Fluid volume deficit, altered temp, actual infection, pain,

Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the
cystic duct.

• Gallbladder inflammation usually results from a gallstone blocking the flow of bile.
• Typically, people have abdominal pain that lasts more than 6 hours, fever, and nausea.
• Ultrasonography can usually detect signs of gallbladder inflammation.
• The gallbladder is removed, often using a laparoscope.

Cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a
stone blocks the cystic duct, which carries bile from the gallbladder.

Cholecystitis is classified as acute or chronic.

Acute Cholecystitis: Acute cholecystitis begins suddenly, resulting in severe, steady pain in the
upper abdomen. At least 95% of people with acute cholecystitis have gallstones. The
inflammation almost always begins without infection, although infection may follow later.
Inflammation may cause the gallbladder to fill with fluid and its walls to thicken.

Rarely, a form of acute cholecystitis without gallstones (acalculous cholecystitis) occurs.

Acalculous cholecystitis is more serious than other types of cholecystitis. It tends to occur after
the following:

• Major surgery
• Critical illnesses such as serious injuries, major burns, and bodywide infections (sepsis)
• Intravenous feedings for a long time
• Fasting for a prolonged time
• A deficiency in the immune system

It can occur in young children, perhaps developing from a viral or another infection.

Chronic Cholecystitis: Chronic cholecystitis is gallbladder inflammation that has lasted a long
time. It almost always results from gallstones. It is characterized by repeated attacks of pain
(biliary colic). In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute
inflammation, usually due to gallstones, and may become thick-walled, scarred, and small. The
gallbladder usually contains sludge (microscopic particles of materials similar to those in
gallstones), or gallstones that either block its opening into the cystic duct or reside in the cystic
duct itself.

Symptoms

A gallbladder attack, whether in acute or chronic cholecystitis, begins as pain. The pain of
cholecystitis is similar to that caused by gallstones (biliary colic) but is more severe and lasts
longer—more than 6 hours and often more than 12 hours. The pain peaks after 15 to 60 minutes
and remains constant. It usually occurs in the upper right part of the abdomen. The pain may
become excruciating. Most people feel a sharp pain when a doctor presses on the upper right part
of the abdomen. Breathing deeply may worsen the pain. The pain often extends to the lower part
of the right shoulder blade or to the back. Nausea and vomiting are common.

Within a few hours, the abdominal muscles on the right side may become rigid. Fever occurs in
about one third of people with acute cholecystitis. The fever tends to rise gradually to above
100.4° F (38° C) and may be accompanied by chills. Fever rarely occurs in people with chronic
cholecystitis.

In older people, the first or only symptoms of cholecystitis may be rather general. For example,
older people may lose their appetite, feel tired or weak, or vomit. They may not develop a fever.

Typically, an attack subsides in 2 to 3 days and completely resolves in a week. If the acute
episode persists, it may signal a serious complication. A high fever, chills, a marked increase in
the white blood cell count, and cessation of the normal rhythmic contractions of the intestine
(ileus—see Gastrointestinal Emergencies: Appendicitis) suggest pockets of pus (abscesses) in the
abdomen near the gallbladder from gangrene (which develops when tissue dies) or a perforated
gallbladder.

If people develop jaundice (see Manifestations of Liver Disease: Jaundice) or pass dark urine and
light-colored stools, the common bile duct is probably blocked by a stone, causing a backup of
bile in the liver (cholestasis). Inflammation of the pancreas (pancreatitis) can develop. It is
caused by a stone blocking the ampulla of Vater, near the exit of the pancreatic duct.

Acalculous cholecystitis typically causes sudden, excruciating pain in the upper abdomen in
people with no previous symptoms or other evidence of a gallbladder disorder. The inflammation
is often very severe and can lead to gangrene or rupture of the gallbladder. In people with other
severe problems (including people in the intensive care unit for another reason), acalculous
cholecystitis may be overlooked at first. The only symptoms may be a swollen (distended),
tender abdomen or a fever with no known cause. If untreated, acalculous cholecystitis results in
death for 65% of people.

