Cholecystitis

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - David Martin as part of the Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - David Martin, Spencer Fuehne, Admin, Lucinda hampton, Elaine Lonnemann, Laura Ritchie, Dave Pariser, 127.0.0.1, WikiSysop, Kim Jackson and Wendy Walker  

Definition/Description

Cholecystitis is inflammation of the gallbladder which can be acute or chronic and occur with (calculus) or without (acalculus) gallstones.  It occurs most often as a result of impaction of the gallstones in the cystic duct, leading to obstruction of bile flow and painful distention of the gallbladder  Other causes may be typhoid fever or a malignant tumor.

Acute Cholecystitis

Inflammation of the gallbladder that develops over hours, usually resulting from a cystic duct obstruction by a gallstone . This form of gallbladder disease usually subsides within 1 to 7 days with a conservative plan of treatment

Chronic Cholecystitis

Chronic Cholecystitis is long standing gall bladder inflammation or prolonged episodes of acute cholecystitis almost always caused by gallstones . The gallbladder wall is thickened with fibrosis noted between the layers of the gallbladder and liver This can also be called cystic duct inflammation.  A cholecstectomy, or removal of the gallbladder, is required when symptoms do not resolve with conservative treatment, or may be indicated if a person has chronic cholecystitis .

Cholecystitis often occurs due to untreated gallstones.  Cholelithiasis, or gallstones, are small, pebble-like substances that develop in the gallbladder called calculi . Gallstones occur when liquid stored in the gallbladder is not secreted properly and hardens into pieces of stone-like material. The liquid—called bile—helps the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs it. The gallbladder contracts and pushes the bile into a tube—called the common bile duct—that carries it to the small intestine, where it helps with digestion .  Gallstones can also be collection of cholesterol, bile pigment or a combination of the two, which can form in the gallbladder or within the bile ducts of the liver.  Cholesterol stones form due to an imbalance in the production of cholesterol or the secretion of bile. 80 percent of all gallstones diagnosed are of cholesterol form .  Pigmented stones are primarily composed of bilirubin, which is a chemical produced as a result of the normal breakdown of red blood cells .  The bilirubin stones account for 20 percent of the stones being diagnosed .  Someone can develop what is called acholelithiasis cholecystitis, or inflammation of the gallbladder without gallstones . 

Prevalence

In the United States, the most common type of gallstones is made of cholesterol.  Bilirubin gallstones are more common in Asians and Africans, but are seen in diseases that damage red blood cells such as sickle cell anemia.  American Indians have the highest rate of gallstones in the United States. The majority of American Indian men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30 .

Gallstones, occur increasingly with advancing age, so 20% of men and 35% of women have gallstones present by the age of 75.  It is estimated that 15-20 million people in the United States have gallstones .  Cholelithiasis is the fifth leading cause of hospitalization among adults.  Gallstones account for 90% of all gallbladder and duct diseases . Greater than 80% of patients are asymptomatic with gallstones.

Cholelithiasis is the most common gastrointestinal disease in the United States.  25 percent of all cases, symptoms and complications develop secondary to the the presence of gallstones.  These cases will require surgery or other forms of treatment . 

Pathology

Cholesterol that is needed to form cholesterol gallstones mainly comes from the diet.  Cholesterol is then absorbed into the liver from the blood by receptors. Each lipoprotein has its own receptor.  Low density lipoproteins are removed from the blood by the binding of the apo B,E receptor. The B1 receptor travels around looking for high density lipoproteins and removes them.  Through a series of reactions and protein interactions helps keep this process moving. 

The bile that is produced in the liver helps aid in the excretion of excess cholesterol. Biliary lipids that are secreted from the liver help compose bile. Each of the lipids secreted into bile has a specific transporter. Once the lipids are secreted into the bile, the phospholipids and cholesterol form vesicles while the bile salts form micelles. The vesicles and micelles interact and pass through the gallbladder. 

Cholesterol needs detergent properties of the phospholipids and bile salts to remain a liquid solution. If there is a larger presence of cholesterol in bile, the bile will become oversaturated with cholesterol and then crystals will form. 

