Acute and chronic calculous cholecystitis

Calculous cholecystitis is an inflammation of the gallbladder, which occurs as a result of the presence of concrement in the gallbladder. Approximately 50-75% of cases of cholecystitis in bile are detected by bacteria. However, it is believed that the bacterial infection in the gallbladder leads to development of cholecystitis.

Clinically, the disease manifests itself in pain and soreness in the right hypochondrium, in acute course (acute cholecystitis), muscle tension of the anterior abdominal wall in the right hypochondrium can be noted also.

The main diagnostic method is ultrasound, which determines the presence of concrements in the gallbladder and signs of inflammation.

Treatment consists of antibiotic therapy and removing the gallbladder (cholecystectomy).

• Epidemiology of calculous cholecystitis

The prevalence of calculous cholecystitis is directly related to the epidemiology of cholelithiasis. So, in the USA, approximately 10-20% of the population suffer from cholelithiasis and one-third of them develop acute cholecystitis. In the world, calculous cholecystitis is most common among Scandinavians and Pima Indians.

Cholecystitis, like cholelithiasis, is more common among women.

The frequency of cholecystitis increases with age, which may be due to changes in the hormonal background.

• Classification of calculous cholecystitis: There are two main forms of calculous cholecystitis:

• Acute calculous cholecystitis.
  It is an inflammation of the gallbladder, which develops within a few hours. Occurs as a result of obstruction of the cystic duct with bile calculi.

• Chronic calculous cholecystitis.
  This is a long-term inflammation of the gallbladder, resulting from the presence of concrements in it.
• ICD-10 codes
• K80.0 - Stones of the gallbladder with acute cholecystitis.
• K80.1 - Stones of the gallbladder with another cholecystitis.
• K80.4 - Stones of the bile duct with cholecystitis.

Aetiology and pathogenesis

The main cause of the development of calculous cholecystitis is the concrement of the gallbladder, causing the obstruction of the cystic duct.

Risk factors for the development of calculous cholecystitis are:

• Female.
• Ethnic factor (more often among Scandinavians and Pima Indians).
• Obesity or, conversely, a sharp decrease in body weight.
• Some medicines (especially the reception of hormonal contraceptives by women).
• Pregnancy.
• Age (increased risk of disease with age).

• Pathogenesis of acute cholecystitis

In normal circumstances,  the bile in the gallbladder always flow freely  through  its duct into the common bike duct. For some reasons , like a blockage of the bile duct by a stone or compression by a tumor,  structures etc , the normal flow of the bile is stopped. The bile in the gallbladder become congested, bile stasis. The stasis of bile in the gallbladder serve as a breeding site for bacteria. As a result of bile stasis,  pro-inflammatory enzymes become activated, e.g Phospholipase A. This pro-inflammatory enzyme converts lecithin into lysolecithin. Lysolecithin is a harmful product to the cell membrane. As more of lysolecithin are accumulate, it damages the mucus membrane of the gallbladder. The damaged mucus membrane produces more fluid in the bladder. This causes the bladder to become more extended, and the pressure inside it also increases.  The combined action of the lysolecithin and increased pressure in the bladder cause the production of the inflammatory mediators eg prostaglandins,  which causes more damage to the mucus membrane. As the pressure continues to increase in the bladder, the vessels of the wall of the bladder also become affected: squeezed and prevent blood flow in it and eventually leads to necrosis of the bladder.

Also, infection of the gallbladder and its perforation is possible.

• Pathogenesis of chronic cholecystitis

Chronic cholecystitis can occur after acute, but often develops independently and gradually.

Damage to the gallbladder wall in chronic cholecystitis varies from mild infiltration to thickening and fibrotic wrinkling. In chronic cholecystitis, the inflammatory-scar process covers all layers of the gallbladder wall. It is gradually sclerized, thickened, in places lime is deposited in it, which creates conditions for the maintenance of the inflammatory process and its periodic exacerbations.

