Cholecystitis refers to inflammation of the gallbladder. It is most commonly caused by gallstones which can block the cystic duct and cause bile to build up. There are two main types - acute cholecystitis which occurs suddenly and causes severe pain, and chronic cholecystitis which is a long-term lower intensity inflammation. Diagnosis involves blood tests, imaging like ultrasound or CT scans. Treatment options include pain medication, antibiotics if infected, and surgical removal of the gallbladder (cholecystectomy) for severe or long-term cases.

1. Cholecystitis
By
Ms. Ekta S Patel
AP

2. Meaning:
 Cholecystitis is inflammation of the
gallbladder.
 Cholecystitis can be acute or sudden
in onset, or present for long time or
chronic.
 Its most commonly associated with
stone of gallblader.

3. Causes:
 Gallstones. Most often, cholecystitis is the
result of hard particles that develop in
gallbladder (gallstones). Gallstones can
block the tube (cystic duct) through which
bile flows when it leaves the gallbladder.
Bile builds up, causing inflammation.
 Tumor. A tumor may prevent bile from
draining out of your gallbladder properly,
causing bile buildup that can lead to
cholecystitis.

4.  Bile duct blockage. Kinking or scarring
of the bile ducts can cause blockages
that lead to cholecystitis.
 Infection. AIDS and certain viral
infections can trigger gallbladder
inflammation.
 Blood vessel problems. A very severe
illness can damage blood vessels and
decrease blood flow to the gallbladder,
leading to cholecystitis.

5. Types:
Cholecystitis
Acalculus
Calculus

6.  Acalculous cholecystitis: is an
inflammatory disease of the
gallbladder without evidence of
gallstones or cystic duct obstruction
 Calculous cholecystitis: is an
inflammatory disease of the
gallbladder with evidence of
gallstones.

7. Cholecystitis
Acute
Chronic

8.  Acute cholecystitis is the sudden
inflammation of the gallbladder that causes
marked abdominal pain, often with nausea,
vomiting, and fever.
 Chronic cholecystitis is a lower intensity
inflammation of the gallbladder that lasts a
long time. It may be caused by repeat attacks
of acute cholecystitis. Chronic cholecystitis
may cause intermittent mild abdominal pain,
or no symptoms at all. Damage to the walls of
the gallbladder leads to a thickened, scarred
gallbladder. Ultimately, the gallbladder can
shrink and lose its ability to store and release
bile.

9. • Due to etiological factor
• Gallstone obstruct the flow
• Impacted gallstone causes bile to
become trapped in gallbladder
• Buildup of bile causes irritation and
pressure in the GB
• GB become inflamed and distented

10. • Edema of GB obstruct the bile flow
• Cells in GB wall may become oxygen
staved and die as the distended organ
presses on vessel and impairs blood
flow
• Dead cell slough off and exudates
covers ulcerated area.
• Cholecystitis

11. Clinical manifestation
 Severe pain in upper right or center abdomen
 Pain that spreads to right shoulder or back
 Tenderness over abdomen when it's touched
 Nausea
 Vomiting

12.  Fever
 Cholecystitis signs and symptoms
often occur after a meal, particularly a
large or fatty one.
 Clay colored stool
 Jaundice

13. D/E:
 Ultrasound: This can highlight any gallstones and
may show the condition of the gallbladder.
 Blood test: A high white blood cell count may
indicate an infection
 Liver Function test
 Billirubin (Blood and urine )
 Computerized tomography (CT) scans: Images
of the gallbladder may reveal signs of
cholecystitis.

14.  Hepatobiliary iminodiacetic acid (HIDA)
scan: Also known as a cholescintigraphy,
hepatobiliary scintigraphy or
hepatobiliary scan, this scan creates
pictures of the liver, gallbladder, biliary
tract and small intestine.

15. Treatment
 Fasting, to rest the gallbladder
 Low-fat diet
 Pain medication
 Antibiotics to treat infection

16. Surgical management
 Removal of the gallbladder, or cholecystectomy,
can be performed by open abdominal excision or
laparoscopically.
 Laparoscopic cholecystectomy involves several
small incisions in the skin. A camera is inserted
into one incision to help the surgeon see inside
the abdomen.
 tools for removing the gallbladder and inserted
through the other incisions.

17. Cholecystectomy

18. Prevention
 Avoiding saturated fats
 Keeping to a regular breakfast, lunch and
dinner times and not skipping meals
 Exercising 5 days per week for at least 30
minutes each time
 Losing weight, because obesity increases
the risk of gallstones

19.  Avoiding rapid weight loss as this increases the
risk of developing gallstones
 A healthy weight loss is generally around 0.5 to 1
kilograms, of body weight per week
 Diets high in fat and low in fiber may increase the
risk of gallstones. To lower risk, choose a diet
high in fruits, vegetables and whole grains.

