Acute cholecystitis:

Cholecystitis is inflammation of the gallbladder.

More than 90% of the time acute cholecystitis is from blockage of the cystic duct by a gallstone.[1]
Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity,
diabetes, liver disease, or rapid weight loss.[4] Occasionally acute cholecystitis occur as a result of
vasculitis, chemotherapy, or during recovery from major trauma or burns.

Etiological types:
1.calculous cholecystitis: gallstones blocking the flow of bile account for 90% of cases of
cholecystitis (acute calculous cholecystitis).[1][14] Blockage of bile flow leads to thickening and
buildup of bile causing an enlarged, red, and tense gallbladder.[1] The gallbladder is initially sterile but
often becomes infected by bacteria, predominantly E. coli, Klebsiella, Streptococcus, and Clostridium
species.

2.Acalculous cholecystitis

In acalculous cholecystitis, no stone is in the biliary ducts.[13] It accounts for 5–10% of all cases of
cholecystitis and is associated with high morbidity and mortality rates.[13] Acalculous cholecystitis is
typically seen in people who are hospitalized and critically ill.[13] Males are more likely to develop
acute cholecystitis following surgery in the absence of trauma.[14][18] It is associated with many
causes including vasculitis, chemotherapy, major trauma or burns.

Pathogenesis:
Obstruction/stasis:Gallstones are the most common cause of gallbladder inflammation but it can also
occur due to blockage from a tumor or scarring of the bile duct

Chemical irritation:Concentrated bile, pressure, and sometimes bacterial infection irritate and
damage the gallbladder wall, causing inflammation and swelling of the gallbladder.[1] Inflammation
and swelling of the gallbladder can reduce normal blood flow to areas of the gallbladder, which can
lead to cell death due to inadequate oxygen

Bacterial infection:

he gallbladder is initially sterile but often becomes infected by bacteria, predominantly E. coli,
Klebsiella, Streptococcus, and Clostridium species.

Pancreatic reflux:
Continuous PBR causes chronic inflammation and injury of the biliary tract mucosa and particularly of
the gallbladder mucosa where bile concentrates and pancreatic enzymes pooling reaching high
levels.High levels of pancreatic enzymes have been found within the whole spectrum of gallbladder
diseases, benign and malignant, including acute and chronic cholecystitis.

Signs and symptoms

Most people with gallstones do not have symptoms.

[1] When a gallstone lodges in the cystic duct, they experience biliary colic.[1] Biliary colic is
abdominal pain in the right upper quadrant or epigastric region. It is episodic, occurs after eating
greasy or fatty foods, and leads to nausea and/or vomiting. People who suffer from cholecystitis most
commonly have symptoms of biliary colic before developing cholecystitis. The pain becomes more
severe and constant in cholecystitis. Nausea is common and vomiting occurs in 75% of people with
cholecystitis.[14] In addition to abdominal pain, right shoulder pain can be present.[13]

On physical examination, fever is common.[14] A gallbladder with cholecystitis is almost always

tender to touch.[13] Because of the inflammation, its size can be felt from the outside of the body in
25–50% of people with cholecystitis.[13] Pain with deep inspiration leading to termination of the
breath while pressing on the right upper quadrant of the abdomen usually causes pain (Murphy's
sign). Murphy's sign is sensitive, but not specific for cholecystitis.[15] Yellowing of the skin (jaundice)
may occur but is often mild. Severe jaundice suggests another cause of symptoms such as
choledocholithiasis.[14] People who are old, have diabetes, chronic illness, or who are
immunocompromised may have vague symptoms that may not include fever or localized tenderness.

Diagnosis:

Blood tests

In someone suspected of having cholecystitis, blood tests are performed for markers of inflammation
(e.g. complete blood count, C-reactive protein), as well as bilirubin levels in order to assess for bile
duct blockage.[14] Complete blood count typically shows an increased white blood count (12,000–
15,000/mcL).[14] C-reactive protein is usually elevated.

Ultrasound findings :

suggestive of acute cholecystitis include gallstones, fluid surrounding the gallbladder, gallbladder wall
thickening (wall thickness over 3 mm),[27] dilation of the bile duct, and sonographic Murphy's sign.

X-ray:

may reveal cholecystoenteric fistula, very few gallstones are radio opaque

Cholescintigraphy:

specific test for acute cholecystitis. Technetium-IDA scan. Obstruction of bile duct or inflamed gall
bladder lining.
Ultrasonography:

can detect enlarged pancreas, gall bladder, or calculi .

