Cholecystitis (gallbladder inflammation) is usually caused by gallstones. This often leads to an infection with bacteria. Cholecystitis is almost always treated by surgical removal of the gallbladder to avoid serious complications. Read everything you need to know about symptoms and treatment of gallbladder infection here.
ICD codes for cholecystitis disease: K81
• Symptoms: Mainly pain in the upper abdomen, along with loss of appetite, nausea, vomiting, fever or tachycardia; partial jaundice.
• Treatment: Surgical removal of the gallbladder; pain relievers and antispasmodic drugs; Dissolving gallstones is no longer recommended today.
• Prognosis: In acute cholecystitis, the gallbladder is usually removed quickly; with chronic inflammation, slight pain occurs again and again; increased risk of cancer if the gallbladder is scarred.
• Diagnosis: medical history, physical examination, blood test, imaging tests (especially ultrasound and CT).
• Prevention: 100% prevention is not possible; However, a healthy and balanced diet reduces the risk of gallstones and thus also of cholecystitis.
What is cholecystitis?
Cholecystitis (Gallbladder inflammation) is a disease of the gallbladder wall. In most cases, it is caused by gallstone disease (cholelithiasis). The gallbladder is a hollow organ located below the liver. Its appearance is reminiscent of a pear. The human gallbladder is typically eight to twelve centimeters long and four to five centimeters wide. It stores the bile (bile) produced in the liver cells. She thickens him up. The bile is needed to digest fats in the intestine.
Classification of cholecystitis
Doctors refer to inflammation of the gallbladder as “cholecystitis” (chole = bile; kystis = bladder). If the gallbladder inflammation is the result of gallstone disease (90 percent of cases), it is called calculous cholecystitis. If gallbladder inflammation occurs without stones, doctors speak of acalculous cholecystitis. In addition, experts distinguish between acute cholecystitis and chronic cholecystitis.
Frequency of cholecystitis
About 10 to 15 percent of people worldwide develop gallstones, which later cause gallbladder inflammation in 10 to 15 percent of people. Gallstones are most common in patients over the age of 55.
Cholecystitis caused by stones is more common in women than in men. This is mainly because gallstones are about twice as common in women as in men. Non-stone related inflammation of the gallbladder affects men more often than women.
Chronic cholecystitis appears to be more common than acute. However, there is no precise information on the frequency of gallbladder inflammation, since the majority of patients either do not visit the doctor or are not admitted to the hospital.
What are the symptoms of cholecystitis?
The typical symptoms of cholecystitis are pain that begins in the upper abdominal region above the stomach and gradually moves to the right upper quadrant. They usually appear initially in spasmodic waves (biliary colic) when the gallbladder contracts and tries to remove the gallstones.
In the further course of almost all gallbladder infections, those affected feel pain in the right abdomen continuously (over several hours). If the doctor presses on this spot, the pain increases. They may radiate to the back, right shoulder, or between the shoulder blades.
If there is an inflammatory disease of the bile ducts (cholangitis) in addition to gallbladder inflammation, this sometimes leads to what is known as jaundice (icterus). The conjunctiva (scleral jaundice) and, in advanced stages, the skin turn yellow. The yellow color is caused by the blood pigment bilirubin, which is collected in the bile after old red blood cells are broken down.
Cholecystitis in children
If the gallbladder is inflamed in children, similar symptoms occur. However, gallbladder infections lead to jaundice and white to greyish stools (acholic stools) much more quickly in young children than in adults. The children are easily irritable and often cry. Many parents report that their child has a loss of appetite.
Older children and adolescents often suffer from typical symptoms such as nausea and vomiting. At the beginning of cholecystitis, children often only feel an unpleasant feeling of pressure instead of upper abdominal pain, which only develops into cramping pain over time.
Cholecystitis in adults
In older people, signs of an inflamed gallbladder are often faint. Symptoms such as pain or fever are usually absent. Many only feel a slight pain when pressure is applied to the upper right abdomen. Some sufferers just feel exhausted and tired. This is especially true if you also suffer from diabetes (diabetes mellitus).
Even with chronic cholecystitis, the symptoms are less pronounced. Those affected usually only suffer from a slight feeling of pressure and flatulence. In contrast, inflammation of the gallbladder without stones (acalculous cholecystitis) quickly leads to a serious clinical picture, namely blood poisoning (sepsis) with a high fever.
How is cholecystitis treated?
According to current standards, cholecystitis is usually treated surgically. The gallbladder and the stones it contains are completely removed. The medical term for this surgical procedure is cholecystectomy.
