The gallbladder is a small, pear-shaped sac located beneath the liver. It stores bile, a fluid that is produced by the liver and aids in digestion. When bile is needed, as when people eat, the gallbladder contracts, pushing bile through the bile ducts into the small intestine. (See also Overview of Gallbladder and Bile Duct Disorders Overview of Gallbladder and Bile Duct Disorders The liver produces bile, a greenish yellow, thick, sticky fluid. Bile aids digestion by making cholesterol, fats, and fat-soluble vitamins easier to absorb from the intestine. Bile also helps... read more .)
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 (see Figure: View of the Liver and Gallbladder View of the Liver and Gallbladder Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts... read more ).
Cholecystitis is classified as acute or chronic.
Acute cholecystitis begins suddenly, resulting in severe, steady pain in the upper abdomen. At least 95% of people with acute cholecystitis have gallstones Gallstones Gallstones are collections of solid material (predominantly crystals of cholesterol) in the gallbladder. The liver can secrete too much cholesterol, which is carried with bile to the gallbladder... read more . 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 Acalculous cholecystitis Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct. Typically, people have abdominal pain, fever, and nausea. Ultrasonography can usually... read more ) occurs. However, the gallbladder may contain sludge (microscopic particles of materials similar to those in gallstones). Acalculous cholecystitis is more serious than other types of cholecystitis. It tends to occur after the following:
Critical illnesses such as serious injuries, severe burns Burns are injuries to tissue that result from heat, electricity, radiation, or chemicals. Burns cause varying degrees of pain, blisters, swelling, and skin loss. Small, shallow burns may need... read more , or a bloodstream infection (sepsis Sepsis and Septic Shock Sepsis is a serious bodywide response to bacteremia or another infection plus malfunction or failure of an essential system in the body. Septic shock is life-threatening low blood pressure ... read more )
Intravenous feedings for a long time
Fasting for a long time
A deficiency in the immune system
Certain disorders involving blood vessel inflammation (vasculitis) Overview of Vasculitis Vasculitic disorders are caused by inflammation of the blood vessels (vasculitis). Vasculitis can be triggered by certain infections or drugs or can occur for unknown reasons. People may have... read more , such as systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic autoimmune inflammatory connective tissue disorder that can involve joints, kidneys, skin, mucous membranes, and blood vessel walls. Problems in the... read more , polyarteritis nodosa Polyarteritis Nodosa (PAN) Polyarteritis nodosa is a form of vasculitis involving inflammation of medium-sized arteries. Any organ can be affected but usually not the lungs. Polyarteritis nodosa can be rapidly fatal or... read more
Acute acalculous cholecystitis can occur in young children, perhaps developing from a viral or other infection.
Chronic cholecystitis is gallbladder inflammation that has lasted a long time. It almost always results from gallstones and from prior attacks of acute cholecystitis Acute cholecystitis Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct. Typically, people have abdominal pain, fever, and nausea. Ultrasonography can usually... read more . Chronic cholecystitis is characterized by repeated attacks of pain (biliary colic) that occur when gallstones periodically block the cystic duct.
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 gallstones may block the opening of the gallbladder into the cystic duct or block the cystic duct itself. The gallbladder usually also contains sludge. If scarring is extensive, calcium may be deposited in the walls of the gallbladder, causing them to harden (called porcelain gallbladder).
A gallbladder attack, whether in acute or chronic cholecystitis, begins as pain.
The pain of acute cholecystitis is similar to biliary colic (pain caused by gallstones Gallstones are collections of solid material (predominantly crystals of cholesterol) in the gallbladder. The liver can secrete too much cholesterol, which is carried with bile to the gallbladder... read more ) but is more severe and lasts longer. 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 stiff. 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.
In older people, the first or only symptoms of cholecystitis may be vague. 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. Increasingly severe pain, a high fever, and chills suggest pockets of pus (abscesses) in or a tear (perforation) in the gallbladder. Abscesses result from gangrene, which develops when tissue dies. A large stone may tear the gallbladder's wall and pass into the small intestine and block it. This blockage may cause abdominal pain and bloating.
If people develop jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more 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 Cholestasis Cholestasis is reduction or stoppage of bile flow. Bile is the digestive fluid produced by the liver. Disorders of the liver, bile duct, or pancreas can cause cholestasis. The skin and whites... read more ).
Inflammation of the pancreas (pancreatitis Overview of Pancreatitis Pancreatitis is inflammation of the pancreas. The pancreas is a leaf-shaped organ about 5 inches (about 13 centimeters) long. It is surrounded by the lower edge of the stomach and the first... read more ) can develop. It is caused by a stone blocking the ampulla of Vater (where the common bile duct and the pancreatic duct join together).
Acalculous cholecystitis typically causes sudden, excruciating pain in the upper abdomen in people with no previous symptoms or other evidence of a gallbladder disorder (see Biliary Pain Without Gallstones Biliary Pain Without Gallstones Pain similar to that caused by gallstones sometimes occurs in people who have no gallstones or who have gallstones too small to be detected by ultrasonography. It is called acalculous biliary... read more ). The inflammation is often very severe and can lead to gangrene or rupture of the gallbladder.
