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Gallbladder & extrahepatic bile ducts

Cholecystitis

Acute cholecystitis

Authors: Tiffany Sheganoski, D.O., Aaron R. Huber, D.O.

Editorial Board Member: Monika Vyas, M.D.

Deputy Editor-in-Chief: Catherine E. Hagen, M.D.

Last author update: 29 November 2021

Last staff update: 3 January 2025

Copyright: 2003-2025, PathologyOutlines.com, Inc.

PubMed Search: Acute cholecystitis

Table of Contents

Cite this page: Sheganoski T, Huber AR. Acute cholecystitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/gallbladderacutecholecystitis.html. Accessed January 11th, 2025.

Definition / general

Abrupt destructive process of gallbladder
- Not typical inflammation; neutrophils often absent
- Most often due to stones blocking cystic duct
- ~50% of cases complicated by aerobic bacterial infection

Essential features

Inflammation of gallbladder induced by choleliths, ischemia or substances
Gallbladder wall thickening and pericholecystic fluid seen on transabdominal ultrasound
Complications, such as perforation, seen most often in acalculous cholecystitis
Cholecystectomy within 72 hours is typically curative

ICD coding

ICD-9:
- 574.00 - calculus of gallbladder with acute cholecystitis, without mention of obstruction
- 574.01 - calculus of gallbladder with acute cholecystitis with obstruction
- 574.30 - calculus of bile duct with acute cholecystitis, without mention of obstruction
- 574.31 - calculus of bile duct with acute cholecystitis with obstruction
- 574.60 - calculus of gallbladder and bile duct with acute cholecystitis, without mention of obstruction
- 574.61 - calculus of gallbladder and bile duct with acute cholecystitis, with obstruction
- 575.0 - acute cholecystitis
Reference: Gastroenterol Rep (Oxf) 2017;5:36

Epidemiology

10 - 15% of American population
Native American women have highest rates
- As high as 73% in women > 30 years (Surg Clin North Am 2014;94:455)

Sites

Gallbladder

Pathophysiology

Calculous
- Blockage of neck or cystic duct
  - Typically by gallstones or biliary sludge
  - Continued production of mucus by gallbladder with no outlet
- Increased pressure within gallbladder
- Venous stasis
- Arterial stasis
- Gallbladder ischemia and necrosis (Surg Clin North Am 2014;94:455)
Acalculous
- Bile stasis and ischemia not provoked by a physical blockade of cystic duct
  - Ischemia due to:
    - Activated factor XII
    - No collateral blood supply; complete reliance on cystic artery (Surg Clin North Am 2014;94:455)

Etiology

Calculous
- Due to stones physically blocking cystic duct
Acalculous
- 2 - 15% of cases (Histopathology 2005;47:485)
- Greater complication risk
  - More likely to get gangrenous cholecystitis and subsequent perforation (Infect Dis Clin North Am 2010;24:885)
AIDS related
- Similar clinical picture
- Due to cytomegalovirus, cryptosporidia or microsporidia
Cocaine induced (Mills: Sternberg's Diagnostic Surgical Pathology 5th Edition, 2012)
- Seen in young, healthy patients
- Suspect when concurrent vascular thrombosis

Clinical features

Classic: right upper quadrant pain, nausea, vomiting, anorexia, fever

Diagnosis

Combination of history, physical, laboratory and imaging findings (Surg Clin North Am 2014;94:455)

Laboratory

Leukocytosis
Hyperbilirubinemia and elevated liver function tests
- May indicate choledocholithiasis (Surg Clin North Am 2014;94:455)

Radiology description

Transabdominal ultrasound
- Gallbladder wall > 4 mm
- Pericholecystic fluid
Cholescintigraphy
- Hepatic 2,6-dimethyl-iminodiacetic acid (HIDA) injected intravenously
- Gallbladder not visualized (Surg Clin North Am 2014;94:455)

Radiology images

Images hosted on other servers:

Acalculous choleystitis imaging

Prognostic factors

Complications
- Perforation, pericholecystic abscess, fistula
Mortality from untreated complications is 20% (BMJ Clin Evid 2008;2008:0411)

Case reports

53 and 58 year old women with empyematous cholecystitis and a 75 year old man with perforated cholecystitis, who were treated with robotic cholecystectomy in the emergency setting (Medicine (Baltimore) 2019;98:e16010)
59 year old man with COVID-19 pneumonia and ischemic gangrenous cholecystitis (World J Emerg Surg 2020;15:43)
66 year old man with COVID-19 pneumonia and acute acalculous cholecystitis (Ann Med Surg (Lond) 2020;58:73)
68 year old woman with COVID-19 pneumonia and concurrent acute cholecystitis (BMC Infect Dis 2020;20:437)

Treatment

Antibiotics
Cholecystectomy
- Within 72 hours preferred for surgical candidates
Cholecystostomy drain for critically ill, poor candidates (Infect Dis Clin North Am 2010;24:885)

Clinical images

Images hosted on other servers:

Inflamed gallbladder with exudate

Gross description

Distention / edema of gallbladder
Serosa
- Exudate
- Color alteration
- Hemorrhagic
Wall
- Thickened up to 2 cm
- Edematous
- Hemorrhagic
Mucosa
- May see ulcers
Cholelith(s)
- In neck or cystic duct
Lumen
- May see bile, hemorrhage, fluid mixture of cholesterol and calcium carbonate (J Hepatobiliary Pancreat Surg 2007;14:15)

Gross images

Images hosted on other servers:

Acute (with
empyema) and
chronic cholecystitis
with gallstone

Microscopic (histologic) description

May not see acute inflammatory cells unless there is a secondary bacterial infection or choledocholelithiasis
Erosion of mucosa
Edema
Myofibroblasts, lymphocytes, plasma cells, eosinophils and pigment laden macrophages
Fibrin
- Thrombi in small veins
- Sometimes fibrinoid necrosis (Int J Clin Exp Pathol 2013;6:91)

Microscopic (histologic) images

Contributed by Aaron Huber, D.O.

Hemorrhagic mucosa

Acute inflammation and erosion

Inflamed and reactive epithelium

Videos

Overview of acute cholecystitis

Imaging findings in cholelithiasis and acute cholecystitis

Sample pathology report

Gallbladder, cholecystectomy:
- Acute calculous cholecystitis

Differential diagnosis

Gallbladder cancer:
- Frozen section analysis during cholcystectomy if suspected (Hepatobiliary Pancreat Dis Int 2015;14:300)

Board review style question #1

A patient undergoes removal of the pictured organ. What symptoms or presentation would suggest that the etiology of the condition that leads to removal of this organ is related to cocaine use?

Amaurosis fugax
Hematemesis
Melena
Vascular thrombosis

Board review style answer #1

D. Cocaine induced cholecystitis is seen in young, otherwise healthy patients and should be suspected when there is vascular thrombosis along with involvement of other parts of the gastrointestinal tract.

Comment Here

Reference: Acute cholecystitis

Board review style question #2

What imaging finding would suggest that the pictured organ should be surgically removed in the appropriate clinical context?

Focal fat stranding
Gallbladder wall > 4 mm
Inflamed appendix > 6 mm in diameter
Round / ovoid collection of barium in the stomach

Board review style answer #2

B. Thickening of the gallbladder wall > 4 mm as well as pericholecystic fluid may be seen on ultrasound imaging in a case of acute cholecystitis.

Comment Here

Reference: Acute cholecystitis

Board review style question #3

What factors make the pictured organ susceptible to ischemia necessitating removal, even in the absence of physical blockade of the duct?

Location in zone 3, furthest from the hepatic artery
Location within a watershed zone
No collateral blood supply
Sensitivity to atherosclerosis of the inferior mesenteric artery

Board review style answer #3

C. Cases of acalculous cholecystitis may occur because the gallbladder is completely reliant on the cystic artery, with no collateral blood supply.

Comment Here

Reference: Acute cholecystitis

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