Complications:
Mechanical jaundice/Obstructive Jaundice (Cholestatic Liver Disease)
This develops when the flow of bile normally excreted by the liver is either reduced or blocked and
retained in the bloodstream. There are a number of possible root causes of cholestasis including:
gallstones; tumours of the pancreas/bile duct or liver; a reaction to the use of certain therapeutic
drugs such as analgesics, anti-bacterials, and non-steroidal anti-inflammatories; hormonal changes
brought on by pregnancy; and alcoholic liver disease.

Symptoms

These include jaundice, fatigue and pruritus (itching). Other symptoms can include dark coloured
urine and light coloured stools.

Diagnosis
Liver function tests

A ward test of the urine in obstructive jaundice will demonstrate the presence of bilirubin and the
absence of urobilinogen. The plasma bilirubin will be elevated and will be principally in the conjugated
form. Small changes only should occur in the alanine aminotransferase (ALT) and the aspartate
aminotransferase (AST), which are indicative of hepatocyte injury

Liver biopsy

Endoscopic retrograde cholangiopancreatography

This may demonstrate that a duct stone is the cause of the jaundice. If the patient is unfit for surgery,
has cholangitis as a result of the stone or has already had a cholecystectomy, then the ideal treatment
is ERCP/sphincterotomy and stone extraction. If the patient has an intact gall bladder containing
stones, the history is typical of stone disease and he or she is fit (the majority), then it is best to treat
by a laparoscopic cholecystectomy with intraoperative cholangiography, followed by laparoscopic
duct exploration if a stone is still present in the duct. If the latter is unsuccessful, the duct can be
explored by open operation immediately or by performing a post-operative ERCP and sphincterotomy
to remove the stone.

Treatment

Treatment depends on the diagnosed cause or underlying problem, which may be due to problems
within the liver or outside it.

Perforation/rupture: Rupture is a rare but serious complication that leads to abscess formation or
peritonitis.[14] Massive rupture of the gallbladder has a mortality rate of 30%
Empyema

Untreated cholecystitis can lead to worsened inflammation and infected bile that can lead to a
collection of pus surrounding the gallbladder, also known as empyema

Fistula formation and gallstone ileus

The inflammation of cholecystitis can lead to adhesions between the gallbladder and other parts of
the gastrointestinal tract, most commonly the duodenum.[13] These adhesions can lead to the
formation of direct connections between the gallbladder and gastrointestinal tract, called fistulas.[13]
With these direct connections, gallstones can pass from the gallbladder to the intestines. Gallstones
can get trapped in the gastrointestinal tract, most commonly at the connection between the small
and large intestines (ileocecal valve). When a gallstone gets trapped, it can lead to an intestinal
obstruction, called gallstone ileus, leading to abdominal pain, vomiting, constipation and abdominal
distension.

Treatment:

Conservative management:

I.v fluid : dextrose solution, electrolytes,

Anticholinergic drugs:reduce gastric and pancreatic secretion, also relaxation of sphincter of oddi.

Analgesics: for pain

Antibiotics:This may consist of a broad spectrum antibiotic; such as piperacillin-tazobactam,

ampicillin-sulbactam, ticarcillin-clavulanate (Timentin), a third generation cephalosporin
(e.g.ceftriaxone) or a quinolone antibiotic (such as ciprofloxacin) and anaerobic bacteria coverage,
such as metronidazole. For penicillin allergic people, aztreonam or a quinolone with metronidazole
may be used.

Stop conservative treatment in case of :

* very ill or old patient not responding to conservative treatment.

* obvious protrusion of gall bladder causing abdominal distension.

Operative treatment:

Laparoscopic cholecystectomy is performed using several small incisions located at various points
across the abdomen. Several studies have demonstrated the superiority of laparoscopic
cholecystectomy when compared to open cholecystectomy (using a large incision in the right upper
abdomen under the rib cage). People undergoing laparoscopic surgery report less incisional pain
postoperatively as well as having fewer long term complications and less disability following the
surgery.[31][32] Additionally, laparoscopic surgery is associated with a lower rate of surgical site
infection
Cholecystostomy:

Puncture of gall bladder fundus, aspiration of bile through syringe, palpation and pushing of bile
contents or stones in the neck region, insertion of a rubber tube into the incision of puncture, and
drainage .

Post-operative treatment:

Tube is removed after 5-7 days. Choliangiography through tube to identify remaining stones.