What is Acute Cholecystitis?
Acute cholecystitis is a medical term for inflammation of the gallbladder. This inflammation usually occurs when the duct of the gallbladder becomes blocked. Surgery is the most effective treatment for cholecystitis, but if needed, there are non-surgical treatments available too. Cholecystitis can occur with or without gallstones, and it can be a short-term (acute) or long-term (chronic) condition.
Both men and women can develop cholecystitis, but it is more common in certain groups of people. It can cause a variety of signs and symptoms, and sometimes, it might be mistaken for other conditions such as peptic ulcer disease, irritable bowel syndrome, heart disease, or pancreatitis (an inflammation of the pancreas). Because of this, it’s important for doctors to make a careful diagnosis.
What Causes Acute Cholecystitis?
Acute cholecystitis, a type of gallbladder inflammation, is caused by a blockage in the cystic duct. Normally, the liver produces a substance called bile which travels to the bile duct and is stored in the gallbladder. After you eat spicy or fatty foods, the gallbladder releases the bile through the cystic duct into the bile duct and then to the duodenum, which is part of the small intestine, to help digest the food.
Sometimes, the gallbladder can concentrate the bile, making it thicker than usual. This thicker bile can form stones when the normal balance inside the gallbladder is disrupted. This can happen if the bile remains in the gallbladder too long, substances from liver like cholesterol and lipids get too much, the concentration process is disturbed, and cholesterol crystals start to form.
If the cystic duct gets blocked because of a stone, it’s called acute calculous cholecystitis. Sometimes, the pain caused by temporary blockage of the cystic duct by gallstones is called biliary colic. If the pain doesn’t go away after six hours, then it’s considered acute calculous cholecystitis. If there’s no stone but there’s still a blockage, it’s called acute acalculous cholecystitis.
Whatever the cause of the blockage, it will eventually cause swelling in the gallbladder wall. This can reduce blood flow to the gallbladder, causing it to become gangrenous, or dead tissue. The gangrenous gallbladder can become infected which leads to acute emphysematous cholecystitis. These conditions can become life-threatening, and if the gallbladder ruptures, there’s a high risk of death.
Around 95% of people with acute cholecystitis have gallstones. But just because you have gallstones doesn’t mean you need treatment. Only around 20% of people with gallstones but no symptoms will develop symptoms within 20 years. Since only about 1% of people with gallstones but no symptoms will have complications before they start having symptoms, it’s usually not necessary to have gallbladder surgery if you have gallstones but no symptoms.
Risk Factors and Frequency for Acute Cholecystitis
Gallbladder disease can affect both men and women, but it is more likely in certain groups. These include women, people who are overweight, pregnant women, and people in their 40s. People who’ve had a major weight loss or a serious illness are also more at risk. The tendency to form gallstones, which contribute to gallbladder disease, can run in families. Certain medical conditions that cause the breakdown of blood cells, such as sickle cell disease, can also increase the likelihood of getting gallstones.
- Gallbladder disease can affect both men and women.
- It’s more common in women, overweight individuals, pregnant women, and those in their 40s.
- Major weight loss or a serious illness can increase the risk.
- The ability to form gallstones, which are often a part of gallbladder disease, can be inherited.
- Medical conditions that break down blood cells, like sickle cell disease, can increase the chances of forming gallstones.
Signs and Symptoms of Acute Cholecystitis
Chronic cholecystitis is a condition that is usually characterized by ongoing pain in the upper right section of the abdomen, bloating, difficulty tolerating certain foods (especially fatty and spicy ones), increased gas, and bouts of nausea and vomiting. This pain can sometimes radiate to the back or the shoulder area, and it can last for years before the condition is finally diagnosed. Acute cholecystitis presents with the same symptoms, but they tend to be worse. These symptoms can sometimes be mistaken for heart problems. Upper right abdominal pain when pressed deeply – a symptom known as Murphy’s sign – is a classic indicator of this disease. Often, patients will be able to recall a meal that provoked the acute attack, such as eating a heavy meal like pork chops and gravy.
