Description of the disease
Calculous cholecystitis is a special form of cholecystitis, which is characterized by the presence of stones (concrements) in the gall bladder. The disease is one of the manifestations of gallstone disease.
Calculous cholecystitis is characterized by inflammation of the gallbladder and the presence of stones in it. Concrements are mainly mixed (calc-pigment-cholesterol), homogeneous bilirubin (pigment) or cholesterol are less common. The size of the stones can reach the size of a chicken egg, and the number varies from units to hundreds, the shape is different.
They can be located in the cavity of the gallbladder, which is observed in 75% of cases and maintain with its presence a weak inflammatory process leading to fibrosis, as well as the deposition of calcium salts (calcification). But if the stones are in the bile duct, they are able to hinder or block the outflow of bile, to cause acute inflammation, characterized by the appearance of attacks of biliary colic.
The prevalence rate of the disease is quite high, reaching 10% of the entire adult population, most often people over 40 years old suffer, but there are cases when calculous cholecystitis was diagnosed in children. Women are several times more likely to suffer from this disease, which is explained by the specifics of their hormonal background.
The following populations are at risk of developing the disease:
women and especially pregnant women;
people who are obese or those who have dramatically reduced their weight;
representatives of the Scandinavian and Indian peoples, they have a much higher level of the disease than the rest;
those who take drugs and contraceptives that affect hormonal levels.
Factors leading to the formation of gallstones and the development of calculous cholecystitis:
dyscholium (changes in the composition of bile);
cholestasis (stagnation of bile);
inflammatory component, in this case, primary cholecystitis.
In a healthy body, such components of bile as pigments, minerals, bile acids, lipids have a colloidal state. But when the ratio between the concentration of cholesterol and bile acids changes, the first one precipitates and subsequently crystallizes. Such a situation can be provoked by an unhealthy diet, diabetes, hepatitis, obesity, and infectious diseases.
Dyscholia helps to thicken the bile and its stagnation, which leads to various types of infection of the gallbladder by such pathogens as bacteroids, E. coli and others. The infection causes inflammatory changes in the walls of the gallbladder.
Increase the lithogenicity (the ability to stone formation) of bile is capable of fasting or overeating, high content in the diet of animal fats, physical inactivity, heredity, and long use of hormonal contraception.
Often, calculous cholecystitis is preceded by normal, non-calculous, which leads to a disturbance in the dynamics of emptying of the gallbladder.
The risk of disease is higher in patients with pancreatitis, biliary dyskinesia, duodenitis, chronic gastritis, liver cirrhosis, helminth infections and Crohn’s disease.
Features of the clinical picture allow us to distinguish chronic and acute forms of calculous cholecystitis. The course of each of them may be complicated or uncomplicated. There are catarrhal, purulent, gangrenous and phlegmonous forms. Based on the symptoms, it is possible to distinguish typical, atypical, cardiac, intestinal, esophagalgic variants of the development of the disease.
Calculous cholecystitis has 4 stages:
precancer, initial, in most cases reversible stage – thick bile forms stasis, microliths in the gallbladder;
the formation of stones;
the development of the chronic stage of the disease;
Signs and symptoms of calculous cholecystitis
The presence of stones in the gallbladder may not affect the condition of a person in any way; therefore, at the initial stage, the disease is often asymptomatic, latent.
Symptomatology is directly dependent on the stage of the disease, therefore acute calculous cholecystitis is characterized by the following signs of biliary colic:
acute pain syndrome, localized in the right side and extending to the shoulder or right scapula region, caused by diet, alcohol, exercise or stress disorders;
nausea, vomiting of gastric and biliary contents;
fever, which is especially characteristic of purulent inflammation;
the appearance of weakness and cold sweat;
some manifestations of jaundice with a change in color of feces: feces contain a lot of fat and have a discolored appearance, and urine is darker than usual.
Manifestations of chronic calculous cholecystitis are smoother:
frequent pain in the region of the right hypochondrium;
the appearance of acute pain syndrome caused by malnutrition, which gradually subsides by itself;
paroxysmal pain occurring 3 hours after eating fatty, salty or fried foods;
nausea and belching with a bitter taste;
violation of the rules of nutrition can cause single attacks of vomiting with bile.
Chronic calculous cholecystitis
The chronic stage of the development of calculous cholecystitis is characterized by the presence of stones in the gall bladder, mild inflammatory process and periodic manifestations of the disease.
The chronic period can be almost asymptomatic or manifest itself with bouts of biliary colic. With the latent form of the disease, a person experiences a feeling of heaviness on the right side of the hypochondrium. Suffering from flatulence, diarrhea, heartburn, belching, feels bitter in the mouth. After overeating or fatty foods, unpleasant symptoms increase.
Hepatic colic can occur suddenly, in most cases, it is preceded by a violation of the diet, hard physical labor, psycho-emotional stress. The onset of colic causes spastic contractions of the gallbladder and its ways, caused by irritation of the mucous membranes with stones. There is a sharp pain of a pricking character of varying intensity, localized in the right hypochondrium and radiating to the right side of the shoulder, shoulder blade and neck. The duration of the attack can vary from a few minutes to a couple of days.
Colic may be accompanied by fever, vomiting, which does not alleviate the condition of the patient. Patients are agitated, the dynamics of the pulse can be slow, rapid or arrhythmic. Blood pressure changes insignificantly. Elderly patients may develop reflex angina.
At the moment of an attack, the tongue becomes wet, a patina may be present, the abdomen is tense, swollen, painful in the region of the right hypochondrium, epigastrium. The blood test does not detect abnormalities, the gallbladder and liver are not enlarged, there are no symptoms of peritoneal irritation.
