Cholecystitis (Gallbladder Inflammation)

What are gallstones and how do they block the flow of bile?

Gallstones are hardened deposits of the digestive fluids that form in your gallbladder, and can range in size from a tiny grain of sand (called sludge) to a golf ball. They are made up of either cholesterol or pigment stones. Gallstones made of cholesterol are yellow-greenish in color, and are more common. Pigment stones are mostly made of bilirubin, a substance that is created when the liver breaks down red blood cells.

Gallstones themselves are not necessarily a problem. It’s possible to have gallstones sitting in your gallbladder, never bothering you and, in that case, they don’t need to be treated. However, gallstones that leave the gallbladder can get stuck in your ducts (tubes). They block the flow of bile out of your gallbladder, which causes a buildup of bile. These events cause the walls of your gallbladder to become inflamed and swell, and that can lead to bacterial infection of the bile. Your life can even be in danger unless you seek prompt medical and surgical help.

How does the gallbladder work?

The gallbladder connects to your liver by a duct system (tubes) that look like a tree trunk with branches. There are many ducts, or “branches” inside your liver. These tree branches connect to two main tree limbs in your liver, called the right and left hepatic ducts. These two ducts merge (like the trunk of a tree) to form your common hepatic duct. One main “tree limb” coming off the common hepatic duct is called the cystic duct. It connects directly into your gallbladder. The common hepatic duct, the “tree trunk,” continues but its name changes to the common bile duct. Your common bile duct empties into the duodenum section of the small intestine.

Bile, a fat-dissolving liquid substance that is made continuously by your liver, travels through the duct system and enters your digestive system at the duodenum. When you are not eating, a valve structure at the common bile duct and duodenum connection, called the major duodenal papilla, is usually closed. This allows the bile to reflux back through the cystic duct into your gallbladder to be stored. During mealtime, your gallbladder contracts, and the valve opens, pushing the stored bile out of your gallbladder, through the cystic duct and down the common bile duct into your intestine. Bile mixes with the partially digested food, further helping the breakdown of the fat in your diet.

Gallstones, or even sludge, in the gallbladder can obstruct this normal flow of bile, leading to cholecystitis.

Who is at risk to get cholecystitis?

- You are at greater risk of developing cholecystitis if you:

- Have a family history of gallstones.

- Are a woman age 50 or older.

- Are a man or woman age 60 or older.

- Eat a diet high in fat and cholesterol.

- Have overweight/obesity.

- Have diabetes.

- Are of Native American, Scandinavian or Hispanic descent.

- Are currently pregnant or have had several pregnancies.

- Takes estrogen replacement therapy or birth control pills.

- Have lost weight rapidly.

What causes cholecystitis?

Cholecystitis is commonly caused by gallstones that have blocked your cystic duct, which prevents bile from exiting your gallbladder. Your gallbladder becomes swollen and may become infected with bacteria. Less common causes include blocked bile ducts due to scarring, reduced blood flow to your gallbladder, tumors that block the flow of bile from your gallbladder, or viral infections that inflame your gallbladder.

What are the symptoms of cholecystitis?

Symptoms can be acute or chronic.

Acute cholecystitis comes on suddenly and causes severe, ongoing pain. More than 95% of people with acute cholecystitis have gallstones. Pain begins in your mid to upper right abdomen and may spread to your right shoulder blade or back. Pain is strongest 15 to 20 minutes after eating and it continues. Pain that remains severe is considered a medical emergency.

Chronic cholecystitis means you’ve had repeated attacks of inflammation and pain. Pain tends to be less severe and doesn’t last as long as acute cholecystitis. The repeated attacks are usually caused by gallstones blocking the cystic duct intermittently.

Other signs and symptoms of cholecystitis may include:

- Tenderness in your abdomen when it's touched.

- Nausea and bloating.

- Vomiting.

- Fever above 100.4 F (38 C). Fever may not be present in older adults and usually doesn’t occur in people with chronic cholecystitis.

- Chills.

- Abdominal pain that gets worse when taking a deep breath.

- Abdominal pain and cramping after eating – especially fatty foods.

- Jaundice (a yellowing of skin and eyes).

How is cholecystitis diagnosed?

Your healthcare professional will ask about your symptoms. They may order blood work to check your white blood cell count and how well your liver is working. A higher than normal white blood cell count is a sign of an infection, inflammation, or an abscess.

