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How serious is acute cholecystitis?

 

How serious is acute cholecystitis?

How serious is acute cholecystitis? The biliary system consists of the gall bladder, bile ducts, and associated systems involved in the secretion and transportation of bile. The biliary system’s primary functions are to drain waste products from the liver into the duodenum and control bile’s release to aid digestion.  The greenish-yellow bile is produced by liver cells and consists of cholesterol, bile salts, and some waste products. Bile salts, particularly, help digest fats and remove waste. Bile is then excreted out of the body in feces (Keus et al. 2006). A complication of the gallbladder, Cholecystitis may be classified as acute or chronic. In acute cholecystitis (AC), the gall bladder is dilated and edematous. Its wall is thickened and inflamed (Lack 2003). Acute acalculous cholecystitis seems to progress more rapidly to gangrene and perforation than acute calculous cholecystitis (gallstones-induced cholecystitis). Thus a timely diagnosis involving a combination of clinical signs, laboratory findings, and imaging techniques is necessary. (Keus, Broeders, and Laarhoven 2006).

Since the symptoms of cholecystitis resemble other medical complications and, at times, typical signs of AC may be poorly distinguished in some scans as in Computed tomography (CT), which is not sensitive or specific for AC and is, therefore, an accurate diagnostic process with high specificity is required. The article discusses the role of various imaging modalities in identifying AC cases.

 

 

Etiology:

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. A gallstone usually causes it in the cystic duct, which connects the gallbladder to the hepatic duct (calculous AC). Other causes of cholecystitis may include bacterial infection in the bile duct system, tumors of the pancreas or liver, and decreased blood supply to the gallbladder (Acalculous AC). Pregnant women may develop cholecystitis due to accumulating thick gallbladder sludge.  It is made up of fine particles of material similar to gallstone. Kimura et al. (2007) state that Acute cholecystitis also has other causes, besides the gallstones, such as ischemia; certain chemicals that enter biliary secretions; drug disorders; infections with microorganisms, protozoa, and parasites; collagen disease; and allergic reactions. Acute acalculous cholecystitis is also associated with a recent operation, trauma, burns, multisystem organ failure, and parenteral nutrition.

 

Epidemiology:

About 10% of the population has gallstones.  In the younger age group, the incidence of gallstones in females to males has a ratio of 2:1, which increases in females with advancing age. After 60 years of age, 10-15% of males have gallstones compared to 20-40% of females. The prevalence of gallstones in females is also associated with childbearing, HRT, oral contraceptives, and obesity. The majority of cases are calculous cholecystitis, while acalculous cholecystitis is caused to 5-15% of cases only (Lack 2003).

The mortality is reported to be less than 10% for AC giving the impression that it is not a fatal disease, except for the elderly and/or patients with the acalculous disease (Kimura et al. 2007). Sharma and Steel (2009) referred to the literature regarding mortality and morbidity due to AC cholecystitis. Gallstones result in morbidity when they become symptomatic. The incidence of AC falls is mostly due to increased acceptance by patients of laparoscopic cholecystectomy (removal of gall bladder) as a treatment for symptomatic gallstones. However, immunocompromised patients may show mortality of up to 15%.  Complicated cholecystitis has 25% mortality (e.g., gangrene, emphysema of gallbladder). Perforation of the gallbladder occurs in 3-15% of patients with cholecystitis and is associated with 60% mortality. People from Hispanic or northern European countries are more likely to have gallstones.

 

How serious is acute cholecystitis? Case Study A brief case history:

A 51-year-old woman presented to the emergency room with a 24-hour history of abdominal pain that began approximately one hour after a reportedly heavy party dinner. The pain began as a dull ache in the epigastrium but then localized in the right upper quadrant (RUQ). She reports some nausea but no vomiting. Since she arrived at the ER, the pain has decreased significantly. She also confirmed a few such previous episodes in the recent past. Her medical history is significant for type II diabetes mellitus. On physical examination, her temperature is 38.0 C. Other vital signs are normal. The abdomen shows tenderness in the RUQ. The liver, rectal and pelvic examinations are normal. Her WBC count is 13,000/mm on arrival. Serum chemistry revealed total bilirubin 1.8 mg/dL, direct bilirubin 0.6 mg/dL, alkaline phosphatase 130 U/L, AST 50 U/L, and ALT 35 U/L. Ultrasonography of the RUQ demonstrates stones in the gallbladder, a thickened gallbladder wall, and a common bile duct diameter of 4.0 mm (Tsai et al. 2005).

