What is Chronic Cholecystitis?
Chronic cholecystitis is a long-term condition where the gallbladder remains inflamed, impeding its ability to empty properly. This can progress slowly, sometimes with episodes of increased pain known as acute biliary colic, or it can become more serious and require immediate medical attention, which we refer to as acute cholecystitis. There are typical signs and symptoms, and some groups of people are more likely to have this disease.
There are two types of chronic cholecystitis: one that happens in conjunction with gallstones, known as calculous, and one that occurs without gallstones, known as acalculous. However, most chronic cholecystitis cases are found to be connected with gallstones.
What Causes Chronic Cholecystitis?
Chronic cholecystitis, or long-term inflammation of the gallbladder, usually happens because of gallstones. It’s thought to be caused by frequent bouts of acute (short-term) cholecystitis or constant irritation from gallstones that result in inflammation of the gallbladder. Sometimes, this term is used to describe belly pain that comes from the gallbladder not emptying properly. This condition can also overlap with another issue known as Sphincter of Oddi dysfunction, and is often termed as biliary or gallbladder dyskinesia.
Certain factors can increase the risk of developing gallstones, including:
- Being female
- Being overweight
- Quickly losing weight
- Being pregnant
- Being older
- Belonging to Hispanic or Pima Indian heritage
Risk Factors and Frequency for Chronic Cholecystitis
Chronic cholecystitis, or long-term inflammation of the gallbladder, typically goes hand-in-hand with the occurrence of gallstones. However, direct statistics on this condition are sparse.
Gallstones affect a significant part of the global population, with 10-20% of people developing them at some point in their lives. Still, it is worth noting that 80% of these cases don’t display any symptoms. In the United States alone, around 500,000 surgeries are carried out each year to address gallbladder disease. The chance of developing gallstones increases as people get older, and over a quarter of women over the age of 60 are likely to have them. Overall, approximately 14 million women and 6 million men aged between 20 and 74 in the United States have gallstones.
- Obesity, particularly among women, ups the likelihood of developing gallstones due to an increase in cholesterol in the bile.
- Those who experience drastic weight loss or follow fasting diets are at higher risk due to a slowdown in their bile flow.
- Estrogen, a hormone more prevalent in women, has been linked to a higher likelihood of gallstone development. This is due to factors such as an increase in bile cholesterol and a decrease in the gallbladder’s ability to contract. As a result, women of reproductive age or those using estrogen-based contraceptives are twice as likely to form gallstones compared to men.
- People with chronic diseases, such as diabetes, may see an increase in gallstone formation and reduced gallbladder contraction due to a nerve disorder known as neuropathy.
Signs and Symptoms of Chronic Cholecystitis
Chronic cholecystitis is a condition where patients may experience dull pain in the upper right side of their abdomen. This pain may wrap around the waist and extend to the middle of the back or towards the right shoulder blade. Unlike acute cholecystitis where pain comes after eating, this pain rarely occurs after meals, but may worsen after eating fatty foods. Additional common symptoms include nausea, occasional vomiting, increased gas and bloating, which tend to flare-up during the evenings or nights.
This condition typically lasts for weeks or even months with symptoms slowly becoming worse over time or appearing more frequently. Fever and a fast heart rate are less common symptoms. It’s crucial to note that older adults might show unclear symptoms yet they are at a risk of their condition progressing to a more complicated stage. Therefore, doctors need to rely on strong clinical judgment to correctly diagnose chronic cholecystitis.
- Dull pain in upper right abdomen
- Pain might extend to waist and back or right shoulder blade
- Increased discomfort after consuming fatty foods
- Nausea
- Occasional vomiting
- Increased gas and bloating
- Symptoms often appear during evenings or nights
- Worsening of symptoms over weeks or months
Testing for Chronic Cholecystitis
Chronic cholecystitis, which refers to long-term inflammation of the gallbladder, can be hard to diagnose through laboratory tests alone. Often, patients with chronic cholecystitis might not show the usual signs of the disease such as an increased white blood cell count and abnormal liver function tests. However, basic lab tests including blood counts, metabolic panel, and liver functions would still be carried out. Additionally, depending on the patient’s condition, heart tests like EKG and troponins might also be needed.
If chronic cholecystitis is suspected, the most preferred diagnosis method is an ultrasound of the right upper part of the abdomen. This non-invasive procedure, commonly available in most healthcare facilities, can effectively evaluate the state of the gallbladder. It helps in identifying any wall thickening, inflammation, gallstones, or sludge in the gallbladder.
Another useful diagnostic tool is a CT scan with intravenous contrast, which often reveals the presence of gallstones, an increased bile density, and gallbladder wall thickening. Although certain signs like a distended gallbladder and enhanced blood flow in the nearby liver area are more suggestive of acute cholecystitis, an increase in gallbladder wall enhancement is more commonly seen in the chronic state. Unfortunately, since there can be overlapping signs between acute and chronic cholecystitis, it might be necessary at times to perform both ultrasound and CT to establish a clear diagnosis.
