This condition, which is very frequent, is linked in the vast majority of cases to lithiasis. It must be treated rapidly in order to relieve pain and avoid complications and recurrences. The reference treatment is a cholecystectomy (removal of the gallbladder).

1. What is cholecystitis and what is the difference between acute and chronic cholecystitis?

Cholecystitis is an inflammation of the gallbladder and its excretory duct, the cystic duct. The term cholecyst comes from the Greek word for gallbladder, and the suffix "it" means inflammation. The gallbladder is a small organ located on the right side of the body, against the liver. The liver makes bile, which is a liquid that is essential for digesting fats. The gallbladder is responsible for storing the bile. During digestion, the gallbladder contracts to eject bile through the cystic duct into the duodenum. The bile solubilizes the fats in the small intestine to better absorb them.

Inflammation of the cystic duct and the gallbladder is linked, in the vast majority of cases, to the presence of biliary lithiasis (gallstone) which obstructs the cystic duct. This is called acute cholecystitis. According to the SNFGE (French National Society of Gastroenterology), 90% of acute cholecystitis is caused by lithiasis, and these lithiases are very frequent since they affect about 15% of the population. The lithiasis blocks the cystic duct, which leads to biliary stasis and inflammation that can cause damage to the organ.

Sometimes cholecystitis is not caused by a stone and is called lithiasis cholecystitis. According to the MSD manual, about 5-10% of cholecystitis are non-lithiasis. When acute cholecystitis recurs or when there is a recurrence of gallstones, the gallbladder is regularly inflamed. The gallbladder eventually becomes fibrous: its walls thicken, the gallbladder hardens, and it has more difficulty in functioning, we speak then of chronic cholecystitis. Cholecystitis is to be distinguished from angiocholitis, which is a rarer condition. Angiocholitis is an infection of the bile ducts most often due to lithiasis blocking the bile duct (the main duct connecting the common hepatic duct that exits the liver to the cystic duct) or to parasitic invasion.

2. What are the symptoms of cholecystitis?

Cholecystitis is an inflammation that is usually painful. The pain is sudden in onset, often occurring after meals and during the night, and may last for several hours. It can also radiate to the back. There are also signs of abdominal defense, i.e., a painful contraction in the right hypochondrium (right side of the abdomen) and epigastrium. Cholecystitis may cause nausea and vomiting, but does not cause jaundice because the main excretory pathway of the liver is not obstructed.

The inflammation may be coupled with a bacterial infection, in which case there are infectious signs, such as a fever of varying severity. Cholecystitis can also cause a respiratory blockage during deep inspiration, this is called Murphy's sign. Untreated cholecystitis can lead to gallbladder perforation with biliary peritonitis, but can also lead to an abscess or erosion of the gallbladder wall.

3. What causes cholecystitis?

In most cases, acute cholecystitis is caused by lithiasis. Cholestasis occurs when there is too much cholesterol in the bile, when the cholesterol-solubilizing factors are not present, or when the gallbladder does not contract enough. When a stone blocks the cystic duct, bile stasis occurs. This stasis causes a release of inflammatory enzymes, including an enzyme called phospholipase A. The mucous membrane of the gallbladder secretes more fluid than the organ can absorb, which eventually distends the gallbladder and increases inflammation. This fragility is a breeding ground for infection, especially bacterial infection.

In the case of lithiasis cholecystitis, the causes are variable, they can be related to :

sepsis or important burns ;
very long fasting;
Following a surgical operation;
parenteral nutrition, because this type of nutrition favors biliary stasis;
immunodeficiency syndrome;
gallbladder motility disorders;
vasculitis (a rare autoimmune disease)
Parasitic infection;
chronic conditions such as diabetes or cardiovascular disease.
In all cases, there is ischemia of the gallbladder wall.

