Understanding Cholecystitis And Choledocholithiasis

Overview

Feeling discomfort after fatty meals? It could be gallstones. This article explores cholecystitis (gallbladder inflammation) and choledocholithiasis (gallstones in bile ducts). Both cause pain and may require medical attention. We'll explain how your gallbladder and bile ducts work, how gallstones form trouble, symptoms to watch for, and treatment options.

The gallbladder and bile ducts

The gallbladder and bile ducts collaborate to facilitate fat digestion in the small intestine. Bile, a liver-produced fluid containing cholesterol and bilirubin, is stored and concentrated by the gallbladder during fasting periods. Upon eating, a network of bile ducts transports the concentrated bile to the small intestine. However, gallstones, hardened deposits within the gallbladder, can disrupt this process. Blockage of the cystic duct by gallstones prevents bile release, leading to cholecystitis (inflammation). Additionally, gallstones migrating to the common bile duct can obstruct bile flow from the liver and gallbladder. This blockage can manifest as intensified pain, jaundice due to accumulated bilirubin, and even pancreatitis if the pancreatic duct is compromised. Understanding this interplay between the gallbladder, bile ducts, and gallstone formation is crucial for recognising potential complications and seeking timely medical attention.^{1, 2}

Cholecystitis

What is cholecystitis?

Cholecystitis refers to the inflammation of the gallbladder, a pear-shaped sac located beneath the liver. This organ stores bile, a digestive fluid produced by the liver, and releases it into the small intestine to aid in fat digestion. Inflammation can arise from either infection or obstruction within the gallbladder or its connecting bile ducts.³

Causes and prevalence 

Causes

Cholecystitis can arise from blockages by gallstones (calculous cholecystitis) or other factors (acalculous cholecystitis).^4,5

Calculous cholecystitis (Gallstone-related)

• This is the most frequent type, affecting around 10% of people with symptomatic gallstones over a decade
• Gallstones obstruct the cystic duct, increasing pressure and triggering inflammation in the gallbladder wall
• Secondary bacterial infections with E. coli and others can occur
• Risk factors include:
  • Individual factors: obesity, rapid weight loss, female sex, certain ethnicities
  • Medical conditions: diabetes, pregnancy, gastrectomy, use of specific medications
  • In children: congenital disorders like hemolytic anaemia or cystic fibrosis

Acalculous cholecystitis (Non-gallstone related)

• This type has a multifactorial cause, often involving:
  • Stasis (stagnation of bile) and ischemia (reduced blood flow) in the gallbladder wall
  • Subsequent local inflammatory response

• Risk factors include:
  • Critical illness: sepsis, hypotension, cardiovascular disease
  • Other medical conditions: total parenteral nutrition, immunosuppression, major trauma, burns
  • Infections: opportunistic pathogens in AIDS or immunosuppressed patients
  • Blockages: cystic duct obstruction due to cancer, inflammation, or lymph node issues

• Most frequent form in children: risk factors here differ:
  • Infectious diseases (EBV, hepatitis A), parasitosis
  • Systemic vasculitis (Kawasaki disease)
  • Congenital malformations of the gallbladder or biliary tract

• Childhood obesity: increasing prevalence is leading to more cholesterol gallstones and potential acalculous acute cholecystitis

Prevalence⁵

• Around 95% of cholecystitis cases involve gallstones
• Not all gallstones cause symptoms. Only about 20% of people with gallstones develop symptoms within 20 years 

Symptoms and signs

Cholecystitis can present in two main forms: chronic and acute. While the underlying cause is the same (usually gallstones), the way it manifests differs.^3,4,5

Acute cholecystitis

Symptoms appear suddenly and are more severe:

1. Main symptom: right upper abdominal pain, intense in the upper right belly area.
2. Accompanying symptoms: fever, nausea, and vomiting may occur alongside the pain.

Physical examination signs (for both chronic and acute):

1. Murphy sign: involuntary pausing of inhalation when pressure is applied to the right upper quadrant during palpation (highly suggestive)
2. Right upper quadrant tenderness/pain: detected during a physical exam
3. Palpable mass: a mass might be detectable in the upper right abdomen (in some cases)

Chronic cholecystitis

Symptoms develop gradually over time.

1. Main symptom: persistent upper right abdominal pain, may worsen progressively.
2. Accompanying symptoms: bloating, especially after eating
3. Food intolerance: sensitivity to greasy/spicy foods causing increased gas, nausea, and vomiting
4. Pain in other areas: discomfort radiating to the mid back or shoulder blade 

Treatment

The primary goal of cholecystitis treatment is to address the inflamed gallbladder. 

