by Richard Mitchell, MD, PhD

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    00:01 Okay, then, let's jump in immediately and start talking about inflammation of the gallbladder or cholecystitis.

    00:08 Most of the time, cholecystitis is going to be due to gallstones.

    00:11 It's a complication of those and their obstruction of either the cystic duct or the common bile duct.

    00:18 So, that would be calculus cholecystitis. In the acute setting, you suddenly impact the ducts, the cystic duct or common bile duct with the stone and you get acute inflammation with associated edema, dilation of the duct, and there's intense pain.

    00:38 You may have a more chronic slow motion form of a calculus cholecystitis where it's a little bit of obstruction over and over and over again, the associated inflammation with time can lead to fibrosis of the gallbladder or the cystic duct.

    00:53 And this is not associated with that intense acute onset pain.

    00:57 But there will be mechanical irritation from the gallstones.

    01:02 You may have small recurrent attacks of acute cholecystitis that resolve but the ongoing inflammation in the biliary tree definitely increases the risk of malignancy, either in the gallbladder or in the biliary ducts.

    01:19 There is also acalculous cholecystitis. So, acalculous meaning no stone.

    01:24 The gallbladder inflammation in this case is probably due to bile stasis and then, that kind of stasis with or without kind of sludging, without a formal stone may cause secondary ischemia.

    01:37 This is usually in the chronically ill population. It may also occur in immunocompromised hosts.

    01:43 And so, someone who's been in the hospital for a long time may develop symptoms related to inflammation of the gallbladder. Ultrasound may not find any stone.

    01:54 The overall epidemiology of this. So, in the same way that gallstones, Choleliths were common in women, occur in ages around 40 to 50.

    02:04 Cholecystitis is also going to be more common in women than in men with a peak incidence in the ages 40 to 50.

    02:12 It doesn't occur just because you have gallstones.

    02:15 Only about 10% of patients who actually have gallstones will develop either acute or chronic cholecystitis.

    02:22 Other risk factors associated with cholecystitis, inflammation of the gallbladder include pregnancy or hormone therapy that has to go along with the fact that women get it more commonly than men.

    02:32 And this has to do with the effects of estrogen on the production of bile salts versus conjugated bilirubin and the relative levels of the different constituents within the gallbladder.

    02:43 So, it's all related mostly to cholelith formation. Older age clearly is associated with this.

    02:50 The Native American and Hispanic populations have a higher incidence of choleliths otherwise, in any other setting, and so, will have a higher incidence also of cholecystitis and obesity and diabetes, again, associated with the formation of stones, so, that's going to be a risk factor for the inflammation associated with stones.

    03:12 The pathophysiology overall, so, in calculous cholecystitis, not really a hard thing to understand. Gallstones that form, typically, within the gallbladder itself are - move out into the cystic duct and then, can block the biliary tree, leading to distension and associated inflammation.

    03:32 And it's shown here at the junction of the cystic duct and the common bile duct.

    03:36 But it can occur more distally or more proximally.

    03:41 In acalculous cholecystitis, there's relative biliary stasis, no stone.

    03:46 The gallbladder will be distended as a result of that stasis.

    03:50 And then, there's secondary vascular compromise that leads to the inflammation.

    03:56 Clinical presentation overall is going to be mostly pain and it's going to be pain in the right upper quadrant.

    04:02 So, you will have the patient describe to you that I have this pain.

    04:09 It's usually post-prandial, so, it's associated with eating food. It can be prolonged for up to hours.

    04:15 It's happening post-prandially because that's when the gallbladder is ejecting its contents or attempting to eject its contents into the duodenum.

    04:24 In particularly, in fatty meals which will cause a greater contraction of the gallbladder through the effects of cholecystokinin, you will have more effects following a meal.

    04:36 There may be radiation to the right scapula, so, posterior and then, on the right side.

    04:43 That's the so called Boas sign. You may have pain during palpation.

    04:49 That's a Murphy sign. So, you press and it's like, "Oh, I don't like that." You may also have a palpably enlarged gall bladder. That's the Courvoisier sign.

    04:58 So, all these signs that are classic. They don't have to be present.

    05:02 So, you need to have a reasonably high index of suspicion in the appropriate patient with the symptomatology of post-prandial pain in the right upper quadrant.

    05:12 There may be, depending, because this is inflammation, there may be fever.

    05:16 The kind of systemic manifestations. And the patient won't feel like eating.

    05:20 There may be nausea and vomiting. Again, whenever you dilate a viscus anywhere within the body, that is perceived as pain and can drive nausea and vomiting.

    05:33 Making the diagnosis. Laboratory tests will help but they're not going to be that specific.

    05:38 Imaging is going to eventually make the appropriate diagnosis but you may see elevations of bilirubin and alkaline phosphatase.

    05:45 And, again, alkaline phosphatase is a reasonably good biomarker for obstruction anywhere within the biliary tree.

    05:52 Notably, bilirubin and alk phos can be completely normal in relatively uncomplicated cases.

    05:58 So, you can't use that to rule out cholecystitis.

