Chapter 1 of 7 · Fundamentals
Pathophysiology
Pathophysiology and Risk Factors of Cholecystitis
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What the experts said
Cholecystitis is an obstructive diverticulopathy, similar to appendicitis or diverticulitis of the colon, involving blind pouches with narrow outlets that can become obstructed.
When the cystic duct becomes obstructed by a stone or mucus plug, gallbladder contents increase due to secretion while arterial inflow at 120 mmHg continues but venous outflow at 7-8 mmHg is overcome, trapping blood within the gallbladder wall.
Biliary colic occurs when the obstructing stone falls away early in the process, allowing the patient to become asymptomatic, and this can recur with multiple episodes of intense pain.
Without relief of obstruction, the gallbladder may undergo ischemia, leading to pericholecystic fluid, empyema, and subhepatic abscess.
Acalculous cholecystitis occurs when the gallbladder becomes atonic in patients who haven't been eating for a long time or are critically ill, with continued fluid secretion and poor emptying despite absence of stones.
Southwestern Indians and patients in South America have a high incidence of gallstones due to genetic predispositions.
Patients with hemolytic diseases such as sickle cell anemia or spherocytosis can develop bile salt stones.
Patients with rapid weight loss from diets or weight loss surgery develop gallstones with increased frequency.
Biliary colic typically presents with right upper quadrant pain and nausea, often with vomiting, 20 minutes to 2 hours after eating due to cholecystokinin secretion from duodenal mucosa in response to fat.
Murphy's sign—tenderness with a deep breath in the right upper quadrant that stops the patient's breath—suggests cholecystitis but can be present in other conditions including pancreatitis.
Transaminases are elevated out of proportion in hepatocellular disease, while alkaline phosphatase and GGT are elevated out of proportion in biliary duct obstruction.
Right upper quadrant ultrasound is superior to CT scan for initial diagnosis of cholecystitis and biliary colic because it shows gallbladder anatomy, wall thickness, pericholecystic fluid, stones in the gallbladder, and common bile duct diameter.
CT scan is better than ultrasound when pancreatitis is suspected or there is any question about the pancreas.
ERCP should not be performed for minimal bilirubin elevation (less than 2) or acute pancreatitis that improves in the first day, as studies show two-thirds of these patients have a normal duct because they passed the stone.
ERCP should be performed when bilirubin is 4 or higher and not improving, as other conditions like ampullary tumors and ductal problems could cause elevated bilirubin.
Patients should not be taken to the operating room for gallbladder operation with deep jaundice without advanced biliary imaging like ERCP or MRCP.
Intraoperative cholangiogram should be performed if there is elevated bilirubin, abnormal liver functions, dilated duct on ultrasound, or recent pancreatitis—this is called selective cholangiography.
HIDA scan evaluates gallbladder function rather than anatomy; if the gallbladder does not fill, this indicates cystic duct obstruction and acalculous cholecystitis.
CCK cholecystography with IV cholecystokinin or fatty meal evaluates gallbladder motility; a normal gallbladder has an ejection fraction over 35%, while ejection fraction less than 35% indicates biliary dyskinesia.
Current practice is to perform surgery during the index hospitalization after patient stabilization, rather than the old approach of bed rest, NPO, IV antibiotics, discharge, and delayed surgery in six weeks.
Percutaneous transhepatic cholecystostomy to vent the gallbladder can be used in unstable patients (such as recent MI) with acute cholecystitis, allowing delayed surgery when the patient is lower risk.
Antibiotic coverage for cholecystitis should target E. coli, Enterococcus, Klebsiella, and Enterobacter, with cephalosporins and fluoroquinolones being appropriate choices.
The cystic duct can have aberrant entries including into the right hepatic duct, an accessory right hepatic duct, or can run parallel with the common duct in a common sheath all the way to the papilla of Vater.
Anatomical variations include double gallbladder, totally intrahepatic gallbladder, and cystic artery that can flip over the cystic duct.
Calot's triangle is bordered by the cystic duct below and the cystic artery above.
The critical view of safety requires visualization of the cystic duct, cystic artery, and location of the common duct before dividing any structures.
The gallbladder bed should be inspected with the abdomen deflated after removing the gallbladder, as pneumoperitoneum pressure can mask bleeding.
Conversion to open surgery is indicated for dense adhesions, unclear anatomy, unplanned bleeding, or lack of progress, and is a management decision rather than a failure.
Post-operative tachycardia, hypotension, or requirement for fluid pushes in the recovery room is not normal and may indicate acute bleeding from the cystic artery, requiring immediate return to the operating room.
A patient presenting to the emergency department 2-3 days post-operatively with right upper quadrant pain should be assumed to have a complication, most often a bile leak.
For suspected bile leak, CT scan showing fluid in the gallbladder fossa should be tapped by radiology to confirm bile, followed by pigtail catheter placement and immediate ERCP.
A biliary stent lowers pressure in the normal direction to zero, allowing bile leak from cystic duct or duct of Luschka to heal within days, with stent removal at six weeks.
Retained common bile duct stones can be removed with ERCP with a 95% success rate.
A patient with cholecystitis should not leave the hospital until they have their operation performed.