Common mechanisms associated with cholesterol stone formation are:

1. Stasis of bile in the gallbladder- this may occur when insoluble or supersaturated cholesterol is absorbed into the wall of the gallbladder.  This leads to difficulty contracting the smooth muscles.  This commonly seen in pregnancy, after a period of weight loss, RA patients, and patients receiving total parenteral nutrition (TPN). 
2. Changes in mucin glycoproteins- there are several proteins that interact with the miced micelles during the tranport process from the liver to the gallbladder, mucin glycoproteins are shown to form cholesterol stones.  Patients who experience rapid weight loss may have an increase in mucin glycoprotein production
3. Processses that may increase the amount of cholesterol or reduce the amount of bile salts or phospholipids that are secreted into bile

Pigemented stones:

Black stones are caused by an increase in the production of unconjugated bilirubin.  This type of stone occurs in the patient population who have chronic hemolysis (i.e. sickle cell anemia) or have end-stage liver disease.

Brown stones are less common.  These occur in geographic areas where biliary infections are prevelant.  Brown stones can form in the gallbladder or in the ducts and form secondary to anaerobic bacterial infections. 

Cholecystitis, if left untreated, can result in infectious complications, extreme inflammation, tissue necrosis, gangrenous gallbladder, absceses, or perforation.

Clinical Presentation

• Colicky Right Upper Quadrant Pain and tenderness especially near the right subcostal region especially after the person has eaten fatty foods. 
• Symptoms worse immediately after eating (inflammation of the gallbladder)
• Low grade fever to high grade fever
• Chills
• Pain and nausea 1-3 hours after eating (gallstones)
  
• Vomiting
• Abdominal Pain- may be intermittent or steady
• Rigors with rebound tenderness or ileus
• Interscapular pain 
• Heartburn, belching, flatulence, epigastric discomfort, and food intolerance (especially to fats and cabbage) . 
• Jaundice- this is a result of blockage of the common bile duct .
• Green hued skin
• Persistent pruritis or skin itching can occur at peripheral sites that are innervated by the same spinal cord level as the gallbladder 
  
• Anterior rib pain (tip of 10th rib; can also affect ribs 11 and 12) .
• Dark Urine, Light Stools
• Bleeding from skin and mucous membranes and weight loss- late signs of gallbladder cancer
• Feeling of fullness or indigestion
• Referred viscerogenic heart pain

If a patient presents with any of the following they should be advised to see their doctor immediately:

• prolonged pain—more than 5 hours
• nausea and vomiting
• fever—even low-grade—or chills
• yellowish color of the skin or whites of the eyes
• clay-colored stools

• Referred pain: R upper trapezius and shoulder, R interscapular (T4-T8), R subscapular region
• Celiac (abdominal) and splanchnic (visceral) connect the sympathetic fibers of the biliary system in turn producing the referral of interscapular radiating pain primarily right sided. The splanchnic nerves intertwine with the phrenic nerve (diaphragm) producing referral pain to the right shoulder. 

Most gallstones are asymptomatic: approximately 30% cause symptoms of cholecystitis.  Gallstones in the older population may not cause pain, fever, or jaundice.  Mental confusion and shakiness may be the only symptoms the elderly patient may present with . 

Associated Co-morbidities

The development of pigmented stones is not fully understood. People who develop pigmented stones often have liver cirrhosis, biliary tract infections, or hereditary blood disorders—such as sickle cell anemia—in which the liver makes too much bilirubin.  If a person already has gallstones present this may lead to the formation of more gallstones. Secondary complications from untreated AC include sepsis, peritonitis, and cholecystoenteric fistulas. 

Medications

Actigall, Ursodiol

• Naturally ocurring bile acid
• Gallstone dissolution therapy used for radiolucent stones <20 mm.  Patients need to be monitored every 6 months with ultrasound. This should also be used for 3 months after dissolution and must be given with food.  It is not recommended for children. May cause diarrhea, dyspepsia, abdominal pain, nausea, vommiting, dizziness, and constipation.  Actigall woks by decreasing cholesterol synthesis, secretion, and absorption.  It also works by altering bile cholesterol composition.

