Section 10. Liver and Gallbladder Disorders

Chapter 140. Gallbladder Disorders

Topics: Introduction | Gallstones | Cholecystitis | Bile Duct Tumors

Cholecystitis

Cholecystitis is inflammation of the gallbladder wall, usually resulting from a gallstone obstructing the cystic duct.

Acute cholecystitis is the sudden onset of inflammation of the gallbladder, resulting in severe, steady upper abdominal pain (biliary colic), which may occur repeatedly. Chronic cholecystitis is long-standing inflammation of the gallbladder characterized by repeated attacks of pain (gallbladder attacks) over a prolonged period.

At least 95% of people with acute cholecystitis have gallstones. The inflammation almost always begins without infection, although infection may follow later. Rarely, acute cholecystitis occurs in a person without gallstones (acalculous cholecystitis). Acalculous cholecystitis is a serious disease. It tends to occur after major injuries, operations, burns, bodywide infections (sepsis), and critical illnesses--particularly in people receiving prolonged intravenous feedings. It can occur in young children as well, perhaps originating as an infection (viral or other).

In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually from gallstones, and may become thick-walled, scarred, and small. The gallbladder generally contains sludge or gallstones that often obstruct its outlet or the cystic duct.

Symptoms

A gallbladder attack, whether in acute or chronic cholecystitis, begins as severe, steady pain (biliary colic), usually in the right upper part of the abdomen. The person typically feels a sharp pain when a doctor presses on the upper right part of the abdomen. The pain may worsen when the person breathes deeply and often extends to the lower part of the right shoulder blade. The pain may become excruciating; nausea and vomiting are usual. The pain usually lasts more than 12 hours.

Within a few hours, the abdominal muscles on the right side become rigid. Fever occurs in about one third of people but is less likely in older people. The fever tends to be slight at first, then rises gradually to above 100° F (38° C).

Typically, an attack of cholecystitis subsides in 2 to 3 days and completely disappears in a week. If the attack persists, it may signal a serious complication. A high fever, chills, a marked increase in the white blood cell count, and a cessation of the normal propulsive movements of the intestine (ileus (see Section 9, Chapter 132)) suggest formation of an abscess (a pus-filled pocket of infection), gangrene (death of tissue), or a perforated (pierced) gallbladder.

Other complications may occur. A gallbladder attack accompanied by jaundice (see Section 10, Chapter 135) and other evidence of a backup of bile into the liver (cholestasis), such as passing light-colored stools, indicates that the common bile duct is obstructed (usually partially) by a stone. If blood test results reveal an increased level of a pancreatic enzyme (amylase or lipase), the person may have inflammation of the pancreas (pancreatitis) caused by a stone obstructing the pancreatic duct.

In acalculous cholecystitis, typically the person has no previous symptoms or other evidence of gallbladder disease and experiences sudden, excruciating pain in the upper abdomen. Usually, the disease is very severe and can lead to gangrene or rupture of the gallbladder. If the person has other severe problems (for example, the person is in the intensive care unit), acalculous cholecystitis at first may be overlooked.

Diagnosis

Doctors diagnose cholecystitis, both acute and chronic, based on the person's symptoms and the results of tests that suggest gallbladder inflammation. Increased levels of white blood cells suggest inflammation or infection or both. Ultrasound scans often confirm the presence of gallstones in the gallbladder, which may be responsible for the attacks. Ultrasound scans can also show thickening of the gallbladder wall, which is typical of chronic cholecystitis.

Cholescintigraphy is an imaging technique that is useful when acute cholecystitis is difficult to diagnose. In this test, a radioactive tracer is injected intravenously and its movement from the liver through the biliary tract is followed. Images are taken of the liver, bile ducts, gallbladder, and upper part of the small intestine. If the tracer does not fill the gallbladder, it is presumed that the cystic duct is obstructed by a gallstone.

Treatment

A person with acute or chronic cholecystitis who experiences a gallbladder attack usually is hospitalized, is given fluids and electrolytes intravenously, and is not allowed to eat or drink. A doctor may pass a tube through the nose and into the stomach, so that suctioning can be used to keep the stomach empty and reduce fluid accumulating in the intestines, which do not work properly because of the inflammation of the abdominal cavity. Antibiotics usually are given.

In acute cholecystitis, if the diagnosis is certain and the risk of surgery is small, the gallbladder usually is removed during the first day or two of the illness. If necessary, gallbladder removal may be delayed; if the attack subsides, removal may wait 6 weeks or more. If a complication such as an abscess, gangrene, or perforation of the gallbladder is suspected, immediate surgery is necessary.

In chronic cholecystitis, treatment generally involves surgical removal of the gallbladder, usually by laparoscopic cholecystectomy, once the acute episode subsides.

In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder.

After gallbladder removal for cholecystitis with gallstones, a small percentage of people develop new or recurring episodes of pain that feel like gallbladder attacks even though they no longer have a gallbladder. The cause of these episodes is not known, but episodes may result from an abnormal function of the sphincter of Oddi, the opening at the base of the bile duct that controls the release of bile into the small intestine. Pain is believed to result from increased pressure in the ducts caused by resistance to the flow of bile or pancreatic secretions. In some people, small gallstones remaining after surgery may cause pain. A doctor can use endoscopic retrograde cholangiopancreatography to widen (by cutting) the sphincter of Oddi. This procedure usually relieves symptoms in people who have a recognizable abnormality of the sphincter. In many others, the pain is caused by another problem, such as the irritable bowel syndrome or even peptic ulcer disease.