1. Cholecystitis
Lecture 31

2. • Cholecystitis (Greek, -cholecyst, "gallbladder",
combined with the suffix -itis, "inflammation")
is inflammation of the gallbladder, which
occurs most commonly due to obstruction of
the cystic duct with gallstones (cholelithiasis).

3. Classification
• Acute: calculous & acalculous
• Chronic
• Acute superimposed on chronic

5. Acute Cholecystitis
• Acute calculous cholecystitis is an acute
inflammation of the gallbladder, precipitated
90% of the time by obstruction of the neck or
cystic duct.
• It is the primary complication of gallstones
and the most common reason for emergency
cholecystectomy.

6. Aacalculous cholecystitis
• Cholecystitis without gallstones called
acalculous cholecystitis may occur in severely
ill patients and accounts for about 10% of
patients with cholecystitis.

7. Pathogenesis.
• Acute calculous cholecystitis results from
chemical irritation and inflammation of the
obstructed gallbladder.

8. • The action of mucosal phospholipases
hydrolyzes luminal lecithins to toxic
lysolecithins.

9. • The normally protective glycoprotein mucus
layer is disrupted, exposing the mucosal
epithelium to the direct detergent action of
bile salts.

10. • Prostaglandins released within the wall of the
distended gallbladder contribute to mucosal and
mural inflammation.

11. • Gallbladder dysmotility develops; distention
and increased intraluminal pressure
compromise blood flow to the mucosa.

12. • Acute calculous cholecystitis frequently
develops in diabeticpatients who
have symptomatic gallstones.

14. Pathogenesis
• Acute acalculous cholecystitis is thought to result
from ischemia. The cystic artery is an end artery
with essentially no collateral circulation.

15. Risk factors for acute acalculous
cholecystitis include:
(1) Sepsis with hypotension and multisystem
organ failure;
(2) Immunosuppression;
(3) Major trauma and burns;
(4) Diabetes mellitus; and
(5) Infections.

16. Morphology.
In acute cholecystitis the gallbladder is usually
enlarged and tense, and it may assume a
bright red or blotchy, violaceous to green-
black discoloration, imparted by subserosal
hemorrhages.

17. • The serosal covering is frequently layered by
fibrin and, in severe cases, by a definite
suppurative, coagulated exudate.

21. Morphology
• In calculous cholecystitis, an obstructing
stone is usually present in the neck of the
gallbladder or the cystic duct.

22. • The gallbladder lumen may contain one or
more stones and is filled with a cloudy or
turbid bile that may contain large amounts of
fibrin, pus, and hemorrhage.

23. • In mild cases the gallbladder wallis
thickened, edematous, and hyperemic.

24. • In more severe cases it is transformed into a
green-black necrotic organ, termed
gangrenous cholecystitis,
with small-to-large perforations.

25. • The invasion of gas-forming organisms,
notably clostridia and coliforms, may cause
an acute “emphysematous” cholecystitis.

26. Clinical Features.
• An attack of acute cholecystitis begins with
progressive right upper quadrant or
epigastric pain, frequently associated with
mild fever, anorexia, tachycardia, sweating,
nausea, and vomiting.

28. • The pain may be referred pain that is felt in
the right scapula rather than the right upper
quadrant or epigastric region (Boas' sign).

29. • It may also correlate with eating greasy, fatty,
or fried foods.

30. • The Murphy sign is specific, but not sensitive
for cholecystitis.

31. • Elderly patients and those with diabetes may
have vague symptoms that may not include
fever or localized tenderness.

32. • More severe symptoms such as high fever,
shock and jaundice indicate the development
of complications such as
• abscess formation,
• perforation or
• ascending cholangitis.

33. • Another complication, gallstone ileus,
occurs if the gallbladder perforates and forms
a fistula with the nearby small bowel, leading
to symptoms of intestinal obstruction.

34. • Clinical symptoms of acute acalculous
cholecystitis tend to be more insidious, since
symptoms are obscured by the underlying
conditions precipitating the attacks.

35. • As a result of either delay in diagnosis or the
disease itself, the incidence of gangrene and
perforation is much higher in acalculous than
in calculous cholecystitis.

37. Chronic Cholecystitis
• Chronic cholecystitis may be a sequel to
repeated bouts of mild to severe acute
cholecystitis,
• but in many instances it develops in the
apparent absence of antecedent attacks.

38. • Since it is associated with cholelithiasis in
more than 90% of cases, the patient
populations are the same as those for
gallstones.

39. • supersaturation of bile
predisposes to both chronic inflammation
and, in most instances, stone formation.

40. • Unlike acute calculous cholecystitis,
obstruction of gallbladder outflow is not a
requisite.

41. • , the symptoms of calculous chronic
cholecystitis are biliary colic to indolent right
upper quadrant pain and epigastric distress.

42. Morphology.
• The morphologic changes in chronic
cholecystitis are extremely variable and
sometimes minimal.

43. • The serosa is usually smooth and
glistening but may be dulled by subserosal
fibrosis.
• Dense fibrous adhesions

44. • On sectioning, the wall is variably thickened,
and has an opaque gray-white appearance.

45. • In the uncomplicated case
• the lumen contains fairly clear, green-yellow,
mucoid bile and usually stones. The mucosa
itself is generally preserved.

46. Microscopy
• In the mildest cases, only scattered
lymphocytes, plasma cells, and macrophages
are found in the mucosa and in the
subserosal fibrous tissue.

47. • In more advanced cases there is
marked subepithelial and subserosal
fibrosis, accompanied by mononuclear
cell infiltration.

48. • Outpouchings of the mucosal epithelium
through the wall
(Rokitansky-Aschoff
sinuses) may be quite prominent.

50. Acute superimposed on chronic
cholecystitis
Superimposition of acute
inflammatory changes implies
acute exacerbation of an already chronically
injured gallbladder.

51. Porcelain gallbladder
• In rare instances extensive dystrophic
calcificatio
n within the gallbladder wall may yield a
porcelain gallbladder, notable for a markedly
increased incidence of associated cancer.

53. • Xanthogranulomatous cholecystitis is also a
rare condition in which the gallbladder has a
massively thickened wall, is
shrunken, nodular, and chronically inflamed
with foci of necrosis and hemorrhage.

54. • Finally, an atrophic, chronically
obstructed gallbladder may
contain only clear secretions, a
condition known as
hydrops of the gallbladder.

55. Clinical Features.
• Usually characterized by recurrent attacks of
either steady or colicky epigastric or right
upper quadrant pain.

56. • Nausea, vomiting, and intolerance for fatty
foods are frequent accompaniments.