Brief overview
- Symptoms: Mainly pain in the upper abdomen, along with loss of appetite, nausea, vomiting, fever or palpitations; sometimes jaundice.
- Treatment: Surgical removal of the gallbladder; painkillers and antispasmodic drugs; dissolution of gallstones no longer recommended today
- Prognosis: In acute gallbladder inflammation, usually rapid removal of the gallbladder; in chronic inflammation, mild pain occurs again and again; increased risk of cancer in the case of a scarred gallbladder
- Causes & risk factors: In 90 percent of cases, gallstones prevent outflow of bile and lead to inflammation; risk factors include obesity or pregnancy, which may lead to gallstones
- Diagnosis: Medical history, physical examination, blood test, imaging procedures (especially ultrasound and CT)
What is cholecystitis?
Gallbladder inflammation (cholecystitis) is a disease of the wall of the gallbladder. In most cases, it is caused by gallstone disease (cholelithiasis). The gallbladder is a hollow organ located below the liver. Its appearance is reminiscent of a pear. The human gallbladder is usually eight to twelve centimeters long and four to five centimeters wide. It stores the bile (gall) produced in the liver cells. In the process, it thickens it. The bile is needed to digest fats in the intestines.
Classification of gallbladder inflammations
Frequency of gallbladder inflammation
Worldwide, about ten to 15 percent of people develop gallstones, which later cause gallbladder inflammation in ten to 15 percent of patients. Gallstones are most common in patients over the age of 55.
Stone-related gallbladder inflammation is more common in women than in men. This is mainly because gallstones are about twice as common in women as in men. Non-stone-related cholecystitis affects men more often than women.
Chronic cholecystitis appears to be more common than acute cholecystitis. However, there is no accurate data on the incidence of cholecystitis because a large proportion of patients either do not see a doctor or are not hospitalized.
What are the symptoms of cholecystitis?
In the further course of almost all gallbladder inflammations, affected persons experience continuous pain (for several hours) in the right abdomen. If the physician presses on this area, the pain intensifies. Under certain circumstances, it radiates to the back, the right shoulder or between the shoulder blades.
Some patients also suffer from loss of appetite, nausea and vomiting, (mild) fever or palpitations (tachycardia). However, diarrhea is not a typical symptom of gallbladder inflammation.
If, in addition to an inflammation of the gallbladder, an inflammatory disease of the bile ducts (cholangitis) occurs, this sometimes leads to so-called jaundice (icterus). In this case, the conjunctiva of the eyes (scleral icterus) and, in advanced stages, also the skin turn yellow. The yellow color is caused by the blood pigment bilirubin, which is collected in the bile after the breakdown of old red blood cells.
Gall bladder inflammation in children
Typical symptoms such as nausea and vomiting often only affect older children and adolescents. At the beginning of cholecystitis, children often only feel an unpleasant sensation of pressure instead of an upper abdominal pain, which only develops into cramping pain over time.
Gall bladder inflammation in the elderly
In the elderly, the signs of an inflamed gallbladder are often mild. Symptoms such as pain or fever are usually absent. Many only feel a slight pain when pressure is applied to the right upper abdomen. Some sufferers merely feel fatigued and tired. This is especially true if they also suffer from diabetes mellitus.
How is cholecystitis treated?
According to today’s standards, cholecystitis is usually treated surgically. This involves the complete removal of the gallbladder and any stones it contains. The medical term for this surgical procedure is cholecystectomy.
In most cases, this operation is performed by means of laparoscopy. Instruments are inserted into the abdomen through small abdominal incisions and the gallbladder is cut out with them (laparoscopic cholecystectomy). In some cases, the gallbladder is removed directly through an incision in the abdominal wall. This open cholecystectomy is necessary, for example, if the stone mass contained in the gallbladder is too large.
According to the German guidelines, removal of the gallbladder in such cases should be performed after six weeks. In general, studies indicate that the chance of complications is lower the earlier after the onset of symptoms the surgery is performed.
Recent studies mention another treatment option for these high-risk patients: inserting a metal tube (stent) into the bile duct to relieve the gallbladder.
