ACUTE cholecystitis is inflammation of the gall bladder, a pear-shaped organ located under the liver in the upper right side of the abdomen.

Usually caused by blockage of the duct leading from the gallbladder, the cystic duct, by gallstones, the condition is termed calculous or gallstone cholecystitis. It can also be obstructed by sediments or sludge from around the ducts from the liver connected to the gall bladder — biliary tree — masses like polyps or tumours, foreign bodies, and parasites.

Cholecystitis that occurs without gallstones is termed acalculous cholecystitis and is usually seen in patients with critical illness, burns, severe infections, post surgery, and major trauma.

RISK FACTORS

Gallstones are commonly found in patient’s who are fat, female, fertile, and the age of 40 and above.

Therefore the risk factors for gallstones include obesity, older age, female, pregnancy, having many children, taking oestrogen hormones, rapid weight loss, and the Indian race. Blacks and whites have a lower prevalence of gallstones.

SIGNS AND SYMPTOMS

Most people with gallstones have no symptoms, an estimated 10 per cent of the population in the USA. Only one or two out of every 10 people with gallstones will ever have pain and only seven per cent will require surgery. Less than five per cent will have complications such as acute cholecystitis. In Jamaica gallstones are very common, especially due to the prevalence of patients with sickle cell disease.

Gallstones may be made from cholesterol (80 %) or pigmented (black and brown stones). Black stones are seen in patients with cirrhosis of the liver and sickle cell disease, while brown stones are associated with infections and are usually found elsewhere in the biliary tree. Gallstones are formed when bile, a substance made in the liver and stored in the gallbladder to aid in digestion, becomes very saturated. They also form when the gallbladder has defects in its motion and absorption.

When the cystic duct is obstructed, whether by gallstones, parasites or tumours, the gallbladder continues to produce mucus and pressure builds up in it causing decrease movement of blood in the veins and arteries. The areas of the gallbladder mucosa or wall devoid of blood flow then become starved of oxygen and the areas undergo death of the cells. This can lead to the gallbladder forming a bag of pus or bursting, spilling its contents into

the abdomen.

The patient with acute cholecystitis presents with pain in the upper right abdomen or in the area of the stomach. The pain can often radiate to the back. The pain waxes and wanes, often described as colicky, which means coming in waves of intensity. It worsens after a fatty meal as that triggers contraction of the gallbladder to release its stored bile to emulsify the fats to aid in digestion.

Nausea, vomiting, fever, increased pulse rate, and a feeling of decreased appetite may also be present in a patient presenting with acute cholecystitis.

When the doctor presses under the right rib cage, over the gallbladder, the patient will stop breathing in, due to intense pain, which is known as Murphy’s sign.

DIAGNOSIS

The patient should present to the emergency department once they are experiencing these symptoms. The doctor will do blood tests which may show an increase in the white cell count. An ultrasound clinches the diagnosis and may show the stones or sludge, an enlarged gall bladder, thickened gall bladder wall, or fluid around the gall bladder. Other investigations can be done such as cholescintigraphy (HIDA scan), by injecting ionising radiation in the veins and the liver takes it and gets rid of it through its ducts. The gall bladder will not be seen if obstructed. An MRI can also be used, but it is usually unavailable and expensive with the advantage of not having radiation involved.

TREATMENT

Treatment of cholecystitis is usually surgery by opening the belly and removing the gall bladder, however, laparoscopy has become the standard. It affords a smaller cut on the abdomen, early discharge from hospital, reduced pain, and an earlier return to normal life. The timing of the surgery is dependent on the surgeon and the patients’ presentation. Early surgery may be chosen versus delayed surgery in one to two months after treatment of the patient with antibiotics and settling down of the inflammation.

The prognosis of a patient with acute cholecystitis is usually good, however, with complications such as rupturing of the gall bladder, pus in the gall bladder, gangrene, and overwhelming infection, there may be increased morbidity and mortality.

Dr Romayne Edwards is a consultant emergency physician at the University Hospital of the West Indies and an associate lecturer at the University of the West Indies.