Health

Cholecystitis – Causes, Symptoms and Treatments

✅ Evidence Based Article

Cholecystitis is a fairly common gastrointestinal disorder. In the United States, it accounts for more than 200, 000 hospital admissions each year. (1)

It is potentially serious and can cause life-threatening complications if left untreated. In this article, we discuss the causes, signs and symptoms, diagnosis, treatment, diet modifications and prevention of cholecystitis.

What is cholecystitis?

Cholecystitis is an inflammation of the gallbladder. The gall bladder is a four-inch pear-shaped organ that is positioned on the right upper quadrant of the abdomen, just under the liver. It stores bile, which is needed for digestion of fats in food.

Cholecystitis commonly occurs in people with gallstones. For gallstones to occur, it can be due to supersaturation of bile with cholesterol, slowed or no movement in the gallbladder or acceleration formation of crystals in the gallbladder. (2)

Cholecystitis can either be acute (occurs suddenly) or chronic (recurs multiple times).

What Causes Cholecystitis?

There are two main causes of cholecystitis: calculous and acalculous cholecystitis.

Calculous cholecystitis is the commonest (accounts for about 95% of the cases (3) and is less serious. It develops when the cystic duct (the opening of the gall bladder) gets blocked by a gallstone or biliary sludge.

Biliary sludge is a mixture of particulate solids that have precipitated from bile. The blockage then causes bile to build up in the gall bladder and increases pressure. The concentrated bile and sometimes bacteria, irritate the bladder, causing inflammation and swelling.

If not treated, the blockage can impede blood flow, and consequently lead to cell death.

Acalculous cholecystitis is less common and more dangerous. It develops secondary to infections (such as HIV), chemotherapy, injury to the gall bladder or due to another illness. An injury may be due to burns, surgery, or trauma, such as in an accident.

What increases the chances of having cholecystitis?

Cholecystitis can affect anyone, but women are at a higher risk than men. (4) Other risk factors include: (5)

Obesity. Excess fats in the body change the composition of bile and make it more likely that cholesterol will precipitate to form crystals, which then become gallstones.

Age. It is more common in individuals over the age of 40.

Family history of gallstones and cholecystitis.

Drugs such as oral contraceptives and pregnancy. Elevated levels of estrogen and progesterone cause higher cholesterol levels in bile and cause changes on the gallbladder motility.

Rapid weight loss. The body speedily metabolizes fats, which makes the liver excrete extra cholesterol in bile, increasing the risk of gallstones.

Diabetes. The high triglyceride levels, stasis in the bile duct and insulin resistance in diabetes mellitus contribute to increased concentration in bile constituents and slow flow in the ducts.

Liver disease. People with non-alcoholic fatty liver disease and Viral C hepatitis have cholesterol supersaturated bile and hence have a very high risk of formation of biliary sludge, which slows the flow of bile contents out of the gallbladder.

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What are the Signs and symptoms?

The main symptom is sudden intense and sharp pain on the right upper part of the abdomen that lasts longer than a few hours. The pain may spread to the shoulder and is precipitated by eating a fatty meal. Moreover, it gets worse when inhaling.

Additional symptoms include:

  • Fever
  • Nausea and vomiting
  • Loss of appetite
  • Mild yellowing of the skin (jaundice)
  • Tenderness of the abdomen on touch
  • Loose and light-colored stool

The gold standard of diagnosing cholecystitis

The diagnosis of cholecystitis is guided by the history of the signs and symptoms, physical examination, imaging studies, and laboratory investigations.

1.History taking

The doctor asks about the symptoms, the characteristics of the pain, when it started and the precipitating factors. They will also be interested in whether the patient has a history of gallstones or cholecystitis because this condition often recurs.

2.Physical examination

Physical examination gives the clinician a chance to reveal how tender the gallbladder is. The clinician checks whether there is a positive Murphy’s sign (6) by asking you to take and hold a deep breath while palpating the upper right quadrant of the abdomen.

If there is pain elicited, then there is a positive Murphy’s sign, a strong indicator of acute cholecystitis.

3.Blood workups

Although blood workups are not always reliable for diagnosing cholecystitis, they are necessary for investigating underlying problems and for ruling out other conditions. (7) A complete blood count shows a high white blood cell level if there is an infection.

Liver function tests are ordered to assess how well the liver is working. (8) Urinalysis helps rule out renal calculi and pyelonephritis.

4.Imaging studies

The American College of Radiology (ACR) (9) recommends the following imaging tests:

Abdominal ultrasound shows the gallbladder, the internal abdominal organs and also, blood flow in and out of the gallbladder. It can as well demonstrate thickening of the gallbladder wall and any obstructions on the cystic duct.

CT scan gives a more detailed outlook of the abdominal organs, and it allows better evaluation of other complications other than cholecystitis.

Percutaneous Transhepatic Cholangiography (PTC)- by using a dye, PTC can show how bile is moving from the liver through to the gallbladder and throughout the body. The dye is injected into the bile ducts then images are taken to locate any obstruction.

Hepatobiliary iminodiacetic acid (HIDA) scan uses nuclear imaging to view the gallbladder, bile ducts, and the liver. The clinician can observe how the liver excretes bile, its flow to the gallbladder and how it enters the small intestines.

Since HIDA is a nuclear medicine test, it is contraindicated in pregnant women.  

