Cholecystitis: Etiology, Classification, Clinical Manifestations, Diagnosis, and Treatment

Cholecystitis is an inflammation in the gallbladder caused by impaired bile outflow. The condition may develop due to a mechanical obstruction by gallstones (calculous cholecystitis) or for other reasons (acalculous cholecystitis).

Classification of Cholecystitis

By type of the disease:

• Acute,
• Chronic.

By etiology:

• Calculous (associated with gallstones),
• Acalculous (not caused by gallstones).

By clinical and morphological features:

• Catarrhal,
• Phlegmonous,
• Gangrenous.

3D models of cholecystitis according to clinical and morphological features:

Acute Catarrhal Cholecystitis

Acute Phlegmonous Cholecystitis

Acute Gangrenous Cholecystitis

By severity:

• Mild: limited gallbladder inflammation;
• Moderate: gallbladder inflammation persists for more than 72 hours, and its walls bear signs of destructive changes;
• Severe: total gallbladder destruction accompanied by signs of multiple organ failure.

Etiology and Pathogenesis

Inflammation of the gallbladder wall may arise due to certain damaging factors.

Based on the cause, cholecystitis is differentiated into its calculous and acalculous forms.

1. Calculous cholecystitis

Cholecystitis develops secondary to gallstones (cholelithiasis) when a solitary or multiple calculi obstruct the cystic duct or gallbladder neck. The obstruction increases intraluminal gallbladder pressure, damages its mucosa, and causes local ischemic changes in the gallbladder wall. This triggers inflammation and the release of biologically active substances and inflammatory mediators.

Only 50–75% of cholecystitis cases secondary to cholelithiasis have a bacterial nature. The most commonly identified gram-negative bacteria are: E. coli, Klebsiella spp., Pseudomonas spp., Enterobacter spp. Among gram-positive bacteria, Enterococcus spp. and Streptococcus spp. are most frequent. Anaerobes include Clostridium spp.

2. Acalculous cholecystitis

Unlike the calculous form,acalculous cholecystitis is caused by a variety of factors, such as impaired gallbladder contractility, hematogenous infection, systemic conditions, intestinal infections, or congenital bile duct disorders (e.g., choledochal cyst). However, all of these causes follow the same inflammation mechanism in the gallbladder wall that is typically observed in calculous cholecystitis.

Clinical Manifestations

Cholecystitis is associated with a range of signs and symptoms, such as:

• Pain,
• Dyspepsia,
• Inflammation,
• Peritoneal irritation,
• Obstructive jaundice.

In general, pain in cholecystitis typically manifests as biliary colic. The episode of biliary colic may resolve spontaneously or with the help of antispasmodic drugs. The pain is intense. It is typically localized in the right upper quadrant (right hypochondrium) but may sometimes radiate to the adjacent regions (lumbar region, scapula, or shoulder). As the condition progresses, the pain tends to exacerbate and irritate the peritoneum.

Furthermore, dyspepsia may develop secondary to pain. This syndrome covers nausea, vomiting, and a bitter taste in the mouth. Vomiting, either single-episode or repeated, usually brings no relief.

Even during the first few days, patients often have a low-grade fever, which may gradually rise to a moderate fever as the inflammation progresses.

During examination, a healthcare professional should pay particular attention to signs of jaundice, including the yellow discoloration of the skin, sclerae, and mucous membranes. Dark urine and pale stools are quite common. The primary cause of these symptoms is a gallstone, either solitary or multiple, that obstructs (or blocks) the hepatobiliary system.

Diagnosis of Cholecystitis

Diagnosis of cholecystitis is based on clinical evaluation and investigations (both laboratory and instrumental).

1. Clinical evaluation: physical examination, vital signs (body temperature, heart rate, respiratory rate, blood pressure), and abdominal palpation.
2. Laboratory tests: complete blood count (CBC), urinalysis, and blood tests (liver function tests, inflammatory markers, electrolytes). In critically ill patients, the acid-base balance should also be assessed.
3. Investigations: abdominal ultrasound, plain abdominal and chest X-ray, computed tomography (CT), and esophagogastroduodenoscopy (EGD).

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Treatment of Cholecystitis

Cholecystitis can be managed with medical or surgical approaches.

Medical Management

Medical therapy is aimed at stabilizing the acute episode and preparing the patient for potential surgery.

• Pain relief: Nonsteroidal anti-inflammatory drugs (NSAIDs) and antispasmodics are used to control pain.
• Infusion therapy: Intravenous fluids help to reverse any toxic effects of the condition and restore fluid and electrolyte balance.
• Antimicrobial therapy: Antibiotics are administered when signs of a bacterial infection develop. The exact medications are chosen based on microbial sensitivity and the patient’s allergy history.

Surgical Management

Surgical removal of the gallbladder (cholecystectomy) is the definitive treatment for cholecystitis.

If conservative treatment has proven efficient and acute cholecystitis has no complications, elective cholecystectomy may be performed. However, when medications have failed and the condition progresses, emergency surgery is required. In this case, the intervention is most feasible within the first 24–72 hours after the onset.

There are two main surgical approaches:

• Laparoscopic cholecystectomy: Removal of the gallbladder through small abdominal incisions; minimally invasive and considered the gold standard.
• Open cholecystectomy: Performed through either an upper midline incision or an incision in the right hypochondriac region.