What is Hydrops cholecystitis?

Hydrops Cholecystitis: Definition and Clinical Implications

Hydrops cholecystitis refers to a severely distended gallbladder filled with clear, sterile fluid ("white bile") resulting from complete obstruction of the cystic duct, typically by gallstones, leading to inflammation and potential complications if left untreated. 1

Pathophysiology

Hydrops cholecystitis develops through the following mechanism:

• Complete obstruction of the cystic duct (most commonly by gallstones in 90-95% of cases) 2
• Continued secretion of mucus by the gallbladder mucosa 3
• Progressive distension of the gallbladder with clear, sterile fluid 3
• Increased intraluminal pressure (averaging 61.5 cm saline) 3
• Mucosal inflammation and impaired reabsorptive processes 3

Diagnostic Features

Clinical Presentation

• Right upper quadrant pain and tenderness
• Fever and nausea (may be associated with eating)
• In critically ill or sedated patients, these symptoms may be absent, requiring a high index of suspicion 4
• Laboratory findings may include elevated alkaline phosphatase or glutaryl transferase 4

Imaging Findings

• Ultrasound (first-line imaging):

  • Distended gallbladder (transverse diameter >5cm)
  • Thickened gallbladder wall (>3mm)
  • Pericholecystic fluid
  • Echogenic structures with posterior acoustic shadowing (if gallstones present)
  • Sensitivity 81-88%, specificity 80-83% 1, 2

• CT with IV contrast (if ultrasound is equivocal):

  • Gallbladder distension
  • Wall thickening
  • Pericholecystic inflammation/stranding
  • Adjacent liver parenchymal hyperemia (early finding) 1

• Hepatobiliary Scintigraphy (HIDA scan):

  • Gold standard diagnostic test when ultrasound is inconclusive
  • Non-visualization of gallbladder within 60 minutes indicates cystic duct obstruction
  • Sensitivity 86.7-89.3%, specificity 66.8-79% 1, 2

Management

Initial Approach

• NPO (nothing by mouth)
• IV fluid resuscitation
• Electrolyte correction
• Pain control
• Antibiotic therapy 1

Definitive Treatment

• Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is the preferred approach 4, 1
• Early surgery is associated with:
  • Fewer postoperative complications (11.8% vs 34.4% for delayed surgery)
  • Shorter hospital stay (5.4 vs 10.0 days)
  • Lower hospital costs 2

Alternative Approaches

• Percutaneous cholecystostomy may be considered for patients with high surgical risk, but is associated with higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 1, 2
• Should be viewed as a bridge to definitive surgical intervention 1

Special Considerations

Acalculous Hydrops

• Occurs in 5-10% of acute cholecystitis cases 2
• More common in critically ill patients
• May be associated with conditions like Kawasaki disease in children 5, 6
• In Kawasaki-associated hydrops, medical management is preferred with surgical intervention reserved for complications 5

Complications if Untreated

• Progression to gallbladder perforation
• Peritonitis
• Sepsis
• Increased morbidity and mortality 1

Clinical Pitfalls to Avoid

• Delayed diagnosis: Symptoms may be absent or atypical in sedated or critically ill patients 4
• Inadequate imaging: Relying solely on ultrasound findings of gallstones without assessing for pericholecystic changes 1
• Delayed treatment: Increases risk of complications; prompt intervention is recommended 1
• Overlooking common bile duct involvement: Essential to assess for common bile duct dilatation or stones 1

In summary, hydrops cholecystitis represents a severe form of gallbladder distension requiring prompt diagnosis and treatment, with early laparoscopic cholecystectomy offering the best outcomes for most patients.