Diagnosis

Doctors diagnose cholecystitis based mainly on symptoms and results of imaging tests.
Ultrasonography is the best way to detect gallstones in the gallbladder. Ultrasonography can also
detect fluid around the gallbladder or thickening of its wall, which are typical of acute
cholecystitis. Often, when the ultrasound probe is moved across the upper abdomen above the
gallbladder, people report tenderness.

Cholescintigraphy, another imaging test, is useful when acute cholecystitis is difficult to

diagnose. For this test, a radioactive substance (radionuclide) is injected intravenously. A gamma
camera detects the radioactivity given off, and a computer is used to produce an image. Thus,
movement of the radionuclide from the liver through the biliary tract can be followed. Images of
the liver, bile ducts, gallbladder, and upper part of the small intestine are taken. If the
radionuclide does not fill the gallbladder, the cystic duct is probably blocked by a gallstone.

Liver blood tests are often normal unless the person has an obstructed bile duct. Other blood tests
can detect some complications such as a high level of a pancreatic enzyme (lipase or amylase) in
pancreatitis. A high white blood cell count suggests inflammation, an abscess, gangrene, or a
perforated gallbladder.

Treatment

People with acute or chronic cholecystitis need to be hospitalized. They are not allowed to eat or
drink and are given fluids and electrolytes intravenously. A doctor may pass a tube through the
nose and into the stomach, so that suctioning can be used to keep the stomach empty and reduce
fluid accumulating in the intestine if the intestine is not contracting normally. Usually, antibiotics
are given intravenously, and pain relievers are given.

If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder is usually
removed within 24 to 48 hours after symptoms start. If necessary, surgery can be delayed for 6
weeks or more while the attack subsides. Delay is often necessary for people with a disorder that
makes surgery too risky (such as a heart, lung, or kidney disorder). If a complication such as an
abscess, gangrene, or perforated gallbladder is suspected, immediate surgery is necessary.

In chronic cholecystitis, the gallbladder is usually removed after the acute episode subsides.

In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder.

Surgical removal of the gallbladder (cholecystectomy) is usually done using a flexible viewing
tube called a laparoscope. After small incisions are made in the abdomen, the laparoscope and
other tubes are inserted, and surgical tools are passed through the incisions and used to remove
the gallbladder.

Prognosis
The prognosis for cholecystitis is favorable in the majority of cases. Cholecystectomy (either
laparoscopic or open surgery) is associated with a 0.1% mortality rate in individuals under 50
years of age and 0.8% in those over age 50 (Gladden). The less invasive laparoscopic procedure
is associated with less pain, a shorter hospital stay, and a shorter recovery period than the open
procedure. Cholecystectomy provides a complete resolution of symptoms in 75% to 90% of
cases. After cholecystectomy, gallstones may occur in the bile ducts, a condition known as
choledocholithiasis.

In cases in which cholecystitis is treated nonsurgically (conservatively) with medication only,

25% of individuals will have another episode of acute cholecystitis within 1 year, and 60% will
have another episode within 6 years (Gladden).

Complicated cases of cholecystitis such as critically ill patients, those with perforated
gallbladder, acalculous cholecystitis, gangrenous cholecystitis, secondary pancreatitis, or sepsis
have a less favorable prognosis, with mortality as high as 50% to 60% depending on the
specifics of the complication (Gladden).

Introduction

Cholecystitis is inflammation of the gallbladder, a small organ near the liver that plays a part in
digesting food. Normally, fluid called bile passes out of the gallbladder on its way to the small
intestine. If the flow of bile is blocked, it builds up inside the gallbladder, causing swelling, pain,
and possible infection

 Acute cholecystitis is inflammation of the gallbladder Indar

[ and Beckingham, 2002].
 It is estimated that 95% of people with acute cholecystitis have gallstones or biliary sludge
that have become impacted at the neck of the gallbladder. The following are risk factors for
gallstone formation [Ahmad et al, 2000]:

• Female gender.
• Increasing age.
• Obesity.
• Rapid weight loss.
• Pregnancy.

