What Is Acute Cholecystitis

Overview

The gallbladder is an organ situated under the liver in the abdomen. The liver produces a digestive juice called bile, which is stored in the gallbladder. It is released into the small intestine for digesting the fat in the food. Acute cholecystitis is a condition of inflammation of the gallbladder. It usually happens when the bile gets trapped in the gallbladder and hardens, causing inflammation and infection. It is a painful condition. The hardened collection of bile material in the gallbladder is known as gallstones.¹ Most commonly, the cause is blockage of the bile duct (tube leading out of the gallbladder) due to gallstones. Other causes are tumours, serious illness and certain infections.

Causes and risk factors

Causes

• Gallstones (Cholelithiasis): Gallstones are the concentrated materials of the bile formed in the gallbladder. Mostly, they don’t cause any problems until they pass into the bile duct. Bile contains cholesterol, bilirubin, bile salts, and lecithin, whereas gallstones are made up of cholesterol and bilirubin, and they turn into stones as they harden. Gallstones grow gradually as bile materials continue to accumulate over time. Smaller gallstones tend to cause more problems as they can pass through the bile duct and cause blockages, whereas the bigger ones don't easily pass through.²
• Blocked bile ducts: Gallstones or any tiny particles can block the bile duct. Scarring of the bile duct can also cause blockage.
• Infection: Certain viral infections or bacterial infections can cause cholecystitis such as Epstein-Barr virus and cytomegalovirus.³
• Tumour: A growth or tumour can lead to blockage as it prevents the gallbladder from draining bile out completely.
• Severe illness: Severe illness can cause damage to the blood vessels, which can lead to a decrease in the supply of blood in the gallbladder (ischaemia).

Risk factors

1. Having a family history of gallstones
2. Following a high-fat diet
3. Obesity
4. Diabetes
5. Losing weight rapidly can lead to an increased risk of gallstones

Symptoms and clinical presentation

• Sudden onset of pain in the upper right side of the abdomen, tenderness while touching.
• Location and radiation of pain: According to the severity, the pain spreads from the abdomen towards the shoulder and the back.
• Nausea and vomiting
• Fever and Chills
• Jaundice: It occurs due to the high level of bile pigment called bilirubin, where the eyes and mucous membrane turn a yellow colour. Bilirubin is the byproduct of red blood cells which gives the yellow colour. Jaundice is a sign of a disease condition affecting the liver, gallbladder or pancreas.⁴
• Murphy's sign: This is seen during the physical examination by the doctor, where the patient is asked to hold their breath and the abdomen is examined. If pain occurs while the doctor is examining, it is a positive Murphy’s sign diagnosis.

Diagnosis

Medical history and physical examination: 

The doctor will ask about the symptoms the patient is experiencing and will enquire whether the patient has any other disease for which they are taking medications. A physical examination of the abdomen will then be done to know the condition of the disease.

Lab tests 

• Liver function: This is a blood test used to measure different enzymes, proteins, and other substances in the liver.
• Complete blood count (CBC): Complete blood count helps in measuring the red blood cells, haemoglobin levels, platelet count, and white blood cell count. An increase in white blood cell count is a sign of infection, inflammation, and abscess.
• Ultrasound: Abdominal ultrasound is used to examine the gallbladder and the bile duct. It shows no sign of inflammation, gallstones or any deformity present.
• Computed tomography (CT scan):  This scan shows detailed images of the liver, gallbladder and bile ducts. It gives clearer and more detailed images than an X-ray.
• Magnetic resonance cholangiopancreatography (MRCP): It is a type of magnetic resonance imaging scan which can see the liver, gallbladder, bile ducts, and structures of the pancreas in more detail. It shows if there are gallstones, inflammation or any blockage in the bile ducts.
• Hepatobiliary nuclear imaging (HIDA scan): A procedure in which a chemical radioactive tracer is injected into the bloodstream. This can then be viewed by a scanning camera to evaluate the liver, bile ducts, and gallbladder. The radioactive tracer gives off energy in the form of gamma rays, which gives a detailed picture of the organs and tissues. It tracks the flow of the bile in the bile duct from the liver to the small intestines, which is known as the biliary system.