    06:02 Overall, the transaminases or the transferases are not going to be particularly elevated.

    06:07 There's not a lot of the hepatocyte damage. There will be a leukocytosis because this is inflammation.

    06:12 So, we will drive an elevated white cell count, predominantly, neutrophils.

    06:17 Ultrasound as I said, is going to be your test of choice. So, you will see gallbladder wall thickening and edema.

    06:23 That's an inflammation. You may see dilated bile ducts somewhere along the biliary tree, depending on where the stone has impacted.

    06:32 You will often be able to identify a stone or a sludge. You can also see a sonographic Murphy's sign.

    06:41 So, what that is remember, Murphy's sign, positive Murphy's sign is you palpate the right upper quadrant and they go "ouch". Now, you do that with the sonograph or with the echo probe and they go "ouch", sonographic Murphy's sign.

    06:56 That will make the diagnosis in the vast majority of cases.

    07:01 However, there can be equivocal ultrasounds and in that case, what we would do is an hepatobiliary iminodiacetic acid HIDA scan.

    07:11 A HIDA scan is a radiotracer and it's taken up and metabolized in the same way that bile acids or that bile precursors are in the liver and we can watch as that radiotracer is metabolized by the liver and then, accumulated within either the gallbladder or following kind of squeezing of the gallbladder by meals or whatever, you can see it eject into the cystic duct and then, the common bile duct.

    07:43 If you have abnormalities in terms of the formation of the HIDA tracer through the liver and into the gallbladder or if you have abnormal motion of the radiotracer from the gallbladder through the cystic duct and into the common bile duct, that can be indicative and is used as a diagnostic evaluation for saying that there is then a cholecystitis.

    08:10 Computer tomography overall can be used but it's not going to be as useful.

    08:15 And magnetic resonance, cholangiopancreatography, specifically, looking for areas of bile duct thickening or inflammation may also be used.

    08:30 How are we going to manage this? So, in an initial setting before you call your friendly neighborhood surgeon, you're going to give analgesia, fluid hydration, electrolyte correction, antiemetics because they're vomiting, antibiotics to cover then secondary bacterial infections in the setting of this inflammation.

    08:48 Surgery is going to be what you need to do. You have to do a cholecystectomy and remove the gallbladder and that will remove then the source of the inflammation along with the presumed stone that's going to be there.

    09:04 You can do this as an endoscopic procedure, the endoscopic retrograde cholangiopancreatography, ERCP if there's a stone and you need to dilate a duct, that may be a way to do this but in general, I think that most patients will probably end up going to surgery.

    09:21 You may want to calm down an acute cholecystitis if it's really hot, very inflamed, you may not operate immediately.

    09:30 You'll give analgesia, fluid hydration, antiemetics and antibiotics and wait for the thing to cool down.

    09:36 And then, you'll go in and remove it.

    09:39 The complications depending on the degree of inflammation and necrosis and secondary infection, etc.

    09:45 is that you can get emphysematous cholecystitis.

    09:47 In fact, that's now the microorganisms within the ascending bile is become - start fermenting and you see air within the wall of the gallbladder or the ducts.

    10:03 That's a very bad sign. You can get a gallstone ileus.

    10:07 So, if gallstones make it into kind of the distal part of the gall duct system, then, you can get in the duodenum, a secondary ileus.

    10:23 So, the bowel will kind of quit functioning and won't have its normal peristaltic motion.

    10:28 You're going to have perforation of the gallbladder with severe infection, inflammation, and ischemia.

    10:34 Hepatic duct obstruction, so, within the portion of the biliary tree within the hepatic, within the liver, can become secondarily obstructive due to edema and/or other inflammation.

    10:51 The so called Mirizzi syndrome and clearly, with ongoing inflammation, particularly, with chronic cholecystitis, you have an increased risk of malignancy, up to two-fold.

    11:03 And that's another strong indication to do the surgery and remove that tissue before it develops cholangiocarcinoma. With that, we've covered cholecystitis.

    About the Lecture

    The lecture Cholecystitis by Richard Mitchell, MD, PhD is from the course Disorders of the Biliary Tract.

    Included Quiz Questions

    1. Chronically ill patients
    2. Men
    3. Patients undergoing testosterone supplementation
    4. Teenagers
    5. Elderly patients
    1. Pregnancy
    2. Older age
    3. Native American heritage
    4. Ulcerative colitis
    5. Rheumatoid arthritis
    1. Fatty meal
    2. Alcohol-laced meal
    3. High-carbohydrate meal
    4. Vegetarian meal
    5. High-protein meal
    1. Ultrasound
    2. Hepatobiliary iminodiacetic acid scan
    3. Abdominal X-ray
    4. CT-guided biopsy
    5. MRI abdomen
    1. Pancreatic pseudocyst
    2. Emphysematous cholecystitis
    3. Gallstone ileus
    4. Gallbladder perforation
    5. Hepatic duct obstruction

    Author of lecture Cholecystitis

     Richard Mitchell, MD, PhD

    Richard Mitchell, MD, PhD

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