Imaging tests that could be ordered include:

Abdominal ultrasound: This test uses sound waves to examine the gallbladder and the bile ducts. It helps identify signs of inflammation in your gallbladder, the presence of gallstones, and thickening or swelling of the gallbladder wall.

Hepatobiliary nuclear imaging (HIDA scan): This is an imaging test that involves an injected radioactive substance. A gamma camera sees the radiation as it moves through the different tracts of the digestive system. If that substance doesn’t enter your gallbladder, then the healthcare provider knows the organ is blocked, indicating cholecystitis. This test can also detect the function of the gallbladder and its ability to eject the bile once stimulated. This is called the ejection fraction of the gallbladder, which is considered normal when it is above 30-35%.

Magnetic Resonance Cholangiopancreatography (MRCP): This type of MRI shows details of your liver, gallbladder, bile ducts, structures and ducts of the pancreas as well. It can show gallstones, inflammation or blockage of the bile ducts and gallbladder and if there is any inflammation of the pancreas.

Abdominal Computed Tomography (CT Scan): This X-ray test shows details of your liver, gallbladder and bile ducts. It shows inflammation of the gallbladder.

How can cholecystitis be treated?

Treatment of cholecystitis usually takes place in the hospital. Treatments may include:

- Fasting, to rest the gallbladder.

- IV fluids to prevent dehydration.

- Pain medication.

- Antibiotics to treat infection.

- Removing the gallbladder. This surgery, called a cholescystectomy, is usually performed by making tiny cuts (incisions) through the abdomen to insert a laparoscope (tiny camera) to see inside the abdomen and surgical instruments to remove the gallbladder. The gallbladder is usually removed within 24 to 48 hours of admission if you have a confirmed case of acute cholecystitis.

- Draining the gallbladder to treat and prevent the spread of infection. This procedure, called percutaneous cholecystostomy, is usually reserved for those who are too ill to undergo surgery.

- Removing gallstones in the area blocking the common bile duct. This procedure, done by an endoscopist, called endoscopic retrograde cholangiopancreatography (ERCP), is reserved for patients with a suspected or confirmed blocked common bile duct, and can clear the duct of stones and sludge.

What is it like to recover from gallbladder surgery?

Recovery from gallbladder surgery, when done laparoscopically, is usually uneventful. As with any surgery there can be minimal pain at the incision sites. Most patients are discharged from the hospital shortly after the surgery, and do not require additional testing or interventions. If the surgery is done through a larger wound (open surgery) then the recovery can be slower and require more days in the hospital.

Can I live without my gallbladder?

Yes, you can live a normal life without a gallbladder. Since the gallbladder’s main role is the storage of the bile, and bile is made continuously by the liver, you don’t need your gallbladder for normal digestion. Bile can still flow directly from your liver, through the common bile duct and into the small intestine.

What complications can occur if cholecystitis is not treated?

Complications can range from ongoing infection to possible death.

Severely Infected gallbladder: A blocked gallbladder that is extremely uncomfortable and painful. Without treatment, it could lead to an overwhelming infection, or even gangrene of the gallbladder.

Cholangitis: An acute infection of the main bile ducts and liver that can be extremely life-threating if not promptly treated.

Inflamed pancreas (Pancreatitis): Your common bile duct and the pancreatic duct share the same “valve” into the duodenum. If a gallstone blocks that valve, the potent pancreatic enzyme juice excreted by the pancreases gets backed up causing pancreatitis, which can also be severe and life threatening.

What if I have cholecystitis during pregnancy?

During early and later pregnancy cholecystitis can be treated by antibiotics. Surgery is usually a safe option during the second trimester, but can also be performed safely at any time if antibiotics fail to treat the infection.

How can cholecystitis be prevented?

You can reduce your risk of developing cholecystitis by:

Eating a healthy diet: Choose to eat a healthy diet – one high in fruits, vegetables whole grains and healthy fats – such as the Mediterranean diet. Stay away from foods high in fat and cholesterol.

Exercising: Exercise reduces cholesterol, and the lower the cholesterol level the lower the chance of getting gallstones.

Losing weight slowly: If you are making efforts to lose weight, don’t lose more than one to two pounds a week. Rapid weight loss increases your risk for developing gallstones.