• Crohn's disease.
• Hyperlipidaemia.
• Diabetes mellitus.
• Genetics (e.g. maternal family history of gallstones).

 Approximately 5% of people who present with acute cholecystitis do not have gallstones.
These are usually people who have been hospitalized for trauma or acute biliary illness [Indar
and Beckingham, 2002; Kimura et al, 2007].
 If acute cholecystitis is untreated the following complications may occur [Kimura et al,
2007]:

• Perforation of the gallbladder.

• Biliary peritonitis.
• Peri-cholecystic abscess.
• Fistula (between the gallbladder and duodenum).

 Mortality from acute cholecystitis is estimated to be less than 10%. The mortality of elderly
people (over 75 years of age) tends to be higher than that of younger people, and comorbidity
such as diabetes may increase the risk of death [Kimura et al, 2007].

Other
Acute cholecystitis is inflammation of the gallbladder.

Your gallbladder is a small organ connected to your liver. It stores the bile produced in your
liver, and releases it into your small intestines to help digest fat.

Around 95% of cases of acute cholecystitis are due to gallstones or biliary sludge (mixture of
bile and other matter) becoming trapped at the opening of the gallbladder.

The other 5% are usually people who have been in hospital being treated for trauma or acute
biliary illness (illness relating to bile or the liver).

Presentation

Acute acalculous cholecystitis most commonly occurs in hospitalized patients who did not have
gallbladder disease previously but who have severe concomitant medical and surgical conditions.
Known populations at risk include postoperative patients (especially patients who have
undergone abdominal surgery), patients with extensive burns, patients with trauma, and patients
receiving prolonged parenteral nutrition. Other reported associations include prolonged fasting,
use of high-dose opioid analgesics, and mechanical ventilation.

A small subset of patients present in the outpatient setting with symptoms that are easier to
localize. Clinical and imaging evaluation are much more accurate in this setting. These patients
are diagnosed earlier in the disease course and have a better prognosis.

In the pediatric population, acute cholecystitis is rare; approximately one half of cases occur in
the absence of demonstrated calculi. These patients are more likely to present in the outpatient
setting and most often are treated with cholecystectomy.

The most frequent physical and laboratory findings include fever, right upper quadrant (RUQ)
pain, nausea, leukocytosis, and elevation of liver-associated enzymes and bilirubin. All of these
clinical parameters are nonspecific. In almost all instances in which it can be evaluated,
abdominal pain is present; however, it is often not localized to the RUQ. Fever is present in two
thirds of patients, and leukocytosis and liver function abnormalities are present in approximately
80%.

Related Lit
Diagnostic value of gallbladder emptying variables in
chronic acalculous cholecystitis as assessed by fatty
meal cholescintigraphy.

The variables investigated were latent period, gallbladder ejection fraction (GBEF) and patterns
of gallbladder emptying. In addition, two other biliary system motility variables were
investigated including the onset of gallbladder filling and biliary-to-bowel transit time.
METHODS: Thirty-nine healthy volunteers underwent fatty meal cholescintigraphy (CS)
prospectively to determine the normal values of these variables. Retrospectively, fatty meal CS
studies of 88 patients suspected of having CAC were retrieved and reprocessed to obtain
corresponding values of these variables, which then compared with normal values. RESULTS:
The mean onset of gallbladder filling for patient groups was not significantly different from
volunteer group mean. The mean+/-SD GBEF value for CAC group (29+/-20%) was
significantly lower than volunteer group value (54+/-23%), whereas for non-CAC group (60+/-
21%) it was not significantly different. The latent period was found invariable and not significant
in CAC diagnosis. Two patterns of gallbladder emptying were noted: ended and continuous. The
pattern of gallbladder emptying did not affect the mean GBEF and was found insignificant in the
diagnosis of CAC. There was no significant difference in the number of cases with late biliary-
to-bowel transit time between the groups. CONCLUSION: The single most important
gallbladder emptying variable in diagnosing CAC is the GBEF. The latent period and the pattern
of gallbladder emptying as well as the onset of gallbladder filling and biliary-to-bowel transit
time are of no significant diagnostic value in CAC.