Non-surgical treatment measures
The physician treats the spasmodic pain of gallbladder inflammation with painkillers (analgesics) and antispasmodic drugs (spasmolytics). In addition to analgesics, the administration of antibiotics is often necessary to fight the pathogens causing bacterial gallbladder inflammation. Recent studies also show that painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) partially reduce the risk of gallbladder inflammation in existing gallstones.
Home remedies such as warm compresses on the right upper abdomen are a possible option to relieve pain in addition to medical treatment. Herbal agents are sometimes used to reduce the risk of gallstones. However, treatment of pre-existing gallbladder inflammation with home remedies is strongly discouraged.
Home remedies have their limitations. If symptoms persist for a long period of time, do not improve or even get worse, you should always consult a doctor.
Dissolving risky gallstones
If the gallstones cause only mild discomfort, it is possible to dissolve the gallstones with medication (litholysis). This simultaneously reduces the risk of gallbladder inflammation. For litholysis, doctors usually administer ursodeoxycholic acid (UDCA) as capsules.
However, the risk of stones forming again and causing gallbladder inflammation is very high. If a patient suffers from gallstones or cholecystitis symptoms again after non-surgical treatment, the gallbladder is surgically removed (cholecystectomy).
The use of so-called extracorporeal shock wave lithotripsy to break up gallstones is no longer recommended in the guidelines. In this procedure, the gallstones are externally bombarded with sound waves via an applied transmitter, thereby crushing them. The debris pieces are then excreted through the intestines.
However, even after this treatment, new gallstones usually form very quickly, increasing the risk of gallbladder inflammation. In addition, the cost-benefit ratio is worse than for cholecystectomy.
Gall bladder inflammation: course of the disease and prognosis
How long patients are on sick leave after surgery varies from individual to individual. However, the hospital stay usually lasts only a few days. After that, those affected should take it easy for a few weeks.
The gallbladder is not a vital organ, so concerns about surgical removal are often unfounded. It is possible that patients tolerate strongly spiced and fatty foods less well after cholecystectomy gallbladder inflammation. However, this often improves over the years.
Complications
If cholecystitis is diagnosed at a late stage, there is a risk of life-threatening complications. In the early stages of cholecystitis, these include in particular pus accumulation (empyema) in the gallbladder and major tissue damage due to an undersupply of blood (gangrenous cholecystitis). Such complications increase the risk of a life-threatening course of the disease and are always treated surgically.
Particularly in the case of stone-related gallbladder inflammation, there is a risk of the gallbladder wall rupturing in the further course. This causes bile to empty into surrounding organs or body cavities and the inflammation to spread. This often leads to abscesses, for example around the gallbladder (pericholecystitic abscess) or in the liver.
If bile enters the abdominal cavity, physicians refer to this as a free perforation. The result is usually peritonitis (bilious peritonitis). This contrasts with “covered” perforation. In this case, the tear in the gallbladder wall is covered by loops of intestine, for example, and no bile escapes.
Fistulas
In the opposite way, stones sometimes enter the intestine and occlude it (gallstone ileus). In rare cases, a connection to the skin forms from the gallbladder inflammation (biliocutaneous fistula).
Bacterial blood poisoning (sepsis)
In gallbladder inflammation with bacteria, the pathogens sometimes enter the bloodstream and cause dangerous bacterial blood poisoning (sepsis). This complication is especially feared in emphysematous cholecystitis. However, acalculous, or non-stone, cholecystitis is usually the result of such sepsis.
Chronic gallbladder inflammation
As the disease progresses, the gallbladder sometimes shrinks. If calcium deposits form in the gallbladder wall, this leads to the so-called porcelain gallbladder. This also causes no symptoms, but significantly increases the risk of gallbladder carcinoma. In about a quarter of all patients, the porcelain gallbladder degenerates malignantly. Chronic cholecystitis and its complications are also treated by total cholecystectomy.
Gall bladder inflammation: causes and risk factors
In about 90 percent of cases, patients first have gallstones before gallbladder inflammation develops. These stones block the gallbladder outlet (cholecystolithiasis), the bile duct (choledocholithasis) or the junction at the small intestine. As a result, the bile no longer flows out and accumulates in the gallbladder. As a result, the gallbladder is overstretched and its wall is compressed.
