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
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
• 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.
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.