C h a p t e r 3 0
Disorders of Hepatobiliary and Exocrine Pancreas Function
747
(85% to 90%) are associated with the presence of gall-
stones (calculous cholecystitis).
3,4,44,45
The remaining
cases (acalculous cholecystitis) are associated with sep-
sis, severe trauma, or infection of the gallbladder. Acute
acalculous cholecystitis, which involves ischemic rather
than inflammatory changes associated with stones, can
rapidly progress to gangrene and perforation.
44
Acute
calculous
cholecystitis occurs when a stone
becomes impacted in the cystic duct and inflammation
develops behind the obstruction. It has been theorized
that obstruction of the cystic duct leads to the release of
mucosal phospholipase from the epithelium of the gall-
bladder. These lipases, in turn, lead to disruption of the
normal glycoprotein mucous layer, exposing the muco-
sal epithelium to the destructive action of concentrated
bile salts.
3,4
Acute
acalculous
cholecystitis is thought to
result from ischemia. The cystic artery is an end artery
with essentially no collateral circulation.
3
Contributing
factors may include inflammation and edema of the gall-
bladder wall, stasis of bile, and conditions that lead to
cystic duct obstruction in the absence of frank stone for-
mation. Risk factors for acute acalculous cholecystitis
include sepsis with hypotension and multisystem organ
failure, immunosuppression, major trauma and burns,
diabetes mellitus, and infections.
3,44
Persons with acute cholecystitis usually experience an
sudden onset of upper right quadrant or epigastric pain,
frequently associated with mild fever, anorexia, nausea,
vomiting.
43–45
Whereas in biliary colic the cystic duct
obstruction is transient, in acute cholecystitis it is per-
sistent. Persons with calculous cholecystitis usually, but
not always, have experienced previous episodes of biliary
pain. The pain may appear with remarkable suddenness
and constitute a surgical emergency. In the absence of
medical attention, the attack usually subsides in 7 to
10 days and frequently within 24 hours. In persons who
recover, recurrence is common. The onset of acalculous
cholecystitis tends to be more insidious because the man-
ifestations are obscured by the underlying conditions
precipitating the attack. In the severely ill patient, early
recognition is crucial because a delay in treatment can
prove life-threatening. Persons with acute cholecystitis
usually have an elevated white blood cell count and many
have mild elevations in AST, ALT, ALP, and bilirubin.
Chronic Cholecystitis
Chronic cholecystitis results from repeated episodes of
acute cholecystitis or chronic irritation of the gallblad-
der by stones.
3,4
It is characterized by varying degrees
of chronic inflammation. Gallstones almost always are
present. Cholelithiasis with chronic cholecystitis may
be associated with acute exacerbations of gallbladder
inflammation, common duct stones, pancreatitis, and,
rarely, carcinoma of the gallbladder.
The manifestations of chronic cholecystitis are more
vague than those of acute cholecystitis. There may be
intolerance to fatty foods, belching, and other indications
of discomfort. Often, there are episodes of colicky pain
with obstruction of biliary flow caused by gallstones. The
gallbladder, which in chronic cholecystitis usually contains
stones, may be enlarged, shrunken, or of normal size.
Diagnosis andTreatment of Gallbladder
Disease
The methods used to diagnose gallbladder disease include
ultrasonography, cholescintigraphy (nuclear scanning),
and CT scans.
43–45
Ultrasonography is widely used in
diagnosing gallbladder disease and has largely replaced
the oral cholecystogram in most medical centers. It can
detect stones as small as 1 to 2 cm, and its overall accu-
racy in detecting gallbladder disease is high. In addition
to stones, ultrasonography can detect wall thickening,
which indicates inflammation. It also can rule out other
causes of right upper quadrant pain such as tumors.
Cholescintigraphy, also called a
gallbladder scan,
relies
on the ability of the liver to extract a rapidly injected
radionuclide, technetium-99m, bound to one of several
iminodiacetic acids, that is excreted into the bile ducts.
Serial scanning images are obtained within several min-
utes of the injection of the tracer and every 10 to 15 min-
utes during the next hour. The gallbladder scan is highly
accurate in detecting acute cholecystitis. Although CT
is not as accurate as ultrasonography in detecting gall-
stones, it can show thickening of the gallbladder wall or
pericholecystic fluid associated with acute cholecystitis.
Gallbladder disease usually is treated by removing
the gallbladder. The gallbladder stores and concen-
trates bile, and its removal usually does not interfere
with digestion. Laparoscopic cholecystectomy has
become the treatment of choice for symptomatic gall-
bladder disease.
45
The procedure involves insertion of a
FIGURE 30-16.
Cholesterol gallstones.The gallbladder
has been opened to reveal numerous yellow cholesterol
gallstones. (From Herrine SK, Navarro VJ, Rubin R.The liver
and biliary system. In: Rubin R, Strayer DS, eds. Rubin’s
Pathology: Clinicopathologic Foundations of Medicine. 6th ed.
Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams &
Wilkins; 2012:732.)
