Discover the causes, symptoms, and treatment options for acute cholecystitis, a condition that causes severe abdominal pain. Get expert guidance on managing this condition at Meri Sehat.

Acute Cholecystitis

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Ismail Munir

Overview

Acute cholecystitis is characterized by a sudden inflammation of the gallbladder. 
The gallbladder plays an important role in digestion by storing and releasing bile, a fluid produced by the liver that helps break down fats in the small intestine. Gallstones can often block the flow of bile from the gallbladder, resulting in acute cholecystitis. 
&nbsp;

This is called calculous acute cholecystitis. However, infections, tumors, and bile duct problems can also result in inflammation, causing acalculous cholecystitis.

Approximately 80% of gallstones are asymptomatic but tend to cause symptoms when they block the flow of bile<a href="#accordion">[5]</a>. Women have a 2-3 times higher incidence of gallstones than men<a href="#accordion">[2]</a>. Therefore, the incidence of calculous acute cholecystitis is also greater in women<a href="#accordion">[2]</a>. However, acalculous cholecystitis is more frequent in elderly men<a href="#accordion">[2]</a>.

The prevalence of gallstones, a major risk factor of cholecystitis, also varies by race and gender. Western countries have a higher prevalence rate (10-15%), while Asian communities report a prevalence of 3-4%<a href="#accordion">[10]</a>. In Pakistan, gallstones affect 8-20% of patients over the age of 40 and 60 years<a href="#accordion">[10]</a>.

If left untreated, acute cholecystitis can lead to severe, life-threatening complications, such as perforation of the gallbladder. Moreover, persistent acute cholecystitis can develop into chronic cholecystitis.

Surgical removal of the gallbladder, also called cholecystectomy, is often the preferred treatment option. It is the most commonly performed major surgery by general surgeons, accounting for 500,000 operations annually<a href="#accordion">[2]</a>&nbsp;. 
&nbsp;

Acute cholecystitis can be classified based on its causes<a href="#accordion">[1]</a>: 
&nbsp;

Calculous Cholecystitis: This type of cholecystitis occurs when a gallstone blocks the cystic duct, causing inflammation and swelling of the gallbladder. This is the most common type of acute cholecystitis. 
&nbsp;

Acalculous Cholecystitis: This type of cholecystitis is less common and occurs when there are no gallstones present in the gallbladder. It is usually seen in critically ill patients, such as those hospitalized for a long time or who have had major surgery. Acalculous cholecystitis may also occur as a result of infection, trauma, or certain medications. 
&nbsp;

Signs and Symptoms

The gallbladder is responsible for storing bile and releasing it into the small intestine for the digestion of fat. Bile is produced by the liver which connects to the gallbladder with the help of the cystic duct. The cystic duct then forms the common bile duct which directs the bile to the duodenum. A valve present at the common bile duct and duodenum connection is usually closed when the person is not eating. During mealtime, the gallbladder contracts and the valve opens, allowing stored bile to be released into the intestine. However, gallstones or sludge in the gallbladder can obstruct the flow of bile, leading to cholecystitis<a href="#accordion">[1]</a>.

Severe upper abdominal pain is the most common presenting symptom of acute cholecystitis. It typically begins in the epigastric region before localizing to the right upper quadrant of the abdomen. The pain may also radiate to the right shoulder or scapula.

In some cases, patients may present with a &lsquo;colicky&rsquo; pain. This is due to temporary obstruction by the gallstones. If the pain does not resolve within 6 hours, the diagnosis is changed from biliary colic to acute calculous cholecystitis. 
&nbsp;

Other common signs and symptoms of acute cholecystitis include:

<ul>
	<li>Nausea and vomiting.</li>
	<li>Fever and chills.</li>
	<li>Yellowing of the skin and whites of the eyes (<a href="https://merisehat.pk/disease/jaundice-65">jaundice</a>).</li>
	<li>Loss of appetite and weight loss.</li>
	<li>Tenderness and swelling in the abdomen.</li>
	<li>Bloating and indigestion.</li>
	<li>Itching</li>
</ul>

These symptoms can vary in severity and may come and go, but they generally worsen over time. Moreover, they worsen after eating 
&nbsp;

Note: If you experience any of these symptoms, it is important to seek medical attention immediately, as untreated acute cholecystitis can lead to serious complications, such as a ruptured gallbladder or infection 
&nbsp;

Causes

The most common cause of acute cholecystitis is the blockage of the cystic duct by a gallstone. However, other factors may contribute to the development of acute cholecystitis, including: 
&nbsp;

Bile Duct Blockage: A blockage in the bile duct can cause the bile to back up into the gallbladder, leading to inflammation and infection.

