Cholecystitis

In this episode, we discuss both acute and chronic forms of cholecystitis, highlighting common complications. We also cover challenges before and after gallbladder surgery.

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Transcript

Welcome back to the AudioBoards, today, we’re discussing cholecystitis.

First we’ll dive into Acute cholecystitis, what causes it, how it presents, and how it's managed.

Acute cholecystitis is primarily caused by obstruction of the cystic duct, leading to inflammation of the gallbladder. In most cases, this is associated with gallstones . However, it can also be triggered by infections like cytomegalovirus , cryptosporidiosis , and microsporidiosis , especially in patients with AIDS . Additionally, conditions like vasculitis —such as polyarteritis nodosa and Henoch-Schönlein purpura , or medications like GLP-1 receptor agonists —can also contribute.

In some cases, acalculous cholecystitis , which occurs without gallstones, may develop, particularly in patients who have undergone major surgery , or are critically ill .

So, what does an acute attack of cholecystitis actually look like?

A typical attack often begins after a fatty meal and is characterized by sudden, steady pain in the epigastrium or right hypochondrium . There’s often tenderness over the right upper quadrant of the abdomen, and if you’re checking for a Murphy’s sign , you’ll see pain and an inhibition of inspiration when the area is palpated.

Other signs include muscle guarding and rebound tenderness. In some cases, a palpable gallbladder might be found. If jaundice occurs and persists, it could point to choledocholithiasis. Along with this, vomiting and fever are common, and lab results typically show an elevated white blood cell count along with elevated levels of bilirubin, aminotransferase, and alkaline phosphatase.

How do we confirm the diagnosis? Let’s talk about some of the tests used.

On plain abdominal films, you might see radiopaque gallstones. Ultrasonography of the right upper quadrant is the most common first test, though it’s not the most sensitive for diagnosing acute cholecystitis. What it can show, though, is gallbladder wall thickening , pericholecystic fluid , and a sonographic Murphy sign , all of which are suggestive of the condition.

For a more specific diagnosis, a HIDA scan , or technetium-99-m h epatobiliary imaging , can demonstrate an obstructed cystic duct. To improve the test’s accuracy, sometimes morphine is administered intravenously to induce spasms of the sphincter of Oddi .

If there’s concern for complications such as perforation or gangrene , advanced imaging like CT or MRI may be necessary.

But of course, we must also consider other possible conditions that could mimic acute cholecystitis.

In the differential diagnosis, we have perforated peptic ulcer , acute pancreatitis , appendicitis —especially if the appendix is high-lying— liver abscess , hepatitis , or even conditions like pneumonia with pleurisy on the right side. Myocardial ischemia can also present with similar symptoms.

Now, let’s talk about the complications and how we manage acute cholecystitis.

If left untreated, one serious complication is gangrene of the gallbladder , which can occur due to ischemia from splanchnic vasoconstriction and intravascular coagulation . This can lead to perforation , which may form a pericholecystic abscess , and rarely, can cause generalized peritonitis . Other severe complications include necrosis , emphysematous cholecystitis , and empyema .

In most cases, acute cholecystitis can be managed conservatively. This includes withholding oral feedings , providing intravenous fluids , and administering analgesics for pain relief. Antibiotics , like cephalosporins and metronidazole , are commonly given to cover both aerobic and anaerobic bacteria. For pain relief, morphine or meperidine is often used.

Since there’s a high risk of recurrent attacks, laparoscopic cholecystectomy is typically performed within 24 hours of admission . If surgery is not immediately possible, particularly in older patients or those with diabetes , careful monitoring is crucial. Some high-risk patients might benefit from ultrasound-guided aspiration , percutaneous cholecystostomy , or even ERCP to drain the gallbladder.

In cases of gangrene or perforation , immediate cholecystectomy is mandatory.

Now, let's explore two important concepts related to gallbladder surgery— Pre and Post-cholecystectomy syndromes .

Pre-Cholecystectomy Syndrome:

In some patients with biliary pain , traditional imaging like X-rays or ultrasounds might not show any obvious issues. However, gallbladder scintigraphy shows a markedly reduced emptying of the gallbladder after a test dose of cholecystokinin , then a cholecystectomy can actually cure the pain.

Another possible diagnosis to consider in these patients is sphincter of Oddi dysfunction , where the muscle controlling the flow of bile and pancreatic juice doesn’t work properly, causing pain.

Post-Cholecystectomy Syndromes

After gallbladder removal, some patients continue to experience biliary pain . It might suggest that the diagnosis was wrong before surgery—perhaps the pain was actually due to other conditions like esophagitis , pancreatitis , radiculopathy , or even functional bowel disease .

After surgery, other potential causes of pain should be considered, such as choledocholithiasis , bile duct strictures , or issues like dilatation of the cystic duct remnant or neuroma formation in the duct walls.

If a patient has right upper quadrant pain , along with chills , fever , or jaundice , that’s a red flag for possible biliary tract disease , and further tests are needed. Endoscopic ultrasound is usually the go-to method to look for stones or strictures .

In some cases, biliary pain can also happen with elevated liver enzymes or a dilated bile duct . If that's the case, it could point to a sphincter of Oddi dysfunction . A test called biliary manometry measures the pressures in the sphincter to help confirm the diagnosis.

So, how do we treat these post-surgery issues?

There are a few treatment options. Endoscopic sphincterotomy is often the most effective for patients with sphincter dysfunction or stenosis, though some patients may still have lingering pain. Medications, like calcium channel blockers , nitrates , or even antidepressants like duloxetine , may help reduce symptoms. In some cases, botulinum toxin injections into the sphincter may also be an option.

For more severe cases that don’t respond to medication, more invasive treatments like surgical sphincteroplasty or even removal of the cystic duct remnant may be necessary.

Now, let’s take a look at chronic cholecystitis , a condition that develops after repeated episodes of acute cholecystitis or from ongoing irritation of the gallbladder wall, often due to gallstones . In some cases, this leads to changes in the gallbladder itself, where the wall thickens or even hyperplasia can make the gallbladder wall appear like a benign tumor, a condition known as adenomyomatosis. Another complication that can arise from chronic cholecystitis is Mirizzi syndrome , which happens when a stone in the neck of the gallbladder compresses the common hepatic duct , leading to jaundice . There’s also a rare and aggressive form called xanthogranulomatous cholecystitis . This variant is characterized by grayish-yellow nodules or streaks on the gallbladder wall, caused by lipid-laden macrophages . It can present with acute jaundice and is considered a serious condition.

So, what are some of the complications that can arise from chronic cholecystitis ?

In some cases, chronic cholecystitis can lead to acute flare-ups of gallbladder inflammation, and even cause other issues like bile duct stones , fistulization to the bowel , or even pancreatitis .

One specific finding associated with chronic cholecystitis is a calcified gallbladder , also known as a porcelain gallbladder . This condition is concerning because it’s linked to an increased risk of gallbladder carcinoma . If you see this on imaging, cholecystectomy is strongly recommended. Interestingly, the risk of gallbladder cancer is higher when the calcification is mucosal rather than intramural .

That’s all for today’s episode. Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode!

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