Cholezystitis

Cholecystitis is an inflammation of the gallbladder. It most commonly refers to acute calculous cholecystitis, where obstruction of the cystic duct by gallstones leads to gallbladder inflammation, though acalculous cholecystitis can occur in critically ill patients without stones. Chronic cholecystitis results from repeated bouts of inflammation and fibrosis.

Etiology and pathophysiology: The typical sequence starts with obstruction of the cystic duct by a gallstone. This causes gallbladder distention, stasis, bacterial overgrowth, and inflammation. In acalculous cases, gallbladder ischemia and stasis contribute. Conditions such as severe illness, trauma, or procedures can predispose to acalculous cholecystitis.

Clinical features: Acute cholecystitis presents with sudden, severe right upper quadrant or epigastric pain that may radiate to the right shoulder or back, often lasting several hours. Fever, nausea, and vomiting are common. A positive Murphy sign on examination supports gallbladder inflammation. Jaundice is not typical unless there is concomitant biliary obstruction.

Diagnosis: Ultrasound is the first-line test, showing gallstones, gallbladder wall thickening, pericholecystic fluid, and sometimes a sonographic Murphy sign. Laboratory studies typically reveal leukocytosis; mild transaminase or alkaline phosphatase elevations may occur if bile duct involvement is present. If ultrasound is inconclusive, a HIDA scan can assess gallbladder function and cystic duct obstruction. CT or MRCP may be used to evaluate complications or other causes.

Treatment: Initial management includes hospitalization, nil per os, IV fluids, and broad-spectrum antibiotics targeting enteric organisms. Definitive treatment is cholecystectomy, usually laparoscopic, within 24–72 hours for acute calculous cholecystitis when feasible. High-risk patients may undergo percutaneous cholecystostomy with delayed surgery.

Prognosis and complications: Prompt treatment reduces risk of complications such as gallbladder gangrene, perforation, empyema, fistula formation, or gallstone-related obstruction. Chronic cholecystitis can lead to biliary symptoms and may require elective cholecystectomy.