Infection: Infection of the gallbladder can lead to acute cholecystitis.

Tumor: A tumor in the gallbladder or bile ducts can cause a blockage, leading to acute cholecystitis.

Trauma: Trauma to the gallbladder or bile ducts can cause acute cholecystitis.

Certain Medications: Certain medications can cause inflammation of the gallbladder, leading to acute cholecystitis.

Genetic Factors: Certain genetic factors can increase the risk of developing gallstones, which can lead to acute cholecystitis. 
&nbsp;

Diagnosis

There are no screening guidelines for acute cholecystitis. A history and physical examination typically direct doctors to evaluate the patient for the condition. 
&nbsp;

The following workup helps diagnose acute cholecystitis:

<h5>Physical Exam</h5>

During a physical exam, the doctor may palpate the area over the gallbladder to check for tenderness or pain. 
&nbsp;

<h5>Blood Work</h5>

The following laboratory tests can help diagnose acute cholecystitis:

<ul>
	<li>Amylase And Lipase - Elevated levels typically indicate acute pancreatitis but may also point to acute cholecystitis.</li>
	<li>Bilirubin - Common bile duct obstruction can cause elevated levels of bilirubin and alkaline phosphatase (ALP).</li>
	<li>Complete Blood Count (CBC) - An increased white blood cell count may be present.</li>
	<li>Liver Function Tests - Elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) help evaluate for hepatitis and acute cholecystitis.</li>
	<li>Pregnancy Testing -&nbsp;Is advised for all women of childbearing age. 
	&nbsp;</li>
</ul>

<h5>Imaging Tests</h5>

These are a few diagnostic imaging tests to rule out the condition: 
&nbsp;

<ul>
	<li>Ultrasound: An ultrasound can be used to visualize the gallbladder and check for the presence of gallstones or inflammation. It is the preferred diagnostic imaging test for acute cholecystitis.</li>
	<li>CT Scan: A CT scan may be used to get a detailed picture of the gallbladder and surrounding structures. It is preferred in cases of complicated cholecystitis, or when ultrasound is unable to provide a clear diagnosis.</li>
	<li>HIDA Scan: A HIDA (hepatobiliary iminodiacetic acid) scan is a nuclear medicine test that can evaluate for blockage of the gallbladder and bile ducts. It can also measure the ejection fraction of the gallbladder; normal levels are above 30-35%.</li>
	<li>Endoscopic Retrograde Cholangiopancreatography (ERCP): An endoscope is used to visualize the bile ducts and remove any gallstones causing a blockage. 
	&nbsp;</li>
</ul>

Treatment

Treatment for acute cholecystitis typically involves a combination of medical and surgical interventions. The goals of treatment are to relieve symptoms, prevent complications, and prevent the recurrence of the condition: 
&nbsp;

<ul>
	<li>
	<h5>Initial Intervention</h5>
	</li>
</ul>

NPO (nothing by mouth) And IV Fluids: The patient is advised to refrain from eating or drinking anything by mouth until the symptoms have improved. Instead, they are administered fluids through an IV to prevent any dehydration. 
&nbsp;

Pain Management: Acute cholecystitis is typically associated with severe abdominal pain, so pain management is an important aspect of treatment. Over-the-counter pain relievers such as acetaminophen or ibuprofen can help to alleviate mild to moderate pain. Stronger prescription pain medications may be necessary for more severe pain. 
&nbsp;

Antibiotics: Antibiotics are typically prescribed to treat the infection associated with acute cholecystitis. The choice of antibiotic will depend on the severity of the infection, the patient&#39;s age and medical history, and any allergies they may have. 
&nbsp;

