Gallbladder inflammation or cholecystitis is a dangerous condition. This article tells all you need to know: symptoms, causes, treatment.
Biliary disease or gallbladder disease is a term that describes several types of conditions that affect the gallbladder and the ducts that connect it and the liver to the small intestine.
Biliary colic, choledocholithiasis, and cholecystitis are some of the many gallbladder disease faces; this article focuses on acute cholecystitis. Acute cholecystitis is the medical term that describes gallbladder inflammation. The most common cause of acute cholecystitis is obstruction of the biliary tree due to gallstones. Although it used to be a life-threatening condition, modern medicine has improved treatment techniques making it a condition with an excellent prognosis (possible outcomes).
In the United States, 10% to 20% of the population suffers from gallstones. Of that 10% to 20% of the population that suffer from gallstones, around 30% will develop cholecystitis due to gallstones. The occurrence of acute cholecystitis correlates directly with age; the older you are, the more likely you are to have cholecystitis. The condition is three times more frequent in women than in men; the exact reason for its uneven sex distribution remains unknown.
Gallbladder removal (laparoscopic cholecystectomy) is the most common complex procedure performed by general surgeons in the United States. On average, 500.000 people suffer from acute cholecystitis each year in the United States.
What is the biliary tree, and what does it do?
The main function of the biliary tree is to carry bile from the liver to the small intestines. Bile is a substance the liver produces to help the small intestine digest lipids (fat). The liver excretes bile through the left and right hepatic ducts, which converge to form the common hepatic duct.
The gallbladder is a pouch that stores some of the bile produced by the liver. This pouch connects with the common hepatic duct through a very tiny vessel called the cystic duct. After the cystic duct merges with it, the common hepatic duct changes its name to the common bile duct that receives pancreatic enzymes through the pancreatic duct to end up in the duodenum finally.
What is bile exactly?
Bile is a greenish or yellowish substance produces by the liver. It contains water, bilirubin, biliary salts (the component that helps with digestion), and fat (mainly cholesterol). Gallstones appear to form when there is too much cholesterol or too much bilirubin in the bile; the exact mechanism behind it remains a mystery.
The problem with these stones is that they can get stuck somewhere. That is where the trouble begins.
What is the purpose of the gallbladder?
The gallbladder is not an essential organ; it stores bile and contracts during the digestive process to release it into the small intestine. However, bile also reaches the small intestine directly from the liver and through the common bile duct. Therefore, although it serves a small purpose during the digestive process, surgeons are not hesitant to remove it when necessary. You will not miss it afterward.
What causes inflammation in the gallbladder?
In around 90% of cases, gallbladder inflammation is a consequence of gallstones getting stuck in the cystic duct. This blockage causes the gallbladder to fill up with pressure. Suppose the stone remains there for enough time. In that case, it will cause inflammation with fluid infiltration and gallbladder thickening due to fluid. If this process lasts long enough, the gallbladder tissue will begin to die, leading to gallbladder perforation.
The remaining 10% of cases represent acalculous cholecystitis. Acalculous gallbladder disease is an inflammatory disease of the gallbladder in which there are not any gallstones involved. Although it is relatively rare, acalculous cholecystitis tends to be more severe than calculous cholecystitis and has a worse prognosis. It occurs due to stagnant bile in patients in patients with gallbladder stasis. These are commonly very ill patients that suffer from other severe conditions such as sepsis, HIV infection (in its last stages), diabetes, or cardiovascular disease.
What are the risk factors for cholecystitis or gallbladder inflammation?
Besides having gallstones, other important risk factors that increase the risk of suffering from biliary colic and cholecystitis include:
- Quick or sudden weight loss
- Female sex
- Using oral contraceptives
- Liver transplantation
- Being over the age of 50
- The use of certain drugs: Ceftriaxone and Octreotide
- Being overweight
It is important to note that although women are more likely than men to suffer from cholecystitis, men tend to suffer from more severe cholecystitis with a higher frequency of complications.
Can children get cholecystitis?
Although cholecystitis is mostly an adult disease, pediatric cholecystitis has gained recognition as a relatively frequent problem in the last few decades. The latest statistics reveal that approximately 4% of all cholecystitis cases occur in the pediatric population. Although in adults, gallstones remain the most important cause of cholecystitis, in children, acalculous cholecystitis is more frequent than in adults.
