Etiology, Pathophysiology, and Clinical Manifestations of Cholecystitis
What is Cholecystitis?
Several disorders affect the biliary system and interfere with normal drainage of bile into the duodenum.
Cholecystitis is the acute or chronic inflammation of the gallbladder.
Classification
There are two classifications of cholecystitis:
Calculous cholecystitis. In calculous cholecystitis, a gallbladder stone obstructs bile outflow.
Acalculous cholecystitis. Acalculous cholecystitis describes acute inflammation in the absence of
obstruction by gallstones.
Pathophysiology
Calculous and acalculous cholecystitis have different origins.
Obstruction. Calculous cholecystitis occurs when a gallbladder stone obstructs the bile outflow.
Chemical reaction. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema
occur.
Compression. Blood vessels in the gallbladder compressed, compromising its vascular supply.
Statistics and Incidences
Cholecystitis account for most patients requiring gallbladder surgery.
Although not all occurrences of cholecystitis are related cholelithiasis, more than 90% of patients with
acute cholecystitis have gallstones.
The acute form is most common during middle age.
The chronic form usually occurs among elderly patients.
Causes
The causes of cholecystitis include:
Gallbladder stone. Cholecystitis is usually associated with gallstone impacted in the cystic duct.
Bacteria. Bacteria plays a minor role in cholecystitis; however, secondary infection of bile occurs in
approximately 50% of cases.
Alterations in fluids and electrolytes. Acalculous cholecystitis is speculated to be caused by alterations in
fluids and electrolytes.
Bile stasis. Bile stasis or the lack of gallbladder contraction also play a role in the development of
cholecystitis.
Clinical Manifestations
Cholecystitis causes a series of signs and symptoms:
Pain. Right upper quadrant pain occurs with cholecystitis.
Leukocytosis. An increase in the WBC occurs because of the body’s attempt to ward off pathogens.
Fever. Fever occurs in response to the infection inside the body.
Palpable gallbladder. The gallbladder becomes edematous as infection progresses.
Sepsis. Infection reaches the bloodstream and the body undergoes sepsis.
Complications
Cholecystitis can progress to gallbladder complications, such as:
Empyema. An empyema of the bladder develops if the gallbladder becomes filled with purulent fluid.
Gangrene. Gangrene develops because the tissues do not receive enough oxygen and nourishment at all.
Cholangitis. The infection progresses as it reaches the bile duct.
Assessment and Diagnostic Findings
Studies used in the diagnosis of cholecystitis include:
Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial
diagnostic procedure).
Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of
gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can
be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized
during OCG, or when symptoms persist following cholecystectomy. IVC may also be done preoperatively
to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy,
and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively.
Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the
common bile duct through the duodenum.
Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between
gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of
obstructive jaundice and reveals calculi in ducts.
Cholecystography (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated
in acute cholecystitis because patient is too ill to take the dye by mouth.
Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between
obstructive/nonobstructive jaundice.
Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when
barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate
abnormal gallbladder ejection.
Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases;
calcification of the wall or enlargement of the gallbladder.
Chest x-ray: Rule out respiratory causes of referred pain.
CBC: Moderate leukocytosis (acute).
Serum bilirubin and amylase: Elevated.
Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are
markedly elevated in biliary obstruction.
Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases absorption
of vitamin K.
Ultrasonography. Ultrasound is the preferred initial imaging test for the diagnosis of acute cholecystitis;
scintigraphy is the preferred alternative.
CT scan. CT scan is a secondary imaging test that can identify extra-biliary disorders and acute
complications of cholecystitis.
MRI. Magnetic resonance imaging is also a possible secondary choice for confirming a diagnosis of acute
cholecystitis.
Oral cholecystography. Preferred method of visualizing general appearance and function of the
gallbladder.
Cholecystogram. Cholecystography reveals stones in the biliary system.
Abdominal x-ray. Radiopaque or calcified gallstones present in 10% to 15% of cases.