In cases where patients cannot get a CT scan due to issues like radiation exposure or kidney injury, an MRI can be a good alternative. However, to confirm a diagnosis of chronic cholecystitis, the most suitable test is a hepatobiliary scintigraphy or a HIDA scan with cholecystokinin(CCK). For this test, a tracer is injected into the bloodstream and then gets concentrated in the gallbladder. CCK is then administered, and the percentage of gallbladder emptying, known as ejection fraction (EF), is calculated. An EF below 35% at the 15-minute mark suggests a dysfunctional gallbladder, hinting at chronic cholecystitis.
Treatment Options for Chronic Cholecystitis
The best way to treat long-term gallbladder inflammation, or chronic cholecystitis, is through a procedure called laparoscopic cholecystectomy. This surgery, which is usually done in an outpatient setting, has a low risk of complications and does not require a lengthy hospital stay. An alternative option is an open cholecystectomy, which involves a larger incision and a longer recovery time. This surgery may be needed for patients who can’t undergo a laparoscopic procedure due to things like previous surgeries that resulted in a lot of scarring.
A procedure called an endoscopic retrograde cholangiopancreatography (ERCP) typically precedes the surgery if there’s a worry about gallstones in the common bile duct.
Some patients may not be suitable for surgery or may prefer not to have it. If this is the case, conservative treatments are an option. This involves keeping a close eye on the patient’s condition and asking them to maintain a low-fat diet to help lessen the symptoms. In some cases, ursodeoxycholic acid, a medication known as UDCA or ursodiol, can be helpful in reducing gallbladder attacks and inflammation, but more research is needed to confirm its effectiveness in treating chronic cholecystitis.
For patients who show no symptoms of chronic cholecystitis but have been diagnosed through incidental findings, treatment will depend on their overall health status and whether there’s any risk of gallbladder cancer. If there’s no fears of cancer, these patients can also be closely monitored.
What else can Chronic Cholecystitis be?
Sometimes, chronic gallbladder inflammation can have symptoms that are similar to other common medical conditions, and a detailed examination of these symptoms can help doctors figure out the correct diagnosis. Here are some symptoms related to those conditions:
- Acute gallbladder inflammation: If you feel constant, severe pain on the right side of your abdomen that lasts for hours, and is accompanied by fever, nausea, and vomiting, this could suggest acute gallbladder inflammation.
- Gallbladder cancer: If you experience chronic abdominal symptoms along with weight loss or other major health changes, this could be a sign of gallbladder cancer. Imaging tests and biopsy (a look at the cells under a microscope) help in confirming the diagnosis.
- Peptic ulcer disease: If you have upper abdominal pain and feel full early during meals, you might have peptic ulcers. Warning signs include weight loss, anemia (low red blood count), black stools or trouble swallowing.
- GERD: If you often experience a burning sensation in the upper abdomen or behind the breastbone and sometimes food comes back up after eating, you might have GERD (Gastroesophageal Reflux Disease).
- Gastric cancer: If you have the warning signs of peptic ulcers, persistent vomiting, indications of cancer or other risk factors, we need to consider the possibility of stomach cancer.
- Heart attack: With certain types of heart attack, you may feel upper abdominal pain along with nausea and vomiting. You might also feel dizzy or short of breath, or have risk factors for heart disease. In that case, you need tests for heart disease.
- Mesenteric ischemia: This condition means the blood flow to the intestines is reduced. The acute version can present as severe pain, while the chronic version may present as pain after meals. This condition’s warning signs are old age, risk factors for hardening of the arteries, bloody stools, and weight loss.
- Mesenteric vasculitis: If you have ongoing abdominal symptoms that cannot be explained by routine tests and show signs consistent with inflammation of the blood vessels, this might suggest a rare but potentially dangerous condition called mesenteric vasculitis.
What to expect with Chronic Cholecystitis
In general, straightforward cases of cholecystitis often have a very good prognosis. Simple treatments can often alleviate symptoms in many cases. Typically, a preventive measure such as an elective cholecystectomy is performed to avoid potential future issues. Although this surgical procedure is generally safe, injuries to the bile duct can occur and should be monitored during recovery.
Possible Complications When Diagnosed with Chronic Cholecystitis
Bacterial growth in the gallbladder can cause acute cholecystitis, or collections of pus. In some situations, a gallstone might wear away into the duodenum (part of the small intestine) and become embedded in the terminal ileum, the last part of the small intestine, a condition called gallstone ileus.
There are rare instances where a patient might develop emphysematous cholecystitis, which is caused by gas-producing bacteria like clostridia, E.coli, and klebsiella. This situation occurs most commonly among diabetics and has a high mortality rate.
There’s an ongoing debate about the relationship between chronic cholecystitis, a condition characterized by inflammation of the gallbladder, and gallbladder cancer. Despite evidence suggesting that chronic inflammation might increase the risk of cancer, there isn’t enough data to establish a strong link.
One specific form of chronic cholecystitis is Xanthogranulomatous cholecystitis, where ongoing inflammation results in significant thickening, fibrosis and extension beyond the wall of the gallbladder. This severe form carries risks for complications such as abscesses and fistulas and is considered as a possible precancerous condition.
Porcelain gallbladder often doesn’t have any symptoms. The relationship with cancer is still up for debate but most agree that it could slightly increase the risk of developing cancer.