The causes that lead to gallstone formation in children are not the same ones that cause gallstone formation in adults. Some important risk factors in children include:
- Abdominal surgery
- Hemolytic disease
- Malabsorption syndromes
- Cardiac failure
- Bronchopulmonary dysplasia
- Bowel resection (due to any cause)
- Artificial heart valves
Children have a higher risk of having cholecystitis due to parasitic infection than adults. Ascaris lumbricoides is a parasitic worm that typically lives inside the small bowel. Still, in some cases (mainly if the parasitic load is high), the parasite migrates to the biliary tree obstructing it and producing cholecystitis.
Although cholecystitis symptoms are very similar in both adults and children, biliary colic symptoms are much vaguer in infants. In particular, small children usually don’t complain of right upper abdominal pain and just show irritability and gastrointestinal symptoms like vomiting. Unlike adults, children with gallstones typically present with jaundice (yellow coloring of skin, eyes sclera, and mucous membranes, i.e., eyeballs)
As adult cholecystitis, pediatric cholecystitis has an excellent prognosis when treated appropriately. However, in children with underlying conditions like sepsis or heart failure, the prognosis is poorer than in the general population.
What does a gallbladder inflammation or attack feel like?
Gallbladder symptoms include the following.
Gallbladder pain is the most common symptom usually begins in the middle-upper part of the abdomen and then relocates in the right upper side.
- Some patients also complain of pain radiation to the upper shoulder. The pain begins as colicky but evolves into a constant, severe pain in a few hours.
- Fever (in some cases but not all)
- Nausea and vomiting
Patients with acute cholecystitis often report having a history of previous short episodes of colicky pain in the upper abdomen but never as severe as cholecystitis and never as long. These episodes are biliary colics. The stone blocks the cystic duct temporarily (not enough time to cause gallbladder inflammation).
Biliary colic is more common after a heavy meal that acts as a stimulus for gallbladder contraction. The main difference between biliary colic and cholecystitis is that the former usually lasts less than 6 hours.
What are the complications of gallbladder pain?
Untreated acute cholecystitis has a very high risk of turning into something more serious; here are some of the most common complications:
- Empyema: If inflammation lasts long enough, bacteria will proliferate into the gallbladder filling it with pus. Patients who experience bacterial infection have a higher fever than most cholecystitis patients and a higher white blood cell count.
- Emphysematous Cholecystitis: Sometimes, gas-producing bacteria proliferate inside the small bowel filling it with gas, thus producing emphysematous cholecystitis. Although rare, emphysematous cholecystitis is a severe medical emergency that requires urgent treatment as it can lead to gangrene and perforation.
- Gangrenous cholecystitis: This is a cholecystitis type in which gallbladder inflammation is so severe the tissue dies (necrosis), leading to gallbladder perforation and sepsis. When the gallbladder perforates, the infection spreads to the rest of the abdomen, producing peritonitis and, in some cases, an abscess. This complication requires immediate gallbladder surgery.
- Sepsis: Severe bacterial infections can lead to sepsis. There is a global inflammatory response in the whole body that can lead to multiple organ failure and death.
Are there other complications of gallstones besides acute cholecystitis?
- Pancreatitis: Acute pancreatitis occurs when a gallstone moves from the gallbladder, and instead of getting stuck in the cystic duct, it impacts the pancreas duct. Symptoms include a dull and severe pain in the middle of the upper abdomen that radiates to the back, vomiting, nausea, and low-grade fever. Severe pancreatitis is a serious condition that can lead to multiple organ failure and death. Gallstone pancreatitis is one of the most common forms of pancreatitis.
- Gallbladder cancer: Nowadays, gallstones’ presence appears to be an important risk factor for gallbladder cancer. By the time of diagnosis, four of every five gallbladder cancer patients have gallstones. However, there isn’t any evidence yet of a direct relationship, in part because gallbladder cancer is sporadic, and the presence of gallstones is a widespread condition.
- Gallstone Ileus: This rare but severe complication of gallstones occurs when an abnormal channel between the gallbladder and the small intestine (called a fistula) opens up. This allows gallstones to travel to the terminal part of the small intestine blocking it. Bowel obstruction is a medical emergency that requires immediate treatment and might end up in surgery.
