Understanding cholecystitis and cholangitis

Gallstones are not new; they have been causing havoc as far back as 3500 years ago, and today, they are still leaving their mark. They are the most common gastrointestinal tract disorders, affecting about 10% of Western society.^1,4 Gallstones can cause numerous conditions, such as:⁸ 

• Pancreatitis
• Gall bladder cancer
• Cholecystitis
• Cholangitis
• Infection
• Jaundice 

Out of all these, two conditions are very similar—their similarities can be found everywhere, from definitions to causes to their development. Although similarities run deep, like fraternal twins, they can also be differentiated through the use of key elements that make one different from another. 

Cholangitis and cholecystitis are both inflammatory conditions associated with the biliary system, and gallstones are one of their many similarities.^1,3 While the general outcome of cholecystitis has improved over the past 20 years because of improvements in ultrasonography and hepatobiliary scanning, cholangitis still remains life-threatening, given the right environment.^2,5

Overview of cholecystitis and cholangitis 

What are cholecystitis and cholangitis?

Cholecystitis is an inflammatory condition of the gallbladder, in which gallstones are usually the culprit. This is because gallstones obstruct the cystic ducts, leading to the onset of inflammation.¹ Cholangitis is an infection of the biliary ductal system.³ It was first discovered in 1877 by Charcot JM, and it presented with a triad of fever, jaundice, and right upper quadrant pain.³    

What causes cholecystitis and cholangitis?

Cholecystitis and cholangitis are conditions that are primarily caused by biliary obstructions.^4,5 This obstruction in both conditions could be due to:^1,3,4,5,7 

• Malignancies 
• Bacteria such as Escherichia coli, Klebsiella, and Streptococcus faecalis
• Biliary sludge 

There are other causes of cholangitis and cholecystitis. However, when cholecystitis occurs without gallstones, it presents as a life-threatening condition called acalculous cholecystitis.⁴ Other causes of cholecystitis and cholangitis include:^4,5

Risk factors of cholecystitis and cholangitis 

Certain risk factors can make an individual vulnerable to these biliary conditions. These risk factors include.^1,5,6

How do cholecystitis and cholangitis develop?

Although cholecystitis and cholangitis share a similar pathophysiology of obstructed biliary obstruction, there are some distinct differences in how they develop. These differences include:^1,5

What are the symptoms of cholecystitis and cholangitis?

Another distinction between cholecystitis and cholangitis is in their symptoms. These symptoms include:^{1, 2,4,5} 

How are they diagnosed?

Cholecystitis is diagnosed in two ways. The first involves using a triangle of symptoms and signs of inflammation found in peritonitis localised in the right upper quadrant of the patient.¹ These three symptoms have to be present to make a diagnosis of cholecystitis. They include:¹

• Constant pain in the right upper quadrant for more than 12 hours 
• Tenderness in the right upper quadrant with or without the presence of the Murphy sign or a palpable mass
• Inflammatory responses such as fever, above-normal white blood cell count, erythrocyte sedimentation rate, and C-reactive proteins 

The second way to diagnose cholecystitis is through transabdominal imaging. However, it is mostly used to diagnose chronic cholecystitis.⁴

Cholangitis, on the other hand, is diagnosed based on the following criteria:⁵

• Clinical features: Cholangitis is suspected in patients presenting with the Charcot triad and Reynold's pentad 
• Laboratory results: Elevated white blood cell count, that is, leukocytes <4 or >10 G/L, and a CRP of 10 mg/L 
• Imaging studies: Biliary dilatation and imaginary proof of the cause through magnetic resonance cholangiopancreatography, ultrasound, and computed tomography
• Blood culture

Diagnosis is definite when there is a presence of systemic inflammation, that is, fever with or without corresponding laboratory values, along with the presence of cholestasis and imaging studies showing biliary dilatation or evidence of cause.⁵ 

How can they be treated?

When looking at the management of cholecystitis, there are two ways it can be treated. It involves doing the surgical procedure at the onset or delaying it until later.⁴ There are:⁴ 

• Early cholecystectomy (EC): It involves performing a cholecystectomy during the initial hospital admission to prevent relapses and long hospital stays. 
• Delayed cholecystectomy (DC): The patient is given antibiotics during their initial stay, and a procedure called cholecystectomy is done in 4–8 weeks. It provides a field with less inflammation, leading to fewer complications, and there will be no need to conduct an open procedure.

On the other hand, when managing cholangitis, a different course of action is taken. These actions include:⁵

• Antimicrobial treatment: It can be treated with a penicillin/b-lactamase inhibitor, third-generation cephalosporin, or carbapenem. 
• Biliary drainage: This is done for moderate and severe cholangitis; however, if mild cholangitis doesn't respond to treatment, then biliary drainage is done. Billary drainage is done with the aid of endoscopic retrograde cholangiopancreatography within 24-28 hours of the onset of cholangitis. This reduces the risk of organ failure, mortality, and hospital stays. Other procedures for biliary drainage are endoscopic nasobiliary drainage and percutaneous transhepatic cholangiography.
• Surgery: Open drainage surgery is only considered if endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and endoscopic nasobiliary drainage do not work or are contraindicated.

What are the complications of cholecystitis and cholangitis?

Some complications of cholecystitis and cholangitis include:^{1 4 5} 

How do I prevent cholangitis and cholecystitis?

The following measures can be taken to reduce the risk of developing cholecystitis and cholangitis:

• Management of gallstones 
• Regular exercises 
• Regular checkups for those with biliary conditions.
• Avoid a rapid loss of weight 
• Regular checkups for those over the age of 60 
• Balanced diet: Avoid high-fat diets 

Summary

Cholangitis and cholecystitis are biliary conditions that are a product of biliary obstruction—however, while cholecystitis affects the neck of the gallbladder, cholangitis affects the biliary ducts. Although both conditions can be caused by malignancies, biliary obstructions, and parasites, they differ in some symptoms. 

Cholangitis presents with symptoms like the Charcot triad and Reynold's pentad, while cholecystitis presents with nausea, vomiting, and anorexia, to name a few. Another distinction would be in the way they develop. Where cholecystitis blockages cause an inflammatory response, cholangitis blockages cause bacteria to reflux, which infects the bile.  

Cholecystitis's main diagnosis is based on the presence of all three symptoms: 

• Constant pain in the right upper quadrant for more than 12 hours 
• Tenderness in the right upper quadrant with or without Murphy's sign or palpable mass
• Inflammatory responses 

Cholangitis diagnosis involves imaging studies, blood cultures, laboratory results, and clinical features.

Cholecystitis is treated with surgery; however, in cholangitis, surgery is the last resort. Other interventions, like antimicrobial treatment and bladder drainage, are done first. The complications of this condition are numerous, especially for cholangitis. Therefore, preventive measures should be taken.