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Cholecystitis

Overview

Cholecystitis means inflammation (swelling and redness) of the gallbladder. The gallbladder is a sac attached below the surface of the liver. It is a pear-shaped structure having a body, fundus, neck, and cystic duct. Its primary function is to store “bile,” a greenish fluid produced by the liver and is carried into the gallbladder via the Hepatic duct. Both hepatic and cystic ducts combine to form a Common Bile Duct (CBD) which secretes bile into the small intestine when the food we eat reaches there. The gallbladder releases bile into the Cystic duct, which carries it into the small intestine to digest fats. The gallbladder can typically store about 25-30ml of bitterness. Bile comprises 97% water, bile salts, cholesterol, and bilirubin.

Epidemiology

Inflammation of the gall bladder can be due to many causes, of which the most common is the obstruction of the gall bladder neck or the cystic duct. The following are the factors contributing to it:

  • Gallstones (mainly due to cholesterol accumulation)
  • Mucus
  • Worms
  • Tumors

 All of the above factors lead to blockage, ultimately causing the release of various toxins and hence inflammation of the gallbladder.

Types

According to the duration of the disease, Cholecystitis can be of two types.

  • Acute Cholecystitis
  • Chronic Cholecystitis

Signs and Symptoms

Acute Cholecystitis can present typically with the following features:

  • Right upper quadrant abdominal pain
  • Pain at the tip of the  right shoulder (not in all cases)
  • Fever
  • It can also present with nausea, vomiting, and jaundice in a few cases.

Chronic Cholecystitis presents with recurrent upper abdominal pain, mostly at night and after meals.

Risk Factors

It occurs commonly in females as compared to males, and the following are the factors that increase the risks of developing cholecystitis:

  • Increased dietary cholesterol and fat consumption
  • Pregnancy
  • Hormone therapy
  • Older age (18-65 years)
  • Obesity
  • Losing or gaining weight rapidly
  • Diabetes

Other less common factors are gallbladder tumors and any severe systemic disease.

Diagnosis

The diagnosis of cholecystitis is mainly clinical, but to confirm it, your healthcare provider may order some specific lab investigations after conducting a proper physical examination of the abdomen and taking the patient's history.  On review, right abdominal tenderness (Pain on touching) and rigidity may be found. Your doctor may also check for Murphy’s sign, i.e., asking you to inhale deeply and at the same time press on your liver which will cause a sudden arrest of inhalation due to pain and Boas sign (increased sensitivity to touch).

Other than the above following are some lab investigations to confirm the diagnosis:

  • Blood complete picture (showing increased WBC count)
  • Serum transaminase and serum amylase (raised in case of gallstones) levels.
  • Plain X-ray abdomen (showing gallstones)
  • Ultrasonography-investigation of choice (detect gallstones and gall bladder wall thickening due to cholecystitis)
  • HIDA scan
  • CT-scan (in cases of perforation)

Differential Diagnosis

Following are some of the differential diagnoses of cholecystitis:

  • Cholelithiasis
  • Choledocholithiasis
  • Pancreatitis
  • Peptic Ulcer
  • Acute Hepatitis
  • Liver Abscess

These differentials can be ruled out based on the history given by the patient, the examination performed, and the investigations.

Complications

Inflammation of the gallbladder can cause severe complications if left untreated or managed inappropriately. Following are some of the intricacies of Cholecystitis:

  • Gangrenous cholecystitis (tissue death due to decreased blood supply)
  • Perforation of the gallbladder
  • Emphysematous cholecystitis
  • Cholecystoenteric fistula with gallstone ileus
  • Empyema of gallbladder

Treatment

Cholecystitis can be managed conservatively in milder forms, i.e., medical management but the definitive treatment in all cases is Cholecystectomy, which involves surgical removal of the gall bladder.

  • Medical management includes:
  • The patient should have an appropriate bed rest
  • Analgesics (pain killers) medication – NSAIDS or Opioids
  • Appropriate antibiotics – Cephalosporin or Piperacillin along with Metronidazole
  • Nasogastric aspiration – in cases of severe persistent vomiting

Surgical management includes;

  • It is preferred to perform cholecystectomy in all cases despite medical management because its’ recurrence rate is about 70% in medically treated individuals. It can be “Early cholecystectomy” (within 24-48hours) or “Interval cholecystectomy” (after 6weeks).
  • Cholecystectomy can either be performed as “Open Cholecystectomy,” in which a surgeon opens up the abdomen to identify vital structures and remove the gallbladder or “Laparoscopic Cholecystectomy,” in which abdominal space is enlarged by filling it up with carbon dioxide gas and four probes are inserted into abdomen and gall bladder is removed.

Medications

After cholecystectomy, there are several lifestyle changes the patients have to opt for a speedy recovery and reduce future complications. They include:

  • Taking appropriate rest
  • Drinking plenty of fluids
  • Avoiding lifting heavy things
  • Eating a low-fat diet
  • Eating in small frequent meals
  • Eating a diet containing fruits, vegetables, and grains

Prognosis

In cases with no complications or mild to moderate symptoms, it has an excellent recovery rate and very low mortality. On the other hand, the prognosis gets bad in complicated cases, but with the advancement of techniques and instruments, a doctor can prevent complications and manage cholecystitis well.

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