• Histological picture of cholecystitis

Oedema and venous stasis are attributed to early acute changes.

Histological changes in acute cholecystitis are usually superimposed 5on the histological pattern characteristic of chronic cholecystitis.

Specific signs include: fibrosis, flattening of the mucosa and the presence of cells of chronic inflammation. In 56% of cases, mucosal hernias (Rokitansky-Ashot sines) are detected, caused by an increase in hydrostatic pressure. Point necrosis and infiltration by neutrophils can also occur.

With progression of the lesion develops gangrene and perforation.

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Clinic and complications

• Clinical picture of acute cholecystitis

Characterized by acute pain ("biliary colic"). The pain is localized in the epigastric or right subcostal area, irradiates into the back below the angle of the right scapula, the right shoulder, less often to the left half of the trunk.

Pain usually occurs at night or early in the morning and grows within an hour. In contrast to the usual biliary colic, the pain with acute cholecystitis is longer (more than 6 hours) and more pronounced.

The occurrence of pain can be preceded by the use of fatty, spicy, spicy food and alcohol, as well as emotional experiences.

Pain can be accompanied by excessive sweating, grimace of pain on the face and forced pose - on the side with legs clamped to the stomach.

There is nausea, vomiting, sometimes with an admixture of bile.

The fever usually appears 12 hours after the onset of the attack and is associated with the development of bacterial inflammation. In elderly and senile patients, an increase in body temperature may not occur and the first or only symptom may be systemic nonspecific manifestations (lack of appetite, vomiting, malaise and weakness).

The appearance of jaundice indicates at least partial obstruction of the common bile duct.

• Clinical picture of chronic cholecystitis

Typical dull, aching pain in the region of the right hypochondrium of a permanent nature or arising 1-3 hours after the intake of abundant and especially fatty and fried foods.

Pain radiates upward, into the region of the right shoulder and neck, right shoulder blade. Periodically, there may be a sharp pain resembling a biliary colic. However, sometimes even expressed inflammatory changes in the gallbladder may not be accompanied by symptoms of biliary colic.

Usually chronic calculous cholecystitis is not accompanied by an increase in body temperature.

Quite often such phenomena as: nausea, irritability, insomnia.

Jaundice is not typical.

Complications of calculous cholecystitis

·         Empyema of the gallbladder (develops as a result of bacterial infection).

·         Formation of the vesicouteral fistula. It develops as a result of erosion and breakthrough of the concrement through the wall of the gallbladder into neighbouring organs (most often in the duodenum), and there may be gallstone obstruction of the intestine.

·         Emphysematous cholecystitis (develops only in 1% of cases as a result of the multiplication of gas-forming microorganisms, such as: E coli, Clostridia perfringens and Klebsiella species).

·         Sepsis.

·         Pancreatitis.

·         Perforation of the gallbladder (develops in up to 15% of patients).

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Diagnostics

The diagnosis of cholecystitis can be suspected when there is pain in the right upper quadrant, accompanied by an increase in body temperature.

Diagnosis of the disease, in addition to collecting anamnesis and physical examination, includes visualization and laboratory methods of diagnosis, the main one of which with calculous cholecystitis is ultrasound.

Objectives of diagnosis

§     As early as possible verification of the diagnosis.

§     Detection of complications.

§    Definition of indications and contraindications to surgical treatment.

• Diagnostic Methods
• Anamnesis history When collecting an anamnesis should clarify the prescription of the appearance of pain and their localization, as well as the relationship with eating and physical activity. You should also ask about the presence of additional symptoms of cholecystitis, which include fever, nausea.

·         Physical examination

     Examination. With acute calculous cholecystitis, there is superficial breathing, the stomach is weakly involved in the act of breathing. Approximately 15% of cases can be yellowing of the skin. For chronic calculous cholecystitis jaundice is not characteristic.