This operation is usually performed using a laparoscopy. The instruments are inserted into the abdomen via small abdominal incisions and the gallbladder is excised with them (laparoscopic cholecystectomy). In some cases, the gallbladder is removed directly through an incision in the abdominal wall. This open cholecystectomy is necessary, for example, when the stone mass contained in the gallbladder is too large.
The two forms of cholecystitis with a high risk of complications, the acalculous and the emphysematous form, are usually treated immediately with surgery. There is a high risk of surgery in patients with many or particularly serious previous illnesses and in elderly patients. With them, the accumulated bile and possibly also pus can be temporarily drained through a tube through the skin (cholecystotomy and percutaneous drainage).
According to the CDC guidelines, the gallbladder should be removed after six weeks in such cases. In general, studies indicate that the earlier the surgery is performed after the onset of symptoms, the lower the chance of complications.
Recent studies mention another therapy option for these risk patients: the insertion of a metal tube (stent) in the bile duct to relieve the gallbladder.
Non-surgical treatment measures
The doctor treats the spasmodic pain of cholecystitis with painkillers (analgesics) and antispasmodic drugs (spasmolytics). In addition to painkillers, the administration of antibiotics is often necessary to combat the pathogens of bacterial gallbladder inflammation. Recent studies also show that painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) partially reduce the risk of gallbladder inflammation in the case of existing gallstones.
In addition, doctors recommend not eating for at least 24 hours. This is to relieve the gallbladder. However, it is also important that patients with cholecystitis drink enough fluids. In the hospital, fluids are usually given as an infusion through a vein. The doctors also pay attention to the electrolyte balance (e.g. potassium and sodium levels in the blood).
Home remedies such as warm compresses on the upper right abdomen are a possible option to relieve the pain in addition to medical treatment. Herbal agents are sometimes used to reduce the risk of gallstones. However, treating an existing inflammation of the gallbladder with home remedies is strongly discouraged.
Home remedies have their limits. If the symptoms persist over a longer period of time, do not get better or even get worse, you should always consult a doctor.
Dissolution of risky gallstones
If the gallstones only cause minor symptoms, there is the option of dissolving the gallstones with medication (litholysis). This also reduces the risk of gallbladder inflammation. For litholysis, doctors usually administer ursodeoxycholic acid (UDCA) as capsules.
However, this substance only dissolves cholesterol-containing stones that cannot be seen in the X-ray image (X-ray negative stones). In addition, for UDCA to be used, the gallbladder must still be functioning and the bile duct must be patent. The success of the treatment is checked by ultrasound. The guidelines recommend continuing to take the UDCA for three months thereafter.
However, the risk of stones forming again and causing gallbladder inflammation is very high. If a patient suffers from gallstones or symptoms of cholecystitis again after non-surgical treatment, the gallbladder is surgically removed (cholecystectomy).
The use of so-called extracorporeal shock wave lithotripsy to break up the gallstones is no longer recommended in the guidelines. In this procedure, the gallstones are bombarded with sound waves from the outside via a transmitter and thereby broken up. The debris is then excreted through the intestines.
But even after this treatment, new gallstones usually form very quickly, which increases the risk of gallbladder inflammation. In addition, the cost-benefit ratio is worse than that of a cholecystectomy.
Cholecystitis: course of the disease and prognosis
The prognosis of acute cholecystitis is good if treated early. In particular, early surgical removal of the gallbladder reduces the risk of complications. Studies also show that patients leave the hospital faster if they have surgery within the first few days of diagnosis.
How long patients are on sick leave after the operation varies from person to person. Most of the time, however, the hospital stay only lasts a few days. After that, those affected should take it easy for a few weeks.
The gallbladder is not a vital organ, so fears of surgical removal are often unfounded. It is possible that patients who have had a gallbladder infection with a cholecystectomy are less able to tolerate spicy and fatty foods. However, this often improves over the years.
If the diagnosis of cholecystitis is made late, there is a risk of life-threatening complications. In the early stages of cholecystitis, this includes accumulations of pus (empyema) in the gallbladder and major tissue damage due to insufficient blood supply (gangrenous cholecystitis). Such complications increase the risk of a life-threatening course of the disease and are always treated surgically.
Especially in the case of stone-related cholecystitis, there is a risk of the gallbladder wall breaking through as the disease progresses. As a result, bile empties into surrounding organs or body cavities and the inflammation spreads. This often leads to abscesses, for example around the gallbladder (pericholecystic abscess) or in the liver.