Laparoendoscopic single site cholecystectomy: the first

100 patients.

Laparoendoscopic single site (LESS) surgery promises improved cosmesis and possibly less
pain. However, given the small series reported to date, true estimates of the advantages and
possible disadvantages of LESS surgery remain unknown. This study was undertaken to evaluate
the first 100 patients undergoing LESS cholecystectomy at our institution. Patients referred for
cholecystectomy since November 2007 were considered for LESS cholecystectomy. Outcomes,
including blood loss, operative time, complications, and length of stay, were recorded. Outcomes
are compared with an uncontrolled concurrent group of patients undergoing multi-incision
laparoscopic (i.e., conventional) cholecystectomy. One hundred patients with a median age of 44
years underwent LESS cholecystectomy; 30 patients with a median age of 46 years underwent
conventional cholecystectomy over the same time period. Median operative time (70 vs 66
minutes, P = 0.67, Mann-Whitney) and hospital length of stay (1 vs 1 day, P = 0.81, Mann-
Whitney) were not different for patients undergoing LESS or multi-incision cholecystectomies,
respectively. Five patients undergoing LESS cholecystectomy had postoperative complications:
cystic duct stump leak (one), pain control issues (three), and urinary retention (one). LESS
cholecystectomy is a safe and effective alternative to conventional cholecystectomy. It can be
undertaken without added operative time and provides patients with minimal, if any, scarring.
Transdermal Rather Than Oral Hormone Therapy May Help
Avoid Cholecystectomy

News Author: Laurie Barclay, MD

CME Author: Laurie Barclay, MD

Authors and Disclosures

CME Released: 07/16/2008; Valid for credit through 07/16/2009

• Print This

• Email this

processing....

July 16, 2008 — Gallbladder disease is common in postmenopausal women, and use of hormone
replacement therapy (HRT) increases the risk. Use of transdermal hormone therapy rather than
oral therapy in a 5-year period could avoid 1 cholecystectomy in every 140 users, according to
the results of a prospective cohort study reported in the July 11 Online First issue of the BMJ.

"Randomised controlled trials and observational studies have shown a clear increase in the risk
of gallbladder disease (cholelithiasis, cholecystitis, or cholecystectomy as outcomes) with use of
hormone replacement therapy by postmenopausal women," write Bette Liu, from the University
of Oxford, United Kingdom, and colleagues from the Million Women Study Collaborators. "We
examined the relation between method of administration and type of hormone replacement
therapy and the incidence of gallbladder disease in a large cohort of postmenopausal women in
the United Kingdom."

In the Million Women Study, 1,001,391 postmenopausal women registered with the National
Health Service (NHS) in England and Scotland were recruited between 1996 and 2001 from
NHS breast screening centers and observed by record linkage to routinely collected NHS
hospital admission data for gallbladder disease. Mean age at enrollment was 56 years. Primary
endpoints were adjusted relative risk (RR) and standardized incidence rates of hospitalization for
gallbladder disease or for cholecystectomy on the basis of use of HRT.

Of 19,889 women admitted for gallbladder disease during follow-up, 17,190 (86%) had a
cholecystectomy. Current HRT users were more likely than never-users of HRT to be admitted
for gallbladder disease (RR, 1.64; 95% confidence interval [CI], 1.58 - 1.69). However, risks
were lower with transdermal vs oral therapy (RR, 1.17; 95% CI, 1.10 - 1.24 vs RR, 1.74; 95%
CI, 1.68 - 1.80; P for heterogeneity < .001).