     Palpation. Characterized by soreness and tension of the abdominal muscles in the right hypochondrium or epigastrium. Approximately in 30-40% of cases the bottom of the gallbladder is palpable. In chronic cholecystitis, the gallbladder is not palpated in most cases, as it is usually wrinkled due to a chronic scar-sclerosing process.

      A positive symptom of Murphy is an involuntary retention of breath on inspiration with pressure on the right hypochondrium. Pain during inspiration during palpation of the right hypochondrium (Kehr's symptom). Painfulness when tapping along the edge of the right rib arc (Ortner's symptom). Symptom Geno de Moussi-Georgievskogo (phrenicus symptom) - soreness when pressing a finger between the legs of the right sterno-claviculo-mastoid muscle.

      Percussion. When percussion of the stomach - tympanitis (reflex paresis of the intestine).

·         Laboratory diagnostic methods

      Laboratory indicators for cholecystitis are non-specific and poorly assisted in the diagnosis.

      In acute cholecystitis, leukocytosis can occur with a shift of the leukocyte formula to the left.

     The increase in ALT and AST can be noted with cholecystitis and obstruction of the common bile duct. An increase in the total bilirubin and alkaline phosphatase activity can be observed with obstruction of the common bile duct.

Visualizing diagnostic methods

·         Ultrasound of the abdominal cavity organs
       Sensitivity and specificity of ultrasound for the detection of gall bladder stones is more than 95% (in the case of concrements more than 2 mm in diameter). The sensitivity of this method for cholecystitis is 90-95%, and specificity 78-80%. Ultrasound is most informative in carrying out this study on an empty stomach (refraining from eating food for 8 hours) before conducting a diagnostic study.

      Ultrasound-signs of acute cholecystitis are:-Liquid in the near-bubble space.

-Thickening of the wall of the gallbladder (more than 4 mm).

Ultrasound. The thickening of the wall is determined.

               Ultrasound. The arrow indicates the concrement, wedged into the cystic duct.

·         Radiography

       Biliary calculi in radiography can be visualized in 10-15% of cases. But this sign does not indicate the mandatory presence of cholecystitis. The presence of gas in the lumen or wall of the gallbladder is characteristic of emphysematous cholecystitis caused by gas-forming bacteria, such as E. coli, Clostridium and Streptococcus species. Emphysematous cholecystitis is most common among men with diabetes or with cholecystitis without cholecystitis.  Diffuse calcification of the gallbladder ("porcelain bladder") is most often associated with the development of carcinoma, but according to one retrospective study - Towfigh (2001), partial calcification of the gallbladder has no connection with carcinoma

   radiography of the abdominal cavity. The arrow indicates gas in the gallbladder, which is characteristic of emphysematous cholecystitis.

·         CT and MRI
      The sensitivity and specificity of these methods of investigation in the detection of acute cholecystitis is more than 95%. Also, these methods allow you to inspect the surrounding organs and tissues, which can help in difficult diagnostic cases.

      The signs of cholecystitis, determined by this method of investigation, include: 
·         Thickening of the wall of the gallbladder (more than 4 mm).
·         The accumulation of fluid near the bladder.
·         Subserosal edema.
·         Gas within the walls of the gallbladder (emphysematous cholecystitis).
·         Tearing off the mucous membrane 

        CT. The picture of emphysematous cholecystitis

·         Hepatocholescintigraphy

     Hepatocholescintigraphy makes it possible to accurately diagnose acute cholecystitis in up to 95% of cases. The sensitivity and specificity of this method lie in the ranges of 90-100% and 85-95%, respectively.  Usually the labelled substance enters the gallbladder, the common bile duct and small intestine for 30-45 minutes. The purpose of morphine improves the visualization of the gallbladder, since this drug increases the resistance of the bile current through the sphincter of Oddi, which contributes to the filling of the gallbladder (under the condition of the patency of the cystic duct).The introduction of morphine, thus, helps to reduce the number of false positive results of scintigraphy, which can be observed in seriously ill, immobilized patients with stagnant thick bile.