- Ongoing pain in the upper right section of the abdomen
- Bloating
- Difficulty tolerating certain foods (especially fatty and spicy ones)
- Increased gas
- Bouts of nausea and vomiting
- Pain sometimes radiates to the back or shoulder
- Increased severity of symptoms in acute cholecystitis
- Murphy’s sign – upper right abdominal pain when pressed deeply
- Patients can often recall a meal preceding the acute attack
Testing for Acute Cholecystitis
When diagnosing a condition called cholecystitis, a thorough physical exam and understanding of your medical history is vital. Blood tests such as a complete blood count and a comprehensive metabolic panel also play a critical role. For persistent cholecystitis cases, these test results may appear normal. However, in sudden or severe cases, your white blood cells and liver enzymes might be raised. A high bilirubin level, over 2, could suggest the presence of a stone in the common bile duct. It’s important to note that despite severe gallbladder disease, tests might still show normal values. Your doctor will also check your amylase and lipase levels to rule out pancreatitis.
A CT scan often works as the first imaging test ordered at the emergency room. This scan can reveal signs of cholecystitis and gallstones. But the gold standard for initially assessing gallbladder disease is a gallbladder ultrasound. This screening can usually show a thick gallbladder wall and gallstones, which are typical signs of this condition.
For acute cholecystitis, a more specific imaging test, known as a hepatobiliary (HIDA) scan, is recommended. The scan can help diagnose gallbladder function or a blockage in the cystic duct. In cases where no gallstones are present, the addition of a drug called cholecystokinin (CCK) can be used to diagnose a type of cholecystitis where stones aren’t present, known as acalculous cholecystitis. This can be indicated by an ejection fraction of less than 35%.
Treatment Options for Acute Cholecystitis
The best way to manage cholecystitis, or inflammation of the gallbladder, is through a procedure called laparoscopic cholecystectomy. This method comes with a low risk of complications, and patients usually heal pretty fast. However, in scenarios where the patient might not be suitable for the laparoscopic method, an open technique can be applied.
For patients who are very sick and may not be able to withstand surgery, a temporary solution might be percutaneous drainage, where the gallbladder is drained using a needle inserted through the skin. Occasionally, less severe chronic cholecystitis cases in patients who might not be able to tolerate surgery are managed with a diet that’s low in fat and spice, but the effectiveness of this approach can vary.
There’s also medical treatment of gallstones with ursodiol, a bile acid that can help dissolve gallstones. Although this treatment occasionally has success, it’s not a guaranteed solution.
What else can Acute Cholecystitis be?
Here’s a simplified list of some medical conditions that doctors might consider when making a diagnosis. These conditions might show similar symptoms to each other, so it’s important for the doctor to make accurate assessments:
- Appendicitis (an inflammation of the appendix)
- Biliary colic (severe abdomen pain due to gallstones)
- Cholangitis (an infection of the bile duct)
- Mesenteric ischemia (poor blood supply to the intestines)
- Gastritis (inflammation of the stomach lining)
- Peptic ulcer disease (sores in the stomach lining)
Professionals in the medical field conduct thorough tests to ensure they are treating the correct condition and providing the best care for their patients.
Possible Complications When Diagnosed with Acute Cholecystitis
Acute cholecystitis, or inflammation of the gallbladder, can lead to several complications including:
- Formation of a bile pool outside the bile duct, known as a biloma
- Collections of pus inside the abdominal cavity, referred to as intraabdominal abscesses
- Injury to the bile duct
- Damage to the liver, or hepatic injury
- Damage to the small intestine, or small bowel injury
- Possible infections
- Stones remaining in the bile duct after treatment
- Bleeding
Recovery from Acute Cholecystitis
After having their gallbladder removed, most patients can usually go home the same day. Any pain they experience is often minor and can be managed with common painkillers available without a prescription.
Some patients may have severe shoulder pain because of trapped carbon dioxide gas from the laparoscopic process. They should be reassured that this discomfort will start to fade as they move around and the gas is gradually absorbed by the body. This can take up to three days.
Before leaving the hospital, patients should be informed about potential difficulties with tolerating oily foods, which can lead to discomfort or diarrhea. This could be a temporary or slightly permanent situation due to the slower breakdown of fat resulting from the loss of bile stored in the now removed gallbladder. However, most patients will eventually see an improvement in these symptoms as the liver increases its bile production over time.
Patients should have a follow-up appointment about 3-4 weeks after the operation.