Chapter 11i
ACUTE AND CHRONIC CHOLECYSTITIS
1. DEFINITION
Cholecystitis – inflammation of the gall is one of the most frequent disorders of the alimentary tract. The ICD 10AM Code is K81. Although classically it has been subdivided into the acute and chronic varieties, it is likely that they are both part of a spectrum which is most often caused by gall stones. It is necessary, however, to emphasise that the majority of gall stones remain asymptomatic and cholecystitis develops in 1-3% of persons with them (1).
Classically acute cholecystitis manifests as an acute right hypochondrial
pain lasting from minutes to hours, often beginning at night and often in
young women. The pain, in contradistinction to that of biliary colic, lasts
longer than 6 hours but in three quarters of episodes of acute cholecystitis,
the patient gives a prior history of biliary colic. The acute pain, often with
vomiting, radiates to the back and in one third of cases, the gall bladder
becomes palpable as it distends. If the acute episode fails to resolve then
infection is likely to supervene, generally with E.coli, Klebsiella or
S.faecalis, producing an acute inflammatory process in the gall bladder with
pain, nausea, vomiting, fever; later a mass in the right hypochondrium may
appear. It is estimated that in 90% of cases obstruction of the neck of the
gall bladder by stone or sludge initiates the process. The gall bladder then
becomes distended with supersaturated bile leading to inflammation in the
wall with prostaglandin liberation. This finding has led to the use of
NSAIDs in acute cholecystitis; given early they are beneficial in reducing
inflammation. In about half of the patients the stone drops back into the gall
bladder, relieving the obstruction but in about 20% of patients, resolution
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fails to occur and cholecystectomy is necessary. If left untreated, about 10%
of cases go on to a complication such as perforation and even peritonitis.
A variant of acute cholecystitis is acalculous cholecystitis where acute and chronic cholecystitis may occur in the absence of a stone. It is seen particularly after surgery, trauma and burns and in elderly males.
Mucocoele of the gall bladder occurs when an obstructed gall bladder does not become infected and the bile is replaced by mucus. Empyema of the gall bladder occurs when the gall bladder appears to be filled with pus but in half such cases the fluid is sterile.
2. DESCRIPTIVE EPIDEMIOLOGY
Remarkable for such a common condition, the literature is largely silent on solid data concerning the epidemiology. The topic cries out for epidemiological studies.
3. INCIDENCE AND PREVALENCE
Apart from simple statements largely applying to western societies, the literature mainly concerns the surgical aspects such as the management, timing and the nature of surgical intervention and investigation.
References
1. Indar AA, Beckingham IJ. Acute cholecystitis. BMJ 325 (7365):639-43 (2002).
