Acute cholecystitis

Acute cholecystitis is an inflammatory condition of the gallbladder, typically resulting from obstruction of the cystic duct. It is a common surgical emergency that can lead to serious complications if not promptly diagnosed and managed. Early recognition and appropriate treatment are essential for favorable outcomes.

Introduction

Acute cholecystitis is characterized by sudden onset of right upper quadrant abdominal pain, often accompanied by nausea, vomiting, and fever. Most cases are caused by gallstones obstructing the cystic duct, although acalculous forms can occur in critically ill patients.

The condition accounts for a significant proportion of hospital admissions for biliary disease and can progress to complications such as gangrene, perforation, or sepsis if left untreated. Prompt diagnosis using clinical evaluation, laboratory testing, and imaging is crucial for effective management.

Etiology and Risk Factors

Gallstone-related Causes

The majority of acute cholecystitis cases are associated with gallstones blocking the cystic duct, leading to bile stasis, increased intraluminal pressure, and inflammation.

• Obstruction of the cystic duct by gallstones
• Stone composition and size influencing obstruction risk
• Predisposing factors such as obesity, female sex, and age over 40

Acalculous Cholecystitis

Acalculous cholecystitis occurs in the absence of gallstones and is often seen in critically ill patients or those with severe trauma or burns.

• Pathogenesis related to biliary stasis and ischemia
• Increased susceptibility in intensive care or postoperative patients

Other Contributing Factors

• Bacterial infection, often secondary to bile stasis
• Vascular compromise leading to ischemia of the gallbladder wall
• Chronic conditions causing biliary stasis, such as diabetes or prolonged fasting

Pathophysiology

Acute cholecystitis develops primarily due to obstruction of the cystic duct, which results in accumulation of bile, increased intraluminal pressure, and gallbladder wall distension. This initiates an inflammatory cascade, leading to mucosal edema, leukocyte infiltration, and vascular congestion.

Bacterial infection often complicates the condition, with common pathogens including Escherichia coli, Klebsiella species, and Enterococcus species. Ischemia of the gallbladder wall further contributes to necrosis and increases the risk of complications such as gangrene and perforation.

Clinical Presentation

Symptoms

• Right upper quadrant abdominal pain, often radiating to the right shoulder or back
• Nausea and vomiting
• Fever and general malaise
• Anorexia
• Occasional jaundice if biliary obstruction extends to the common bile duct

Physical Examination Findings

• Localized tenderness in the right upper quadrant
• Positive Murphy’s sign, indicating inspiratory arrest on palpation
• Guarding or rigidity over the affected area
• Signs of systemic inflammation such as tachycardia and mild hypotension in severe cases

Laboratory and Diagnostic Evaluation

Laboratory Tests

Laboratory investigations help support the diagnosis of acute cholecystitis and assess the severity of inflammation.

• Complete blood count: Often reveals leukocytosis with a left shift.
• Liver function tests: Mild elevation of AST, ALT, ALP, and bilirubin may be present if bile ducts are affected.
• Inflammatory markers: Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) indicate systemic inflammation.

Imaging Studies

• Ultrasound: First-line imaging modality; may show gallstones, gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy’s sign.
• Hepatobiliary iminodiacetic acid (HIDA) scan: Used to confirm cystic duct obstruction in equivocal cases.
• CT and MRI: Useful for detecting complications such as perforation, abscess, or gangrene and for evaluating atypical presentations.

Complications

If left untreated, acute cholecystitis can lead to several serious complications, which increase morbidity and mortality.

• Gangrenous cholecystitis: Necrosis of the gallbladder wall due to ischemia.
• Perforation and abscess formation: Can lead to localized or generalized peritonitis.
• Empyema of the gallbladder: Pus accumulation within the gallbladder lumen.
• Biliary peritonitis: Resulting from rupture of the gallbladder into the peritoneal cavity.
• Sepsis: Systemic infection secondary to severe inflammation or perforation.

Management

Initial Stabilization

Immediate management focuses on stabilizing the patient and controlling inflammation.

• Fluid resuscitation: Intravenous fluids to maintain hydration and hemodynamic stability.
• Pain management: Analgesics such as NSAIDs or opioids for severe pain.
• Antibiotic therapy: Broad-spectrum intravenous antibiotics targeting common biliary pathogens.

Definitive Treatment

The definitive treatment depends on patient stability and severity of the condition.

• Early laparoscopic cholecystectomy: Preferred treatment for most patients; reduces hospital stay and recurrence risk.
• Open cholecystectomy: Indicated in cases with severe inflammation, adhesions, or anatomical difficulties.
• Percutaneous cholecystostomy: Recommended for critically ill or high-risk surgical patients as a temporizing measure.

Supportive Care

• Monitoring vital signs and laboratory parameters
• Maintaining nutritional support, often with initial bowel rest
• Observation for potential complications such as perforation or abscess formation

Prevention and Prognosis

Preventive measures aim to reduce the risk of acute cholecystitis and its recurrence, particularly in patients with known gallstones.

• Elective cholecystectomy for patients with symptomatic gallstones
• Maintaining a healthy weight and balanced diet to prevent gallstone formation
• Management of underlying metabolic disorders such as diabetes or hyperlipidemia
• Regular follow-up in high-risk patients to monitor for biliary complications

The prognosis of acute cholecystitis is generally favorable with timely diagnosis and appropriate treatment. Delayed intervention increases the risk of complications, morbidity, and mortality.

Recent Advances and Research

Recent developments in the management of acute cholecystitis have focused on minimally invasive techniques and improved diagnostic protocols.

• Advances in laparoscopic and robotic-assisted cholecystectomy have reduced operative morbidity and hospital stay.
• Enhanced imaging modalities such as high-resolution ultrasound and MRI improve detection of complications and atypical presentations.
• Novel antibiotic regimens and targeted therapy help optimize infection control and reduce resistance.
• Research into biomarkers and scoring systems aids in risk stratification and severity assessment.
• Emerging protocols for early intervention in high-risk and critically ill patients have improved outcomes.

References

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