 

Clinical diagnosis:

Acute cholecystitis is defined as an inflamed gallbladder resulting in pain, especially in

The right hypochondrium, generally with accompanying fever and leucocytosis. Ultrasound may show thickening of the gallbladder wall and a hypoechogenic rim or halo (Keus et al. 2006).  A gallstone usually causes it in the cystic duct. A typical attack of cholecystitis lasts two to three days. The major symptoms of cholecystitis may include intense and sudden pain in the upper right quadrant of the abdomen, recurrent painful attacks for several hours after meals, pain that gets worse with deep breaths and may pass on to the right shoulder blade, nausea, vomiting, abdominal bloating, chills, jaundice. The patients may experience these symptoms to a different degrees (Spira et al. 2002). The diagnosis of acute cholecystitis was made in a patient who presented with right upper quadrant or epigastric pain of more than 2 hours’ duration, had RUQ tenderness with localized peritoneal signs, and had a confirmatory radiologic study demonstrating gallstones as evidence of acute cholecystitis. Most frequently, patients had abdominal ultrasound studies that demonstrated gallstones, gallbladder wall thickening, pericholecystic fluid, and an ultrasound-induced Murphy’s sign (Madan et al. 2002). The present case correlates well with the symptoms of acute cholecystitis as there are other indicators, viz. leucocytosis, enhanced levels of bilirubin, ALT, ASP, and ALP, and elevated temperature.  Diabetic patients are at risk of decreased blood supply to the gall bladder and are on a controlled diet. The patient’s condition was probably aggravated on this account, combined with a heavy meal (likely to be high fat).

 

Anatomy of biliary system:

The normal gall bladder (GB) is A pear-shaped sac attached to the undersurface of the right lobe of the liver (Fig 1). It is covered with a stretch of the peritoneum to about 60% of its surface however the surface covered may vary.  The adult GB is about 10 cm in length and 3-4 cm in width. The wall is usually 1-2 cm thick, but the wall thickness varies depending on whether the gall bladder is relaxed or contracted.  The organ has three parts broad outer part is the fundus, the central body part, and an ‘S-shaped neck with an infundibulum.  The neck connects GB with the cystic duct. The mucosa of the cystic duct is gathered into folds, near the neck forming spiral valves.  These valves contain smooth muscle fibers in the lumen controlling filling and emptying of the gall bladder. The capacity of adult GB is 40 -70 ml though it can accommodate up to 100ml fluid.  The cystic duct is 2.5 cm in length and opens into duodenum at another end.  The length of the cystic duct appears smaller (1.5 cm) than its anatomic length due to its tortuous path (Lack 2003)..

The GB concentrates, stores and release bile produced by liver cells. Besides, the organ secretes gall bladder mucins with role in protection of epithelium. The intake of fatty meals and, to some extent, proteins cause the contraction of GB.  Cholecystokinin is the hormone responsible for the contraction GB wall. As a result, emptying of bile into duodenum occurs (Lack 2003).

Pathology:                

Acute cholecystitis causes sudden, severe pain in the upper right part of the abdomen. Most patients have gallstones and inflamed gallbladder walls, usually without infection, which may set in afterward. The fluid in the gall bladder walls causes these walls to thicken.  Acalculous cholecystitis is rare and may be due to major surgery, critical illness, or injuries, including burns and sepsis. Long fasting or intravenous feeding may also cause acalculous cholecystitis.  This is a more severe form of cholecystitis than calculous  (gallstone) cholecystitis and occurs in young children due to infections. Chronic cholecystitis is gallbladder inflammation that has lasted long and is always due to gallstones. It is characterized by repeated attacks of biliary colic (Yasutoshi et al. 2007). The pathological examinations show leucocytosis, elevated levels of bilirubin, and serum enzymes.Alkaline phosphatase, Alanine transaminase (ALT) and Aspartate transaminase (AST).

 

Role of imaging modalities in the diagnosis of AC:

