From the Guidelines
The primary cause of acute cholecystitis is gallstone obstruction of the cystic duct, which occurs in approximately 90-95% of cases. This blockage prevents bile from flowing out of the gallbladder, leading to inflammation and potential infection. When a gallstone becomes lodged in the cystic duct, bile accumulates in the gallbladder, causing increased pressure, decreased blood flow, and chemical irritation from concentrated bile salts. The trapped bile can become infected with bacteria, typically from the intestinal tract, worsening the inflammatory process 1.
Key Points
- Gallstones are the most common cause of acute cholecystitis, responsible for 90-95% of cases
- Less common causes include biliary sludge, tumors, or acalculous cholecystitis (inflammation without stones), which can occur in critically ill patients
- Symptoms typically include right upper quadrant pain, fever, nausea, and vomiting
- Treatment usually involves antibiotics, pain management, and eventual cholecystectomy (gallbladder removal), either during the acute episode or after inflammation subsides
According to the most recent guidelines, early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile 1. The 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis recommend ELC as the preferred treatment option.
Treatment Options
- Early laparoscopic cholecystectomy (ELC) is the preferred treatment option
- Cholecystostomy may be an option in critically ill patients with multiple comorbidities and unfit for surgery or patients who do not show clinical improvement after antibiotic therapy for 3–5 days 1
- Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal 1
In terms of source control, adequate source control represented by cholecystectomy should be performed as an urgent procedure with short course postoperative antibiotic therapy (1–4 days) 1. The 2023 WSES, GAIS, SIS-E, SIS-A guidelines on source control in emergency general surgery recommend this approach for Class A or B patients with complicated acute cholecystitis.
Source Control
- Adequate source control represented by cholecystectomy should be performed as an urgent procedure with short course postoperative antibiotic therapy (1–4 days)
- Cholecystostomy may be an option in critically ill patients with multiple comorbidities and unfit for surgery or patients who do not show clinical improvement after antibiotic therapy for 3–5 days 1
From the Research
Causes of Acute Cholecystitis
- The primary cause of acute cholecystitis is the obstruction of the cystic duct, which is often associated with the presence of gallstones 2, 3.
- Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis 3.
- Acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically occurs in the setting of severe critical illness and accounts for approximately 5% to 10% of cases 3.
Pathogenesis
- The pathogenesis of acute cholecystitis is most often explained by obstruction of the cystic duct, but research has shown that there are more contributing factors than just obstruction alone 4.
- The obstruction of the cystic duct can lead to inflammation of the gallbladder, which can cause a range of symptoms, including acute right upper quadrant pain, fever, and nausea 3.
Special Considerations
- In patients who are not eligible for early laparoscopic cholecystectomy, percutaneous cholecystostomy tube placement may be an effective therapy, but it is associated with higher rates of postprocedural complications compared with laparoscopic cholecystectomy 3.
- For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube placement should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy 3.