20. CHOLELITHIASI
S

21. Meaning
 It is a common disorder of biliary
system.
 The term “cholelithiasis” is derived
from the Greek word “chole” meaning
“bile”, “lith”, meaning “stone” & “iasis”
meaning “process”.

22.  Therefore, the process of stone
formation in the bile (gall bladder) is
known as cholelithiasis.
 These stones are composed of
cholesterol, bile pigments and
calcium.

23.  Gall stones are present in about 95%
of the patient who have acute
cholecystitis.

24. Incidence
 Its incidence is higher in female,
obese persons, multiparous women &
persons over 40 years of age.
 They are not common in children &
young adults but become increasingly
prevalent after 40 years of age.

25. Types
 Gall stone can vary in size and shape
from as small as a grain of sand to as
a golf ball.

26.  Cholesterol stones
 It accounts for about 80% of
gallstones.
 It may vary from light yellow to dark
green or brown & are usually oval in
shape.
 Are about 2-3 cm long, each often
having a tiny, dark central point.

28.  Pigment stones:
 It accounts for 20 % of the cases.
 Are small and dark and comprise
bilirubin and calcium salts that are
found in bile.
 They contain less than 20% of
cholesterol.

30.  Mixed stones:
 Typically contain 20-80% cholesterol.
 Other common constituents are
calcium carbonate phosphate, bilirubin
and other pigment.
 Because of calcium content, they are
often radiographically visible.

32. Risk Factors Etiology:
 The actual cause of gallstone is
unknown.
 Sex: Women are twice as men to
develop gallstones.
 Excess estrogen from pregnancy,
hormone replacement therapy & oral
contraceptives increases cholesterol
level in the bile & decreases the
gallbladder movement which can lead to
gallstones.

33.  Family history: • Gallstones often run in
families.
 Weight: • A large clinical study showed
that being even moderately overweight
increases the risk for developing
gallstones.
 • The most likely reason is that the
amount of bile salts in bile is reduced
resulting in more cholesterol. • Increased
cholesterol reduces gallbladder emptying
which predisposes stone formation
(cholesterol type)

34.  Diet:
 Diet high in fat & cholesterol & low in
fiber increases the risk of developing
gallstones.
 The excess dietary cholesterol is not
converted to bile salts but is excreted
instead as cholesterol crystals in the
bile.

35.  Rapid weight loss/prolong fasting:
 In prolong fasting & rapid weight loss
body metabolizes fat & is transferred
into the liver.
 Liver secrets extra cholesterol in bile
can cause gallstones.
 In addition, the gallbladder doesn't
empty properly.

36.  Age:
 People older than 60 years are more
prone because, as people age
increases, the body tends to secrete
more cholesterol in bile.

37.  Ethnicity:
 American Indians & Mexican –
Americans are at higher risk for
gallstones.
 Gallstones are common in Asian
populations.

38.  Cholesterol – lowering drugs:
 These drugs actually lowers
cholesterol in blood & in turn
increases the amount of cholesterol
secreted into the bile which increases
the risk of gallstones.

39.  Diabetes:
 These patients have high levels of
fatty acids called triglycerides.
 These fatty acids may increases the
risk of gallstones.

40.  Cystic fibrosis:
 In cystic fibrosis the bile is dehydrated
& becomes more acidic than normal
bile, & its flow into the small intestine
is reduced.
 Dehydrated bile can collect in the GB
& can produce gallstones.

41.  Hemolysis:
 Liver is unable to conjugate bilirubin.
 Increased unconjugated bilirubin
concentration in bile.
 Formation of pigment stone or
bilirubinate stone.

42.  Stasis of bile.
 Cholesterol precipitates the formation
of crystals.
 Bile supersaturated with cholesterol.

43.  Drugs (oral contraceptives):
 Causes the liver to excrete more
cholesterol into the bile.
 Bile supersaturated with cholesterol.
 Formation of cholesterol stone.

46. S/S:
 Gallstones may be silent, producing
no pain & only mild gastrointestinal
symptoms.
 Such stones may be detected
incidentally during surgery or
evaluation for untreated problems.
cholecystitis).

