Treating acute cholecystitis

If your GP suspects you have acute cholecystitis, you will probably be admitted to hospital
for treatment.
Antibiotics
You will first be given an injection of antibiotics into a vein. Broad-spectrum antibiotics are
used, which can kill a wide range of different bacteria.
Once your symptoms have stabilised, you may be sent home and given an appointment to return
for surgical treatment (see below).
Alternatively, if your symptoms are particularly severe or you have a high risk of complications,
you may be referred for surgery a few days after antibiotic treatment.
A cholecystectomy is the most widely used type of surgery for cases of acute cholecystitis.
Surgery
A cholecystectomy is the surgical removal of the gallbladder. There are two types of
cholecystectomy:
laparoscopic cholecystectomy
open cholecystectomy
These are described below.
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy is a type of keyhole surgery. It is the most widely used type of
cholecystectomy. A laparoscopic cholecystectomy is carried out under a general anaesthetic,
which means you will be asleep during the operation and will not feel any pain.
During a laparoscopic cholecystectomy, the surgeon makes four small cuts, each about 1cm or
smaller, in your abdomen (tummy) wall. One incision is made near your belly button and the
other three made across your upper abdomen.
Your abdomen is inflated with carbon dioxide gas passed through the cuts. Inflating your
abdomen gives the surgeon a better view of your organs and more room in which to work.
The surgeon passes an instrument called a laparoscope through one of the incisions. A
laparoscope is a small, rigid tube that has a light source and a camera at one end. The camera
transmits images of the inside of your abdomen to a television monitor.
The surgeon then passes small instruments down the other incisions to remove your gallbladder
and any gallstones. After your gallbladder has been removed, the incisions are closed.
As this technique only involves making small cuts in your abdomen, you will not experience
much pain afterwards. You should also recover quickly from the effects of the operation. Most
people are able to return home either on the day of the surgery or the day after.
Read about laparoscopic cholecystectomy for more information about the procedure.
Open cholecystectomy
A laparoscopic cholecystectomy is not recommended if you:
are in the third trimester (the last three months) of pregnancy
for some people with cirrhosis (scarring of the liver)
In these circumstances, an open cholecystectomy may be recommended.
An open cholecystectomy may also be carried out if a planned laparoscopic cholecystectomy is
not successful.
As with a laparoscopic cholecystectomy, an open cholecystectomy will be carried out under
general anaesthetic so you will not feel any pain during the procedure. The surgeon will make a
large cut in your abdomen to remove your gallbladder.
An open cholecystectomy is an effective method of treating acute cholecystitis, but has a longer
recovery time than laparoscopic cholecystectomy. Most people take about six weeks to recover
from an open cholecystectomy.
Percutaneous cholecystostomy
If your symptoms are severe or you are in poor health, your care team may decide immediate
surgery is too dangerous.
In such circumstances, a temporary measure known as a percutaneous cholecystostomy may be
carried out. A percutaneous cholecystostomy may be performed under a local anaesthetic, which
numbs your abdomen. This means you will be awake during the procedure.
The surgeon will use an ultrasound scan to guide a needle to the site of your gallbladder. The
needle is then used to drain bile out of the gallbladder, which should help relieve inflammation
(swelling). Once your symptoms improve, your gallbladder can be surgically removed.
Living without a gallbladder
You can lead a perfectly normal life without a gallbladder. The organ can be useful but it's not
essential. Your liver will still produce bile to digest food.
However, some people who have had their gallbladder removed have reported symptoms of
bloating and diarrhoea after eating fatty or spicy food. If certain foods do trigger symptoms, you
may wish to avoid them in the future.
Acute cholecystitis and pregnancy
Surgical intervention should be delayed until after delivery unless conservative treatment fails or
symptoms recur in the same trimester. When surgery is indicated in pregnancy, laparoscopic
cholecystectomy has been shown to be safe
Acalculous Cholecystitis
Pathophysiology
The main cause of this illness is thought to be due to bile stasis and increased lithogenicity of
bile. Critically ill patients are more predisposed because of increased bile viscosity due to fever
and dehydration and because of prolonged absence of oral feeding resulting in a decrease or
absence of cholecystokinin-induced gallbladder contraction. Gallbladder wall ischemia that
occurs because of a low-flow state due to fever, dehydration, or heart failure may also play a role
in the pathogenesis of acalculous cholecystitis.