- Acute cholangitis: Cholangitis is inflammation of the bile ducts. Symptoms are quite similar to cholecystitis; the main difference is jaundice (yellow coloring of the skin and mucous membranes). Cholangitis can be a chronic or acute condition. Cholangitis can even lead to altered consciousness and confusion in severe cases.
- Choledocholithiasis: It occurs when a gallstone gets stuck further down the biliary tree in the common bile duct. Symptoms include jaundice, dark-colored urine, white stool, loss of appetite, and pain in the right upper quadrant. In some cases, the condition can further complicate into a form of liver disease called biliary cirrhosis.
How do you recognize gallbladder inflammation?
Although clinicians can distinguish biliary colic from acute cholecystitis using a timeframe, this is unpractical (particularly if you are the one feeling the pain). Fortunately, doctors have a quick, practical, and inexpensive method to diagnose gallbladder inflammation.
Abdominal ultrasound is the preferred method to diagnose gallbladder disease. Ultrasonography detects 95% of all cholecystitis cases. Although ultrasonography is an operator-dependent test, even inexperienced radiologists can easily diagnose cholecystitis using this technique. Ultrasound findings suggestive of gallbladder inflammation (besides detecting gallstones inside the gallbladder) include the following:
- Gallbladder wall thickening greater than 4mm
- Maximal abdominal tenderness when pressing the ultrasound probe over the visualized gallbladder (sonographic murphy’s sign)
- Fluid around the gallbladder
Using contrast-enhanced ultrasonography also helps to detect gangrenous cholecystitis. However, ultrasonography alone has its limitations, such as identifying the cystic duct and having difficulties identifying common bile duct stones.
In the context of acute right upper abdominal pain, ultrasonography alone has a 22% chance of giving a false positive (being positive in the ultrasound, although not actually having cholecystitis). Furthermore, suppose the patient in question has pancreatitis simultaneously, which is a common complication. In that case, ultrasonography is not enough, by itself, to precisely identify acute cholecystitis.
Besides, ultrasonography what other imaging tests are useful in cholecystitis or gallbladder inflammation?
Although abdominal ultrasound is the preferred initial test, other imaging modalities help increasing diagnostic accuracy.
These diagnostic adjuncts include:
- Plain abdominal radiograph: It is not particularly useful in gallbladder disease but can detect some calculi inside the gallbladder. But most radiographs of gallbladder patients are completely normal.
- CT scanning: This treatment modality is pricier and more complicated than abdominal ultrasound. However, it is useful for patients in which obesity or gas difficult the visualization of the gallbladder. CT scanning detects more than 95% of cholecystitis, making it more powerful than ultrasonography. It also explores the tissue around the gallbladder when the diagnosis of cholecystitis is uncertain.
- MRI scanning: MRI scanning is more expensive and harder to do (requires the patient to remain still in the MRI machine for a very long time) than CT scanning and does not provide any significant additional information. However, in pregnant patients that should not receive radiation, it represents a valid diagnostic alternative.
- Magnetic Resonance Cholangiopancreatography: This is a non-invasive procedure that helps to evaluate the biliary tree, the pancreatic duct, and the liver in cholecystitis patients who are also suspected of having an obstruction in the common bile duct or the pancreatic duct.
What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)?
ERCP is a complex endoscopic procedure that explores the biliary tree, the pancreatic duct. It is an office-based procedure done under sedation. In it, the surgeon or gastroenterologist inserts a flexible tube (endoscope) through your mouth into the duodenum where the pancreatic duct opens; he or she will then push a needle through the scope to get a better view of the pancreatic duct and the biliary pathways.
Although ERCP is not useful in cholecystitis itself, your healthcare provider might choose to do it when there is a high risk of simultaneous common bile duct obstruction. In this context, an ERCP can diagnose the problem and also solve it by removing the stone from the biliary pathways. Patients with common bile duct stones should have them removed before gallbladder removal surgery or during the procedure itself.
Among its defects is the fact that it is a very high-cost procedure that requires an extremely skilled operator. There is also a 3% possibility of developing acute pancreatitis as a complication of the procedure.
Which laboratory tests are useful in cholecystitis or gallbladder inflammation?
Some blood tests can also be of aid when trying to diagnose acute cholecystitis. Some of these include:
- Complete blood count: Usually reveals a high blood count with an increase in the neutrophile percentage.