For women using oral HRT, the risk for gallbladder disease was slightly greater with use of
equine estrogens vs estradiol (RR, 1.79; 95% CI, 1.72 - 1.87 vs RR, 1.62; 95% CI, 1.54 - 1.70; P
for heterogeneity < .001). Higher vs lower doses also increased the risk. For equine estrogens of
more than 0.625 mg, RR was 1.91 (95% CI, 1.78 - 2.04) vs 0.625 mg or less (RR, 1.76; 95% CI,
1.68 - 1.84; P for heterogeneity = .02). For estradiol of more than 1 mg, RR was 1.68 (95% CI,
1.59 - 1.77) vs 1 mg or less (RR, 1.44; 95% CI, 1.31 - 1.59; P for heterogeneity = .003).

With time since stopping HRT, the risk for gallbladder disease decreased (P for trend = .004).
When cholecystectomy was considered as the outcome, findings were similar. Standardized
hospital admission rates for cholecystectomy per 100 women during 5 years were 1.1 in never-
users of HRT, 1.3 with transdermal HRT, and 2.0 with oral HRT.

Limitations of this study include some changes in HRT use occurring during follow-up, potential
confounding factors, and some non–NHS-funded admissions not included in the follow-up,

"Gallbladder disease is common in postmenopausal women and use of [HRT] increases the risk,"
the study authors write. "Use of transdermal therapy rather than oral therapy over a five year
period could avoid one cholecystectomy in every 140 users."

Cancer Research United Kingdom, the NHS breast screening programme, and the UK Medical
Research Council supported this study. The study authors have disclosed no relevant financial
relationships.

BMJ. Published online July 11, 2008.

http://cme.medscape.com/viewarticle/577596

New Guidelines Address Management of Common Bile

Duct Stones

News Author: Laurie Barclay, MD

CME Author: Laurie Barclay, MD

Authors and Disclosures

CME Released: 03/25/2008; Valid for credit through 03/25/2009

• Print This

• Email this

processing....

March 25, 2008 — New guidelines issued for management of common bile duct stones (CBDS)
have been published in the March 5 Online First issue of Gut.
"The last 30 years has seen major developments in the management of gallstone related disease,
which in the United States alone costs over 6 billion dollars per annum to treat," write Earl Jon
Williams, from the British Society of Gastroenterology (BSG) and the Royal Liverpool
University Hospital, Liverpool, United Kingdom, and colleagues. "As a consequence clinicians
are now faced with a number of potentially valid options for managing patients with suspected
CBDS. It is with this in mind that the following guidelines have been written."

New imaging techniques allow accurate visualization of the biliary system without requiring duct
instrumentation. These include magnetic resonance (MR) cholangiography and endoscopic
ultrasound (EUS). Use of endoscopic retrograde cholangiopancreatography (ERCP) is now
widespread and is considered a routine procedure. Laparoscopic cholecystectomy has largely
replaced open cholecystectomy, and it is often accompanied by laparoscopic exploration of the
common bile duct (LCBDE).

The BSG commissioned these guidelines, which were subsequently reviewed, revised, and
endorsed by the Clinical Standards and Services Committee of the BSG, the BSG Endoscopy
Committee, the ERCP stakeholder group, the Association of Upper Gastrointestinal Surgeons of
Great Britain and Ireland, and the Royal College of Radiologists.

After a preliminary search of the literature in 2004 of PubMed and MEDLINE, the findings were
summarized and were presented to the BSG Endoscopy Committee, which developed principal
clinical questions to be addressed by the guidelines. A multidisciplinary guideline-writing group
then wrote provisional guidelines.

Some of the specific recommendations are as follows:

• Hepatobiliary cases should be discussed in a multidisciplinary setting (grade

C).
• Symptomatic patients in whom evaluation suggests ductal stones should
undergo extraction if possible (grade B).
• Transabdominal ultrasound scanning (USS) is recommended as a preliminary
investigation for CBDS, but it is not a sensitive test for this condition (grade
B).
• EUS and MR cholangiography are both highly effective at confirming CBDS;
patient suitability, accessibility, and local expertise should help decide
between the 2 procedures (grade B).
• When performing endoscopic stone extraction (ESE), the endoscopist should
be assisted by a technician or radiologist who can help with fluoroscopy, a
nurse for safety monitoring, and an additional endoscopy assistant or nurse
to manage guide wires and other technical aspects as needed (grade C).
• ERCP should be done only in patients who are expected to require an
intervention; it is not recommended for use solely as a diagnostic test (grade
B).
• Full blood count and prothrombin time/international normalized ratio (PT/INR)
should be performed within 72 hours before biliary sphincterotomy for ductal
stones; patients with abnormal clotting should undergo subsequent
management based on locally agreed guidelines (grade B).
 • For patients treated with anticoagulants but who are at low risk for
thromboembolism, anticoagulants should be discontinued before endoscopic
stone extraction if biliary sphincterotomy is planned (grade B) as should
newer antiplatelet agents (eg, clopidogrel), 7 to 10 days before biliary
sphincterotomy (grade C). Use of aspirin, nonsteroidal anti-inflammatory
drugs (NSAIDs), and low-dose heparin should not be considered a
contraindication to biliary sphincterotomy (grade B).
• Patients with biliary obstruction or previous features of biliary sepsis should
receive prophylactic antibiotics (grade A).
• Sphincterotomy initiated with use of pure cut may be preferred in patients
with risk factors for post-ERCP pancreatitis but not biliary sphincterotomy–
induced hemorrhage (grade A).
• In most patients undergoing stone extraction, balloon dilation of the papilla
should be avoided because the risk for severe post-ERCP pancreatitis is
increased vs biliary sphincterotomy (grade A).
• Short-term use of a biliary stent, followed by further endoscopy or surgery, is
recommended to ensure adequate biliary drainage in patients with CBDS that
have not been extracted (grade B).
• Use of a biliary stent as sole treatment of CBDS should be limited to patients
with limited life expectancy or prohibitive surgical risk, or both (grade A).
• Pre-cut is a risk factor for complication and should be used only by those with
appropriate training and experience and only in patients for whom
subsequent endoscopic treatment is essential (grade B).
• Operative risk should be evaluated before scheduling intervention, and
endoscopic therapy should be considered as an alternative in high-risk
patients (grade B).
• Intraoperative cholangiography or laparoscopic ultrasound can detect CBDS
in patients who are suitable for surgical exploration or postoperative ERCP
(grade B).
• In patients undergoing laparoscopic cholecystectomy, transcystic and
transductal exploration of the common bile duct are both considered
appropriate for removal of CBDS (grade A).
• When minimally invasive techniques fail to achieve duct clearance, open
surgical exploration is still considered to be an important treatment option
(grade B).

The guidelines also discuss supplementary treatments including mechanical lithotripsy,

extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and laser lithotripsy,
percutaneous treatment, and oral ursodeoxycholic acid. Management of specific clinical
scenarios is also presented.

"Biliary sphincterotomy and endoscopic stone extraction (ESE) is recommended as the primary
form of treatment for patients with CBDS post cholecystectomy," the authors of the guidelines
write. "Cholecystectomy is recommended for all patients with CBDS and symptomatic
gallbladder stones, unless there are specific reasons for considering surgery inappropriate.
Patients with CBDS undergoing laparoscopic cholecystectomy may be managed by laparoscopic
common bile duct exploration (LCBDE) at the time of surgery, or undergo peri-operative
ERCP."
The authors of the guidelines have disclosed no relevant financial relationships.

Gut. Published online March 5, 2008.

http://www.searchmedica.com/resource.html?rurl=http%3A%2F
%2Femedicine.medscape.com%2Farticle%2F365553-
overview&q=Acalculous+Cholecystitis&c=pc&ss=defLink&p=Convera&ds=0&srid=10

Peristalsis

Read More
Bile

Duodenum

Peristalsis is a series of organized muscle contractions that occur throughout the digestive tract.
Peristalsis is also seen in the tubular organs that connect the kidneys to the bladder.

Peristalsis is an automatic and important process that moves food through the digestive system. It
also moves urine from the kidneys into the bladder, and bile from the gallbladder into the
duodenum.

Peristalsis is a normal function of the body. It can sometimes be felt in the abdomen as gas
moves along.