If bile enters the abdominal cavity, doctors speak of a free perforation. The result is usually peritonitis (bilious peritonitis). In contrast to this is the “covered” perforation. The tear in the gallbladder wall is covered by intestinal loops, for example, and no bile escapes.
If a gallbladder infection breaks open to the gastrointestinal tract, there is a risk of so-called bilioenteric/biliodigestive fistulas forming. These are duct-like connections in the stomach, small or large intestine. Some of the air from the intestines enters the bile ducts via these fistulas. This is how air bubbles form in the biliary system, which are visible on X- ray, CT or ultrasound. In this case, doctors speak of aerobilia.
Stones sometimes get into the intestines in the opposite way and block them (gallstone ileus). In rare cases, the inflammation of the gallbladder forms a connection with the skin (biliocutaneous fistula).
In the case of gallbladder inflammation with bacteria, the pathogens sometimes get into the bloodstream and cause dangerous bacterial blood poisoning (sepsis). This complication is feared above all in emphysematous gallbladder inflammation. However, acalculous, i.e. non-stone-related, gallbladder inflammation is usually the result of such sepsis.
The transition from acute cholecystitis to chronic cholecystitis is fluid. Chronic cholecystitis follows acute gallbladder inflammation that has not completely healed. Some patients occasionally complain of pain when there is an acute inflammatory flare-up. As a rule, however, chronic gallbladder inflammation does not cause any symptoms.
As the disease progresses, the gallbladder sometimes shrinks. If calcium deposits in the gallbladder wall, this leads to the so-called porcelain gallbladder. It also causes no symptoms, but significantly increases the risk of gallbladder cancer. In about a quarter of all patients, the porcelain gallbladder becomes malignant. Chronic gallbladder inflammation and its complications are also treated by total cholecystectomy.
Cholecystitis: causes and risk factors
In about 90 percent of cases, patients initially have gallstones before gallbladder inflammation develops. These stones block the outlet of the gallbladder (cholecystolithiasis), the bile duct (choledocholithasis) or the entrance to the small intestine. As a result, the bile no longer drains and builds up in the gallbladder. This stretches it excessively and compresses its wall.
This disrupts the flow of lymph and blood through the vessels in the wall of the gallbladder. The insufficient blood supply causes a lack of nutrients and oxygen in the mucous membrane of the gallbladder.
On the one hand, cells perish, release pollutants and thus trigger gallbladder inflammation. On the other hand, the aggressive substances in the bile acid release special proteins, so-called prostaglandins. In particular, prostaglandins E and F promote gallbladder inflammation. Also, the gallbladder wall sheds more fluid due to the influence of prostaglandins. This stretches the gallbladder even further and the cells in the gallbladder are even less supplied.
The lack of drainage of bile also makes it easier for bacteria to migrate from the intestine into the gallbladder. Therefore, a bacterial infection of the gallbladder sometimes occurs in addition to the inflammation.
Risk factor gallstones
Gallstone disease usually causes gallbladder inflammation when the bile no longer drains properly through the gallstones. Therefore, the risk factors for gallstones also increase the risk of calculous cholecystitis. These risk factors include the so-called ” 6 F “:
- Female (female gender)
- Fat (severe overweight, obesity)
- Fourty (forty years old, generally increasing in age)
- Family (family predisposition).
Rapid weight loss also sometimes leads to gallstones. Certain medications, especially hormone preparations for women, increase the risk of gallstones and thus of gallbladder inflammation. The same applies to pregnant women: an increased occurrence of the hormone progesterone promotes the formation of gallstones and inflammation.
Acalculous inflammation of the gallbladder
The exact cause of cholecystitis not caused by gallstones is not entirely clear. Fundamentally, however, researchers also suspect a blockage or the whereabouts of viscous (concentrated) bile in the gallbladder. Concentrated bile is very aggressive and attacks the lining of the gallbladder when it is not emptied regularly (gallbladder stasis). In healthy people, the messenger substance cholecystokinin (CCK) ensures that bile is emptied into the intestine.
Impaired gallbladder emptying
Serious accidents, serious burns or feverish illnesses such as bacterial blood poisoning (sepsis) dry out the body and make the bile more viscous. If the patient stops eating (e.g. because he is in an artificial coma), the messenger substance CCK is not released. The aggressive, tough, concentrated bile remains in the gallbladder and eventually leads to cholecystitis.
Prolonged fasting also prevents the release of CCK and thus the emptying of the gallbladder. The same applies if a patient is fed artificially for a longer period of time (parenteral nutrition).
