Acute Cholecystitis

Overview of Acute Cholecystitis

• Cholecystitis is inflammation of the gallbladder. The gallbladder is a small, pear-shaped organ on the right side of the belly (abdomen), beneath the liver. The gallbladder holds a digestive fluid (bile) that’s released into the small intestine. 
• In most cases, gallstones blocking the tube leading out of the gallbladder cause cholecystitis. This results in a bile buildup that can cause inflammation. Other causes of cholecystitis include bile duct problems, tumors, serious illness and certain infections. 
• If left untreated, cholecystitis can lead to severe, sometimes life-threatening complications, such as a gallbladder rupture. Treatment for cholecystitis often involves surgery to remove the gallbladder. (2) 

Causes of Acute Cholecystitis

• Gallstones: Most often, cholecystitis is the result of hard particles that develop in your gallbladder (gallstones). Gallstones can block the tube (cystic duct) through which bile flows when it leaves the gallbladder. Bile builds up in the gallbladder, causing inflammation. 
• Tumor:  A tumor may prevent bile from draining out of your gallbladder properly. This causes bile buildup that can lead to cholecystitis. 
• Bile duct blockage: Stones or thickened bile and tiny particles (sludge) can block the bile duct and lead to acute cholecystitis. Kinking or scarring of the bile ducts can also cause blockage. 
• Infection: AIDS and certain viral infections can trigger gallbladder inflammation.
• Severe illness: Very severe illness can damage blood vessels and decrease blood flow to the gallbladder, leading to cholecystitis. (2) 

Types

ACUTE CHOLECYSTITIS 

A. Calculous:

• Obstructive cholecystitis. It is the commonest Calculi cause bile stasis.

B. Acalculous:

• Nonobstructive cholecystitis. It is not uncommon and is seen in patients who are recovering from major

C. Acute emphysematous cholecystitis. (1)

CHRONIC CHOLECYSTITIS 

• Recurrent attacks of cholecystitis will convert the gallbladder into a fibrosed, nonfunctioning, contracted, shrunken, small gall bladder. Gall bladder wall is grossly thickened. Stones are invariably present. Such patients present with classical fatty food intolerance. Murphy’s sign is positive. (1)

Risk Factors of Acute Cholecystitis

• Woman older than 50 
• Man older than 60 
•  higher-weight person
• Diabetes 
• Crohn’s disease 
• End-stage kidney disease 
• Heart disease 
• Hyperlipidemia 
• Sickle cell disease 
• Quick weight loss (3) 

Pathogenesis of Acute Cholecystitis

Inflammation:

• Entire gall bladder is inflamed, swollen and is friable. When the inflammatory exudate surrounding the gall bladder collects under the diaphragm, it results in pain radiating to the right shoulder (C3, 4) due to phrenic nerve irritation. It may undergo complete resolution with antibiotic therapy, but such recurrent attacks are common at a later date.

Perforation:

• Extensive ulcerations of gall bladder may result in perforation with biliary peritonitis and carries a very high mortality rate. Perforation can occur when the stone is impacted in the Hartmann’s pouch.

Obstruction to the neck of gall bladder results in mucocoele or pyocoele (empyema).

•  Empyema of the gall bladder can occur in diabetic patients and is associated with high grade fever, chills, rigors and even septicaemia. 

Gangrene of gall bladder can occur if the blood vessels get thrombosed. All these features are more in an obstructive variety.

• If there is clostridial infection as can occur in diabetics because of extensive gas production in biliary tree and associated toxicity, perforation is likely even without a Stone. (1)

Pathophysiology

• Majority of the cases of calculous cholecystitis are due to organisms such as E. coli, Streptococci, Salmonella, Klebsiella, etc. 
• Acute calculous cholecystitis appears to be caused by obstruction to bile flow from gall bladder by stone or oedema formed as a result of local mucosa! erosion and inflammation caused by stone. Once mucosa is eroded, tissue planes are exposed to bile salts. Toxic bile salts destroy cells by their detergent action leading to necrosis and perforation of gall bladder. (1) 

Sign And Symptoms:

Murphy’s sign

• Keep the fingers in the right hypochondrium and ask the patient to take a deep inspiration.
• At the height of inspiration there is a sudden catch in the inspiration.
• It is due to inflamed gall bladder coming in contact with the abdominal wall under the fingers and producing pain. This is called Murphy’s sign positive. It is a diagnostic sign of acute cholecystitis.

Boas’ sign:

An area of hyperaesthesia between 9th and 11th ribs posteriorly on the right side is a feature. 

Upper abdominal guarding, rigidity.