Ursodeoxycholic Acid

• decreases cholesterol saturation Ezetimide, Zetia
• Cholesterol absorption inhibitor
• Antihyperlipidemic

Diagnostic Tests/Lab Tests/Lab Values

Cholecystitis is usually diagnosed with the use of ultrasound.  An abdominal ultrasound examination is a quick, sensitive, and relatively inexpensive method of detecting gallstones in the gallbladder or common bile duct. This is the test most often used

Murphy's Sign is a screening test performed by clinicians to assess for cholecystitis.

• Patient lies supine with relaxed abdomen
• Therapist places one hand on the right, posterior, inferior costal margin.
• Therapist places the other hand on the right upper abdominal quadrant (subcostal).
• Therapist applies slight pressure (palpates deeply) while patient inspires
  + sign if pain is reproduced or client stops inspiration
  

                     Sensitivity: 86%, 63%, 97%  
                     Specificity: 35%, 94%, 48%
                     +LR (1.32, 9.84, 1.88)
                      -LR (.4, .4, .06)
                     Quadas Scores (9, 9, 10)

The following are also tests that can be used to diagnose cholecystitis:

Cholescintigraphy -  the patient is injected with a small amount of radioactive material and is absorbed by the gallbladder.  Then the gall bladder is stimulated to see how well it contracts or if there is an obstruction within the bile ducts .

Abdominal CT scan

Magnetic Resonance Cholangiography

Complete Blood Cell Count (CBC):  the presence of an elevated white blood count to 12,000-15,000 per microL.   

Liver Function Test - total serum bilirubin levels, serum amniotransferase, and alkaline phosphotase levels are commonly elevated in acute cholecystitis, but normal or minimally elevated in the chronic form .

X-Rays of the abdomen may show radiopaque gallstones in only 15% of all cases .

The diagnosis of gallstones is suspected when symptoms of right upper quadrant abdominal pain, nausea or vomiting occur. The location, duration and “character” (stabbing, gnawing, cramping) of the pain help to determine the likelihood of gallstone disease. Abdominal tenderness and abnormally high liver function blood tests may be present.

Causes , ,

The following are other risk factors that may contribute to the formation of gallstones, particularly cholesterol stones:

• Sex: Women are twice as likely to develop gallstones as men. This is due to an excess amount of estrogen from pregnancy, hormone replacement therapy, and birth control pills appears to increase cholesterol levels in bile.  This then decreases the motility in the gallbladder, which  then can lead to gallstones.
• Family history: Other family members tend to develop gall stones, which leads researchers to believe that people are genetically inclined to develop gall stones.
•  Weight: People who are moderately overweight have an increased risk for developing gallstones. The most likely reason is that the amount of bile salts in the bile is reduced, leading to an increase in cholesterol. The increase in cholesterol reduces the gallbladders ability to empty. Obesity is a major risk factor for gallstones, especially in women.
•  Diet: Diets that are high in fat and cholesterol and low in fiber increases the risk of gallstones due to increased cholesterol in the bile and reduced gallbladder emptying.
•  Rapid weight loss: As the body metabolizes fat during prolonged fasting and rapid weight loss—such as “crash diets" leads to the liver secreting extra cholesterol into the bile, which then can cause gallstones. In addition, the gallbladder does not empty properly.  If a patient has had gastric bypass surgery to help loose weight this puts them at risk for developing gallstones.  
•  Age: People over the age 60 are more likely to develop gallstones than younger people. As people age, the body tends to secrete more cholesterol into bile.  With this increase in secretion of cholesterol there is a simulatneous decrease in bile salt production. 
  
•  Ethnicity: American Indians are genetically predisposed to secrete high levels of cholesterol in bile.  Mexican American men and women of all ages also have high rates of gallstone formation.
•  Cholesterol-lowering drugs: Drugs that lower cholesterol levels in the blood actually increase the amount of cholesterol secreted into bile.  This then leads to an increased risk of gallstones.
•  Diabetes: People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids may increase the risk of gallstone formation.
  
• Drugs: Estrogen is one of the most common studied drug that leads to gallstones.  Other drugs that have been shown to cause the formation of gallstones are ceftriaxone, clofibrate, and octreotide.

