From the Guidelines
Cholecystitis is primarily caused by obstruction of the cystic duct, most commonly by gallstones (calculous cholecystitis) in about 90% of cases, leading to increased pressure, inflammation, and potential bacterial infection 1.
Pathophysiology of Cholecystitis
The pathophysiology of cholecystitis involves several key steps:
- Obstruction of the cystic duct by a gallstone, leading to trapped bile and increased pressure in the gallbladder 1
- Chemical irritation of the gallbladder wall by the trapped bile, compromising blood flow and lymphatic drainage, resulting in ischemia and edema 1
- Potential secondary bacterial infection, typically with enteric organisms like E. coli, Klebsiella, Enterococcus, or Enterobacter 1
- Release of phospholipases that break down lecithin in bile into lysolecithin, which is toxic to the gallbladder mucosa 1
- Contribution of prostaglandins and reactive oxygen species to mucosal damage 1
Types of Cholecystitis
There are two main types of cholecystitis:
- Calculous cholecystitis (90% of cases): caused by gallstones obstructing the cystic duct 1
- Acalculous cholecystitis (10% of cases): occurs without stones, usually in critically ill patients due to bile stasis, ischemia, or systemic inflammation 1
Complications of Cholecystitis
If left untreated, cholecystitis can progress to:
- Gallbladder gangrene
- Perforation
- Abscess formation
- Fistula development
- Peritonitis and sepsis 1 Early diagnosis and treatment of cholecystitis are crucial to prevent these complications and improve patient outcomes 1.
From the Research
Pathophysiology of Cholecystitis
- Cholecystitis is generally associated with the presence of gallstones, which can lead to serious complications 2, 3.
- The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness 3.
- Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis, while approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones 3.
Diagnosis and Treatment
- Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 3.
- Hepatobiliary scintigraphy is the gold standard diagnostic test when an ultrasound result does not provide a definitive diagnosis 3.
- The gold standard treatment of acute cholecystitis is laparoscopic cholecystectomy, which should be performed within 72 hours from diagnosis 2, 3, 4.
- Early laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications, a shorter length of hospital stay, and lower hospital costs 3.
Special Considerations
- In patients who are not eligible for early laparoscopic cholecystectomy, it is suggested to delay surgery at least 6 weeks after the clinical presentation 2.
- Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD) 2.
- A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients 2, 3, 4.