Chronic cholecystitis is a prolonged, subacute condition caused by the mechanical or functional dysfunction of the emptying of the gallbladder. It presents with chronic symptomatology that can be accompanied by acute exacerbations of more pronounced symptoms (acute biliary colic), or it can progress to a more severe form of cholecystitis requiring urgent intervention (acute cholecystitis). There are classic signs and symptoms associated with this disease as well as prevalence in certain patient populations. The two forms of chronic cholecystitis are with cholelithiasis (with gallstones), and acalculous (without gallstones).
A mechanical dysfunctioning of gallbladder emptying is caused by a physical blockage, usually from a gallstone. Many factors produce gallstones. A high concentration of cholesterol in the bile can cause precipitation of the cholesterol in the form of cholesterol stones. High bile salt concentrations and high calcium concentrations can also result in gallstone formation. These gallstones can cause direct irritation of the gallbladder or a mechanical blockage of the cystic duct when the gallbladder is stimulated to empty. Hypokinetic functioning of the gallbladder can lead to a static state of gallbladder bile also precipitating to sludge and gallstones. Chronic acalculous cholecystitis is caused by a hypokinetic emptying of the gallbladder in response to food in the stomach. Gallstones and sludge are not present, but the symptoms are felt to be initiated by the inability of the gallbladder to empty sufficiently.
Risk factors for cholecystitis include:
Over 20 million Americans have gallstones. There are approximately 500,000 cholecystectomies done yearly in the United Stated for gallbladder disease. Many factors increase the risk of gallstone formation and gallbladder disease. The classic chronic cholecystitis patient is fat, 40, fertile, and female. The incidence of gallstone formation increases yearly with age. Over one-quarter of women older than the age of 60 will have gallstones.
Most gallstones are asymptomatic. In the United States, approximately 14 million women and 6 million men with an age range of 20 to 74 have gallstones. The prevalence increases as a person ages. Obesity increases the likelihood of gallstones, especially in women due to increases in the biliary secretion of cholesterol. On the other hand, patients with drastic weight loss or fasting have a higher chance of gallstones secondary to biliary stasis.
Furthermore, there is also a hormonal association with gallstones. Estrogen has been shown to result in an increase in bile cholesterol as well as a decrease in gallbladder contractility. Women of reproductive age or on birth control medication that have estrogen have a two-fold increase in gallstone formation compared to males. People with chronic illness such as diabetes also have an increase in gallstone formation as well as reduced gallbladder wall contractility due to neuropathy.
Occlusion of the cystic duct or malfunction of the mechanics of the gallbladder emptying is the pathophysiology of this disease. Gallstones form from various materials such as bilirubinate or cholesterol. These materials increase the likelihood of cholecystitis and cholelithiasis in conditions such as Sickle Cell disease where red blood cells are broken down forming excess bilirubin and forming pigmented stones. Patients with excessive calcium such as in hyperparathyroidism can form calcium stones. Patients with excessive cholesterol can form cholesterol stones. Occlusion of the common bile duct such as in neoplasms or strictures can also lead to stasis of the bile flow causing gallstone formation with resultant chronic cholecystitis.
The majority of cases of cholecystitis are caused by gallstones. When the cystic duct is obstructed, this leads to distension of the gallbladder and at the same time, the lymphatic drainage and blood flow are compromised-eventually leading to ischemia of the mucosa.
The gallbladder wall may be thickened to variable degrees, and there may be adhesions to the serosal surface. Smooth muscle hypertrophy, especially in prolonged chronic conditions, is present. Calcium bilirubinate or cholesterol stones are most often present and can vary in size from sand-like to completely filling the entire gallbladder lumen. They can be multiple or singular. Acalculous disease may reveal sludge or very viscous bile. These findings are usual precursors to gallstones and are formed from increased biliary salts or stasis. Normal appearing bile can also be present. Various species of bacteria can be found in 11% to 30% of the cases. Rokitansky-Aschoff sinuses are present 90% of the time in cholecystitis specimens. These are a herniation of intraluminal sinuses from increased pressures possibly associated with ducts of Luschka. The mucosa will exhibit varying degrees of inflammation.
Patients with chronic cholecystitis usually present with dull right upper abdominal pain that radiates to the mid back or right scapular tip. It is usually associated with fatty food ingestion. Nausea and occasional vomiting also accompany complaints of increased bloating and flatulence. Often the symptoms occur in the evening. Prolonged less acute symptoms are usually present over weeks or months. Increased frequency and severeness of acute exacerbations (acute biliary colic) is usually seen in the presence of more prolonged chronic symptoms. The classic physical examination will demonstrate right upper abdominal pain with deep palpation (Murphy's sign). Patients are usually not acutely ill but are uncomfortable. Their vital signs are often within normal parameters.