People with acalculous cholecystitis tend to be very ill. For example, they may be in the intensive care unit for another reason and have many other symptoms. Also, because these people are so ill, they may not be able to communicate very clearly. For these reasons, 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.
People with chronic cholecystitis have recurring attacks of pain. The upper abdomen above the gallbladder is tender to the touch. In contrast to acute cholecystitis, fever rarely occurs in people with chronic cholecystitis. The pain is less severe than the pain of acute cholecystitis and does not last as long.
Doctors diagnose cholecystitis based mainly on symptoms and results of imaging tests.
Ultrasonography Ultrasonography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more 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 Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more , 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. Cholescintigraphy is also useful when doctors suspect acute acalculous cholecystitis Acalculous cholecystitis Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct. Typically, people have abdominal pain, fever, and nausea. Ultrasonography can usually... read more .
Liver tests Liver Blood Tests Liver tests are blood tests that represent a noninvasive way to screen for the presence of liver disease (for example, hepatitis in donated blood) and to measure the severity and progress of... read more (blood tests) are done to evaluate how well the liver is functioning and whether it is damaged. However, these tests cannot confirm the diagnosis because results are often normal or only slightly high, unless the bile duct is blocked.
Other blood tests are also done. For example, the number (count) of white blood cells is measured. A high white blood cell count suggests inflammation, an abscess, gangrene Gas Gangrene Gas gangrene is a life-threatening infection of muscle tissue caused mainly by the anaerobic bacteria Clostridium perfringens and several other species of clostridia. Gas gangrene can develop... read more , or a perforated gallbladder.
Computed tomography (CT) Computed Tomography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more of the abdomen can detect some complications of cholecystitis, such as pancreatitis Overview of Pancreatitis Pancreatitis is inflammation of the pancreas. The pancreas is a leaf-shaped organ about 5 inches (about 13 centimeters) long. It is surrounded by the lower edge of the stomach and the first... read more or a tear in the gallbladder.
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 blocked or is not functioning normally.
Usually, people are given antibiotics intravenously (because infection is possible) and pain relievers.
The gallbladder is usually removed within 24 to 48 hours after symptoms start if:
Acute cholecystitis is confirmed and the risk of surgery is small.
People are older or have diabetes because in such people, cholecystitis is more likely to result in infections.
A complication such as an abscess, gangrene Gas Gangrene Gas gangrene is a life-threatening infection of muscle tissue caused mainly by the anaerobic bacteria Clostridium perfringens and several other species of clostridia. Gas gangrene can develop... read more , or perforated gallbladder is suspected.
If necessary, surgery can be delayed for 6 weeks or more while the attack subsides. If people have a disorder that makes surgery too risky (such as a serious heart, lung, or kidney disorder), surgery is delayed until appropriate treatment can control the disorder as well as possible. If surgery needs to be delayed or avoided completely, the gallbladder may need to be drained to help treat and prevent spread of the infection. Drainage can be done by placing a tube through the abdominal wall into the gallbladder, allowing fluid to drain outside the body. Alternatively, a drainage tube can be placed from inside the body during endoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... read more guided by endoscopic ultrasound Ultrasonography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more (EUS). In EUS, an endoscope that contains a tiny ultrasound device at its tip is passed through the mouth into the stomach and the small intestine. The ultrasound images guide the doctor to place a drain between the gallbladder and the small intestine or between the gallbladder and the stomach.
In chronic cholecystitis, the gallbladder is usually removed after the current attack subsides.
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 surgical instruments are inserted through the incisions. Doctors then use the instruments to remove the gallbladder. The laparoscope contains a tiny camera, which enables surgeons to see what they are doing inside the body.
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. Doctors sometimes call this postcholecystectomy syndrome. The cause of this syndrome is not known, but in a few people, it may be malfunction of the sphincter of Oddi (a ring-shaped muscle between the common bile and pancreatic ducts and the small intestine). Malfunction of this muscle can slow the flow of bile and pancreatic secretions from the ducts and thus increase pressure in the ducts, causing pain. Pain may also result from small gallstones that remain in the ducts after the gallbladder is removed. More commonly, the cause is another, unrelated problem, such as irritable bowel syndrome Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is a disorder of the digestive tract that causes recurring abdominal pain and constipation or diarrhea. Symptoms vary but often include lower abdominal pain, bloating... read more or even peptic ulcer disease Peptic Ulcer Disease A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from Helicobacter pylori... read more .
Endoscopic retrograde cholangiopancreatography (ERCP) or cholescintigraphy (see Imaging Tests of the Liver and Gallbladder Imaging Tests of the Liver and Gallbladder Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more ) may be necessary to determine whether the cause of pain is increased pressure. For ERCP, 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 when the pain is caused by malfunction of the sphincter.