<ul>
	<li>
	<h5>Surgery</h5>
	</li>
</ul>

Cholecystectomy: The most effective treatment for acute cholecystitis is the surgical removal of the gallbladder, known as a cholecystectomy. This may be done as an emergency procedure if the patient is in severe pain or if there are signs of complications, such as perforation of the gallbladder or gangrene. In some cases, laparoscopic cholecystectomy can be performed, which is less invasive and has a shorter recovery time than open surgery. 
&nbsp;

Endoscopic Retrograde Cholangiopancreatography (ERCP): This procedure may be performed if there is evidence of gallstones in the bile ducts. During an ERCP, a small camera is inserted into the stomach, and instruments are used to remove the stones. 
&nbsp;

Percutaneous Cholecystostomy: In some cases, a percutaneous cholecystostomy may be performed by passing an endoscope, as a temporary measure to drain fluid from the gallbladder and relieve symptoms. 
&nbsp;

Note: It&#39;s important to note that acute cholecystitis is a medical emergency that requires prompt treatment. If you experience severe abdominal pain, fever, or jaundice, seek medical attention immediately. 
&nbsp;

<ul>
	<li>
	<h5>Lifestyle Modification</h5>
	</li>
</ul>

Dietary Changes: Following a low-fat diet can help reduce the workload of the gallbladder and prevent further inflammation. Avoiding fatty and fried foods, as well as spicy foods and alcohol, can be helpful. Eating smaller, more frequent meals throughout the day can also help. 
&nbsp;

Exercise: Regular exercise can help reduce inflammation and promote healthy digestion. It is best to aim for at least 30 minutes of moderate exercises such as brisk walking, each day. 
&nbsp;

Weight Management: Maintaining a healthy weight can help prevent gallstones from forming and reduce the risk of complications from acute cholecystitis. A healthcare provider should be referred to for effective weight loss strategies. 
&nbsp;

Hydration: Drinking plenty of water can help flush toxins from the body and prevent gallstones from forming. 
&nbsp;

Acute cholecystitis can lead to several complications if left untreated, including<a href="#accordion">[3]</a>&nbsp;: 
&nbsp;

Empyema: A collection of pus within the gallbladder.

Gangrene: Death of the gallbladder tissue due to lack of blood supply.

Perforation: Rupture of the gallbladder, which can cause infection and inflammation of the surrounding organs.

Biliary Sepsis: A severe infection that can spread to other parts of the body, potentially leading to septic shock.

Obstructive Jaundice: A buildup of bilirubin in the blood due to the blockage of the bile ducts, causing yellowing of the skin and eyes.

Pancreatitis: Inflammation of the pancreas, which can occur due to the spread of infection or inflammation from the gallbladder.

Gallstone Ileus: A rare complication of cholelithiasis, occurring in less than 0.5 % of patients with mechanical small bowel obstruction. 
&nbsp;

Some of the risk factors associated with acute cholecystitis include: 
&nbsp;

<a href="https://merisehat.pk/disease/gall-stones-gall-stones-ileus-55">Gallstones</a>: The most common cause of acute cholecystitis is the presence of gallstones. These stones can block the cystic duct, which leads to the inflammation of the gallbladder. 
&nbsp;

Age: Acute cholecystitis is more common in older adults, particularly those over the age of 60. 
&nbsp;

Gender: Women are more prone to develop acute cholecystitis during pregnancy, due to higher levels of estrogen that can lead to the formation of gallstones. 
&nbsp;

<a href="https://merisehat.pk/disease/obesity">Obesity</a>: Being overweight or obese increases the risk of developing gallstones and subsequent acute cholecystitis. 
&nbsp;

Family History: There may be a genetic component to the development of gallstones and acute cholecystitis, making it more likely for those with a family history of these conditions to develop them. 
&nbsp;

<a href="https://merisehat.pk/disease/diabetes-type-1-and-2">Diabetes</a>: Diabetes can increase the risk of developing gallstones, which can lead to acute cholecystitis. 
&nbsp;

Certain Medications: Some medications, such as estrogen therapy, can increase the risk of gallstones and acute cholecystitis. 
&nbsp;

Losing Or Gaining Weight Rapidly: It can increase the risk of developing acute cholecystitis, as it can lead to the formation of gallstones. 
&nbsp;