47.  Pain & biliary colic: – If the gallstone
obstructs the cystic duct, the GB
becomes distended, inflamed &
eventually infected (acute

48.  fever
 palpable abdominal mass.
 Such a bout of biliary colic is caused
by contraction of the GB, which cannot
release bile because of obstruction by
the stone. •

49.  Pt. may have biliary colic with
excruciating (intensely painful) upper
right abdominal pain that radiated to the
back or right shoulder (Kher’s Sign).
 When distended, the fundus of the GB
comes in contact with the abdominal wall
in the region of the right 9th & 10th costal
cartilages. This produces marked
tenderness in the right upper quadrant
on deep inspiration & prevents full
inspiratory excursion (Murphy’s sign).

50.  If the gall stone impacted in cystic
duct, Gallbladder cannot empty.
Mucus secreted, growth occurs and
gall bladder wall is chemically irritated
& continuous dull aching pain
occurs.

51.  Jaundice:
 Occurs in few patients with GB
disease, usually with obstruction of the
common bile duct.
 The bile, which is no longer carried to
the duodenum, is absorbed by the
blood & gives the skin & mucous
membranes a yellow color.
 This is a frequently accompanied by
marked pruritus of the skin.

52.  Changes in the urine & stool color:
 The excretion of the bile pigments by
the kidney gives the urine a very dark
color.
 The feces, no longer colored with
bile pigments, are grayish, like putty
& usually described as clay –
colored.

53.  Vitamin deficiency:
 Obstructions of bile flow also
interferes with absorption of the fat –
soluble vitamins A,D,E & K.
 Patients may exhibit deficiencies of
these vitamins if biliary obstruction has
been prolonged.
 For e.g. the pt. may have bleeding
caused by Vit. K deficiency.

54. DiagnosisDiagnosis
 History collection.
 Physical examination.
 Blood test- LFT, CBC.
 Abdominal X – ray.
 Only 15% - 20% of gallstones are calcified
sufficiently to be visible on X – rays.
 USG (90-95%).
 The procedure is most accurate if the pt.
fast overnight so that the GB is distended.

55.  Radionuclide imaging or
cholescintigraphy:
 Used successfully in the diagnosis of
acute cholecystitis.
 A radioactive agent is administered
intravenously.
 It is taken up the hepatocytes & excreted
rapidly through the biliary tract.
 The biliary tract is scanned & the images
of GB & biliary tract are obtained.

56.  Cholecystography:
 An iodide – containing contrast
agent is administered orally & after
10-12 hrs, X- ray study is done.
 The normal GB fills with this radio –
opaque substance.
 If GB stones are present, they
appear as shadows on the X – ray
film.

57.  Percutaneous Transhepatic
Cholengiogram (PTCA)
 PTCA involves the injection of dye
directly into the biliary tract.
 Because of the relatively large
concentration of dye that is introduced
into the biliary system, all components
of the system including the hepatic
duct, entire length of CBD, the cystic &
GB are outlined clearly.

58.  ERCP (endoscopic retrograde
cholangio pancreatography):
 The examination of the hepatobiliary
system is carried out via a side – viewing
flexible Fiberoptic endoscope inserted
through the esophagus to the
descending duodenum.
 Fluoroscopy & multiple X-rays are used
during ERCP to evaluate the presence &
location of ductal stones.

59.  CT scan
 MRI

60. Medical Management
 Narcotic to decrease pain.
 Antispasmodics and anticholenergics
to reduce spasm and contraction.
 Antibiotic therapy if infection is
suspected.
 Nasogastric suctioning to reduce
nausea and eliminating vomiting.

61.  UDCA (Ursodeoxycholic acid) &
Chenodeoxycholic acid (Chenodiol
/chenix or CDCA) have been used to
dissolve small, radiolucent gallstones
composed of cholesterol.

62.  It acts by inhibiting the synthesis &
secretion of cholesterol, thereby de-
saturating the bile.
 Treatment with UDCA can reduce the
size of existing stones, dissolve small
stones & prevent new stones from
forming.
 6 to 12 months of therapy is required
in many patients to dissolve stones, &
monitoring of the patient for
reoccurrence of symptoms or the
occurrence of side effects is required
during this time.

63.  Dissolving agents:
 By infusing of a solvent (Mono –
octanoin or methyl tertiary butyl ether
/MTBE) into the GB via ERCP, through
a tube/catheter inserted
percutaneously directly into the GB.

64.  Stone removal by instrumentation:
A. A catheter & instrument with a basket
attached are threaded through the T
– tube tract or fistula formed at the
time of T – tube insertion; the basket
is used to retrieve & remove the
stones lodged in common bile duct.
B. Use of ERCP, cutting instrument &
the basket or balloon.

67.  Extracorporeal Shock-Wave
Lithotripsy.
 Extracorporeal shockwave therapy
(lithotripsy or ESWL) has been used
for nonsurgical fragmentation of
gallstones.
 The word lithotripsy is derived from
lithos, meaning stone, and tripsis,
meaning rubbing or friction.

