Cholecystitis

What is cholecystitis?

Cholecystitis is an inflammation of the gallbladder. The gallbladder is the small sac-like organ located in the upper right side of the abdomen, just below the liver. It is attached to the main duct that carries bile from the liver into the intestine. The gallbladder temporarily stores bile, which is a liquid that contains a fat-digesting substance produced in the liver. During a meal, the gallbladder contracts, and bile moves from the gallbladder through small, tube-like passages (called the cystic duct and the common bile duct) into the small intestine. Here, bile mixes with food to help break down fats.

Cholecystitis usually develops when a person has gallstones, which are rock-like deposits that form inside the gallbladder. If a gallstone blocks the cystic duct (the outflow from the gallbladder), bile becomes trapped in the gallbladder. Chemicals in the trapped bile or a bacterial infection can then lead to inflammation of the gallbladder.

There are two types of cholecystitis:

• Acute cholecystitis is the sudden inflammation of the gallbladder that causes marked abdominal pain, often with nausea, vomiting, and fever.
• Chronic cholecystitis is a lower intensity inflammation of the gallbladder that lasts a long time. It may be caused by repeat attacks of acute cholecystitis. Chronic cholecystitis may cause intermittent mild abdominal pain, or no symptoms at all. Damage to the walls of the gallbladder leads to a thickened, scarred gallbladder. Ultimately, the gallbladder can shrink and lose its ability to store and release bile.

Gallstones alone can cause episodes of crampy abdominal pain without any infection. This is called biliary colic.

Women are more likely than men to get gallstones. The risk of gallstones also is higher in:

• anyone older than age 60
• women who are pregnant or have had several pregnancies
• women who take estrogen replacement therapy or birth control pills
• obese people
• people who have lost weight rapidly
• people who eat a high-fat diet.

Symptoms of cholecystitis

Symptoms of acute cholecystitis may include:

• Pain. You may feel this discomfort in the center of the upper abdomen, just below the breastbone, or in the upper right portion of the abdomen, near the gallbladder and liver. In some people, the pain extends to the right shoulder. Symptoms typically start after eating.
• Fever and possibly chills
• Nausea and/or vomiting
• Jaundice (yellowing of the skin or eyes), dark urine and pale, grayish bowel movements. These symptoms appear when gallstones pass out of the gallbladder and into the common bile duct, blocking the flow of bile out of the liver.

When gallstones in the common bile duct block the flow of bile from the liver to the intestine, the patient may develop a serious infection of the bile ducts called cholangitis. The typical symptoms of cholangitis are fever, right upper abdominal pain, and jaundice. Another possible problem that may occur when gallstones pass into the common bile duct is acute pancreatitis (inflammation of the pancreas). Because the duct from the pancreas also flows into the common bile duct, stones there can block the pancreas, which causes it to become inflamed. Like cholangitis, acute pancreatitis can be serious.

The major symptom of chronic cholecystitis is usually intermittent pain. However, some people do not have any symptoms. If there is pain, it is usually mild, and comes and goes. These rather nonspecific symptoms accompany many other illnesses, so you may not be diagnosed with chronic cholecystitis until you have an episode of more severe symptoms during a sudden attack.

Diagnosing cholecystitis

Your doctor will review your medical history and ask about any prior episodes of abdominal discomfort, especially those triggered by high-fat meals. Your doctor will ask if you've had any recent rapid weight loss and about medications you currently take, particularly birth control pills and estrogen replacement therapy (because these can lead to the formation of gallstones).

During the physical exam, your doctor will pay particular attention to the upper right portion of your abdomen, where your liver and gallbladder are located. Blood tests may reveal an elevated white blood cell count, which suggests an infection, or elevated liver enzymes, which suggests a blockage and/or irritation of the gallbladder and bile ducts.

