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The term cholecystitis defines any generic inflammation of the gallbladder, otherwise known as the gallbladder. It can occur in an acute or chronic form and its origin can recognize different causes. Data in hand, in over 85-90% of cases, cholecystitis is associated with biliary lithiasis, ie the presence of stones in the gallbladder and / or in the biliary tract. We therefore speak of calculous cholecystitis.
Cholecystitis and gallstones
Let us briefly recall how gallstones develop as a result of a reduced solubility of cholesterol and bile salts in the bile, normally guaranteed by the generous presence of phospholipids. When this equilibrium is broken, the solubility of these components is lost and crystalline precipitations are formed which, by aggregating, give rise to the calculations. Particularly at risk of calculosis are women compared to men, obese compared to normal weight, individuals who undergo rapid weight loss, subjects with a family member suffering from gallbladder stones, recent pregnancy, history of biliary colic previous years, the intermediate and elderly age (the average age of onset of calculotic cholecystitis is around 60 years).
The pathogenetic mechanisms through which a stone can give rise to cholecystitis are various and include the "direct mechanical insult, of abrasive or pressure origin, of the mucous membrane of the gallbladder. In vogue especially in the past, another hypothesis believes that cholecystitis from cholelithiasis derives from the proliferation of bacteria inside the bile fluid stored in the gallbladder, and considered there beyond measure due to the presence of a stone (in the cystic duct or in the choledochus) which prevents its normal outflow into the intestine. The bacteria would arrive in the gallbladder by going up the biliary canaliculi from the intestine or descending them from the liver by intestinal absorption through the portal circulation, or again by blood or lymphatic pathway. Biliary stasis would cause cholecystitis also through a chemical insult of the gallbladder walls, mediated by the components reabsorbed by the gallbladder mucosa. Also of a chemical nature is the insult deriving from the ascent of pancreatic juices which with their digestive enzymes undermine the integrity of the gallbladder mucosa. Finally, the picture is complicated by the reduced blood supply to the gallbladder ( ischemia) linked to the increase in intraluminal pressure with compression of the blood vessels. The resulting ischemia, in the absence of treatment, can give rise to the fearful complications of cholecystitis: necrosis of the gallbladder wall up to its perforation and extravasation of the bile with chemical and / or bacterial peritonitis.
Alithiasic (or acalcoholotic) cholecystitis
It is a form of cholecystitis independent of the presence of stones, although biliary stasis is common. Rather than the presence of a stone, this phenomenon is to be found in other causes: such as debilitation, sepsis, prolonged bed rest, major surgery, major trauma, especially abdominal trauma, fractures, burns and prolonged parenteral nutrition. More common in elderly males, alithiasic cholecystitis can also be favored by diabetes, acute cardiac events, sickle cell anemia and bacterial, viral or protozoal infections - eg salmonella, typhus, cytomegalovirus, cryptosporidia or microsporidia - especially in immunocompromised patients. Older age and male sex appear to be risk factors; in children, most cases of cholecystitis are non-alcoholic.
It should be remembered that all the causes of obstruction of the cystic duct and of the choledochus of a non-calcotic nature (tumor processes, fibrosis, congenital anomalies) are also responsible for alitiasic cholecystitis.
Symptoms
For further information: Cholecystitis Symptoms
Acute cholecystitis is typically accompanied by symptoms such as fever and pain in the right upper quadrant of the abdomen and / or upper center, which can sometimes extend posteriorly.
Unlike biliary colic, the pain is persistent and continuous even after the acute episode, although it diminishes with the passage of time. The character of rapid regression and possible intermittence that characterizes the pain of typical biliary colic is therefore less.
Painful symptoms associated with cholecystitis are exacerbated by the doctor's palpation of the gallbladder region, and its origin is often associated with a fatty meal.
The intensity of the pain does not necessarily correlate with the severity of the cholecystitis, while the relationship is more truthful with the fever, which - always present - is generally modest in the mild forms, and decidedly higher in the necrotic or purulent forms.
In addition to pain, fever and chills, anorexia (understood as lack of appetite), nausea and vomiting are also common findings.
The "jaundice (yellow coloring of the skin and of the ocular sclerae), more or less evident, is typically related to the forms of lithiasic cholecystitis in which the stones are found in the choledochus, preventing the enteric outflow even of the bile of direct hepatic origin. L" Jaundice can also result from compression of the main bile duct by an over-distended gallbladder or from a dangerous abscess collection.
Chronic cholecystitis, which can result from repeated episodes of acute inflammation or from a "chronic irritation of another nature, can be asymptomatic.
Diagnosis
Characteristic is the elevation of the neutrophilic leukocytes, demonstrable with a simple blood test, together with that of the ESR (erythrocyte sedimentation rate), of the alkaline phosphatase and of any hyperbilirubinemia, in particular of the direct share in case of choledocholithiasis.
All this may be associated with the slight increase in serum transaminases and amylases.
The anamnesis and the clinical picture, together with the laboratory tests and instrumental investigations (ultrasound, CT scan) allow the diagnosis of cholecystitis to be made.
Therapy
For further information: Medicines for the treatment of cholecystitis - Cholecystectomy
The therapy of cholecystitis must be implemented immediately, in order to avoid the risk of serious complications (gangrene and perforation. In addition to physical (in bed) and intestinal (fasting) rest with maintenance or restoration of the hydro-saline balance, the treatment of cholecystitis provides for the use of antispasmodic drugs (scopolamine butylbromide), analgesics (meperidine or pethidine, diclofenac), and antibiotics (piperacillin, ampicillin, netilmicin, cephalosporins). After the acute episode it is advisable to adopt a low lipid and protein content.
In the presence of a rather severe or complicated cholecystitis (empyema - collection of pus due to the presence of pyogenic bacteria - hydrops - accumulation of fluids and mucus with hyperextension of the organ - gangrene, perforation of the gallbladder, peritonitis), a cholecystectomy is necessary. "urgency, a surgery - now performed laparoscopically - through which the gallbladder is removed. The minimally invasive procedure, together with the fact that the gallbladder is an organ of relative importance, ensure complete healing and extensive recovery, effectively eliminating the risk of relapse without significantly affecting the patient's future health.
