Cholecystitis

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

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Definition/Description

Cholecystitis is inflammation of the gallbladder and can be acute or chronic (Merck Manual). 

Acute Cholecystitis

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

Chronic Cholecystitis

Chronic Cholecystitis is long standing gall bladder inflammation most always caused by gallstones (Merck Manual).  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 (G&B).

Cholecystitis often occurs due to untreated gallstones.  Cholelithiasis, or gallstones, are small, pebble-like substances that develop in the gallbladder called calculi (G&S). 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 (NDDIC).  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. Pigmented stones are primarily composed of bilirubin, which is a chemical produced as a result of the normal breakdown of red blood cells (TACG).  Someone can develop what is called acholelithiasis cholecystitis, or inflammation of the gallbladder without gallstones (G&B). 

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 a 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 (NDDIC, TACG).

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 million people in the United States have gallstones.  (G&B).  Cholelithiasis is the fifth leading cause of hospitalization among adults.  They also account for 90% of all gallbladder and duct disseases (G&S).

Clinical Presentation

• Right Upper Quadrant Pain and tenderness especially near the right subcostal region
• Low grade fever to high grade fever (Merck Manual, G&S)
• Chills (Merck Manual, G&S)
• Nausea (G&S)
• Vomitting (Merck Manual)
• Abdominal Pain- may be intermittent or steady (G&B)
• Rigors with rebound tenderness or ileus
• Pain in the back between the shoulder blades (NDDIC, G&B)
• Herartburn, belching, flatulence, epigastric discomfort, and food intolerance (especially to fats and cabbage) (G&B, G&S)). 
• Jaundice- this is a result of blockage of the common bile duct (G&S).
• Persistent pruritis, or skin itching (G&S)
  
• Anterior rib pain (tip of 10th rib; can also affect ribs 11 and 12) (G&S).

If a patient presents with any of the following 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 (NDDIC)
  

Most gallstones are asymptomatice: 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 (G&B). 

Associated Co-morbidities (NDDIC, TACG)

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. 

Medications

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Diagnostic Tests/Lab Tests/Lab Values

Cholecystitis is usually diagonsed 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 (TACG)

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

Cholescintigraphy (Merck Manual)-  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 obstrucion within the bile ducts (NDDIC).

Abdominal CT scan

Magnetic Resonance Cholangiography

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

Liver Function Test (Merck Manual)- 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 (G&B)

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 (NDDIC, TACG, G&S)

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

• Sex: Women are twice as likely as men. Excess estrogen from pregnancy, hormone replacement therapy, and birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, which can lead to gallstones.
  * Family history: Often other family members develop gall stones, which leads to believe there is a genetic link.
  * Weight: People who are moderately overweight increases the 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. Increased cholesterol reduces gallbladder emptying. Obesity is a major risk factor for gallstones, especially in women.
  * Diet: Diets high in fat and cholesterol and low in fiber increase 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”—the liver secretes extra cholesterol into bile, which can cause gallstones. In addition, the gallbladder does not empty properly.
  * 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.
  * Ethnicity: American Indians have a genetic predisposition to secrete high levels of cholesterol in bile.Mexican American men and women of all ages also have high rates of gallstones.
  * Cholesterol-lowering drugs: Drugs that lower cholesterol levels in the blood actually increase the amount of cholesterol secreted into bile, leading 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 gallstones
  

Systemic Involvement

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Physical Therapy Management (current best evidence) (G&B)

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

Alternative/Holistic Management (current best evidence)

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Differential Diagnosis(G&S)

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. 

Case Reports

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Resources

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Recent Related Research (from Pubmed)

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References

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