Cholecystitis (Gallbladder Inflammation)

What is cholecystitis?

Cholecystitis (KO-leh-sis-TY-tiss) is inflammation in your gallbladder, the small, pear-shaped organ that lives under your liver and stores the bile your liver makes. Your gallbladder sends bile to your small intestine after you eat to help digest fats. It sends and receives bile through tiny pipelines called bile ducts. An infection or obstruction in your gallbladder or the bile ducts connected to it can cause inflammation, pain and swelling inside it.

What are the different types of cholecystitis?

Gallbladder inflammation can be:

• Acute (sudden and urgent).
• Chronic (slow and longstanding).
• Calculous (related to gallstones).
• Acalculous (not related to gallstones).

An inflamed gallbladder can be an immediate response to an urgent problem, or a slow response to a long-term problem. This is the difference between acute cholecystitis and chronic cholecystitis.

Gallstones are usually the cause of both chronic and acute cholecystitis. So, most cases are “calculous”. Healthcare providers use “acalculous” to distinguish cholecystitis that’s not related to gallstones.

How common is cholecystitis?

About 15% of the world’s population has gallstones, and about 20% of these will have complications from gallstones, which include cholecystitis. Gallstones cause 95% of all cholecystitis cases.

What are the signs and symptoms of cholecystitis?

Common symptoms of acute cholecystitis include:

• Upper abdominal pain, especially in the upper right. It may also spread to your right shoulder blade or back. Gallbladder pain builds quickly to a peak, which may be severe. It may feel sharp, dull or crampy and may be worse when you breathe deeply. Some people mistake it for chest pain or even a heart attack. Acute gallbladder pain is also called a gallbladder attack.
• Nausea and vomiting are common with a gallbladder attack, but older people may have milder symptoms. They may only experience a vague loss of appetite or sense of unwellness.
• Fever of over 100 degrees Fahrenheit may occur in up to a third of people with acute cholecystitis. A fever may indicate an infection or more severe inflammation. It’s less common in older people.

Additional symptoms may include:

• Abdominal distension (bloating) and tenderness.
• Abdominal muscle stiffness on the right side.
• Weakness and fatigue, especially in older people.

Chronic cholecystitis symptoms tend to be less severe, and they come and go. You might have an episode of biliary colic — abdominal pain with nausea — after a rich or heavy meal. Fatty foods require more bile to digest. Your digestive system signals to your gallbladder to send more bile, which causes it to squeeze harder, increasing the pressure inside it. You might feel this for a few hours afterward.

What is the main cause of cholecystitis?

Gallstones blocking your bile ducts are the most common cause of cholecystitis, both chronic and acute. Gallstones are pieces of hardened bile residue. They usually form at the bottom of your gallbladder, but they can also travel. Sometimes, they can get stuck in a bile duct or in the opening to your gallbladder. This causes bile to back up into your gallbladder. It also can encourage infections inside it.

A gallstone that obstructs the flow of bile from your gallbladder will cause acute cholecystitis. This type gets steadily worse as your gallbladder swells more and more. A drifting gallstone may partly obstruct your gallbladder in an on-and-off way. For example, you may feel it only occasionally, when your gallbladder squeezes out bile to help digest a heavy meal. This can cause chronic cholecystitis.

What else can cause gallbladder inflammation?

While a gallstone causing an obstruction is the most common reason why bile flow may slow and back up into your gallbladder, there are other ways this might happen. For example:

• Biliary stricture. Bile duct diseases that cause chronic inflammation in your bile ducts can eventually lead to scar tissue that narrows your bile ducts. This can obstruct the flow of bile.
• Biliary dyskinesia. This is a functional gallbladder disease that affects your gallbladder’s motility, or muscle activity. It means your gallbladder doesn’t contract enough to move enough bile out.
• Bile stasis. Bile flow may stall due to chronic liver disease or long-term parenteral nutrition. If you’re getting your nutrition from an IV and bypassing your digestive system, bile isn’t needed.
• Cancer. Rarely, a tumor in your gallbladder or in your bile ducts may obstruct the flow of bile.

These conditions develop slowly, so they’re more likely to cause chronic cholecystitis. But they can get steadily worse, and chronic acalculous cholecystitis can progress to acute acalculous cholecystitis.

Other possible causes include:

• Ischemia. Reduced blood flow to your gallbladder can cause chronic or acute inflammation, depending on how severe it is. Ischemia is often a response to critical illness or trauma. It can also be due to a vascular occlusion or inflammation of the blood vessels (vasculitis).
• Infection. You can get a bacterial infection in your gallbladder or bile ducts even without an obstruction trapping the bacteria inside, though this is uncommon. It’s more likely if you have a weakened immune system. Infections can irritate and even erode your gallbladder tissue.

What are the risk factors for getting cholecystitis?

You’re more likely to get cholecystitis if you have gallstones. You’re more likely to have gallstones if you:

• Are a woman.
• Are pregnant.
• Have obesity.
• Have diabetes.
• Have high cholesterol.
• Have lost weight rapidly.
• Are older than 40.
• Are of Hispanic or Native American descent.

