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Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct.
Cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the gallbladder.
Cholecystitis is classified as acute or chronic.
Acute Cholecystitis:
Acute cholecystitis begins suddenly, resulting in severe, steady pain in the upper abdomen. At least 95% of people with acute cholecystitis have gallstones. The inflammation almost always begins without infection, although infection may follow later. Inflammation may cause the gallbladder to fill with fluid and its walls to thicken.
Rarely, a form of acute cholecystitis without gallstones (acalculous cholecystitis) occurs. Acalculous cholecystitis is more serious than other types of cholecystitis. It tends to occur after the following:
It can occur in young children, perhaps developing from a viral or another infection.
Chronic Cholecystitis:
Chronic cholecystitis is gallbladder inflammation that has lasted a long time. It almost always results from gallstones. It is characterized by repeated attacks of pain (biliary colic). In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually due to gallstones, and may become thick-walled, scarred, and small. The gallbladder usually contains sludge (microscopic particles of materials similar to those in gallstones) or gallstones that block its opening into the cystic duct or reside in the cystic duct itself.
Symptoms
A gallbladder attack, whether in acute or chronic cholecystitis, begins as pain. The pain of cholecystitis is similar to that caused by gallstones but is more severe and lasts longer—more than 6 hours and often more than 12 hours. The pain peaks after 15 to 60 minutes and remains constant. It usually occurs in the upper right part of the abdomen. The pain may become excruciating. Most people feel a sharp pain when a doctor presses on the upper right part of the abdomen. Breathing deeply may worsen the pain. The pain often extends to the lower part of the right shoulder blade or to the back. Nausea and vomiting are common.
Within a few hours, the abdominal muscles on the right side may become rigid. Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied by chills. Fever rarely occurs in people with chronic cholecystitis.
In older people, the first or only symptoms of cholecystitis may be rather general. For example, older people may lose their appetite, feel tired or weak, or vomit. They may not develop a fever.
Typically, an attack subsides in 2 to 3 days and completely resolves in a week. If the acute episode persists, it may signal a serious complication. A high fever, chills, a marked increase in the white blood cell count, and cessation of the normal rhythmic contractions of the intestine (ileus—see Gastrointestinal Emergencies: Appendicitis) suggest pockets of pus (abscesses) in the abdomen near the gallbladder or a perforated gallbladder. Abscesses result from gangrene, which develops when tissue dies.
If people develop jaundice (see Manifestations of Liver Disease: Jaundice) or pass dark urine and light-colored stools, the common bile duct is probably blocked by a stone, causing a backup of bile in the liver (cholestasis). Inflammation of the pancreas (pancreatitis) can develop. It is caused by a stone blocking the ampulla of Vater, near the exit of the pancreatic duct.
Acalculous cholecystitis typically causes sudden, excruciating pain in the upper abdomen in people with no previous symptoms or other evidence of a gallbladder disorder. The inflammation is often very severe and can lead to gangrene or rupture of the gallbladder. In people with other severe problems (including people in the intensive care unit for another reason), acalculous cholecystitis may be overlooked at first. The only symptoms may be a swollen (distended), tender abdomen or a fever with no known cause. If untreated, acalculous cholecystitis results in death for 65% of people.
Diagnosis
Doctors diagnose cholecystitis based mainly on symptoms and results of imaging tests. Ultrasonography is the best way to detect gallstones in the gallbladder. Ultrasonography can also detect fluid around the gallbladder or thickening of its wall, which are typical of acute cholecystitis. Often, when the ultrasound probe is moved across the upper abdomen above the gallbladder, people report tenderness.
Cholescintigraphy, another imaging test, is useful when acute cholecystitis is difficult to diagnose. For this test, a radioactive substance (radionuclide) is injected intravenously. A gamma camera detects the radioactivity given off, and a computer is used to produce an image. Thus, movement of the radionuclide from the liver through the biliary tract can be followed. Images of the liver, bile ducts, gallbladder, and upper part of the small intestine are taken. If the radionuclide does not fill the gallbladder, the cystic duct is probably blocked by a gallstone.
Liver blood tests are often normal unless the person has an obstructed bile duct. Other blood tests can detect some complications such as a high level of a pancreatic enzyme (lipase or amylase) in pancreatitis. A high white blood cell count suggests inflammation, an abscess, gangrene, or a perforated gallbladder.
Treatment
People with acute or chronic cholecystitis need to be hospitalized. They are not allowed to eat or drink and are given fluids and electrolytes intravenously. A doctor may pass a tube through the nose and into the stomach, so that suctioning can be used to keep the stomach empty and reduce fluid accumulating in the intestine if the intestine is not contracting normally. Usually, antibiotics are given intravenously, and pain relievers are given.
If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder is usually removed within 24 to 48 hours after symptoms start. If necessary, surgery can be delayed for 6 weeks or more while the attack subsides. Delay is often necessary for people with a disorder that makes surgery too risky (such as a heart, lung, or kidney disorder). If a complication such as an abscess, gangrene, or perforated gallbladder is suspected, immediate surgery is necessary.
In chronic cholecystitis, the gallbladder is usually removed after the acute episode subsides.
In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder.
Surgical removal of the gallbladder (cholecystectomy) is usually done using a flexible viewing tube called a laparoscope. After small incisions are made in the abdomen, the laparoscope and other tubes are inserted, and surgical tools are passed through the incisions and used to remove the gallbladder.
Pain After Surgery:
A few people have new or recurring episodes of pain that feel like gallbladder attacks even though the gallbladder (and the stones) have been removed. The cause is not known, but it may be malfunction of the sphincter of Oddi, the muscles that control the release of bile and pancreatic secretions through the opening of the bile and pancreatic ducts into the small intestine. Pain may occur because pressure in the ducts is increased by sphincter spasms, which hinder the flow of bile and pancreatic secretions. Pain may also result from small gallstones that remain in the ducts after the gallbladder is removed. More commonly, the cause is another problem, such as irritable bowel syndrome or even peptic ulcer disease.
Endoscopic retrograde cholangiopancreatography (ERCP) may be necessary to determine whether the cause of pain is increased pressure. For this procedure, a flexible viewing tube (endoscope) is inserted through the mouth and into the intestine, and a device to measure pressure is inserted through the tube. If pressure is increased, surgical instruments are inserted into the tube and used to cut and thus widen the sphincter of Oddi. This procedure (called endoscopic sphincterotomy) can relieve symptoms in people who have an abnormality of the sphincter.
Last full review/revision December 2007 by Eldon A. Shaffer, MD
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