Your doctor will consider the severity of cholecystitis, your overall health, and potential risks. ^4,5

• Antibiotics:
  • The cornerstone of treatment fighting bacterial infection
  • Broad-spectrum antibiotics are chosen considering allergies, kidney/liver function, and local resistance patterns

• Surgery (Cholecystectomy - removing the gallbladder):
  • Laparoscopic cholecystectomy (ELC) - preferred:
    • Minimally invasive with faster recovery and lower complication rates
    • Involves small abdominal incisions to remove the gallbladder
  • Open cholecystectomy (Alternative):
    • Larger incision for access in patients not suitable for laparoscopy

• Gallbladder Drainage (GBD - temporary solution): 
  • For high-risk patients or not surgical candidates:
    • Percutaneous Transhepatic GBD (Preferred): a drainage tube is inserted through the skin to drain the gallbladder
    • Endoscopic Ultrasound-Guided GBD (EUS-GBD): an alternative for high-risk patients
    • ERCP with Transpapillary Stent: option for patients needing ERCP for bile duct stones
  • GBD is often followed by definitive surgery when the patient's condition stabilizes

• Dietary management and medications:
  • Diet: a low-fat, low-spice diet may be attempted for some mild chronic cases with poor surgical candidacy, but effectiveness varies
  • Medications: they have limited success in dissolving gallstones (e.g., ursodiol)

Choledocholithiasis

What is choledocholithiasis?

Choledocholithiasis, meaning "common bile duct stones," occurs when gallstones, formed in the gallbladder, migrate and block the common bile duct (tube carrying bile to the intestine). Affecting 1-15% of those with gallstones, it's treated with ERCP, a procedure to remove the stones, often followed by laparoscopic gallbladder removal.⁶

Causes

Choledocholithiasis has two main causes for gallstones blocking the common bile duct:^6,7

1. Migrating Gallstones: most commonly, gallstones that form in the gallbladder dislodge and travel down the bile duct, getting stuck in the common bile duct due to their size.
2. Direct Formation: less frequently, stones can develop directly within the common bile duct itself. This is called primary common bile duct stones. 

Symptoms

Choledocholithiasis, referring to gallstones in the common bile duct, can present with a variety of symptoms and signs. ^6,8

1. Pain:
   • The most frequent symptom is pain in the upper right abdomen 
   • This pain is often described as colicky, meaning it comes and goes in waves and can be quite intense

2. Jaundice:
   • This occurs when the bile duct obstruction leads to a buildup of bilirubin, causing a yellowing of the skin and whites of the eyes

3. Other digestive symptoms:
   • You might experience nausea and vomiting
   • Stools may become clay-coloured, and urine may appear dark

4. Additional signs (may not be present in all cases):
   • Fever: this can indicate an infection along with the blockage
   • Itching (pruritus): this can be a bothersome symptom due to bile salts accumulating in the bloodstream

Treatment

Choledocholithiasis treatment focuses on removing the blocking gallstones:^6,8

1. Endoscopic retrograde cholangiopancreatography (ERCP): a procedure where a scope is inserted through the mouth and digestive system to reach the bile duct. During ERCP, a doctor can:
   1. Cut the opening of the common bile duct (sphincterotomy) to allow easier stone removal
   2. Use specialized tools to grasp and remove stones
   3. Place a stent (small tube) to keep the duct open for drainage
2. Surgery (if ERCP fails or is not suitable):
   1. Laparoscopic common bile duct exploration: minimally invasive surgery to remove stones through small abdominal incisions
   2. Open common bile duct exploration: traditional surgery with a larger incision for stone removal
3. Other options:
   1. Cholecystectomy: usually recommended after stone removal to prevent future issues 
   2. Medications: not a cure, but antibiotics might be used for infection and pain relievers for discomfort

Seek medical care

If you're experiencing upper right abdominal pain, nausea, vomiting, indigestion, fever, chills, or jaundice (yellowing of skin and eyes), don't hesitate to seek medical attention. Early diagnosis and treatment are crucial. Contact your doctor or go to the closest emergency department if the pain is severe.

FAQs

Can I have gallstones without any symptoms?

Yes, sometimes gallstones don't cause any noticeable problems. 

What are the potential complications of cholecystitis and choledocholithiasis?

Untreated complications can include pancreatitis, infection spread, and liver damage.

How long does it take to recover from gallstone surgery?

Laparoscopic surgery typically has a quicker recovery benefit, often within a week or two.

Will I need to change my diet after gallbladder removal?

Most people can tolerate a normal diet after recovery, but some may need to adjust fat intake to avoid discomfort. 

Are there any medications that can dissolve gallstones?

In some cases, medication might dissolve small gallstones, but surgery is usually the preferred treatment.

Summary

Gallstones, although small, can cause big problems. They can inflame your gallbladder (cholecystitis), leading to right upper abdominal pain after eating. Even more serious, they can block a bile duct (choledocholithiasis), causing jaundice and other complications. Don't wait for severe symptoms - if you experience any discomfort, especially after fatty meals, see your doctor to discuss potential gallbladder or bile duct issues. Early diagnosis and treatment are key to a healthy digestive system.