The attack of colic stops suddenly, the patient experiences relief, fatigue and weakness.
Acute calculous cholecystitis
Acute calculous cholecystitis is understood to mean a pronounced inflammation of the gallbladder, which contains calculi.
This form of the disease is the second in the list of acute diseases of the abdominal organs. In most cases, it is complicated by concomitant ailments.
An infection that has penetrated the gallbladder and a disturbed bile outflow process leads to the development of the acute form of calculous cholecystitis. Staphylococcus, Pseudomonas and Escherichia coli, enterococci and other microbial flora can enter the ascending and descending pathways (from the duodenum and liver, respectively), as well as lymphogenous and hematogenous. The obstruction of stones in the gallbladder duct or neck of the gallbladder, pathological processes in the periampular zone leads to the difficulty of the outflow of bile. In addition, the development of the acute form of the disease is promoted by atherosclerosis-induced changes in the vessels of the organ, damage to its pancreatic mucosa by the pancreatobilia, caused by pancreatobiliary reflux.
Acute calculous cholecystitis is divided into three types:
All these forms of the disease are accompanied by pericholecystitis, which is characterized by local or widespread adhesions, which limits the area of infection to the right hypochondrium.
The acute form of the disease is manifested by sharp pain, increasing with any physical exertion, nausea, repeated vomiting of a reflex nature.
On examination, dryness of the tongue, slight abdominal distention, its limited participation in the process of breathing, muscle tension and soreness in the projection area of the gallbladder, which has an increased, intense structure, are detected. Body temperature is elevated, a blood test produces neutrophilic leukocytosis and increased ESR.
The duration of the course of the acute form of the disease can reach several weeks. Gradually, it goes into the chronic stage or complications appear.
Phlegmonous calculous cholecystitis
In the case when calculous cholecystitis is complicated by purulent inflammation, accompanied by infiltration of the gallbladder and the appearance of ulcers on its mucous membrane, it means that the disease has entered phlegmonous stage. In this case, the organ wall is greatly thickened due to the abundant absorption of inflammatory exudate. Gall bladder greatly enlarged, filled with pus. The mucosa is hyperemic, lined with fibrin.
The patient experiences severe pain, which increases with a change of position, breathing, cough. The general condition of a person is worsening, the temperature rises, nausea and repeated vomiting appear, the pulse reaches 120 beats per minute. The abdomen is slightly swollen due to intestinal paresis, palpation of the right hypochondrium is painful, reveals an enlarged gallbladder. If calculous phlegmonous cholecystitis is not treated on time, it can turn into gangrenous form, which is a dangerous chance of death.
Gangrenous calculous cholecystitis
This most dangerous stage of the disease is also called gangrene of the gallbladder. This form of cholecystitis is characterized by partial or total necrosis of the wall of the bile organ, which develops on the background of thrombosis of the cystic artery. The onset of gangrene is noted for 3-4 days of illness. Perforation (through integrity) of the bladder wall may occur, followed by the flow of bile into the peritoneal cavity and the appearance of biliary peritonitis. The openings are usually localized on the neck of the gallbladder or in the pocket of Hartmann, in places of accumulation of stones.
Gangrenous calculous cholecystitis is more characteristic of the elderly, in whom the regenerative abilities are reduced and the blood supply to the gall bladder is reduced.
Infections from the adjacent communicating organs, blood and lymph can cause this form of the disease.
The gangrenous form of calculous cholecystitis is evidenced by a sharp increase in temperature in the absence of complaints of well-being, usually appearing at night. The pain syndrome is pronounced, has a spasmodic character and can occupy not only the right area, but also spread to the entire abdomen. The pains are long and intense. The condition is complicated by nausea and vomiting, constipation or diarrhea, headaches, weakness, pallor and moisture of the skin, frequent breathing, drowsiness, faintness, abdominal distension and non-participation in the process of breathing. There may be signs of jaundice.
Treatment of calculous cholecystitis
Therapy for this disease is aimed at solving the following tasks:
stop acute condition;
eradicate the factors contributing to the formation of new stones.
Treatment of calculous cholecystitis can be carried out by conservative and surgical methods. The first includes diet therapy, anesthetics and antispasmodic drugs, antibacterial, detoxification therapy and antiemetic drugs. The second is focused on the removal of the gallbladder and calculus.
In most cases, surgery is the best way to get rid of the disease, since in this case the very source of stone formation is removed. Then conservative measures are used to stabilize the patient and prepare him for the operation.
There are several types of surgery for the treatment of calculous cholecystitis:
Laparoscopy. Several cuts are made on the stomach, through them special tools and an optical device, the laparoscope, are introduced, which transmits an image to the monitor. Extensive opening of the peritoneum is not required, so the period of postoperative recovery is reduced and the appearance of the operated person does not suffer.
Open surgery. The gallbladder is removed through an abdominal incision. The method is used in severe cases, with identified gallbladder infection or the presence of cicatricial adhesions in the abdomen after previous operations. The postoperative period is longer and requires a hospital stay.
Percutaneous cholecystostomy. A drainage tube is inserted into the gallbladder through a small incision in the abdomen. Used for the course of elderly and severe patients who have complications of acute cholecystitis.
When the removal of the gallbladder is impossible according to certain indicators, nonsurgical stone crushing is prescribed with drugs or using extracorporeal shock wave lithotripsy (ESWL). But in the treatment of such methods there is a risk of re-formation of stones.
Article author: Gorshenina Elena Ivanovna | Gastroenterologist
Education: A diploma in the specialty “Medicine” was received at the Russian State Medical University. N.I. Pirogov (2005). Graduate School in Gastroenterology – educational and scientific medical center.