Systemic Involvement

Shoulder pain can be from any of the following:

Cancer-metastases to nodes of axilla or mediastinum, metastases to lungs from the bone, breast, kidney, colorectal, pancreas, and uterus, metastases to thoracic spine from breast, lung, and thyroid, Breast Cancer, Pancreatic Cancer.

Cardiovascular- Thoracic Outlet Syndrome, Myocardial Infarct, Post CABG, Bacterial Endocarditis, Aortic Aneurysm, Empyema and lung abscess, Dissecting aortic aneurysm.

Pulmonary- Pulmonary TB, PE, Spontaneous Pneumothorax, Pancoast's tumor, Pneumonia.

Renal/urologic- Kidney stones, Obstruction, inflammation or infection of the upper urinary tract.

Gastrointestinal/Hepatic- Hiatal Hernia, Peptic/duodenal ulcer, Ruptured Spleen, Liver/gallbladder disease, Pancreatic Disease, Ectopic pregnancy.

Gynecologic- Mastodynia, Subphrenic abscess.

Other- Mononucleosis, Osteomyelitis, Syphillis, Herpes Zoster, Diabetes, Sickle Cell Anemia, Hemophilia, Diaphragmatic hernia, Anterior spinal surgery.

Medical Management (current best evidence),

Surgical Treatment

If a patient comes to you and has been diagnosed with gallstones comes they may not be receiving treatment.  This is because the patient is not having a gallbladder attack or no symptoms are present.  However, if a patient has had several frequent attacks, they need to see their doctor.  The doctor may recommend removing the gallbladder, an operation called cholecystectomy.  In the United States cholecystectomys are the most common surgeries being performed.  Most all of the procedures are performed laproscopically.
Recovery after the surgery usually involves only one night in the hospital, and normal ADL's can be resumed a few days later.  Due to the abdominal muscles not being cut during the surgery, their is less pain and fewer complications than after an “open” surgery.  This type of surgery requires a 5- to 8-inch incision across the abdomen.
If the tests ordered by the physician show an abnormal amount of inflammation, infections and or scarring secondary to other operations, the physician may choose to do an "open surgery" for removal of the gallbladder.  If during the laproscopic procedure the surgeon finds the above mentioned problems a larger incision is made.   Recovery from the open procedure requires a 3-5 day stay in the hospital.  This type of surgery is onle needed in about five percent of all gallbladder operations performed.
One of the most common complications with gallbladder surgery is that there is an increased risk for injury to the bile ducts.  Injury to the common bile duct will cause bile to leak out and cause and extreme amount of pain and a potentially dangerous infection. Mild injuries to the bile ducts can sometimes be treated without surgery. However, major injuries, are more serious and leads to more surgery.

If gallstones are found to be in the bile ducts, the gastroenterologist may use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove the stones before or during gallbladder surgery.  A person on occasion, who has had a cholecystectomy, may be dianosed with gallstones in the bile ducts weeks or years after.  The ERCP procedure is successful in removing the stone in these cases.  If performing an ERCP the surgeon finds gallstones in the gallbladder itself a choleycystectomy has to be performed.  This procedure does not remove stones from the gallbladder.

Nonsurgical Treatment

Nonsurgical approaches are mainly used when a patient has serious medical conditions that prevent surgery.  Nonsurgical treatments are used also only on cholesterol stones. Stones can reocur within 5 years if a patient has been treated nonsurgically.

Some types of nonsurgical treatment are:

1. Oral dissolution therapy. This is where drugs made from bile acids are used to help dissolve the gallstones. The most common drugs used for small stones are ursodiol (Actigall) and chenodiol (Chenix). However, this type of treatment take a really long time for the stone to completely dissolve.
   
2. Contact dissolution therapy. This is an experimental procedure that involves injecting a drug directly into the gallbladder that will help dissolve cholesterol stones. The most common drug that is used in this tupe of treatmnet is, methyl tert-butyl ether.  This is a fast acting treatment that dissolves the stone in 1-3 days.

Physical Therapy Management (current best evidence)

Usual postoperative exercises for any surgical procedure apply, especially in cases where complications may occur.  Early activity assists with the return of intestinal motility, so the patient is encouraged to begin progressive movement and ambulation as soon as possible.

