Chronic Cholecystitis

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Sign and Symptoms Investigations Management

Chronic cholecystitis is a medical condition characterised by persistent inflammation of the gallbladder. The gallbladder, a small organ located beneath the liver, plays a crucial role in the digestion and storage of bile. Bile is a digestive fluid produced by the liver and helps in breaking down fats in the small intestine.
In chronic cholecystitis, the gallbladder becomes inflamed over an extended period, leading to various symptoms and complications.

1. Gallstones (Cholelithiasis): The primary cause of chronic cholecystitis is the presence of gallstones, which are solid accumulations of cholesterol or bilirubin within the gallbladder. These stones can obstruct the cystic duct, preventing the bile from flowing out and leading to the inflammation of the gallbladder. Over time, these recurrent episodes of inflammation can cause chronic cholecystitis to develop.
2. Biliary Sludge: In some cases, a mixture of cholesterol crystals, calcium salts, and mucin called biliary sludge can accumulate within the gallbladder. Biliary sludge can be a precursor to gallstones and may contribute to chronic cholecystitis by disrupting gallbladder function and causing inflammation.
3. Bacterial Infection: The presence of bacteria, particularly Escherichia coli and Klebsiella species, in the bile can lead to bacterial infection of the gallbladder. This infection can occur secondary to gallstone obstruction or may develop independently, causing chronic cholecystitis.
4. Gallbladder Ischemia: Reduced blood flow to the gallbladder, known as gallbladder ischemia, can also be a contributing factor in the development of chronic cholecystitis. Conditions that compromise blood supply to the gallbladder, such as atherosclerosis or vasculitis, can lead to chronic inflammation and subsequent fibrosis of the gallbladder wall.
5. Autoimmune Disorders: Certain autoimmune conditions, such as primary sclerosing cholangitis and chronic active hepatitis, can result in chronic cholecystitis. In these cases, the immune system mistakenly attacks the gallbladder, leading to chronic inflammation and damage.
6. Reflux of Duodenal Contents: The duodenal contents, including bile and pancreatic enzymes, can flow backward into the gallbladder if the sphincter of Oddi (a muscular valve regulating the flow of bile and pancreatic secretions) malfunctions. This reflux can trigger chronic irritation and inflammation of the gallbladder, eventually leading to chronic cholecystitis.

1. Gallstones formation: The majority of chronic cholecystitis cases occur due to the presence of gallstones in the gallbladder. Gallstones are formed when substances such as cholesterol, bile salts, and calcium bilirubinate precipitate and crystallise within the gallbladder. These gallstones can obstruct the cystic duct, limiting the smooth flow of bile and leading to inflammation and stasis within the gallbladder.

2. Bile stasis and bacterial overgrowth: When gallstones obstruct the cystic duct or the gallbladder contracts inadequately, bile flow becomes disrupted. Bile stasis occurs, leading to changes in the bile composition and allowing an opportune environment for bacterial overgrowth. Bacteria, particularly Escherichia coli, enterococci, and anaerobes, can proliferate in the stagnant bile, causing infection and further exacerbating the inflammation.

3. Chronic inflammation: Chronic cholecystitis is characterised by persistent inflammation within the gallbladder. Initially, the gallbladder's epithelial lining undergoes acute inflammation in response to the presence of gallstones or bacterial infection. Over time, this acute inflammation transforms into chronic inflammation. The continuous release of pro-inflammatory cytokines, such as interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α), leads to the recruitment and activation of immune cells, including macrophages and neutrophils. These immune cells contribute to tissue damage and fibrosis, further compromising the gallbladder's normal structure and function.

4. Ischemia and fibrosis: The chronic inflammation and recurrent acute exacerbations in chronic cholecystitis can result in ischemic damage to the gallbladder tissue. Ischemia occurs due to impaired blood supply caused by vascular changes within the inflamed organ. Consequently, the damaged tissue undergoes fibrotic changes, leading to the deposition of excess collagen and scarring. These fibrotic changes ultimately contribute to the gallbladder's stiffening and reduced contractility.

