bloating
• Chills
• Sweating
• Fever
• Belching
• Jaundice – this symptom is unusual in the early statges of cholecystitis and may be found in fewer than 20% of patients.

Diagnosis of Cholecystitis

The most direct diagnostic tests consist of imaging of the abdominal region using ultrasound or computed tomography (CT) scan. This regularly enables direct visualization of the gallstones. Using the hepatobiliary iminodiacetic acid (HIDA) scan, the physician is able to observe the gallbladder, liver, biliary system and small intestine, while allowing for measurement of bile flow and identification of bile obstruction.

The diagnosis of acalculous cholecystitis is difficult due to the absence of characteristic clinico-pathological features of the disease. Imaging tests provide the most direct evidence by showing enlargement of the gallbladder due to the infection.

There are no laboratory tests specific for gallbladder disease. Inflammation and infection can be established through an increase in white blood cells. Abnormal liver function (indicated by levels of bilirubin, alkaline phosphatase and serum aminotransferase) are associated with a gallbladder infection.

In critical cases with difficult diagnosis, percutaneous surgical intervention to detect infection in (and eventually remove) the gallbladder has been performed.

Treatment of Cholecystitis

Asymptomatic patients may not need any treatment. Non-surgical treatment is prescribed during the acute phase of cholecystitis. For mild cases, treatment includes bowel rest, fluids and antibiotics administered through a vein, and pain medicine. In general, the patient should adhere to a diet low on fat to avoid increasing the work load of the gallbladder.

Pain can be very intense (excruciating, even), and is normally managed by the use of opioids. Morphine should be avoided because it may cause a biliary spasm. Some of the analgesic combinations used are:

• Meperidine hydrochloride
• Hydrocodone and acetaminophen
• Oxycodone and acetaminophen

Antibiotics that are administered to control and treat the infection:

• Ampicillin and sulbactam
• Imipenem and cilastatin
• Ciprofloxacin
• Meropenem
• Metronidazole

Antiemetics that are administered to manage nausea and vomiting and to prevent dehydration:

• Prochlorperazine
• Promethazine

In cases where medical treatment fails, surgical removal of the gallbladder might be considered (cholecystectomy). Depending on the specific presentation, some advocate open cholecystectomy or percutaneous surgery. The open procedure is more invasive and requires a longer recovery time.

Prognosis of Cholecystitis

The prognosis for people who had a cholecystectomy and with uncomplicated cholecystitis is very good. However, for chronic complication in cholecystitis, the prognosis is poor, especially when gangrene or perforation occurs.

Preventing Cholecystitis

There are some factors that increase the risk of gallstones and that should be avoided. Fasting, skipping meals and quickly loosing weight are some of those. Obesity has also been associated with gallstone development, and balanced diet and frequent exercise are important to avoid gaining excessive weight.

Living with Cholecystitis

People with cholecystitis should seek immediate medical treatment to avoid further complications. Follow a healthy diet and avoid food with high fat content.

Current Research of Cholecystitis

Endoscopic gallbladder drainage is under evaluation as an alternative therapeutic method to surgery in acute cholecystitis. There are different methods in nonsurgical gallbladder drainage that includes percutaneous transhepatic gallbladder drainage and aspiration, endoscopic nasogallbladder drainage and gallbladder stenting via a transpapillary endoscope, and EUS-guided nasogallbladder drainage and gallbladder stenting via a transmural endoscopic approach.

The association between Salmonella infection of the gallbladder and the development of gallstones is also under investigation. This research will explain in more detail the mechanism by which gallstones lead to infection.

The nature of gallbladder polyps, and its involvement in gallbladder infections and cancer, is another research goal.