Impaired oxygen supply
A reduced blood supply and thus oxygen supply sometimes also leads to inflammation of the gallbladder. This is the case, for example, after a heart attack. Sometimes in sickle cell anemia, the misshaped blood cells clog the small blood vessels in the wall of the gallbladder, causing cholecystitis. In people with diabetes mellitus, the vessels are often damaged by deposits.
Bacteria, viruses and parasites
The bile is normally sterile. However, if cholecystitis occurs after gallbladder congestion, bacteria often rise from the intestine and penetrate the gallbladder wall. The most common germs are Escherichia coli, Klebsiella and enterobacteria. They migrate to the gallbladder either via the bile duct or the lymphatic system.
Bacterial infections are the main cause of serious complications of gallbladder infection. Bacterial gallbladder infections primarily affect patients with a weakened immune system (immunosuppressed) and severely (previously) ill patients, such as patients with sepsis. These also occur in some cases after abdominal surgery or an examination of the pancreas and bile ducts.
A special form of gallbladder inflammation is emphysematous cholecystitis. This is where infection with the gas-forming bacteria E. coli and clostridia occurs. Although this form of gallbladder inflammation is very rare (about one percent of all acute cases), it is extremely dangerous because there is a significantly increased risk of serious complications. This form of cholecystitis primarily affects older, diabetic men with non-stone-related (acalculous) inflammation of the gallbladder.
In addition to bacteria, parasites such as amoebas or flukes are other possible causes of such acalculous gallbladder inflammation.
Infections with salmonella, hepatitis A virus or the human immunodeficiency virus (“AIDS”) also increase the risk of gallbladder inflammation. In HIV patients, the cytomegalovirus and cryptosporidia and microsporidia (parasites) play a particularly important role.
Prevent gallbladder infections
Gallbladder infection is difficult to prevent. First and foremost is preventing gallstone disease as the main risk factor. Eat a high-fiber diet and exercise. This also counteracts the risk factor of being overweight.
Tips for a diet that reduces the risk of gallstones:
- Eat plenty of high-fiber (vegetables) and high-calcium foods.
- Eat fewer carbohydrates (especially foods and drinks high in sugar).
- Use polyunsaturated and monounsaturated fats ( vegetable oils such as olive oil) and omega-3 fatty acids when cooking.
- Avoid saturated fats and trans fats (also called “hydrogenated fats”), which are often found in fast food, pastries, or snack foods like chips.
Avoid extremely low-fat diets and fasting! This reduces the flow of bile from the gallbladder and often causes bile to build up and gallstones to form more easily. Because bile is important for digesting fats, some patients after gallbladder removal cannot tolerate high-fat foods (particularly in large quantities), and fats are sometimes thought to be unhealthy for the gallbladder in general.
Overweight and obesity are risk factors for gallstone formation. If you are overweight, you should ask your doctor for advice on how best to reduce it. Sufficient physical exercise helps to reduce the risk.
However, rapid weight loss after abdominal surgery (gastric bypass, gastric band) also increases the risk of gallstones and thus gallbladder inflammation. Studies have shown that taking ursodeoxycholic acid (UDCA) for six months after gastric band surgery reduces the risk of stones.
It is also important that you trust your doctor. The symptoms of gallbladder inflammation usually improve after the first intake of medication (spasm relievers, painkillers). Nevertheless, the doctor will recommend an operative cholecystectomy. Follow the advice of your treating doctor to avoid serious complications of gallbladder infection.
Cholecystitis: diagnosis and examination
If you suspect that you have gallbladder infection, you should always consult a doctor. In the case of minor symptoms, a family doctor or a specialist in internal medicine (internist) can help. However, severe pain and high fever associated with acute cholecystitis require a hospital stay. If you have first consulted your doctor, he will immediately refer you to a clinic.
As with any disease, taking the medical history (anamnesis) is crucial. It provides the doctor with the first indications of the correct diagnosis. He first asks about possible symptoms of gallbladder inflammation. The doctor may ask the following questions:
- How long and where have your complaints existed?
- Did the pain appear in spasmodic bouts, especially at the beginning?
- Have you recently measured elevated body temperatures?
- Have you had gallstones in the past? Or did your family members often suffer from gallstones?
- Have you been fasting lately?
- What medication are you taking (possibly hormone preparations from the gynaecologist)?
After the detailed questioning, your doctor will examine you physically. Risk factors such as obesity, light skin and possible yellowing of the eyes or skin can be identified without a thorough examination. It will also measure your body temperature. Measuring the pulse and listening to the heart will tell the doctor if the heart is beating excessively fast, which is typical of an infection.
