Can acute cholecystitis lead to peritonitis?

Acute Cholecystitis and Peritonitis: Pathophysiological Connection and Management

Yes, acute cholecystitis can lead to peritonitis, particularly when inflammation progresses to gallbladder perforation, which occurs in 2-11% of acute cholecystitis cases and carries a mortality rate of 12-16%. 1

Pathophysiology of Progression from Cholecystitis to Peritonitis

Acute cholecystitis can progress to peritonitis through several mechanisms:

1. Gallbladder Perforation: The most common pathway, classified into three types 1:

   • Type I (acute): Free perforation with generalized peritonitis
   • Type II (subacute): Pericholecystic abscess with localized peritonitis
   • Type III (chronic): Cholecysto-enteric fistula

2. Risk Factors for Perforation:

   • Severe systemic diseases (diabetes mellitus, atherosclerotic heart disease)
   • Advanced age (Type III perforation more common in elderly)
   • Delayed diagnosis and treatment
   • Gangrenous or emphysematous cholecystitis

3. Bile Contamination: Infected bile in the peritoneal cavity leads to bacterial peritonitis, with E. coli being the most common organism 2

Diagnostic Challenges

• Perforation is rarely diagnosed preoperatively, as symptoms often mimic uncomplicated acute cholecystitis 1

• Imaging findings that suggest perforation or peritonitis:

  • Sonographic "hole sign" in gallbladder wall
  • Defect in gallbladder wall on CT
  • Pericholecystic fluid collection
  • Free intraperitoneal fluid 1

• CT scan is more reliable than ultrasound for diagnosing perforation, showing wall defects and free fluid 1

Management Considerations

1. Early Surgical Intervention:

   • Early diagnosis and immediate surgical intervention significantly decrease morbidity and mortality rates 1
   • Delayed surgical intervention increases mortality, ICU admission rates, and prolongs hospitalization 1, 2

2. Surgical Approach:

   • Laparoscopic cholecystectomy is the preferred approach for acute cholecystitis 3
   • Open cholecystectomy may be necessary in complicated cases or when anatomy cannot be clearly identified 3
   • Conversion to open procedure should be considered for patient safety when needed 3

3. Antimicrobial Therapy:

   • Broad-spectrum antibiotics should be started immediately when peritonitis is suspected 1
   • In severe sepsis or shock, antibiotics should be started within 1 hour 1
   • Antibiotic regimens should be adapted based on bile culture findings 1
   • Common regimens include:
     • Piperacillin/tazobactam
     • Tigecycline
     • Ciprofloxacin plus Metronidazole
     • Carbapenems for severe cases 1, 3

4. Alternative Management for High-Risk Patients:

   • Percutaneous cholecystostomy may be considered as a temporizing measure in critically ill patients unfit for surgery 1, 4
   • However, this is inferior to cholecystectomy for definitive treatment 3

Mortality and Complications

• Mortality from bile peritonitis ranges from 5-20%, with higher rates in hospitals practicing delayed surgery 2

• Infectious complications are the primary cause of death, leading to multiple organ failure 2

• The longer the delay before surgery, the higher the mortality rate 2

Special Considerations

• Elderly patients have higher risk of complications and mortality from bile peritonitis (up to 22.4% in some studies) 5

• Acalculous cholecystitis, though less common, can also lead to gallbladder necrosis and biliary peritonitis 6

• Monitoring for signs of perforation is crucial in all cases of acute cholecystitis, as early intervention significantly improves outcomes 1

• In critically ill patients with severe complicated intra-abdominal sepsis from perforated cholecystitis, open abdomen therapy may be considered for optimal source control 1

The evidence clearly demonstrates that acute cholecystitis can lead to peritonitis through gallbladder perforation, with potentially fatal consequences if not promptly diagnosed and treated.