·         Endoscopic retrograde pancreatocholangiography (ERCP)
      This method of research is used when suspicion of concrements in the common bile duct. ERCP allows visualization of bile ducts, and in the course of this procedure it is possible to extract stones from the common bile duct. However, this method carries a high risk of developing pancreatitis (pancreatitis develops in 3-5% of cases) after this diagnostic procedure.
  

Arrows indicate concretions in the gallbladder and in the common bile duct.

Treatment  

With exacerbation of chronic cholecystitis and prolonged course, treatment is usually performed in a hospital, in the remission phase - in a polyclinic or a sanatorium.

Treatment is aimed at eliminating pain and dyskinetic disorders, as well as suppressing the infection and inflammatory process. In addition, treatment should include treatment of cholelithiasis. More details Treatment of cholelithiasis. .

Acute cholecystitis is an indication for urgent hospitalization in a surgical hospital and, as a rule, requires an operative intervention. When entering the hospital, the initial treatment of patients with acute cholecystitis includes relieving the bowel load, intravenous hydration, anesthesia and the administration of intravenous antibiotics. In light cases of the disease, antibiotic therapy consists in the appointment of one antibacterial agent of a broad spectrum of action. 

• Treatment of acute cholecystitis
• Objectives of treatment
• Coping with an acute condition.
• Prevention of complications.
• Exclusion of conditions conducive to the formation of concrements.

• Methods of treatment of acute cholecystitis
• Conservative therapy

·         Dietotherapy At the beginning of an attack of acute cholecystitis - a water-tea break for 1-2 days. Next, they appoint Diets # 5a , and if all acute events disappear, go to Diets # 5

·         Anesthetics and antispasmodics 
      Pain in acute cholecystitis or exacerbation of chronic can be quite pronounced and require the appointment of narcotic analgesics, while it should be borne in mind that the purpose of morphine is not shown, since this drug increases the tone of the sphincter of Oddi and complicates the outflow of bile.

The following medicines are used:

meperidine (Promedol, Demerol)

The narcotic analgesic providing adequate anaesthesia does not lead to disturbance of a tonus of the sphincter of Oddi. It is prescribed in a single dose of 0.04 g orally / intravenously / intramuscularly / subcutaneously. The daily dose is 0.16 g.

Paracetamol ( Perfalgan UPSA , Panadol )

Non-narcotic analgesic, belonging to the group of NSAIDs. Assign a single dose of 750 mg.

metamizole sodium ( Analgin , Baralgin M )

Non-narcotic analgesic, belonging to the group of NSAIDs. Assign iv or I / m for 1-2 ml of 50% solution 2-3 times / day, the maximum daily dose is 2 g.

papaverine ( Papaverine hydrochloride 

Antibiotic therapy

Antibacterial agents used in the treatment of cholecystitis should affect E. coli, B. fragilis, Klebsiella, Pseudomonas and Enterococcus species.

With a stable condition of the patient with pain and low temperature - ampicillin ( Ampicillin sodium salt ) 4-6 g / day.

In severe septicemia, a combination of antibiotics is recommended:

gentamicin ( Gentamycin sulfate ) 3-5 mg / kg / day + clindamycin ( Dalacin , Clindamycin caps. ) 1,8-2,7 g / day. or

metronidazole ( Metrogel ) + cephalosporin III generation or

imipenem + cilastatin ( Tienam ).

·         Detoxification therapy
        Disintoxication therapy is carried out by intravenous injection of solutions of 5% glucose , saline , haemodesis with a total of 2-3 liters per day.

·         Antiemetic drugs
]       Patients with cholecystitis often experience nausea and vomiting. The use of antiemetics can alleviate the condition of patients, and also prevent the loss of fluid and electrolytes. Recommended promethazine ( Pipolphen ). Antihistamine means with sedative and antiemetic effect. Assign IM or IV in the initial dose of 25 mg, then 12.5-25 mg every 4-6 hours.