The examination of the abdomen plays the most important role. The doctor first listens to the abdomen (auscultation). Decreased bowel sounds indicate inflammation of the peritoneum (peritonitis), especially in the advanced stage. The doctor then feels the abdomen with his hands (palpation).
The so-called Murphy’s sign (named after an American surgeon) is typical of gallbladder inflammation. The doctor presses on the right upper abdomen under the costal arch. Now he will ask you to take a deep breath. As a result, the gallbladder migrates under the pressing hand. If the gallbladder is inflamed, the pressure causes severe pain. You will involuntarily tense your stomach (defensive tension) and possibly stop breathing.
Sometimes the doctor even feels the bulging and inflamed gallbladder directly.
The doctor will take blood samples to determine if the gallbladder is inflamed. Some blood values change particularly frequently in the case of gallbladder inflammation. For example, one often finds more white blood cells (leukocytosis).
Elevated C-reactive protein (CRP) and increased blood sedimentation rate indicate inflammation in the body. Certain proteins (enzymes) in the liver (AST and ALT) are also often increased by inflammation of the gallbladder. The doctor also has the levels of the red blood pigment (bilirubin) and the enzymes gamma-GT and alkaline phosphatase checked.
With a urine test, the doctor wants to rule out damage to the kidneys. Because sometimes an inflammation of the renal pelvis (pyelonephritis) or kidney stones (nephrolithiasis) cause symptoms similar to those of gallbladder inflammation.
If there is a possibility of pregnancy, this will also be checked.
In the case of a high fever and poor general condition (palpitations, low blood pressure), doctors take blood for so-called blood cultures to find out whether bacteria are present in the bloodstream. It is possible that the bacteria have already spread throughout the body via the blood (bacterial blood poisoning, sepsis).
There are many imaging modalities to show the gallbladder and its possible inflammation. A simple and safe method is the ultrasound of the abdomen (abdominal sonography). In case of doubt, a computer tomography or a so-called hepatobiliary functional scintigraphy is ordered. The latter, complex procedure shows the production of bile and its drainage using radioactively marked substances. X-rays are rarely performed.
With the help of an ultrasound device, the doctor detects gallstones that are larger than two millimeters and inflammation of the gallbladder. Thickened, crystallized bile (bile grit) is often also visible and is called “sludge”. This test also partially triggers Murphy’s sign.
Acute inflammation of the gallbladder is revealed on ultrasound by the following features:
- The wall is thicker than four millimeters.
- The gallbladder wall shows itself in three layers.
- A dark accumulation of fluid can be seen around the gallbladder.
- The gallbladder is significantly enlarged.
In the case of inflammation with accumulation of air (emphysematous gallbladder inflammation), the doctor also sees the accumulation of air in the gallbladder (stage 1), in the gallbladder wall (stage 2) or even in the surrounding tissue (stage 3).
Free air in the abdomen indicates a tear or a hole in the gallbladder and represents an emergency. In this case, surgery is performed as soon as possible. The same applies to other complications of gallbladder inflammation, such as accumulations of pus, which can be seen on ultrasound.
Computed tomography (CT)
Ultrasound shows the cystic duct and the common bile duct very poorly or not at all. The pancreas is also often difficult to assess. If an inflammation of the pancreas is also conceivable or if there are general doubts about the diagnosis, the doctors carry out a computer tomography (CT) to confirm the diagnosis.
An x-ray is rarely ordered. Very few gallstones can be visualized with this technique. However, the X-ray of an emphysematous gallbladder infection is usually much more conspicuous. In this case, there is an accumulation of air in the area of the gallbladder
The so-called porcelain gallbladder is visible on both ultrasound and X-rays. This disease is the result of chronic gallbladder inflammation. Because of scarring and calcium deposits, the gallbladder wall hardens and becomes whitish like porcelain.
With an ERCP (endoscopic retrograde cholangiopancreatography), the bile ducts, the gallbladder and the ducts of the pancreas are displayed using X-ray contrast media and a special endoscope. This examination is performed under short-term anesthesia (twilight sleep) and is only performed if doctors suspect gallstones in the main bile duct.
These stones can be removed directly during an ERCP. The point at which the bile duct enters the intestine (papilla vateri) is expanded with an incision so that the stone ideally passes into the intestine and is excreted with the stool.
Sometimes the gallstone needs to be removed using wire loops called a dormia basket. However, ERCP increases the risk of inflammation of the pancreas or bile duct.