How serious is cholecystitis?

Acute cholecystitis is usually caused by something blocking the flow of bile. This can affect more than just your gallbladder. A blockage in your biliary system — the system of organs that exchange bile through your bile ducts — can cause inflammation and possibly infection throughout. Backed-up bile can overflow into your bloodstream, making you sick. Your digestive system also won’t get the bile it needs.

Severe inflammation and swelling in your organs can cause tissue death (gangrene), which can cause the organ to split or tear (gangrenous cholecystitis). Chronic cholecystitis tends to be less severe, but long-term inflammation can still do serious damage. Your gallbladder may develop scar tissue inside, which may make it unable to contract effectively. This can also cause your bile flow to stall.

Complications of cholecystitis include:

• Injury to your liver, bile ducts or pancreas (pancreatitis).
• Impaired digestion and absorption of nutrients in your small intestine.
• Chronic inflammation leading to gallbladder fibrosis (scarring) and impaired functionality.
• Swelling leading to necrosis (tissue death) and gangrenous cholecystitis.
• Gallbladder perforation (a tear), leading to infection of your abdominal cavity (peritonitis).
• Peritonitis leading to an abscess or infecting your bloodstream (septicemia).

How is cholecystitis diagnosed?

A healthcare provider will start by asking you about your symptoms. If they suspect cholecystitis, they might check for it by asking you to take a deep breath while they gently press on your upper right abdomen. If this is painful, it’s a classic sign of cholecystitis (Murphy’s sign). They’ll follow up with tests, including imaging of your gallbladder and bile ducts and blood tests to look for additional clues.

Tests to diagnose cholecystitis may include:

• Complete blood count (CBC).
• Liver function tests.
• Abdominal ultrasound.
• Endoscopic ultrasound.
• CT scan (computed tomography scan).
• HIDA scan (hepatobiliary iminodiacetic acid scan).

Will cholecystitis go away?

All of the causes of cholecystitis require treatment. It’s possible that a gallstone blocking your gallbladder or bile duct could become unstuck on its own, causing your symptoms to go away. But it’s not worth waiting for this to happen — the pain and the risk are too great. If it did happen, it probably wouldn’t be the end of your troubles. The same gallstone or another gallstone could get stuck again.

What is the treatment for cholecystitis?

Cholecystitis is treated immediately in the hospital. Treatment begins with supportive care, including:

• Intravenous (IV) fluids while your digestive system rests.
• IV antibiotics to treat or prevent infections.
• IV pain relief, which most people need.

The definitive treatment for cholecystitis is surgery to remove your gallbladder. Most causes of cholecystitis, including gallstones, originate in your gallbladder itself. In rare cases, surgery might not be necessary if your cholecystitis was caused by something that’s separately treatable, like an infection unrelated to gallstones. You may also need to delay or forego surgery based on other health conditions.

If you’re delaying or foregoing surgery, you might have:

• Fluid drained from your gallbladder to relieve pressure. A healthcare provider might install a drainage tube into your gallbladder through a small incision in your abdomen. Alternatively, they might install a drainage tube from your gallbladder into your digestive tract via an endoscopic ultrasound. This nonsurgical procedure accesses your organs through your mouth.
• Endoscopic gallstone removal. Endoscopic retrograde cholangiopancreatography (ERCP) is another nonsurgical procedure that combines an upper endoscopy with X-ray technology to visualize your biliary system. An endoscopist can pass small tools through the endoscope to remove gallstones stuck in your bile ducts. This can help relieve your immediate symptoms.

Surgery

Even if your present episode of cholecystitis is over — the gallstone that was stuck is no longer stuck, or the symptoms that brought you to the hospital have passed — both chronic and acute cholecystitis are bound to recur. Gallstones that have caused acute cholecystitis once are likely to do so again. Repeat episodes of acute cholecystitis can lead to chronic cholecystitis, and both can do cumulative damage.

To prevent the effects of repeat episodes of gallbladder inflammation, healthcare providers recommend surgery to remove your gallbladder (cholecystectomy). This is a common, minor procedure with minimal side effects. Most people can have it done by minimally invasive laparoscopic surgery. A laparoscopic cholecystectomy requires only a few small incisions. More complicated cases may require open surgery.

What are the after-effects of surgery for cholecystitis?

Your biliary and digestive systems can function well without your gallbladder. Your gallbladder is mainly a storage place for the bile your liver makes. When a surgeon removes your gallbladder, they redirect your bile ducts to send bile directly from your liver to your small intestine. Your body will take a few weeks to months to adapt to this change. You might have temporary symptoms during this time, like:

• Slower bile flow, creating a feeling of pressure or pain in your biliary system.
• Difficulty digesting fats, which causes diarrhea for some people.

What is the outlook if you have inflammation of the gallbladder?

You’ll need treatment in the hospital for cholecystitis, regardless of the type or cause. The hospital can provide immediate pain relief while they look for the cause. It’s usually gallstones, though not always. In most cases, healthcare providers recommend definitive treatment with surgery. Most people have excellent outcomes. Cholecystitis that goes untreated may lead to dangerous complications.