cholecystitis

Gallbladder inflammation: description

Gallbladder inflammation is a disease of the wall of the gallbladder. It arises in most cases by a gallstone disease (cholelithiasis). The gallbladder is a hollow organ that is below the liver. Their appearance is reminiscent of a pear. The human gallbladder is usually eight to twelve inches long and four to five inches wide. It stores the bile (bile) that is produced in the liver cells. She thickens him. The bile juice is needed to digest fats in the intestine.

Classification of gallbladder inflammations

Doctors also speak of cholecystitis in a gall bladder infection (gr chole = bile, kystis = bladder). If gallbladder inflammation is the result of gallstone disease (90 to 95 percent of cases), it is also called calculous cholecystitis. If it comes without stones to gallbladder inflammation doctors speak of an akalkulösen cholecystitis. In addition, experts distinguish an acute from a chronic gall bladder infection.

Cholecystitis frequency

According to a report by the Federal Statistical Office, in 2012 there were 15,126 patients with gallbladder inflammation (main diagnosis) in German hospitals. In most cases, patients were over 55 years old. Most commonly affected were people between the ages of 70 and 75 (1,945 gall bladder infections). The German Medical Journal even speaks of a total of over 64,000 inpatients with gallbladder inflammation.

According to various studies, chronic cholecystitis is about three to eight times more common than an acute one. Precise information on the incidence of gallbladder inflammation can not be provided because most patients either do not visit the doctor or are not hospitalized.

Stone gallbladder inflammation is more common in women than in men. This is mainly due to the fact that gallstones are the main cause of cholecystitis in women about twice as often as in men. Much less often does the gallbladder wall become inflamed even without gallstones. Cholecystitis, for example, is the result of artificial nutrition in intensive care patients. Men with non-stone gall bladder infection are more affected than women.

Gallbladder inflammation: symptoms

The typical gallbladder inflammation symptoms are pain that begin in the upper abdominal region above the stomach and gradually migrate into the right upper abdomen. At first they usually appear in spasmodic waves (biliary colic). In the further course, however, sufferers experience pain in the right abdomen in almost all gall bladder infections throughout (over at least six hours). If the doctor presses on this spot, the pain intensifies. They may also radiate into the back, right shoulder, or between the shoulder blades. Usually, the signs of gallbladder inflammation persist for four to five hours.

Some patients also complain of loss of appetite, nausea and vomiting. In addition, many suffer from (mild) fever and palpitations (tachycardia). If, in addition to gallbladder inflammation, an inflammatory disease of the biliary tract (cholangitis) occurs, yellowing of the conjunctiva (scleral icterus) and, in the advanced stage, of the skin (jaundice = jaundice) may occur. The yellowing is caused by the blood pigment bilirubin. The bilirubin first stains the conjunctiva of the eyes and finally into the skin tissue.

Gallbladder inflammation in children

If the gall bladder is inflamed in children, similar symptoms occur. However, gallbladder inflammations lead to jaundice and white to grayish bowel movements (acholes) in infants much faster than in adults. The children are easily irritated and “whining” and often shout. Many parents also report an appetite loss of their child. Gallbladder inflammation symptoms such as nausea and vomiting often affect older children and adolescents. At the onset of cholecystitis, children often experience an uncomfortable feeling of pressure rather than an upper abdominal pain, which only develops into spasmodic pain over time.

Gallbladder inflammation in the elderly

In older people, the signs are often weak when the gallbladder is inflamed. Symptoms such as pain or fever are usually absent. Many feel only a slight pain when pressure on the right upper abdomen. Some sufferers feel only beaten off and tired. This is particularly the case if they additionally suffer from the diabetes diabetes. Even with chronic gallbladder inflammation the symptoms are weaker. Affected suffer mostly only a slight pressure and flatulence. In contrast, acute cholecystitis (without stones) leads relatively quickly to a serious clinical picture (high-fever sepsis).