Vague mass

• consisting of inflamed gall bladder, omentum, inflammatory exudate can be felt at times. Hence, even if a perforation occurs, generalised peritonitis is uncommon. (1)

Symptoms: 

• Severe pain in right hypochondriac Region.  
• Pain Radiates to right shoulder or back  
• Tenderness on abdomen On Examination  
• Nausea  
• Vomiting  
• Fever  
• Bloating  
• Yellow skin or eyes (2) 

Clinical Examination:

• The presence of positive murphy’s sign on physical examination is highly suggestive of acute cholecysitis. 
• High-grade fever 
• Tachycardia 
• Tachypnea 
• Right upper quadrant abdominal tenderness 
• Rebound tenderness 
• Palpable gallbladder, positive Courvoisier’s sign 
• Voluntary and involuntary guarding may be present. (5)

Diagnosis:

• X-ray of your belly, which will show your internal organs, bones, and tissues 
• Ultrasound, which will show your gallbladder and liver and let doctors check blood flow 
• CT scan, which gives doctors a more detailed look at organs, muscles, and bones than an X-ray can 
• HIDA scan, which checks how your gallbladder squeezes and if bile is blocked. You get a shot of a chemical, and then a scanner traces it as it moves through your body. 
• PTC, which uses a dye injected into your liver to show how bile is moving through your body 
• ERCP, which uses a long, flexible tube threaded down your throat, through your stomach, and into your small intestine. It has a light and camera at the end. This test also uses a dye to check how bile is flowing through your system. (3) 

Differential Diagnosis

Perforated peptic ulcer:

• • Severe sudden pain, severe tenderness in the right hypochondrium, guarding and rigidity caused by perforated peptic ulcer, can mimic acute cholecystitis. Obliteration of liver dullness, coffee ground vomitus, generalised guarding and rigidity clinches the diagnosis of perforated duodenal ulcer.

Acute pancreatitis:

• • A severe pain in upper abdomen, tenderness in the right hypochondrium and epigastrium mimic cholecystitis. One should remember that pain of pancreatitis is more severe and classically radiates to back.

High retrocaecal appendicitis:

• • Especially when appendix is in the subhepatic position. Once inflammatory fluid spreads in the general peritoneal cavity, there will be more difficulty in diagnosing clinically.  

Amoebic liver abscess:

• • Can also mimic very closely. It is more common in male people with alcohol use disorder. Liver is enlarged and one can feel the round lower border of liver very closely. Liver will be extremely tender.

Lobar pneumonia (basal):

• • Can cause right hypochondriac guarding and rigidity. It is a referred pain. (1)

Complications of Acute Cholecystitis

1. Gallbladder-related complications:

• Gangrenous cholecystitis:

  • "This is the most common complication, especially among older people, those who wait to get treatment, and those with diabetes." [11]
  • "Untreated acute cholecystitis can cause tissue in the gallbladder to die (gangrene). This can lead to a tear in the gallbladder, or it may cause your gallbladder to burst." [10]

• Gallbladder perforation:

  • "A tear (perforation) in your gallbladder may result from gallbladder swelling, infection, or death of tissue." [10]

• Empyema of the gallbladder:

  • "This occurs when the gallbladder becomes filled with pus." [11]

2. Biliary tract complications:

• Choledocholithiasis:

  • "The presence of gallstones in the common bile duct." [13]
  • "Can lead to cholangitis, pancreatitis, or obstructive jaundice." [10]

• Cholangitis:

  • "Inflammation of the bile ducts." [11]
  • "Can be a life-threatening condition if not treated promptly." [13]

3. Other complications:

• Pancreatitis:

  • "Inflammation of the pancreas." [11]
  • "Can occur due to obstruction of the pancreatic duct by a gallstone." [10]

• Liver abscess:

  • "A rare complication of acute cholecystitis." [12]

• Biliary fistula:

  • "An abnormal connection between the gallbladder and another organ, such as the small intestine or skin."[13]

Disclaimer: This information is for educational purposes only and should not be considered a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment.

Investigations 

1.Total WBC count is always raised.

2.Blood and urine sugar estimation to rule out diabetes mellitus.

3.Plain X-ray abdomen erect position

• • Gall stones can be demonstrated in 10% of the patients as radio-opaque shadows in the right hypochondrium. in lateral view, the stone is seen in front of vertebral bodies.
  • To rule out other causes such as perforated peptic ulcer (air under diaphragm).
  • Rarely, it may show calcified gall bladder (porcelain gall bladder).

                10% Gall stones are radio-opaque, 90% are radio lucent. Centre of stones may contain radiolucent gas, either

                 triradiate (Mercedes Benz sign) or biradiate (SeaGull sign).

4.Emergency ultrasonography 

• • To demonstrate stones, which cast posterior acoustic shadow.
  • Success rate is > 95%
  • lt can demonstrate inflamed, thickened organ, in cases of acalculous cholecystitis.
  • Demonstration of Murphy’s sign, with the help of ultrasonography is possible which adds to the diagnosis.
  • Ultrasound can also measure gall bladder function by using ultrasonic dimensions of the gall bladder.
  • It can detect gall bladder polyps.               