Complications

• Gangrene: Cholecystitis is very painful and, without proper treatment, can lead to infections and pus formation. This causes death of the tissues of the gallbladder (necrosis).
• Biliary Pancreatitis: This is when the infection and inflammation affect the pancreas. The bile duct empties the bile from the gallbladder into the intestine through the same opening as the pancreatic duct. When the gallstones enter the bile duct and get stuck, it block the drainage of the pancreatic juice from the pancreatic duct and lead to inflammation.
• Bile duct injury can affect the normal functioning of the liver.
• Cholangitis: Inflammation of the bile duct due to bacterial infection.
• Sepsis: A serious condition in which the body responds improperly and causes poor functioning of the organs.
• Peritonitis: A serious condition occurring in the abdomen, where the peritoneum (tissue layer) of the abdomen becomes inflamed due to infection from bacteria or fungi.

Treatment and Management

1. Fasting: During hospitalisation, the patient may not be allowed to have food or drink; this is to give rest to the gallbladder, and it helps in managing the pain.
2. Intravenous Fluids: Giving fluid through the veins to reduce dehydration.
3. Analgesics: This medication helps in reducing the pain and making the patient comfortable.
4. Antibiotics: Taking antibiotics helps reduce infection and pain.⁵
5. Gallstone removal: Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure where they use a combination of X-rays and an endoscope (flexible tube with camera attached at the end). A dye is injected to view the duct and look for any blockage; they then insert a tiny instrument to break or remove the stones, remove tumours or take samples of them for biopsy. A stent is then placed in the narrowed areas to prevent further blockage.⁶
6. Gallbladder drainage: done to remove the infection in cases where surgical removal of the gallbladder is not an option. This helps in preventing the spread of the infection.⁷
7. Cholecystectomy: A surgical procedure where the gallbladder is removed by a gastroenterologist (the doctor specialises in gastrointestinal diseases). Types of surgical procedures:
   • An open surgical procedure is done by giving the patient general anaesthesia, the surgeon makes a lon incision in the abdomen and the gallbladder is removed. This is rarely required.
   • Laparoscopic surgery is where the gallbladder is removed through a minimally invasive procedure. The surgeon makes a small incision in the right side of the abdomen, through which a laparoscope is inserted with a camera fitted at the end to show the gallbladder. Through another small incision, the gallbladder is removed.⁸

Prevention

• Healthy Diet: Following a proper healthy diet which includes more fruits, vegetables and low-fat foods. 
• Gradual Weight Loss: Rapid weight loss can increase the risk of gallstones, so it is advised to lose weight slowly. 
• Exercise: Regular exercise helps in maintaining proper weight and reduces the cholesterol in the body.
• Regular check-ups and monitoring help find any risk factors early on and treat them effectively.
• Maintaining an ideal weight by having a balanced diet and regular exercise. Obesity may lead to the formation of gallstones.

FAQs

Is acute cholecystitis an emergency?

Commonly, people with cholecystitis have gallstones and the pain comes and goes while eating or after having food. In the case of persistent severe pain, it is considered a medical emergency.

What is the main cause of acute cholecystitis?

Gallstones are the most common cause of cholecystitis. Gallstones are the hardened bile material formed in the gallbladder. This can cause blockage in the bile duct and cause cholecystitis.

Can I live without my gallbladder?

Yes, we can live without a gallbladder since the main function of the gallbladder is to just store the bile. Bile is produced by the liver and will continue to be without the gallbladder. 

When should I consult a doctor?

When there is persistent abdominal pain or if symptoms of cholecystitis come back after treatment, it is advised to consult the doctor as soon as possible.

Summary

Acute cholecystitis is a condition of inflammation of the gallbladder. It usually happens when bile gets trapped in the gallbladder, causing inflammation and infection. The hardened collection of bile materials in the gallbladder is known as gallstones. Most commonly, the cause is blockage of the bile duct (tube leading out of the gallbladder) due to gallstones, and it can lead to inflammation. Other causes are tumours, serious illness and certain infections. Surgical removal of the gallbladder is the most commonly recommended treatment.