Cholecystitis

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Key points

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    Disorders of the gallbladder are the most common surgical diseases treated by the general surgeon.

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    Risk factors for gallstones include advanced age, female gender, obesity, and certain ethnicities, including North American Indian.

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    The gold standard treatment of acute cholecystitis is a laparoscopic cholecystectomy.

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    Operating early in the disease course decreases overall hospital days and does not lead to increased complications, conversion to open procedures, or mortality.

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    Cholecystitis during

Overview

Gallstone disease is an ancient problem. Autopsies on Egyptian mummies have shown gallstones from at least 3500 years ago.1 Disorders of the gallbladder are the most common surgical diseases treated by a general surgeon. More than 700,000 cholecystectomies are performed in the United States every year, costing about 6.5 billion dollars. This situation makes gallbladder disease the most costly digestive disorder.2 This article focuses specifically on the pathophysiology, diagnosis, and treatment

Epidemiology

It is estimated that 20 to 25 million Americans (10%–15% of the population) have gallstones.2 Most people with gallstones are asymptomatic.3 Population-based studies suggest that 10% to 18% of those with silent gallstones develop biliary pain and 7% require operative intervention.4, 5 One percent to 4% of those with gallstones develop complications such as acute cholecystitis, gallstone pancreatitis, and choledocholithiasis.6

The prevalence of cholelithiasis in North America varies widely

Risk factors

The development of cholelithiasis is multifactorial. Advancing age is a risk factor for gallstone development in all ethnic groups. Gallstones are rarely reported in infants and children, but prevalence markedly increases in individuals older than 20 years, particularly in women. Female gender is also a risk factor. Women are at a greater risk of having gallstones as well as undergoing operative intervention. Estrogen seems to play a critical role in this increased risk, because pregnancy,

Gallstone formation

The type of gallstone and location in the biliary system vary depending on ethnicity. Most of the gallstones encountered in developed countries are cholesterol stones (about 80%) with a few being pigmented (black stones).

The pathogenesis of cholesterol gallstones is dependent on multiple factors: cholesterol supersaturation in the bile, crystal nucleation, gallbladder dysmotility, and gallbladder absorption.

Pigmented gallstones can be divided into black stones and brown stones. Black stones

Acute cholecystitis

Acute cholecystitis accounts for 14% to 30% of cholecystectomies.9, 10, 11

Laparoscopic Cholecystectomy

As mentioned earlier, laparoscopic cholecystectomy is the gold standard treatment of acute cholecystitis. The shift from open to laparoscopic cholecystectomy occurred in the late 1980s. As surgeon training progressed in laparoscopy, many surgeons started using a single-incision approach known as single-incision laparoscopic cholecystectomy (SILC). The advantages of SILC include the advantages of conventional multiport laparoscopic cholecystectomy (CMLC) over the open approach, as well as

Pathophysiology

Acalculous cholecystitis (ACC) differs from calculous acute cholecystitis because it is not precipitated by occlusion of the cystic duct by gallstones or biliary sludge. Two percent to 15% of patients with acute cholecystitis do not have stone disease.41 ACC is generally the result of biliary stasis and gallbladder ischemia, although the pathophysiology has yet to be determined and is likely multifactorial. It is often associated with critical illness, such as septic shock, severe trauma,

Treatment

The preferred treatment of ACC is cholecystectomy, although many patients diagnosed with ACC are poor surgical candidates. Often, a temporizing percutaneous cholecystostomy is performed, with the plan for a subsequent cholecystectomy once the patient has improved clinically and is fit to undergo an operation.

There is, of course, debate as to which patients are operative candidates and when cholecystostomy should be used instead of cholecystectomy. The literature on this topic is varied and

Chronic cholecystitis

Chronic cholecystitis and biliary colic account for 79% of cholecystectomies.10

Special considerations: acute cholecystitis in pregnancy

Gallstone-related disease remains the second most common nongynecologic condition requiring surgery in pregnant patients (acute appendicitis is more prevalent).47 Acute cholecystitis in pregnancy presents a challenging clinical scenario, which has been the cause of some debate regarding surgical management in this patient population. The surgical dogma advocated by many surgeons in the past has been to pursue nonoperative management of pregnant patients until after delivery, when a

Summary

It is estimated that up to 15% of the American population have gallstones, and disorders of the gallbladder are the most common diseases confronting general surgeons. It is important for general surgeons to be aware that EC for acute cholecystitis has been shown to decrease overall hospital days without leading to increased complications, mortality, or conversion to open procedures. Although cholecystitis is one of the most common general surgical diseases, variations in cause, clinical

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