We will first discuss acute cholecystitis, followed by chronic cholecystitis and other potential complications of acute cholecystitis.
Gallstones are common. Occurring in approximately in 1/8th of the population. The majority are asymptomatic, but about 1-4% will become symptomatic. The presentation of gallstones can widely vary depending the section of the biliary system that is involved.
First let’s recap what bile is and how it forms:
Pathophysiology
Gallstones form due to supersaturation of bile. Depending on the composition of the bile the composition of bile may change. There are 3 main types of gallstones:
- Cholesterol stones - due to excess cholesterol production (correlated to obesity and poor diet).
- Pigment stones - due to excess bile pigments. Commonly seen in individuals who have increased Hb metabolism, as seen in haemolytic anaemia.
- Mixed stones - made up of both cholesterol and bile pigments.
90% of cases of acute cholecystitis form secondary to gallstones (acute calculous cholecystitis) while 10% are considered acalculous cholecystitis.
In acute cholecystitis, obstruction can lead to an infection caused by a number of organisms:
- E. coli (most common)
- Klebsiella
- Enterococcus
It is made up of bile salts, phospholipids, cholesterol, bile pigments/conjugated bilirubin (which are products of Hb metabolism).
The function of bile is to aid absorption of insoluble fats through emulsification.
Bile is made in the liver, and stored in our gallbladder. The gallbladder is located between the right & quadrate lobes of the liver. It connects via the cystic duct to the common bile duct [CBD] (which is also joined by the common hepatic duct). The CBD then joins the pancreatic duct of the pancreas to form the Hepatopancreatic ampulla of Vater.
Cholecystokinin (CCK) is released from the duodenum when digesting food. It’s function is to cause the gallbladder to contract for the release of bile.
We will discuss gallstones and biliary colic further in the correlating CCP, but acalculous cholecystitis may be due to:
- Gallbladder stasis
- Hypoperfusion
- Infection (CMV or cryptosporidium)
😷 Presentation
- RUQ pain or epigastric pain that may radiate to the right shoulder.
- Fever and systemic upset (lethargy, nausea, vomiting, tachycardia)
- Murphy’s sign is a telltale sign - it is positive when pressure is applied to the RUQ and the patient is asked to inspire and they halt inspiration due to the pain from the inflamed gallbladder.
- Guarding may indicate perforation.
It is also important to assess for signs of sepsis.
We can stratify the presentation of cholecystitis into mild, moderate and severe:
- RUQ pain
- Nausea and vomiting
- Fever
- Elevated WCC
- Palpable mass in RUQ
- Symptoms persist >72 hours
- Localised inflammation - development of empyema/gangrene.
- Symptoms of end-organ damage, such as:
- Resistant hypotension
- Lowered GCS
- Oliguria
- Hepatic dysfunction
- Low SpO2
🔍 Investigations
- 🥇 A trans-abdominal ultrasound is the first line investigation. We look for 3 things mainly: 1. Gallstones/sludge 2. Gallbladder wall thickening (>3mm) 3. Bile duct dilatation
- 🥈 HIDA scan - this is a technetium labelled scan that can be used if uncertain.
- 🏆 MRCP is the gold standard investigation, with almost 100% sensitivity.
- CT can be good especially when preparing for a hot cholecystectomy.
- Cholescintigraphy may also be used.
🧰 Management
Management for acute cholecystitis is dependent on the severity level:
Mild cholecystitis:
- Cefuroxime - oral
- Laparoscopic cholecystectomy - within 1 week.
Moderate cholecystitis:
- IV cefuroxime
- IV fluids
- 🏆 Laparoscopic cholecystectomy - within 72 hours.
- Percutaneous cholecystostomy - if the patient is acutely unwell and has an empyema. They may be delayed for surgery (after 6 weeks) but keep a drain in-situ.
Severe cholecystitis:
- ITU admission
- IV cefuroxime
- IV fluids
- 🏆 Laparoscopic cholecystectomy - within 72 hours.
- Percutaneous cholecystostomy - if the patient is acutely unwell and has an empyema. They may be delayed for surgery (after 6 weeks) but keep a drain in-situ.
🚨 Complications
- Bile leak - this is seen after cholecystectomy with a drain in-situ by presence of bile in the drain with abnormal LFTs means a bile leak is likely. Causes include slipped clips on the cystic duct remnant, missed distal common bile duct obstruction by a stone and subsequent 'blowout' higher up, and iatrogenic injury to common hepatic or bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) may identify the site of the leak and allow simultaneous intervention with temporary stenting to allow biliary drainage.
- Post-cholecystectomy syndrome - syndrome of recurring abdominal pain and reflux symptoms that may present months-years after the procedure.
Let’s discuss some complications (apart from sepsis and perforation):
This occurs when a gallstone in the cystic duct is large enough to compress the common hepatic duct (CHD) adjacent to it.
😷 Presentation
It ends up in an obstructive jaundice, despite there being no blockage in the CHD itself.
🔍 Investigations
🧰 Management
As with any empyema, this is a collection of pus, simply within the gallbladder itself.
😷 Presentation
Patients often present with similar presentation to acute cholecystitis.
It has quite a high mortality rate and significant morbidity.
📷 Diagnosis
Ultrasound or CT scan
🧰 Management
Usually occurs in patients with recurrent or untreated cholecystitis ➡️ persistent/chronic inflammation of the gallbladder.
😷 Presentation
Persistent RUQ pain/epigastric pain + nausea & vomiting.
📷 Diagnosis
Ultrasound or CT scan
🧰 Management
Laparoscopic cholecystectomy
⚠️ Complications
- Gallbladder carcinoma
- Biliary-enteric fistula
Cholecystoduodenal fistula
Inflammation of our gallbladder can lead to a fistula formation between the gallbladder and the small intestine. This allows gallstones to move into the small intestine and cause an obstruction.
Depending on where the stone gets lodged, it can cause different issues:
- Bouveret’s syndrome - stone obstructs the proximal duodenum causing issues with the gastric outlet.
- Gallstone ileus - stone gets lodged in the terminal ileum which is the narrowest portion of the small intestine, leading to an obstruction. Pneumobilia (air within the biliary tree) is a hallmark sign of gallstone ileus. It causes symptoms of small bowel obstruction.