Cholecystitis

It is probably inappropriate, although classical, to subdivide chronic and acute calculous cholecystitis. They are part of the same spectrum of disease and are related to inflammation within the gall bladder secondary to obstruction of the cystic duct by stones. With stones in a gall bladder it appears that there is always some degree of inflammatory change, but there is insufficient evidence to suggest that this is a cause of symptoms. The concept of ‘flatulent dyspepsia’ being caused by gallstones in the absence of the classic symptoms of biliary colic is probably inappropriate. Nevertheless, some patients do complain of right hypochondrial pain of varying severity in associa­tion with nausea and occasional vomiting, and some tenderness in the right subcostal region. Flatulent dyspepsia is common in such patients yet many will not be relieved by cholecystectomy. Numerous investigations have been performed to determine whether those with symptoms of dyspepsia will benefit from cholecystectomy; all have proved ineffective and thus the surgeon must rely on clinical judgment.

Clinical features

The patient has specific episodes of right subcostal pain radiating to the back and to the shoulder. Occasionally the pain starts on the left subcostal side or even in the epigastrium, but at its most severe it is invariably on the right side. Pain may radiate to the chest. The pain is usually severe and may last for minutes or even several hours. Frequently, the pain starts during the night and wakes the patient. Minor episodes of the same discomfort may occur intermittently during the day. Dyspeptic symptoms may coexist and be worse after such an attack. As the pain resolves the patient improves and is able to eat and drink again, often only to suffer further episodes. It is of interest that the patient may have several episodes of this nature over a period of a few weeks and then no more trouble for some months.

If the pain does not resolve the patient will become more systemically unwell as infection supervenes. This is associated with a continuous pain, nausea, vomiting and pyrexia. On examination the patient will be tender in the right subcostal area and may develop guarding, even rigidity, and later a mass may be palpable as the omentum walls off an inflamed gall bladder.

Fortunately, this process is limited by the stone slipping back into the body of the gall bladder and the contents of the gall bladder escaping by way of the cystic duct. This achieves adequate drainage of the gall bladder and enables the inflammation to resolve.

If resolution does not occur the gall bladder may perforate with the development of localised peritonitis or an abscess may form; the abscess may then perforate into the peritoneal cavity with a septic peritonitis — this is uncommon, however, because the gall bladder is usually localised by omentum around the perforation.

When examining a patient with acute cholecystitis it should be noted whether the patient is pyrexial, is jaundiced or dehydrated. His or her respiration should be noted to determine whether there is pain on deep inspiration. On examining the abdomen it is important to determine whether the movement is normal or shallow breathing is present with intestinal distension. The abdomen should be palpated gently, working towards the subcostal area where tenderness with guarding may be noted. In some patients a mass may be palpable. Bowel sounds are usually present but reduced.

Differential diagnosis

Conditions commonly presenting similarly to acute cholecystitis are appendicitis, perforated peptic ulcer and acute pancreatitis. Occasionally acute pyelonephritis of the right kidney, myocardial infarction and right lower lobe pneu­monia may lead to confusion. The diagnosis is confirmed by ultrasonography which should show the presence of stones in an inflamed gall bladder with oedema around the gall bladder wall (Fig. 54.32). The stone can often be observed impacted in the infundibulum. A serum amylase estimation should be performed to exclude pancreatitis, and liver functions tests performed to determine whether or not jaundice is present. A mild elevation of the bilirubin can merely be due to oedema around the portahepatis or obstruction of the biliary tree by a stone escaping into the common bile duct. The distended bile duct should be noted on ultrasonography. A chest X-ray will exclude pneumonia, and if there is doubt concerning a cardiac origin then an electrocardiogram should be performed. Renal disease can be excluded by sending the urine for microscopy and culture.

Treatment

Conservative treatment followed by cholecystectomy

Experience shows that in more than 90 per cent of cases the symptoms of acute cholecystitis subside with conservative measures. Nonoperative treatment is based on four principles:

  nasogastric aspiration and intravenous fluid administration;

  administration of analgesics;

   administration of antibiotics — as the cystic duct is blocked in most instances, the concentration of antibiotic in the serum is more important than its concentration in bile. A broad-spectrum antibiotic effective against Gram-negative aerobes is most appropriate (e.g. cephazolin, cefuroxime or gentamycin);

  subsequent management — when the temperature, pulse and other physical signs show that the inflammation is subsiding, the nasogastric tube is removed and oral fluids followed by a fat-free diet are given. Ultrasonography is performed to ensure that no local complications have developed, that the bile duct is of a normal size and that no stones are contained in the bile duct. Cholecystectomy may either be performed on the next available list, or the patient is allowed home to return later when the inflammation has completely resolved.