Some examples of postoperative exercises include:

• breathing exercises
• positioning changes
• coughing
• wound splinting
• compressive stockings
• lower extremity exercises
  

Differential Diagnosis

Obstruction of the gallbladder can lead to:

• biliary stasis
• delayed gallbladder emptying
• These two combined can occur with any pathological condition of the liver, hormonal influencse, and pregnancy.

Cholangitis- this is where the gallstone get lodged further down into the common bile duct.  If bile flow is blocked at the biliare tree this can lead to jaundice.

Primary Biliary Cirrhosis- this is a chronic progressive, inflammatory disease of the liver that involves primarily the intrahepatic bile duct and results in the impairement of bile secretion.  

Gallbladder Cancer- this is closely associated with gallstone disease.  If this is diagnosed it is usually in later stages and often has a poor outcome. 

Gallstone Pacreatitis- this is the inflammation of the pancrease secondary to blockage of the pancreatic duct via a gallstone.  The blockage occurs at the sphincter of Oddi.  If a stone from the gallbladder travels down the common bile duct and gets stuck in the sphincter, it will block the flow of all material from the liver and pancreas. This leads to inflammation of the pancreas and can be quite severe. Gallstone pancreatitis can be a life-threatening disease and evaluation by a physician urgently is needed if someone with gallstones suddenly develops severe abdominal pain

Sphincter of Oddi Dysfunction-  Sphincter of Oddi Dysfunction (SOD) is a symptom complex of intermittent upper abdominal pain and may be accompanied by nausea and vommitting.  This is thought to be caused from scarring or spasm of the sphincter of Oddi muscle. This is a small circular muscle that is a ½ inch in length, located at the end of the bile duct and pancreas duct. This muscle works to keep the bile duct and pancreatic duct muscles closed; this prevents reflux of intestinal contents into the bile duct and pancreas duct. If this muscle should spasm or scar, drainage of the bile duct and/or pancreas duct may be hindered. Abnormal dilation of the bile duct and/or pancreas duct is often associated with an increase in the products and enzymes made by the liver, gallbladder and pancreas, which can be tested for with blood tests (serum liver tests, amylase, lipase). If the ducts are blocked this may result in pain

Peptic Ulcer Disease- characterized by burning, epigastric pain that occurs after meals.  This often wakes patients up at night and pain improves with eating .

Acute Pacreatitis- this is characterized by epigastric or periumbilical abdominal pain radiating to the back .

Scickle Cell Crises- this is typically associated with gallstone disease.  A patient may experience pain anywhere in the body, which can be unrelated to the formation of gallstones .

Appendicitis- a patient may experience pain in the right lower quadrant near the iliac crest.  To rule this out look for rebound tenderness at McBurneys point.  Pain a patient experiences with appendicities may complain that it started in the periumbilical region .

Right Lower Lobe Pneumonia-  a patient who presents with this will have a productive cough and fever.  Listen to a patients breath sounds to help rule this out, in doing so one will hear bronchial breath sounds . 

Acute Coronary Syndrome- a person will typically experience central chest pain that radiates to the left arm or jaw.  A patient may experience pain the epigastrum region.  One thing to be listening for in the history is previous history of chest pain and or look for risk factors for coronary artery disease .

GERD- a patient who presents with thsi will have a burning sensation in chest after meals.  This sensation is made worse on bending over or lying down. A patient may also have acid reflux and dysphagia . 

Prognosis

The prognosis for acute and chronic cholecystitis is good if the patient seeks medical treatment.  Acute attacks should resolve spontaneously, but a person may experience reoccurences.  This may lead to the patient having their gallbladder removed.  Mortality secondary to acute cholecystitis is 5 to 10 percent for clients that are older than 60 and have serious associated diseases .

Case Reports

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

The American College of Gastroenterology-www.acg.gi.org
National Digestive Disease International Clearinghouse-digestive.niddk.nih.gov

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1tsh1RBFJ1LTwmozcf0tcKVkIlT8uvULhzxwN6aGuiPmT9hEWk|charset=UTF-8|short|max=10: Error parsing XML for RSS