Summary

Cholecystitis is an inflammation of the gall bladder that is primarily caused by gall-stones blocking the flow of bile from the gall bladder. However, there can be other reasons too. The condition can be acute or chronic. If diagnosed late or left untreated, it can lead to serious complications including a bursting of the gall-bladder which can be fatal. In this article, we will learn various aspects of the condition so that timely action can be taken by patients.

Introduction to the Hepato-biliary network

The gall-bladder is a small, pear-shaped organ found in the upper right quadrant of the abdomen, and right below the liver. The liver secretes bile which is required for the digestion of fats in the food we consume. The liver sends the bile directly to the common bile duct (CBD) outside the liver, through a smaller pipe called the hepatic duct. The CBD is like the trunk of a tree and has another branch leading into the gall-bladder, called the cystic duct. There is a valve at this junction called the major duodenal papilla, which is closed when the person is not eating or drinking. Because of this closure, some of the bile coming out of the liver (through the hepatic duct) backs up or refluxes into the gall bladder. This way, the gall-bladder becomes a small storage tank for bile produced by the liver.

When the person is eating or drinking, the gall-bladder contracts and the papilla valve opens. Bile flows from the liver and gall-bladder into the CBD. Incidentally, the CBD has one more branch going into the pancreas, called the pancreatic duct. This way, enzymes and hormones produced by the pancreas, as well as bile sent by liver and gall-bladder all converge at a point on the duodenum, which is the early part of the small intestine, and enter the intestine there.

The gall-bladder can develop a condition called gall-bladder stones. Here, small stones made up of either cholesterol or bilirubin start developing inside the gall-bladder. As long as the stones stay inside the gall-bladder, they are harmless. However, due to constant movement of the body and repeated contractions of the gall-bladder while eating or drinking, one or more leave the gall bladder and enter the cystic duct which carries bile out of the gall-bladder into the CBD. There, they can get stuck and block the outflow of bile. This causes cholecystitis. The stone(s) can even slide down and cause blockages anywhere in the CBD, all the way up to the junction on the duodenum.

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Also Read: Types of Gall-bladder Cancer and Treatment

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Causes of Cholecystitis

• Gall-stones: As explained above, gall-bladder stones can block the outflow of bile in the cystic duct and this is the most common cause of cholecystitis.
• Bacterial infection in the bile duct system: A bacterial infection anywhere along the hepato-biliary ducting (or network of ducts connecting liver, gall-bladder and pancreas) can cause cholecystitis in the gall-bladder.
• Tumours in the liver or gall-bladder: Again, a tumour in the liver or gall-bladder can block the outflow of bile from the gall-bladder and hence cholecystitis.
• Reduced blood supply to the gall-bladder: This happens in some diabetics.
• Gall-bladder sludge. Also called biliary sludge, this is a thick paste made of cholesterol crystals, certain calcium salts and calcium bilirubinate pigment. This develops in pregnant women and those who lose weight very quickly. The sludge cannot leave the gall-bladder, and starts accumulating there, causing cholecystitis.
• Infection: HIV (AIDS) and some other viral infections can trigger inflammation in the gall-bladder, and sometimes cholecystitis.
• Severe illness: Severe illnesses including severe fever can damage blood-vessels and reduce blood-flow to the gall-bladder, triggering cholecystitis.
• Trauma or physical injury to the abdomen from surgery, falls and accidents, blunt-force impact, burns and sepsis
• Shock: electric or other forms of shock which can damage blood-vessels and reduce blood-flow to the gall-bladder
• Immune deficiency, or a compromised immune system
• Prolonged or repeated fasting for long durations
• Vasculitis: This is a condition in which the walls of blood-vessels thicken and narrow down the opening inside, which reduces blood-flow. This can happen anywhere in the body and when it happens in the gall-bladder, it can trigger cholecystitis.

Types of Cholecystitis

• Acute (occurs suddenly): As with any acute condition, acute cholecystitis shows strong symptoms such as severe pain in the centre or upper right quadrant of the abdomen. Some people may even experience pain between the shoulder blades. In severe cases, the gall-bladder may develop a deep crack, or even burst, releasing bile into the abdomen, causing a lot of pain. This can be life-threatening and calls for emergency medical attention.
• Chronic (multiple episodes of inflammation spread over time): Such recurring instances of mild swelling, irritation or inflammation of the gall-bladder can damage the wall of the gall-bladder making the wall thicker, the gall-bladder shrunken and loss of its functionality.