5. Impaired gallbladder function: With the development of chronic inflammation, scarring, and structural changes, the gallbladder's ability to store and concentrate bile becomes compromised. The diseased gallbladder may exhibit reduced contractility and impaired emptying, resulting in inadequate release of bile into the common bile duct. This impaired gallbladder function can manifest as symptoms like abdominal pain, bloating, nausea, and vomiting.

1. Abdominal pain: The hallmark symptom of chronic cholecystitis is recurrent, episodic pain in the upper right quadrant of the abdomen. The pain may be mild to severe and can last for several hours or days. It typically occurs after consuming fatty or greasy foods. The discomfort may radiate to the right shoulder or back.

2. Nausea and vomiting: Many individuals with chronic cholecystitis experience persistent nausea, occasionally accompanied by vomiting. These symptoms commonly occur after meals, particularly those containing high-fat content. The inability to tolerate fatty foods is often a key indicator of this condition.

3. Indigestion and bloating: Chronic cholecystitis can affect the digestive process, leading to indigestion, bloating, and feelings of discomfort after eating. Affected individuals may also experience excessive flatulence and belching.

4. Fever and chills: In some cases, chronic cholecystitis can trigger episodes of low-grade fever and chills. These symptoms typically occur during acute exacerbations of the condition and might be accompanied by generalised malaise.

5. Jaundice: Although less common, chronic cholecystitis can cause jaundice. Jaundice is characterised by yellowing of the skin and eyes due to the accumulation of bilirubin, a yellow pigment produced by the breakdown of red blood cells. It occurs when gallstones block the bile ducts, leading to a backup of bile and subsequent liver dysfunction.

6. Changes in stool colour: When chronic cholecystitis is associated with obstructive jaundice, stools may appear clay-coloured or pale. This is due to reduced bilirubin flow into the intestines, resulting in altered stool pigmentation.

Diagnostic Procedures:
In order to confirm the diagnosis of chronic cholecystitis, various diagnostic tests were performed:
1. Abdominal Ultrasound: This non-invasive imaging technique was used to visualise the gallbladder. It helps to detect gallstones or any thickening of the gallbladder wall, an indication of chronic inflammation.
2. Blood Tests: A full blood count (FBC) and liver function tests (LFTs) can be conducted to assess the overall health of the patient and identify any abnormalities.

1. Conservative Management:
In mild cases of chronic cholecystitis, conservative management may be recommended. This approach aims to relieve symptoms and prevent further complications without surgical intervention. Key components of conservative management include:

• Dietary modifications: A low-fat diet is commonly recommended to avoid triggering gallbladder contractions and subsequent pain. A diet rich in fruits, vegetables, and whole grains is encouraged while limiting fatty and processed foods.

• Medications: Certain medications, such as bile acid salts or ursodeoxycholic acid, may be prescribed to dissolve gallstones, particularly cholesterol stones. However, this approach is often slow and may not be effective for everyone.

• Pain management: Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can be used to manage pain during flare-ups.

2. Surgical Interventions:
In cases where conservative management fails or complications arise, surgical interventions become necessary.

3. Lifestyle Modifications:
Apart from the medical and surgical interventions, certain lifestyle modifications can help manage chronic cholecystitis effectively. These include:

• Weight management: Maintaining a healthy weight can reduce the risk of gallstone formation and subsequent complications. Incorporating regular physical exercise and adopting a balanced diet can contribute to weight management.

• Avoiding trigger foods: Identifying foods that trigger symptoms and avoiding them can help minimise the occurrence of painful episodes. High-fat and greasy foods, spicy foods, and excessive caffeine or alcohol intake should be limited or avoided.

• Hydration: Staying adequately hydrated ensures proper bile flow, reducing the chance of gallstone formation. Drinking sufficient water throughout the day is essential.

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