4. Cholecystitis: when to consult?

Cholecystitis must be treated immediately, on the one hand, to relieve the pain, and on the other hand to avoid recurrence and complications. Some cholecystitis resolves quickly on their own, the lithiasis being evacuated rapidly, but the repetition of cholecystitis exposes to chronic forms. Moreover, some cholecystitis can quickly become a medical emergency, so one should not hesitate to consult at the first signs of acute cholecystitis.

When there is significant pain associated with a high fever and nausea and vomiting, you should consult quickly.

5. What are the tests for cholecystitis and how is the diagnosis made?

First of all, the doctor will perform palpation. An obvious sign of cholecystitis is Murphy's sign: when the patient lies on his back and the doctor palpates the gallbladder, during a deep inspiration, the pain is aggravated and blocks the inspiration. Indeed, the inflamed and painful gallbladder presses directly on the diaphragm and cuts off inspiration.

Ultrasound remains the reference examination for diagnosing cholecystitis. This examination shows a thickening of the gallbladder wall of several millimeters. Murphy's sign may also be present on ultrasound and is particularly characteristic of the condition. Ultrasound can also be used to visualize lithiasis as well as any effusions.

In the case of lithiasis cholecystitis, a CT scan or a cholescintigraphy can be prescribed. Cholescintigraphy makes it possible to follow, via the injection of a radioactive product, the path of the bile, and thus to detect a possible obstacle in the path of the bile. This type of cholecystitis is often difficult to diagnose because it develops in people whose health is very poor.

The blood test shows an increase in a type of white blood cell called neutrophils. The level of CRP (C-reactive protein) is also increased, which indicates inflammation. Liver function tests are usually normal. The lipase level is increased. When the stone becomes unblocked, transaminases are also increased.

6. How is cholecystitis treated?

Pain is treated with strong painkillers and, if there is an infection, antibiotics are also prescribed. The standard treatment for symptomatic cholecystitis is cholecystectomy, i.e. removal of the gallbladder. It is the only treatment that allows a definitive cure and avoids relapses. According to the HAS, cholecystectomy is recommended for symptomatic acute lithiasis cholecystitis. In case of visceral failure, this operation should even be scheduled within 72 hours.

Cholecystectomy is usually performed under laparoscopy. Laparoscopy is called minimally invasive because it requires only a few small incisions: usually, 2 or 3 small openings are made to pass a camera and surgical instruments. According to the French Association for Continuing Medical Education in Hepato-Gastroenterology, the 2006 Cochrane review gives this technique as a surgical reference in the treatment of cholecystitis. Generally, the postoperative course is very light, and the hospital stay lasts only one to two days. When cholecystectomy is performed in an emergency or when there are complications, it may be performed by laparotomy (much larger incision of the abdominal wall), the operative follow-up is then more important. For aliphatic cholecystitis, the reference treatment also remains surgery and management of the associated pathology.

7. How to prevent cholecystitis?

The majority of cholecystitis is related to lithiasis. There are two types of cholelithiasis: cholestatic and pigmentary. Cholestatic lithiasis is the most common type. Certain factors increase the risk of suffering from cholestatic lithiasis, such as:

multiple pregnancies;
age: according to Dr. Didier Mennecier (Hepatoweb website), the risk of suffering from lithiasis is 60% after the age of 80;
being overweight or having significant weight variations;
long fasts;
certain medications, especially those that cause biliary stasis;
certain pathologies such as intestinal diseases (Crohn's disease, corresponding to intestinal malabsorption which leads to a decrease in bile secretions, and an increase in the level of cholesterol in the bile.

Some risk factors can be avoided, so it is advisable to :

practice regular physical activity adapted to your needs;
eat fruits and vegetables and foods rich in fiber, and avoid eating foods that are too fatty or too sweet;
avoid being overweight.
Pigmentary lithiasis can be caused by drugs (drugs that promote hemolysis of red blood cells), or linked to a disease such as hemolytic disease where red blood cells are destroyed.

Sources :

SNFGE, Manuel MSD, HAS, Association française de formation médicale continue en hépato-gastro-entérologie, Revue médicale suisse