- Liver enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are mildly elevated in acute cholecystitis. However, extremely high levels (over 1000) are more indicative of hepatitis than of cholecystitis.
- Bilirubin is not typically elevated in cholecystitis; this finding suggests the possibility of common bile duct stones.
- Phosphatase alkaline is elevated in a quarter of cholecystitis patients.
- Amylase and lipase are useful to evaluate the simultaneous presence of pancreatitis, although amylase alone can be vaguely elevated in cholecystitis without pancreatitis.
- All women of fertile age should undergo a pregnancy test when cholecystitis is a diagnostic possibility.
How is gallbladder inflammation or cholecystitis treated?
Cholecystitis treatment depends on the severity of the condition, the duration of symptoms, if cholecystitis is calculous or acalculous and if there are any complications like emphysematous cholecystitis present. However, cholecystitis patients should undergo laparoscopic gallbladder removal surgery (laparoscopic cholecystectomy) within seven days from hospital admission in the great majority of cases.
After admission and diagnosis through abdominal ultrasound, initial treatment includes painkillers for the pain, IV hydration, and antibiotic treatment with a single wide spectrum antibiotic. After this initial management and after all the necessary tests (such as magnetic resonance cholangiopancreatography), your surgeon will perform a laparoscopic cholecystectomy.
Early surgery decreases the risk of complications and results in a shorter hospital stay. The procedure consists of inserting a small tube with a camera and special surgical tools through a few small incisions (less than one inch) in the abdomen. The surgeon visualizes the gallbladder through the camera, removes the gallbladder with the small surgical instruments, and finally extracts it outside the body through one of the incisions. Most gallbladder surgeries require only three to four incisions, but some cases require some more. The procedure lasts approximately one hour.
Most patients are discharged the same day or the day after surgery. They can resume their regular activities approximately one week after the procedure. Complications are rare, but they do occur; some intraoperative complications of gallbladder surgery include the following:
- Hemorrhage (bleeding)
- Perforation of the gallbladder
- Common bile duct injury
Studies report that approximately 1.8% to 27% of all laparoscopic cholecystectomies need conversion to open surgery because of these or other complications during the procedure. An open cholecystectomy requires a 6-inch incision below your ribs on the right side. Converted cases have a higher risk of post-operative complications and result in a longer hospital stay.
What can I expect after the procedure?
It is normal to feel a little weak and tired in the first couple of days after the procedure. During the first week after surgery, your belly may feel a little swollen, and you may experience a bit of right shoulder pain. Some patients also experience gas and the need to burp constantly; a minority of patients have mild diarrhea that lasts for a couple of days. All of these symptoms are entirely normal and will resolve themselves in a week or so.
During the first one to two weeks, you should rest as much as possible, avoid lifting heavy objects and doing strenuous activities like running, bike riding, hiking, cleaning around the house, going to the grocery store, and driving. However, you should not stay completely still. Try walking a little bit each day to prevent blood clot formation; using anti-embolus stocking will also help.
When it comes to diet, you should have small meals, at least during the first month of recovery. You can eat whatever you like except for fatty foods. Fatty foods include things like milk, cheese, fried chicken, hamburgers, ice cream, and basically any type of fast food. Some patients might experience a bit of constipation after surgery. Consuming fiber supplements in the first month after surgery can be a great help. It would also help if you kept yourself hydrated by drinking a lot of fluids.
You should be able to shower 24 to 48 hours after the procedure. While doing this, you must keep the incision patches as dry as possible and make sure to pat them dry as soon as you come out of the shower. Leave the strips of tape in the incision for a week or let them fall alone; your surgeon will leave precise instructions concerning this.
When should I call my doctor or go to the emergency department after my surgery?
Several alarm symptoms should worry you and prompt you to seek immediate medical attention. These include:
- Yellow coloring of the skin or eyes
- Vomiting and being unable to tolerate food or liquids
- Feeling sick to your stomach
- Being unable to poop or pass gas
- Painful swelling of one of your legs (a sign of blood clot formation and deep vein thrombosis)
- Signs of infection such as swelling and redness of the incision sites, pus draining from the incision (surgery injury), or fever.
Do you have symptoms of gallbladder inflammation or cholecystitis?
This tool is a Cholecystitis Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for the disease. Therefore, the tool would tell anybody who uses it the likelihood of their symptoms because of cholecystitis. Using the tool is free and would only take a few minutes.