What is cholecystitis?

Causes and Symptoms

There are basically two types of cholecystitis, calculous and acalculous, both of which could present as acute or chronic inflammation of the gallbladder. The calculous type is seen in 90 percent of cases and is caused by an obstruction of the neck of the gallbladder by gallstones, which are usually composed of cholesterol. The cholesterol stones may block the gallbladder neck and cause an acute attack of cholecystitis, or they may act as chemical irritants and result in chronic inflammation. About 10 percent of cases of cholecystitis are not the result of gallstones and are hence called acalculous. A variety of factors may precipitate an acute attack, such as sepsis, severe trauma, severe burns, and even the postpartum state. Approximately 75 percent of patients with acute cholecystitis are women.

Acute cholecystitis may first come to a medical attention in the emergency room, with the patient complaining of severe, progressive upper-right quadrant pain (biliary colic), which may be associated with nausea, vomiting, and fever and could radiate to the back. Jaundice (yellowish skin) may or may not be present, depending on the degree of obstruction of the gallbladder neck. The attack usually follows a large, fatty meal and can last one to three days. Chronic cholecystitis is usually more insidious in onset and may be relatively asymptomatic; it also may be associated with a vague sensation of indigestion, which eventually progresses to mild, right-upper abdominal distress or long-standing pain.

Diagnosis is usually made with an ultrasound of the abdomen that demonstrates calcified gallstones. Obstruction of the gallbladder neck cannot be visualized, however, and thus requires another imaging test called a hepatobiliary iminodiacetic acid (HIDA) scan. An elevated white blood cell count is also seen in most cases.

Treatment and Therapy

Most acute attacks of cholecystitis may resolve spontaneously, but they should always be considered for surgery, as removal of the gallbladder (cholecystectomy) is the only definitive therapy for the disease. The gallbladder is usually removed using laparoscopic surgery, wherein small incisions are made in the abdomen through which surgical instruments and a fiber-optic camera are passed. In some cases, particularly if the gallbladder is highly inflamed, an open procedure is necessary. In acute attacks, it may also be necessary to maintain adequate nutrition and fluid replacement. A low-fat diet is usually recommended for these patients.

In those patients who decide against surgery, there is a risk of recurrent infections, pain, and even perforation of the gallbladder; the perforation of the gallbladder has a 15 percent mortality rate. Perforation of the gallbladder occurs in less than 3 percent of cases of acute cholescystitis.

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