From the Guidelines
Cholecystitis is primarily caused by gallstones blocking the cystic duct, which occurs in about 90-95% of cases, as stated in the 2017 WSES guidelines for management of intra-abdominal infections 1. This blockage leads to bile buildup, inflammation, and potential infection of the gallbladder. When gallstones obstruct the duct, the concentrated bile becomes irritating to the gallbladder lining, triggering an inflammatory response. Less common causes include biliary sludge, tumors, or strictures that can similarly block bile flow. Acalculous cholecystitis, accounting for 5-10% of cases, develops without gallstones and is typically seen in critically ill patients with sepsis, after major surgery, or during prolonged fasting with TPN (total parenteral nutrition) 1. Risk factors that increase susceptibility include female gender, obesity, rapid weight loss, pregnancy, certain medications (like oral contraceptives), and genetic predisposition. Bacterial infection, particularly with organisms like E. coli, Klebsiella, and Enterococcus, often occurs as a secondary complication once inflammation begins, worsening the condition and potentially leading to gallbladder perforation if left untreated 1.
Some key points to consider in the management of cholecystitis include:
- The importance of early diagnosis and treatment to prevent complications such as gallbladder perforation 1
- The use of ultrasound as the first-line imaging modality for suspected cholecystitis, due to its high sensitivity and specificity 1
- The role of antibiotic therapy in the management of cholecystitis, particularly in cases of complicated cholecystitis or in elderly patients with compromised immune systems 1
- The potential need for surgical intervention, such as laparoscopic cholecystectomy, in cases of severe or complicated cholecystitis 1.
Overall, the management of cholecystitis requires a comprehensive approach that takes into account the underlying cause of the condition, as well as the patient's overall health status and risk factors for complications. The primary goal of treatment should be to reduce morbidity and mortality, and improve quality of life for patients with cholecystitis.
From the Research
Primary Causes of Cholecystitis
- The primary cause of cholecystitis is the obstruction of the cystic duct, usually by a gallstone, leading to inflammation of the gallbladder 2, 3, 4, 5, 6.
- Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis 6.
- Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness 6.
Pathogenesis of Acute Cholecystitis
- 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 3.
- The disease progresses through several phases, including edematous cholecystitis, necrotizing cholecystitis, and suppurative cholecystitis, if left untreated 5.
Risk Factors and Complications
- Possible complications that affect the management of cholecystitis include perforation of the gallbladder, peri-gallbladder abscess, and internal biliary fistula 5.
- During pregnancy, early laparoscopic cholecystectomy is associated with a lower risk of maternal-fetal complications and is recommended during all trimesters 6.
- In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared with nonoperative management 6.