68.  This noninvasive procedure uses
repeated shock waves directed at
the gallstones in the gallbladder or
common bile duct to fragment the
stones.
 The energy is transmitted to the
body through a fluid-filled bag, or it
may be transmitted while the
patient is immersed in a water bath.
 The converging shock waves are
directed to the stones to be
fragmented.

73.  After the stones are gradually broken
up, the stone fragments pass from
the gallbladder or common bile duct
spontaneously, are removed by
endoscopy, or are dissolved with oral
bile acid or solvents.
 Because the procedure requires no
incision and no hospitalization,
patients are usually treated as
outpatients, but several sessions are
generally necessary.

74.  Intracorporeal Lithotripsy.
 Stones in the gallbladder or common
bile duct may be fragmented by
means of laser pulse technology.
 A laser pulse is directed under
fluoroscopic guidance with the use of
devices that can distinguish between
stones and tissue.
 The laser pulse produces rapid
expansion and disintegration of
plasma on the stone surface,
resulting in a mechanical shock
wave.

78.  Electrohydraulic lithotripsy uses a
probe with two electrodes that deliver
electric sparks in rapid pulses,
creating expansion of the liquid
environment surrounding the
gallstones.
 This results in pressure waves that
cause stones to fragment.
 This technique can be employed
percutaneously with the use of a
basket or balloon catheter system or
by direct visualization through an
endoscope.

82. Surgical Management
 Open cholecystectomy:
 In this procedure, the gallbladder is
removed through an abdominal incision
(usually right subcostal) after the cystic
duct and artery are ligated.
 In some patients a drain may be placed
close to the gallbladder bed and brought
out through a puncture wound if there is a
bile leak.
 Usually only a small amount of
serosanguinous fluid will drain in the initial
24 hours after surgery, and then the drain
will be removed.

83.  Laparoscopic Cholecystectomy:
 Laparoscopic cholecystectomy is
performed through a small incision (up
to ½ inch) or puncture made through the
abdominal wall in the umbilicus.
 The abdominal cavity is insufflated with
carbon dioxide (pneumoperitoneum) to
assist in inserting the laparoscope and to
aid the surgeon in visualizing the
abdominal structures.
 The fiberoptic scope is inserted through
the small umbilical incision.

84.  Several additional punctures or small
incisions are made in the abdominal wall
to introduce other surgical instruments
into the operative field.
 The surgeon visualizes the biliary system
through the laparoscope; a camera
attached to the scope permits a view of
the intra-abdominal field to be
transmitted to a television monitor.

86.  Mini-cholecystectomy
 Mini-cholecystectomy is a surgical
procedure in which the gallbladder is
removed through a small incision.
 If needed, the surgical incision is extended
to remove large gallbladder stones.
 Drains may or may not be used.
 The cost savings resulting from the shorter
hospital stay have been identified as a
major reason for pursuing this type of
procedure.
 Debate exists about this procedure
because it limits exposure to all the
involved biliary structures.

88.  Choledochostomy
Choledochostomy involves an incision
into the common duct, usually for
removal of stones.
After the stones have been evacuated, a
tube usually is inserted into the duct for
drainage of bile until edema subsides.
This tube is connected to gravity drainage
tubing.
The gallbladder also contains stones, and
as a rule a cholecystectomy is performed
at the same time.

89.  Surgical Cholecystostomy
 Cholecystostomy is performed when the
patient’s condition prevents more
extensive surgery or when an acute
inflammatory reaction is severe.
 The gallbladder is surgically opened, the
stones and the bile or the purulent drainage
are removed, and a drainage tube is secured
with a purse-string suture.
 The drainage tube is connected to a drainage
system to prevent bile from leaking around
the tube or escaping into the peritoneal
cavity.
 After recovery from the acute episode, the
patient may return for cholecystectomy.

91.  Percutaneous Cholecystostomy.
 Percutaneous cholecystostomy has been used in the
treatment and diagnosis of acute cholecystitis in
patients who are poor risks for any surgical
procedure or for general anesthesia.
 These may include patients with sepsis or severe
cardiac, renal, pulmonary, or liver failure.
 Under local anesthesia, a fine needle is inserted
through the abdominal wall and liver edge into the
gallbladder under the guidance of ultrasound or
computed tomography.
 Bile is aspirated to ensure adequate placement of the
needle, and a catheter is inserted into the gallbladder
to decompress the biliary tract.
 Almost immediate relief of pain and resolution of signs
and symptoms of sepsis and cholecystitis have been
reported with this procedure.
 Antibiotic agents are administered before, during, and
after the procedure.