Complications of acute cholecystitis
Gangrenous cholecystitis is a common complication of acute cholecystitis that occurs in up
to 30% of cases. Gallbladder perforation is a less common but more serious complication
that occurs in around 1 in 100 cases.
Gangrenous cholecystitis
Gangrenous cholecystitis develops when severe inflammation (swelling) interrupts the blood
supply to your gallbladder.
Without a constant supply of blood, the tissue of the gallbladder will begin to die. This is
potentially serious because the dead tissue is vulnerable to serious infection, which can quickly
spread throughout the body.
Known risk factors for gangrenous cholecystitis include:
being male
being 45 years of age or over
having a history of diabetes
having a history of heart disease
It is unclear why these risk factors make a person more vulnerable to gangrenous cholecystitis.
Other than a very rapid heartbeat (more than 90 beats a minute), gangrenous cholecystitis does
not usually cause noticeable symptoms, so is usually diagnosed on the basis of test results.

Gangrenous cholecystitis would be strongly suspected if:
your heart rate is more than 90 beats a minute
you have a very high white blood cell count
the ultrasound scan shows the wall of your gallbladder is thicker than 4.5mm
If gangrenous cholecystitis if suspected, a cholecystectomy will usually be carried out to remove
the gallbladder as soon as possible.
Gallbladder perforation
In cases of severe inflammation, the wall of the gallbladder can tear and infected bile can leak
out. This can cause an infection of the lining of the abdomen (tummy), known as peritonitis.
Symptoms of peritonitis include:
a sudden and very severe abdominal pain
vomiting
chills
a high temperature (fever) of 38C (100.4F) or above
rapid heartbeat (tachycardia)
feeling thirsty
not passing urine or passing much less urine than normal
Peritonitis is treated using a combination of antibiotic injections and surgery to remove the
gallbladder and drain away infected bile.
Causes of acute cholecystitis
The causes of acute cholecystitis can be grouped into two main categories, calculous
cholecystitis and acalculous cholecystitis.
Each of these types is discussed in more detail below.
Calculous cholecystitis
Calculous cholecystitis is the most common, and usually less serious, type of acute cholecystitis.
It accounts for around 90% of all cases.
Calculous cholecystitis develops when the main opening to the gallbladder, called the cystic
duct, gets blocked by a gallstone or by a substance known as biliary sludge. Biliary sludge is a
mixture of bile and small crystals of cholesterol and salt.
The blockage in the cystic duct results in a build-up of bile inside the gallbladder, which causes
pressure inside the gallbladder to increase. For reasons still unclear, the rise in pressure inside the
gallbladder causes the gallbladder to become inflamed and swollen.
In around one in five cases, the inflamed gallbladder becomes infected by bacteria. This can
trigger the more serious complications of acute cholecystitis, such as gangrenous cholecystitis
(tissue death inside the gallbladder).
Acalculous cholecystitis
Acalculous cholecystitis is usually a more serious type of acute cholecystitis. It often requires
admission to an intensive care unit (ICU) for treatment.
Acalculous cholecystitis usually develops as a complication of a serious illness, infection or
injury that damages the gallbladder. Possible causes for acalculous cholecystitis include:
accidental damage to the gallbladder during major surgery
serious injury or burns
blood poisoning (sepsis)
severe malnutrition
HIV or AIDS
Increased risk
Things that increase the risk of getting acute cholecystitis include:
being very overweight (obese), with a body mass index of 30 or more
being female, as women are three times more likely to get acute cholecystitis than men,
although symptoms tend to be more severe in men
being middle-aged, as rates of acute cholecystitis are highest in people who are 40 to 60
years of age
being of East Asian origin, as rates of acute cholecystitis are higher in people of Japanese
and Chinese origin