Endoscopic Retrograde Cholangiopancreatography (ERCP) also uses a dye to show how bile is flowing through the digestive system.

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A long, flexible tube with a camera and light at the leading part is passed down the throat to the small intestines then a contrast material is injected and X-rays are taken.

How is cholecystitis treated?

For the treatment of cholecystitis, a hospital stay of about two to four days is necessary. Treatment approaches include:

Fasting in order to keep the stomach empty and make the gallbladder rest. To prevent dehydration and hypoglycemia, the doctor prescribes intravenous fluids. Fasting is also necessary in anticipation for surgery.

Medications- the doctor prescribes pain killers for abdominal pain control and antibiotics to fight infections.  For mild cases, the doctor prescribes a single broad-spectrum antibiotic such as tazobactam, metronidazole, meropenem or cephalosporins. (10)

Antiemetics are also prescribed if there is nausea and vomiting.

Gallbladder removal, a procedure known as cholecystectomy, is the standard care especially for acute cholecystitis as there is a high risk of recurrence. (11)

Surgery is also indicated if there is perforation of the gallbladder, tissue death or an infection. It is a low-risk procedure that can take one to two hours.

The surgeon makes an incision on the abdomen and resects the gallbladder. After the procedure, bile flows directly from the liver to the small intestines.

Cholecystectomy does not affect digestion and the overall health of the gastrointestinal tract, but more frequent episodes of diarrhea may be observed. (12) To sidestep the effect of diarrhea and bloating, avoid eating high-fat and spicy meals, for the digestive tract to get used to the changes. (13)

Percutaneous Transhepatic Gallbladder Drainage (PTGBD) is considered if one is at high surgical risk. (14) A hollow needle is inserted into the gallbladder, and the biliary sludge is then emptied.

The drawback of PTGBD is that there is a risk that bile can leak into the peritoneal cavity, causing inflammation.

Dietary changes for cholecystitis

Following medical treatment, it is important to make dietary adjustments to regularize bile production and flow. As mentioned above, a high-fat, low fiber diet from a surplus of animal protein and animal fat is the primary nutritional risk of gallstone development, the leading predisposing factor to cholecystitis.

Therefore, it is crucial to incorporate gall-bladder friendly foods and shun those that aggravate the bladder.

Eat a healthy, well-balanced diet full of fiber, fruits, and vegetables, as they are essential for a healthy gall bladder. Go for plant-based proteins such as beans, nuts, lentils, and soy for they are excellent alternatives for red meat (a source of saturated fats) and are also known to prevent lifestyle diseases such as hypertension.

Avoid high-fat and processed foods, greasy or fried oils, full-fat dairy, and cream sauces. They are more difficult to break down, activate the gallbladder and increase cholesterol in bile juice. If you must take fats, take no more than 3 grams. (15) Also, limit caffeine and very sweet foods.

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Replace sugars and refined sugars with complex, high-fiber carbohydrates such as oatmeal, yams, sweet potatoes, whole wheat bread, and brown rice. However, complex carbs should be taken in moderation.

Excessive intake increases the glycemic load, which then increases the risk of cholesterol saturation and contributes to weight gain. (16)

Take small and frequent meal portions. Large portions may upset the digestive system and also cause bile duct spasms.

Take plenty of water, about 8 to 10 glasses per day. Water helps flush out excess cholesterol and keeps bile production and flow smooth.

What problems can cholecystitis cause?

If cholecystitis is not treated it may cause:

  • The infection may spread to other abdominal organs such as the pancreas, causing pancreatitis and peritonitis (infection of the lining of the abdominal wall).
  • Liver damage
  • It can also result in perforation of the gallbladder, causing a fistula or communication between the gallbladder and duodenum. Bile then leaks out to the peritoneum, where it causes peritonitis.
  • Tissue death can also occur, leading to gangrene, shrinkage or bursting of the gallbladder. This is quite serious because the dead tissue is vulnerable to serious infection that can turn to sepsis.

How can Cholecystitis be prevented?

It is possible to lower the chances of developing cholecystitis or even prevent its reoccurrence. There is scientific evidence that the most significant risk factor for cholesterol is the formation of gallstones.

Therefore, taking active steps to prevent gallstones is the most effective way of reducing the risk of cholecystitis.

Maintaining a healthy weight: being obese or overweight increases the amount of cholesterol in bile, raising the chances of developing gallstones. If losing weight, choose sustainable, healthy weight loss approaches that are not rapid and do not involve skipping meals. Aim to lose 0.5 to 1 kilo (1 to 2 pounds) per week.

Healthy diet– high fat and low fiber diets increase the risk of gallstones. To lower the chances, go for food that is high in fruits and vegetables, whole grains, low-fat dairy low healthy choices include eggs soybeans, and peanuts.

Exercise – regardless of whether one is overweight or not, physical activity should be part of a healthy routine. It not only lowers the risk of cholecystitis but it also reduces the risk of cardiovascular diseases and many other chronic illnesses.

The American Heart Association recommends at least 150 minutes of moderate intensity exercise per week. (17)

Moderate alcohol intake– overconsumption of alcohol is one of the major causes of liver diseases in Western countries. (18) Liver damage contributes to bile duct obstruction and extensive fibrosis, which causes low mobility of the gallbladder. If you must consume alcohol, limit it to one drink per day (for women) and two drinks for men. (19)