Native Americans And Hispanics: They are also at increased risk of developing gallstones and subsequent acute cholecystitis, likely due to genetic and lifestyle factors. 
&nbsp;

The best way to prevent acute cholecystitis is to maintain a healthy lifestyle and avoid risk factors that increase the likelihood of developing gallstones. Here are some tips to help prevent acute cholecystitis: 
&nbsp;

Maintain A Healthy Weight: Being overweight or obese increases the risk of developing gallstones, which can lead to acute cholecystitis. Maintain a healthy weight through a balanced diet and regular exercise. 
&nbsp;

Avoid Rapid Weight Loss: Rapid weight loss, such as through crash dieting, can also increase the risk of developing gallstones. Instead, aim for gradual and sustainable weight loss. 
&nbsp;

Eat A Healthy Diet: A diet rich in fruits, vegetables, whole grains, and lean protein can help prevent the formation of gallstones. 
&nbsp;

Exercise Regularly: Regular exercise can help maintain a healthy weight and reduce the risk of developing gallstones. 
&nbsp;

Key Points

<ul>
	<li>The gallbladder is connected to the liver by a system of ducts. Bile, a substance made by the liver to dissolve fat, travels through these ducts and enters the digestive system at the duodenum.</li>
	<li>The cystic duct connects directly to the gallbladder, allowing bile to be stored there when a valve at the common bile duct and duodenum connection is closed.</li>
	<li>During mealtime, the gallbladder contracts and the valve opens, allowing stored bile to be released into the intestine. However, gallstones or sludge in the gallbladder can obstruct the flow of bile, leading to cholecystitis, an inflammation of the gallbladder.</li>
	<li>Acute cholecystitis is a medical condition that involves inflammation of the gallbladder. The gallbladder plays an important role in digestion by storing and releasing bile, a fluid produced by the liver that helps break down fats in the small intestine.</li>
	<li>Acute cholecystitis occurs when the bile ducts leading into the gallbladder become blocked, typically by gallstones.</li>
	<li>Cholecystitis affects approximately 10-20% of Americans, with up to one-third of those with gallstones developing the condition.</li>
	<li>The most common cause of acute cholecystitis is the blockage of the cystic duct by a gallstone. However, other factors may contribute to the development of acute cholecystitis, such as trauma, tumor, genetic factors, infections, and bile duct blockage.</li>
	<li>Treatment for acute cholecystitis typically involves a combination of medical and surgical interventions. The goals of treatment are to relieve symptoms, prevent complications, and prevent the recurrence of the condition.</li>
	<li>The best way to prevent acute cholecystitis is to maintain a healthy lifestyle and avoid risk factors that increase the likelihood of developing gallstones. 
	&nbsp;</li>
</ul>

[1] Cholecystitis: Gallbladder inflammation, symptoms, treatment. Cleveland Clinic.

[2] Vinay K Kapoor MBBS. Acute cholecystitis. Practice Essentials, Background, Pathophysiology.

[3] Acute cholecystitis: Medlineplus medical encyclopedia. MedlinePlus.

[4] Cholecystitis. Mayo Clinic

[5] Acute cholecystitis - symptoms, causes, treatment: Nord. National Organization for Rare Disorders

[6] Pietrangelo A. Chronic cholecystitis: Causes, symptoms & diagnosis. Healthline.

[7] Cholecystitis: Symptoms, causes, diagnosis, and treatment. Medical News Today.

[8] Phatak UR, Chan WM, Lew DF, et al. Is nighttime the right time? Risk of complications after laparoscopic cholecystectomy at night. J Am Coll Surg. 2014;219(4):718-724. doi:10.1016/j.jamcollsurg.2014.05.009

[9] Wong A, Naidu S, Lancashire RP, Chua TC. The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis. ANZ J Surg. 2022;92(5):1091-1096. doi:10.1111/ans.17513

[10] Aqsa Nasir et al; Prevalence of Gallstone Disease and its Correlation with Age among People Undergoing Abdominal Ultrasound in Gujranwala. EAS J Radiol Imaging Technol; Vol-3, Iss-3 (May-Jun, 2021): 142-145. doi:10.36349/easjrit.2021.v03i03.004