5.HIDA scan/PIPIDA scan

6.CT Scan:

• It is done when ultrasound findings are not clear (1)

Treatment

(1). Conservative treatment is followed in majority of the cases (60 to 70%) 

• • Admission in the hospital
  • Aspiration with Ryle’s tube: Aspiration of HCl decreases the stimulus to the secretion of bile. Spasm of gall bladder may come down.
  • Antispasmodics: Injection morphine 8-10 mg IM as analgesic along with injection atropine 0.6 mg to relieve spasm of sphincter of Oddi.
  • Antibiotics: Broad spectrum antibiotics are given against gram +ve, gram -ve and anaerobic organisms. Cefazolin, cefuroxime or amikacin are the drugs of choice. The patient is kept nil orally for 2-3 days and during this time IV fluids are given. After 2-3 days, pain comes down, signs (tenderness) disappear and abdomen becomes soft. Ryle’s tube is removed,  clear oral fluid is given for 2-3 days followed by soft diet.  After 6 weeks, the patient is advised to undergo elective  cholecystectomy. Reason for conservative treatment is in  majority of cases, inflammation will settle down. 

 (2) Cholecystostomy .(1) 

Prevention

• Lower your cholesterol. 
• Exercise regularly. 
• Eat a diet rich in fruits, vegetables, and healthy fats. Eggs, soybeans, and peanuts are great choices. 
• Obesity is a major risk factor for getting gallstones. Losing weight can reduce chances. (3) 

Homeopathic Treatment of Cholecystitis : 

• Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis. 

Which includes 

• The medical history of the patient, 
• Physical and mental constitution, 
• Family history, 
• Presenting symptoms, 
• Underlying pathology, 
• Possible causative factors etc. 

                 A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions. 

What Homoeopathic doctors do? 

• A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’? 
• • The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition. 
  • The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines. 

Homeopathic Medicines for Acute Cholecystitis: 

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a    complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general                            symptoms and constitutional indications also taken into account for selecting a remedy, potency and      repetition of dose by Homeopathic doctor. 

So, here we describe homeopathic medicine only for reference and education purpose. Do not  take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

CHELIDONIUM MAJUS:  

• •  A prominent liver remedy, covering many of the direct reflex symptoms of diseased conditions of that organ. Jaundice due to hepatic and gall bladder obstruction. Gall-colic. Distension. Fomentation and sluggish bowels, constriction across, as by a string. Liver enlarged. Gallstones. Worse – right side, motion, touch, change of weather, very early in morning. Better – after dinner, from pressure.

BERBERIS VULGARIS:

• • Stitches in region of gall bladder; worse, pressure extending to stomach. Catarrh of the gallbladder with constipation and yellow complexion. Stitching pain in front of kidneys extending to liver, spleen, stomach, groins, Poupart’s ligament. Sticking deep in ilium. Worse – motion, standing. It brings on, or increases, urinary complaints.  

AESCULUS HIPPOCASTAMUM:

• • Dull aching in liver and epigastrium. Pain at umbilicus. Jaundice; throbbing in hypogastrium and pelvis. Worse – in morning on awaking, and from any motion, walking; from moving bowels after eating, afternoon, standing. Better – cool open air.  

BRYONIA:  

• • Liver region swollen, sore tensive burning pain, stitches; worse, pressure, coughing, breathing- Tenderness of abdominal wall. Worse – warmth, any motion, morning, eating, hot weather, exertion, touch. Cannot sit up; gets faint and sick. Better – lying on painful side, pressure rest, cold things. 

PODOPHYLLUM:

• • Is especially adapted to persons of bilious temperament. Hot sour belching; nausea and vomiting. Heartburn – gagging or empty retching. Abdomen distended; heat and emptiness. Sensation of weakness or sinking. Can lie comfortably only on stomach. Liver region painful, better rubbing part. Rumbling and shifting of flatus in ascending colon. Worse  in early morning,in hot weather, during dentition. 

CARDUUS MARIANUS: 

• • Pain in region of liver, left lobe very sensitive. Fullness and soreness, with moist skin. Constipation; stools hard, difficult, knotty, alternates with diarrhoea. Stools bright yellow. Swelling of gall bladder with painful tenderness. Hyperaemia of liver, with jaundice. Cirrhosis, with dropsy. (4) 

Diet & Regimen  

Avoid High-fat foods like: 

• • Fried foods 
  • Sausage,  
  • Full-fat milk, cheese, 
  • Cream-based soups and sauces 
  • Butter, mayonnaise, and bottled salad dressing  
  • Waffles, muffins, cakes, pies, cookies, and dessert breads 
  • fast food 
  • Packaged snack foods, including chips, crackers, and chocolate

Take Low fat Healthy Diet: 

• • Fresh fish, 
  • Raw nuts and seeds 
  • Low-fat milk, yogurt, 
  • Broth-based soups 
  • Fat-free sauces  
  • lemon juice, 
  • Whole grain breads, cereals, 
  • Brown rice, quinoa, oats, grits, and baked potatoes 
  • Fresh Fruits  
  • Fresh vegetables 
  • Beans, peas, and lentils.(6)