On the one hand, cells perish, releasing harmful substances and thus triggering gallbladder inflammation. On the other hand, the aggressive substances in bile acid release special proteins known as prostaglandins. Prostaglandins E and F in particular promote gallbladder inflammation. In addition, the gallbladder wall releases more fluid due to the influence of prostaglandin. As a result, the gallbladder is stretched even further and the cells of the gallbladder are even more poorly supplied.
The lack of bile drainage also makes it easier for bacteria to migrate from the intestine into the gallbladder. Therefore, in some cases, a bacterial infection of the gallbladder occurs in addition to the inflammation.
Risk factor gallstones
- Female (female gender)
- Fat (severe overweight, obesity)
- Forty (forty years old, generally increasing with age)
- Fertile (fertile)
- Fair (fair-skinned)
- Family (family predisposition)
Rapid weight loss also sometimes leads to gallstones. Certain medications, especially hormone medications for women, increase the risk of gallstones and thus gallbladder inflammation. The same is true for pregnant women: An increased incidence of the hormone progesterone promotes the development of gallstones and inflammation.
Acalculous gallbladder inflammation
Impaired gallbladder emptying
Severe accidents, serious burns or febrile illnesses such as bacterial blood poisoning (sepsis) dry out the body and thus make the bile more viscous. If the patient no longer consumes food (e.g., because he or she is in an artificial coma), the messenger substance CCK is not released. The aggressive, viscous, concentrated bile thus remains in the gallbladder and eventually leads to gallbladder inflammation.
Prolonged fasting also prevents the release of CCK and thus the emptying of the gallbladder. The same applies if a patient is artificially fed for a longer period of time (parenteral nutrition).
Impaired oxygen supply
Bacteria, viruses and parasites
Bile is normally germ-free. However, if inflammation of the gallbladder occurs after bile stasis, bacteria often rise from the intestines and invade the gallbladder wall. The most common germs are Escherichia coli, Klebsiella and Enterobacteria. They migrate into the gallbladder either through the bile duct or lymphatics.
Bacterial infections are the main cause of serious complications of gallbladder inflammation. Bacterial gallbladder infections primarily affect patients with a weakened immune system (immunosuppressed patients) and severely (pre)ill patients, for example patients with sepsis. They also sometimes occur after abdominal surgery or endoscopy of the pancreatic and bile ducts (ERCP=endoscopic retrograde cholangiopancreatography).
In addition to bacteria, parasites such as amoebae or sucking worms are other possible causes of such an acalculous gallbladder inflammation.
Infections with salmonella, the hepatitis A virus or the HIV virus (“AIDS”) also increase the risk of gallbladder inflammation. In HIV patients, the cytomegalovirus as well as crypto- and microsporidia (parasites) play a decisive role.
Preventing gallbladder infections
Gallbladder inflammation is difficult to prevent. First and foremost, preventing gallstone disease is the main risk factor. Eat a diet rich in fiber and exercise. In this way, you will simultaneously counteract the risk factor of obesity.
Tips for a diet that reduces the risk of gallstones:
- Eat lots of high-fiber (vegetables) and calcium-rich foods.
- Eat fewer carbohydrates (especially food and drinks with a lot of sugar).
- Avoid saturated fats and trans fats (also called “hydrogenated fats”), which are often found in fast foods, pastries, or snacks like chips.
Avoid extremely low-fat diets and fasting! This reduces the release of bile from the gallbladder and often causes bile to back up, making gallstones easier to form. Because bile is important for digesting fats, some patients can’t tolerate very fatty foods (especially in large quantities) after gallbladder removal, and are sometimes under the impression that fats in general are always unhealthy for the gallbladder.
Overweight and obesity are risk factors for gallstone formation. If you suffer from overweight, you should therefore ask your doctor for advice on how best to reduce it. Sufficient physical exercise helps to reduce the risk.
It is also important that you trust your doctor. The symptoms of cholecystitis usually improve after the first intake of medication (antispasmodics, painkillers). Nevertheless, the doctor will recommend you to have a surgical cholecystectomy. Follow the advice of your treating physician to avoid serious complications of cholecystitis.
Gallbladder inflammation: Diagnosis and examination
If you suspect that you are suffering from gallbladder inflammation, you should always consult a doctor. If the symptoms are mild, a family doctor or a specialist in internal medicine (internist) will help. However, in case of severe pain and high fever in the context of acute cholecystitis, a stay in the hospital is necessary. If you have seen your doctor first, he or she will immediately refer you to a hospital.