Your doctor may order radiology tests to look for gallstones. Because the chemical composition of most gallstones often makes them invisible on X-rays, other tests are also used, including:

• Ultrasound. This painless procedure uses sound waves to create images of the gallbladder and bile ducts. An ultrasound is usually the first (and often the only) test needed to confirm that you have gallstones and cholecystitis. Gallstones are usually well seen on ultrasound. Also, a thickened gallbladder wall seen on ultrasound may mean that you may have acute or chronic cholecystitis. Enlarged bile ducts suggest that a stone may have passed out of the gallbladder and into the common bile duct, causing a blockage.
• Cholescintigraphy. This test looks for a blocked gallbladder or bile ducts. You are given an injection of a radioactive chemical that passes out of the blood into the bile ducts. A special camera takes pictures of the chemical's path and can detect blockages in the flow of the chemical.
• CT scan. This test provides an excellent view of the gallbladder, plus the surrounding structures (liver, bile ducts, intestines and pancreas).

Expected duration of cholecystitis

If you have biliary colic, the pain or discomfort may go away or become less severe after several hours if a trapped gallstone passes out of the cystic duct on its own. Your abdomen may continue to ache mildly for about 24 hours.

If you have acute cholecystitis, however, and infection and inflammation continue, your symptoms may get worse and you could develop complications, including a hole in the inflamed gallbladder wall (gallbladder perforation) and an infection that spreads to the lining of the abdomen (peritonitis). This is why people with cholecystitis usually are treated and observed in a hospital until their symptoms improve.

Symptoms of chronic cholecystitis may be present for years before a diagnosis is made. Surgery to remove the gallbladder will prevent symptoms from coming back.

Preventing cholecystitis

Because gallstones cause cholecystitis, you may be able to avoid cholecystitis by controlling the risk factors that can lead to the formation of gallstones. These include watching your weight and avoiding a high-fat diet.

Treating cholecystitis

Acute cholecystitis usually requires hospitalization. You need antibiotics given intravenously (into a vein) to treat infection, and medications to control symptoms of nausea and abdominal pain. Once your pain lessens or goes away, there are no signs of infection, and you are able to drink and eat, you will be able to go home to continue your recovery. Alternatively, your doctor may wish you to stay in the hospital until you have surgery to remove your gallbladder.

Twenty-five percent of people who have acute cholecystitis develop another episode within 1 year; 60% have another episode within 6 years. For this reason, most doctors recommend that people with cholecystitis have the gallbladder removed surgically (cholecystectomy). Sometimes, surgery is scheduled after a person has been discharged from the hospital and has recovered fully. In some cases, your surgeon may decide to do the cholecystectomy before you leave the hospital.

Chronic cholecystitis requires the removal of the gallbladder surgically.

Gallstones in the Common Bile Duct should be removed, to prevent blockage to the flow of bile, and possible cholangitis or pancreatitis. Usually this can be done using a special flexible telescope that is passed down the mouth, through the stomach, and to the opening where the bile duct empties into the intestine. The opening is widened by cutting it slightly, and the stones are then extracted with instruments passed through the telescope. This is called "endoscopic retrograde cholangiopancreatography" (andquot;ERCP"). After the stones are removed with ERCP, your doctor may recommend that you have surgery later, to remove your gallbladder (where the stones usually originate). Occasionally, ERCP is not possible, and abdominal surgery is required to remove stones in the bile duct.

When to call a professional

Call your doctor if you have severe abdominal pain, fever and shaking chills, or jaundice.

Prognosis

Most people recover from episodes of acute cholecystitis within a few days to a few weeks. Rarely, a person can become critically ill from a complication, such as gallbladder perforation, cholangitis or pancreatitis and in rare cases the condition can be fatal.

Removing the gallbladder prevents cholecystitis from coming back. Rarely, gallstones may remain hidden in bile ducts to cause other problems after surgery.

Additional info

American College of Surgeons
https://www.facs.org/

National Digestive Diseases Information Clearinghouse (NDDIC)
https://digestive.niddk.nih.gov/