Conservative treatment is not advised when there is uncertainty about the diagnosis and the possibility of a high retrocaecal appendix or a perforated duodenal ulcer cannot be excluded.

Conservative treatment must be abandoned if the pain and tenderness increase; in this case a percutaneous cholecystostomy performed by the radiologist under ultrasound control will rapidly relieve symptoms. Subsequent cholecystectomy will be required.

Routine early operations

Some surgeons advocate urgent operation as a routine mea­sure in cases of acute cholecystitis. Provided that the operation is undertaken within 48 hours of the onset of the attack, the surgeon is experienced and excellent operating facilities are available, good results are claimed. Nevertheless, the conversion rate in laparoscopic cholecystectomy is five times higher in acute than in elective surgery.

Mucocele of the gall bladder

This occurs when the neck of the gall bladder becomes obstructed by a stone but the contents remain sterile. The bile is absorbed and replaced by mucous secreted by the gall bladder epithelium. The gall bladder may be palpable. Enormous sizes and shapes have been encountered. A mucocele also occurs in those cases of malignancy which occlude the cystic duct, for instance a cholangiocarcinoma.

Empyema of the gall bladder

The gall bladder appears to be filled with pus but, surprisingly in over half of cases, bacteria cannot be cultured from this pus. It may be a sequel of acute cholecystitis or the result of a mucocele becoming infected. The treatment is drainage and, later, cholecystectomy (Fig. 54.33).

Acalculous cholecystitis

Acute and chronic inflammation of the gall bladder can occur in the absence of stones and give rise to a clinical picture similar to calculous cholecystitis. Some patients have non­specific inflammation of the gall bladder, whereas others have one of the cholecystoses. Oral cholecystography is more useful than ultrasonography in the diagnosis of those patients presenting with chronic symptoms, and radioisotope scanning in those presenting acutely. The identification of cholesterol crystals in a duodenal aspirate may also help. Acute acalculous cholecystitis is particularly seen in patients recovering from major surgery, trauma and burns. In these patients the diagnosis is often missed and the mortality rate is 20 per cent.

The cholecystoses (cholesterosis, polyposis, adenomyomatosis and cholecystitis glandularis proliferans)

This is a not uncommon group of conditions affecting the gall bladder in which there are chronic inflammatory changes with hyperplasia of all tissue elements.

Cholesterosis (‘strawberry gall bladder’)

In the fresh state the interior of the gall bladder looks something like a strawberry; the yellow specks (submucous aggre­gations of cholesterol crystals and cholesterol esters) correspond to the seeds (Fig. 54.34). It may be associated with cholesterol stones.

Cholesterol polyposis of the gall bladder

Cholecystography shows negative shadows in a functioning gall bladder, or on ultrasound there is a well-defined polyp present. These are either cholesterol polyposis or adenomatous change. With improving ultrasonography they are seen more frequently and surgery advised only if they change in size.  Figure 54.35 summarises the varieties of this condition. A polyp of the mucous membrane is fleshy and granulomatous. All layers of the gall bladder wall may be thickened but some­times an incomplete septum forms which separates the hyperplastic from the normal. Intraparietal ‘mixed’ calculi may be present. These can be complicated by an intramural, and later extramural, abscess. If symptomatic, the patient is treated by cholecystectomy.

Diverticulosis of the gall bladder

Diverticulosis of the gall bladder is usually manifest as black pigment stones impacted in the out-pouchings of the lacunae of Luschka. Diverticulosis of the gall bladder may be demonstrated by cholecystography, especially when the gall bladder contracts after a fatty meal. There are small dots of contrast medium just outside the gall bladder (Fig. 54.36). A septum may also be present (to be distinguished from the Phrygian cap — Fig. 54.26) and the treatment is cholecystectomy.

Typhoid gall bladder

Salmonella typhi (‘Typhoid Mary’, a cook-general who passed Salmonella typhi in her faeces and urine, was responsible for nearly a score of epidemics of typhoid in and around New York City) or, occasionally, Salmonella typhimunium can infect the gall bladder. Acute cholecystitis can occur. Mote frequently, chronic cholecystitis occurs, the patient being a typhoid carrier excreting the bacteria in the bile. Gallstones may be present (surgeons should not give patients their stones after their operation if there is any suspicion of typhoid!). It is debatable whether the stones are secondary to the salmonella cholecystitis or whether pre-existing stones predispose the gall bladder to chronic infection. Salmonellae can, however, frequently be cultured from these stones. Ampicillin and cholecystectomy are indicated.