Imaging modalities associated with a medical history and clinical examination help diagnose acute cholecystitis.  Ultrasound or ultrasonography can also detect fluid around the gallbladder or the thickening of its wall, which is typical of acute cholecystitis. Hepatobiliary scintigraphy is useful when acute cholecystitis is difficult to diagnose. In this test, a gallstone probably blocks the cystic duct if the radionuclide does not fill the gallbladder. Cholangiography is x-ray examination of the bile ducts using an intravenous (IV) dye. In percutaneous transhepatic cholangiography (PTC), a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray. Similarly, Endoscopic retrograde cholangiopancreatography (ERCP) examines the inside of these organs and detects any abnormalities.  Computed tomography scan (CT or CAT scan) is a diagnostic imaging procedure using a combination of x-rays and computer technology to produce cross-sectional images, or slices in different planes, of the body (Cheng et al. 2004). Rosen et al. (2001) suggested the choice of the sonographic Murphy’s sign, different from the clinical Murphy’s sign used during the physical examination of the gallbladder, to increase the sensitivity of US to 91%. Physicians from the emergency department and admitting surgeons request both US and cholecystoscintigraphy (HIDA) for definitive diagnosis.  Kalimi et al. (2001) found HIDA  to show 86% sensitivity while the US was only 48% thus they suggested HIDA could be used alone to diagnose AC. Binger et al. (2004) also reported a 60% accuracy of US for AC detection. While sonography is very sensitive for detecting gallstones, the ability to predict acute cholecystitis in patients with clinical symptoms appears limited. The scans from different imaging techniques are shown in Fig 2-4 below. Loud et al. (1996) believe that an advantage of the MR technique is that %CE is an independent and more accurate determinant of acute inflammation than wall thickness (Fig 5). However, the ability to elicit a positive Murphy’s sign is an advantage of sonography over MRI.

Treatment and prognosis:

 The patient’s age, general health, and medical history determine specific treatment for cholecystitis.  The treatment is also dependent on extent of the disease and the patient’s Preferences and tolerance to medications and procedures. Treatment for acute cholecystitis usually involves a hospital stay to reduce stimulation to the gallbladder. Antibiotics are administered to reduce inflammation and/or fight infection. The treatment may also use drugs made from bile salts to dissolve stones. A low-fat diet and pain management prove beneficial.  Sometimes, the gallbladder is surgically removed (cholecystectomy), usually by laparoscopy (Paran et al. 2006). Keus et al. (2006) explain that the aims of cholecystectomy in acute cholecystitis are threefold symptom relief, prevention of progression to complications, and prevention of recurrences of gallbladder disease. Cheng et al. (2004) caution that a high-density gallbladder wall sign is not only a specific sign for acute cholecystitis but also a guarded predictor for acute gangrenous cholecystitis. If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder is usually removed within 24 to 48 hours after symptoms start. If necessary, surgery can be delayed for 6 weeks or more while the attack subsides. Delay is often necessary for people with a disorder that makes surgery too risky (such as a heart, lung, or kidney disorder). If a complication such as an abscess, gangrene, or perforated gallbladder is suspected, immediate surgery is necessary. In acute acalculous cholecystitis, immediate gall bladder removal is necessary (Paran et al. 2006). The overall prognosis for cholecystitis is favorable. In some individuals, complications may arise if other organs are involved. Gallstones can return to the bile duct system after surgical removal of the gallbladder. Some patients experience pain even after removal of gall bladder (Paran et al 2006). It may be due to the malfunction of the sphincter of Oddi that control the flow of bile and pancreatic secretion. The other causes of pain, like gall bladder attack, may be small stones in the ducts, peptic ulcers, or irritable bowel syndrome.

Summary and Conclusion:

The gall bladder inflammation is effectively diagnosed by combined clinical and radiologic examinations.  Although the imaging modalities are sensitive to diagnosis of AC, physicians normally request scans by more than one technique for enhanced accuracy.  The researchers differ in this regard.  They believe a single technique that correlates well with clinical and histological examination is sufficient.  Some researchers also emphasise that modification of techniques to visualize exclusive signs of AC is desired (Kalimi et al; Cheng, Ng, and Shih 2004).   For example, signs such as gallbladder wall thickening, gallbladder distention, and, pericholecystic fluid are present in patients not having AC. A CT technique without contrast enhancement revealed a hyperdense gall bladder wall as a high probable sign of acute gangrenous cholecystitis.  Such patients should be given immediate treatment (Cheng et al. 2004). The acceptance of laparoscopic cholestectomy has reduced complications due to AC.

 

References:

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Cheng, She-Meng, Suk-Ping, Ng,and Shin-Lin, Shih. 2004. Hyperdense gallbladder wall sign: An overlooked sign of acute cholecystitis on unenhanced CT.  Journal of Clinical Imaging, 28: 128-131.

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Tsai, Yuan-Ming, Chiao-Hsiung Chuang, Hsiu-Chi Cheng, Wei-Lun Chang, Ai-Wen Kao, and Chiung-Yu Chen. 2005. Usefulness of Fatty-meal Stimulated Gallbladder Contractility by Ultrasonography in the Diagnosis of Acute Cholecystitis. Journal of Medical Ultrasound 13 (4):179-185.

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