Medical history (anamnesis)
- Since when and where do your complaints exist?
- Has the pain been in spasmodic episodes, especially at the beginning?
- Have you recently had elevated body temperatures?
- Have you had gallstones in the past? Or have your family members frequently had gallstone disease?
- Have you fasted recently?
- What medications are you taking (hormone supplements from your gynecologist, if any)?
Physical examination
After the detailed interview, your doctor will examine you physically. Risk factors such as severe obesity, fair-skinnedness, and possible yellowing of the eyes or skin can be detected without a close examination. He will also measure your body temperature. Taking your pulse and listening to your heart will show the doctor if your heart is beating excessively fast, as is typical for an infection.
The so-called Murphy’s sign (named after an American surgeon) is typical of gallbladder inflammation. During this procedure, the doctor presses on the right upper abdomen under the ribcage. Now he will ask you to take a deep breath. This causes the gallbladder to move under the pressing hand. If the gallbladder is inflamed, the pressure will cause severe pain. You will involuntarily tense your abdomen (defensive tension) and may stop breathing in.
Sometimes the doctor will even directly palpate the bulging and inflamed gallbladder.
Laboratory tests
To detect inflammation of the gallbladder, the doctor takes blood samples. Some blood values change particularly frequently in the case of gallbladder inflammation. For example, there are often more white blood cells (leukocytosis).
With a urine examination, the doctor wants to rule out damage to the kidneys. This is because sometimes inflammation of the kidney pelvis (pyelonephritis) or kidney stones (nephrolithiasis) cause similar symptoms to inflammation of the gall bladder.
If there is a possibility of pregnancy, this will also be checked.
If the patient has a high fever and is in poor general health (rapid heartbeat, low blood pressure), doctors draw blood for so-called blood cultures to find out if bacteria are present in the bloodstream. This is because the bacteria may have already spread throughout the body via the blood (bacterial blood poisoning, sepsis).
Imaging procedures
Ultrasound (sonography)
With the help of an ultrasound device, the doctor detects gallstones larger than two millimeters, as well as inflammation of the gallbladder. Thickened, crystallized bile (gallstone) is often also visible and is called “sludge.” Murphy’s sign is also sometimes elicited on this examination.
Acute cholecystitis is indicated by the following features on ultrasound:
- The wall is thicker than four millimeters.
- The gallbladder wall shows up in three layers.
- A dark collection of fluid is seen around the gallbladder.
- The gallbladder is markedly enlarged.
In the case of inflammation with air accumulation (emphysematous cholecystitis), the doctor also sees the air accumulation in the gallbladder (stage 1), in the gallbladder wall (stage 2) or even in the surrounding tissue (stage 3).
Computed tomography (CT)
On ultrasound, the gallbladder duct and common bile duct are very poorly visualized or not visualized at all. The pancreas is also often difficult to assess. If inflammation of the pancreas is also a possibility, or if there is still general doubt about the diagnosis, doctors will perform a computed tomography (CT) scan to confirm the diagnosis.
X-ray
An X-ray is rarely ordered anymore. Very few gallstones can be visualized with this technique. X-rays of emphysematous cholecystitis, however, are usually much more conspicuous. In this case, there is an accumulation of air in the gallbladder area.
Both ultrasound and X-ray reveal the so-called porcelain gallbladder. This condition is the result of chronic gallbladder inflammation. This is because scarring and calcium deposits cause the gallbladder wall to harden visibly and become as whitish as porcelain.
ERCP (endoscopic retrograde cholangiopancreaticography) is used to visualize the bile ducts, gallbladder and pancreatic ducts with the help of X-ray contrast medium and a special endoscope. This examination is performed under short anesthesia (twilight sleep) and is only ordered when doctors suspect gallstones in the common bile duct.
During ERCP, these stones can be removed directly. The point where the bile duct meets the intestine (papilla vateri) is widened with an incision so that the stone ideally passes into the intestine and is excreted with the stool.
Sometimes the gallstone must be removed with the help of wire loops called a dormia basket. However, ERCP increases the risk of inflammation of the pancreas or bile duct.