·         Surgery

• The tactics of treatment of acute cholecystitis

When acute cholecystitis requires the use of active treatment tactics. This tactic is due to the fact that the morphological changes in the gallbladder in the inflammatory process never completely disappear and lead to the development of numerous complications.

It should be remembered that with ongoing infusion therapy, the onset of improvement in the patient's condition is not always a reflection of the "reversibility" of the inflammatory process. Practice abounds with observations when, against the backdrop of ongoing infusion therapy, including antibiotic therapy, and against the background of clinical signs of improvement, the patient developed gallbladder gangrene, its perforation, or the periapubic abscess.

The choice of tactics for treatment of a patient with acute cholecystitis in a modern clinic is already decided in the first hours of stay in the hospital, from the moment of setting and confirming the clinical diagnosis by ultrasound or laparoscopic methods. However, the operation is performed at different times from the moment of hospitalization.

Pre-operative stay in hospital is used for intensive therapy, the duration of which depends on the severity of the patient's physical condition.

The method of choice is early (within the first 72 hours) laparoscopic cholecystectomy, since in this operation the mortality and frequency of complications is lower than with the planned operation conducted after 6-8 weeks of conservative treatment.

Emergency patients are cholecystectomized with acute cholecystitis, complicated by peritonitis, gangrenous cholecystitis, perforation of the gallbladder wall.

Percutaneous cholecystostomy in combination with antibiotic therapy is the method of choice for the treatment of severe patients and elderly patients with complications of acute cholecystitis.

• Tactics of treatment of patients with acute cholecystitis of elderly and senile age in severe condition

Patients elderly and senile with multiple severe concomitant diseases may not suffer cholecystectomy in the acute stage of the disease under any variant of surgical tactics.

The key to solving the problem is a two-stage method of treatment. The first stage, realized under the control of a laparoscope or ultrasound, consists of puncture or microcholecystostomy, that is, one-stage or prolonged decompression and sanation of the gallbladder. Elimination of the leading pathogenetic factor of acute destructive cholecystitis - increased intravesical pressure - allows to stop clinical and inflammatory manifestations of the disease, to prepare the patient and to make the second radical stage of surgical treatment in a relatively safe period.

The two-stage method of treatment allows to significantly reduce postoperative mortality in patients of the "threatened" group (a group of patients at increased risk). However, the method also has a number of shortcomings, the main of which should be considered a long stay in the hospital, a low quality of life in the patient in the case of the formation of a functioning bile fistula, a widespread and often unreasonable use of two-stage methods of treatment of acute cholecystitis in people over 60 years old, the development of new a few, but severe complications associated with the puncture of the gallbladder or the existing cholecystostomy.

• Treatment of chronic cholecystitis

Methods of treatment of chronic cholecystitis

Conservative therapy

·         Dietotherapy

·         Anesthetics and antispasmodics

·         Antibiotic therapy

·           Surgery

• The tactics of treating chronic cholecystitis

Treatment can be done on an outpatient basis. Treatment of chronic cholecystitis is prolonged and begins with the use of medications that facilitate the patient's condition. Treatment without exacerbation is a conservative treatment.

In connection with the fact that in chronic calculous cholecystitis in the gallbladder are determined concrements, it is necessary to solve the problem of their removal. 

Sanatorium treatment is indicated in the absence of exacerbation, cirrhosis of the liver, disconnected gallbladder.

Patients with chronic cholecystitis are recommended to undergo preventive examinations twice a year. Work should not be associated with high physical stress and vibration.

Prognosis

In the uncomplicated course of cholecystitis, the prognosis is quite favorable (with a low mortality rate). Mortality with complicated cholecystitis or cholecystitis in seriously ill patients reaches 50-60%.

Possible rapid progression of cholecystitis to gangrene or empyema of the gallbladder, fistula formation, intrahepatic abscesses and development of peritonitis.

Prevention

Prevention consists, first of all, in preventing the formation of concrements in the gallbladder and in the timely treatment of acute cholecystitis.