Risk Factors

• Heredity: A family history of gallstones increases the risk
• Age: Women over 50 years and men over 60 years are at higher risk
• Diet: Consuming foods high in fat and/or cholesterol
• Obesity or being overweight
• Diabetes mellitus
• Race: Native Americans, Hispanics and Scandinavians, or their descendants, are at higher risk than others
• Pregnancy: A current pregnancy or multiple pregnancies in the past increases the risk
• Contraception: Taking birth-control pills, or oestrogen replacement therapy increases risk
• Rapid weight-loss due to one or more reasons
• Crohn’s disease: A type of inflammatory bowel disease (IBD)
• End-stage kidney disease, or renal failure
• Heart disease
• Hyperlipidaemia or high cholesterol levels in the blood
• Sickle cell disease

Symptoms

• Acute pain in the upper right part of the abdomen
• Pain in the abdomen which goes all the way to the back and below the right shoulder-blade and which gets worse while taking deep breaths
• Nausea and Vomiting
• Loose and light-coloured bowel movements
• Chills and fever above 100.4 F (38 C) in some people
• Poor appetite
• Jaundice (yellowing eyes and skin)
• A bloating sensation in the abdomen
• Tenderness in the abdomen when touched

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Also Read: Gallbladder Problems – Symptoms and Types of Diseases

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Complications

• Emphysematous cholecystitis (infection of the gall-bladder): As bile starts building up in the gall-bladder due to cholecystitis, bacteria that thrive there will multiply and cause this rare, but life-threatening condition. This can lead to pus build-up in the gall-bladder. People who also have diabetes are at more risk.
• Peritonitis: The lining of the abdomen called peritoneum gets infected and inflamed.
• Chronic cholecystitis: If the gall-bladder has not been removed, more and more bouts of cholecystitis will occur, leading to chronic cholecystitis.
• Cholangitis: Cholecystitis causes infection of the main bile-ducts and liver which can have serious consequences including fatality.
• Cholecystoduodenal Fistula: A large gall-stone can push the gall-bladder closer to the duodenum. It can also rupture the outer walls of the gall-bladder and duodenum, creating an abnormal connection between these organs. When this happens, stomach acid can leak into the gall-bladder leading to serious consequences.
• Gall-bladder distention: Cholecystitis causes bile to accumulate in the gall-bladder as mentioned before. It becomes inflamed, swell up and stretch, causing pain. This increases the risk of torn gall-bladder, infection and tissue death.
• Torn gall-bladder. As explained above. The tear or perforation can have serious consequences if not addressed quickly.
• Death of gall-bladder tissue: Cholecystitis that is not treated on time can cause gangrene or death of tissue in the gall-bladder. Gangrene can cause a torn gall-bladder or the gall-bladder to burst.
• Cholestasis: This is rare condition in which the CBD gets blocked, so bile is unable to flow.
• Pancreatitis: As explained earlier, the gall-stone can slide down the CBD and when it blocks the junction of the pancreatic-duct and CBD, it causes a condition called pancreatitis, in which pancreatic juices back-up into the pancreas, leading to inflammation there.

Diagnosis

• Complete blood count (CBC): A high WBC count indicates infection.
• Liver function tests: A series of blood-tests that assess the liver function
• Ultrasound or sonography: Ultrasound of the liver and gall-bladder can reveal blood-flow through different vessels and the presence or absence of cholecystitis.
• Abdominal X-ray
• Abdominal CT scan
• HIDA scan (cholescintigraphy or hepatobiliary scintigraphy): Firstly, a tracer which is a radioactive chemical is injected into the vein. The scanner will monitor the movement of the tracer in the blood-vessels of the liver and gall-bladder. Then, medicine is given to make the gall-bladder contract. The scanner will look for abnormal contractions which can indicate cholecystitis.
• PTC (percutaneous transhepatic cholangiography): A special type of X-ray that uses dye. Blocked bile ducts will show up in the scan, indicating a problem.
• ERCP (endoscopic retrograde cholangiopancreatography): As the name implies, this test uses both an X-ray and an endoscope to capture detailed images of the inside of the bile ducts.

Treatment

• Fasting: By not eating or drinking anything for some time, the inflamed gall-bladder is given some rest.
• IV hydration: Fluids are given through a vein in the arm, to prevent dehydration.
• Antibiotics: This will help fight the infection in the gall-bladder.
• Pain medications: Until the inflammation in the gall-bladder reduces, pain-killers can help reduce the pain.
• ERCP to remove stones: ERCP described earlier can be used to extract the gall-bladder stones that are blocking the ducts, out of the body.
• Cholecystectomy: In this, the gall-bladder is completely removed. The person can live a normal life without a gall-bladder.
• Cholecystostomy: When the above complete removal of gall-bladder is not an option in some patients, then the gall-bladder is drained of all fluid either through the mouth using an endoscope, or through the skin on the abdomen (percutaneous drainage).

 

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