Elderly patients with cholecystitis may present with vague symptoms; both pain and fever may be absent; these patients can quickly progress to complicated disease. The proliferation of bacteria in the gallbladder can lead to empyema with high fever and elevated WBC. In some cases, the gallstone may erode into the duodenum and impact in the terminal ileum, presenting as gallstone ileus.
Rarely the patient may develop emphysematous cholecystitis due to the presence of gas-forming organism like clostridia, E.coli, and klebsiella. This presentation is most common in diabetics and carries a high mortality rate.
The test of choice to diagnose chronic cholecystitis is the abdominal ultrasound. This is noninvasive and can accurately evaluate the gallbladder for a thickened wall or inflammation. It is also the best test to diagnose gallstones or sludge. Often times a CT scan is done during an emergency department visit for abdominal pain. This is also very accurate when diagnosing gallbladder disease but may require IV and or oral contrast and does expose the patient to radiation. The best diagnostic test to confirm acalculous cholecystitis is the HIDA scan (hepatobiliary) with KINAVAC (CCK- cholecystokinin). This is a radionuclide scan where a tracer is given IV. This gets concentrated in the gallbladder. KINAVAC is then administered and the percent that the gallbladder empties (ejection fraction- EF) is calculated. An EF below 35% is considered abnormal and indicative of acalculous chronic cholecystitis. Blood work such as a CBC and comprehensive metabolic panel are usually normal.
Sometimes a CT scan may be required if the disorder is associated with gastrointestinal complications.
On a plain x-ray, gallstones are only seen in 10% of patients. Sometimes the x-ray may reveal a calcified gallbladder.
ERCP is usually done when a bile duct stone is suspected.
The preferred treatment for chronic cholecystitis is a laparoscopic cholecystectomy. This is one of the most common general surgery procedures done in the United States. It has a very low complication rate, less than 2%, with a relatively fast recovery time, about 1 week. Open cholecystectomy can also be performed very safely with a similar complication rate. Recovery time is longer due to the larger incision. This surgery is done in patients who are not laparoscopic candidates such as those with extensive prior surgeries and adhesions. Patients who are not surgical candidates or who prefer not to undergo a surgery can be trialed on conservative therapy. A strict low-fat, bland diet may alleviate symptoms and avoid surgery. Actigall (Ursodiol) has been shown to dissolve certain types of gallstones and provide symptomatic relief in select patients, however, it's success rate is low.
Many other conditions can mimic gallbladder disease. Patients who present with acute biliary colic are often worked up for cardiac issues. Other common conditions with similar presenting symptoms are peptic ulcer disease, irritable bowel disease, inflammatory bowel disease, gastroesophageal reflux disease, pulmonary embolism, and musculoskeletal disorders.
The majority of uncomplicated cases of cholecystitis have an excellent outcome. In many cases, supportive treatments can cause symptoms to subside. While in reality, only about 20% of patients need surgery, today, most surgeons elective remove the gallbladder to prevent future complications. While surgery is safe, bile duct injuries continue to occur with regular frequency.
The diagnosis and management of cholecystitis is a multi-team approach. Propper diagnosis by primary care and prompt referral to surgery is the next step. The surgeon must then identify if cholecystectomy- laparoscopic vs open is indicated or if medical management is more appropriate for the individual patient. Good surgical care with good postoperative follow up is also essential. Early identification and management of any postoperative complication is mandated. Counseling for eating and lifestyle changes is needed for patients being treated conservatively.
|||Saurabh S,Green B, Is hyperkinetic gallbladder an indication for cholecystectomy? Surgical endoscopy. 2018 Sep 12; [PubMed PMID: 30209609]|
|||Andercou O,Olteanu G,Mihaileanu F,Stancu B,Dorin M, Risk factors for acute cholecystitis and for intraoperative complications. Annali italiani di chirurgia. 2017; [PubMed PMID: 29068324]|
|||Wang L,Sun W,Chang Y,Yi Z, Differential proteomics analysis of bile between gangrenous cholecystitis and chronic cholecystitis. Medical hypotheses. 2018 Dec; [PubMed PMID: 30396466]|
|||Benkhadoura M,Elshaikhy A,Eldruki S,Elfaedy O, Routine histopathological examination of gallbladder specimens after cholecystectomy: Is it time to change the current practice? Turkish journal of surgery. 2018 Sep 11; [PubMed PMID: 30248293]|
|||Negrão de Figueiredo G,Mueller-Peltzer K,Zengel P,Armbruster M,Rübenthaler J,Clevert DA, Contrast-enhanced ultrasound (CEUS) and gallbladder diseases - a retrospective mono-center analysis of imaging findings with histopathological correlation. Clinical hemorheology and microcirculation. 2018 Dec 17; [PubMed PMID: 30584127]|
|||Wang JX,Zhang Q,Shen WF,Ren JJ,Xiao R, Laparoscopic cholecystectomy surgery model's system idea for multi-dimensional multi-angle reduction of bile duct injury: A surgeon's experience. Asian journal of surgery. 2018 Dec 24; [PubMed PMID: 30591272]|