Gallbladder inflammation: causes and risk factors

About 90 percent of gall bladder infections precede gallstones. These stones move the gallbladder outlet (cholecystolithiasis), the bile duct (choledocholithasis) or the junction of the small intestine. Due to this so-called obstruction, the bile can no longer run off and accumulates in the gallbladder. This is stretched excessively. As a result, the gallbladder wall is compressed. The blood can no longer flow freely through the vessels in the gallbladder wall and the lymph drainage is also disturbed. In the gallbladder mucosa there is a lack of nutrients and oxygen. The cells of the gallbladder partially die off and lead via released pollutants to gallbladder inflammation.

The bile itself also damages the gallbladder wall with its bile acids and the substance lysolecithin. On the one hand, cells are destroyed and trigger gallbladder inflammation. On the other hand, special proteins, so-called prostaglandins, are released by the aggressive substances. In particular, the prostaglandins E and F promote gallbladder inflammation. In addition, the gallbladder wall secretes more fluid under prostaglandin influence. As a result, the gallbladder will be stretched even further and the mechanism of undersupply further intensified.

Risk factor gallstones

Most gallbladder disease causes gallbladder inflammation, as the bile can not drain properly. Therefore, the risk factors for gallstones also increase the risk of calculous cholecystitis. These risk factors include the so-called “6 f”:

• female (female gender)
• fat (overweight, obesity)
• fourty (forty years old, generally with increasing age)
• fertile
• fair (fair-skinned)
• family (family disposition)

In addition, fast weight loss can also lead to gallstones. Certain medications, especially hormone supplements for women, increase the risk of gallstones and thus gall bladder infections. The same applies to pregnant women: An increased occurrence of the messenger progesterone promotes the development of gallbladder inflammation by stones.

Akalkulöse gallbladder inflammation

The exact formation of gallbladder inflammation not caused by gallstones is not very clear. However, researchers also assume a stasis here or the fate of viscous (concentrated) bile in the gallbladder. Concentrated bile is very aggressive and attacks the mucous membrane of the gallbladder, if it does not deflate regularly (bile stasis). The messenger cholecystokinin (CCK) provides in healthy people for just this emptying of bile into the intestine.

Disturbed gallbladder emptying

Severe accidents, serious burns or febrile illnesses such as bacterial toxemia (sepsis) dry out the body and make the bile more viscous. If the patient does not eat any food (for example, because he is in an artificial coma), the messenger substance CCK is not released. The aggressive, tenacious, concentrated bile remains in the gallbladder and eventually leads to gallbladder inflammation. Even long fasting prevents the release of CCK and thus the gall bladder emptying. The same applies if a patient is fed artificially via the vein (parenteral) over a long period of time (three months).

Disturbed oxygenation and other risk factors

In addition, a reduced blood and thus oxygen supply can ignite the gallbladder. This is the case for example after heart attacks. Sickle cell anemia can also lead to gallbladder inflammation. The misshapen red blood cells clog the blood capillaries of the gallbladder wall. In diabetics, the vessels are damaged by deposits. In addition, infections with Salmonella, the hepatitis A virus or the HI virus (“AIDS”) increase the risk of gallbladder inflammation. In HIV patients, especially the cytomegalovirus, crypto- and microsporidia (parasites) play a crucial role. Due to an increased risk of infection, immunocompromised people are generally at risk of developing gallbladder inflammation.

bacteria

The bile is usually germ-free. However, if gallbladder inflammation occurs after a gall bladder infection, pathogens often rise from the intestine and invade the gallbladder wall. The most common germs are the bacteria Escherichia coli, Klebsiella and Enterobacteria. They migrate either through the bile duct or the lymph channels into the gallbladder. Bacterial infections are the leading cause of serious complications of gallbladder inflammation. Bacterial gall bladder infections primarily affect the immune deficient (immunosuppressed) and severely (pre-) diseased patients (for example in the case of sepsis). But they can also occur after abdominal surgery or a reflection of the pancreatic and biliary ducts (ERCP = endoscopic retrograde cholangiopancreatography).

A special form of gallbladder inflammation is emphysematous cholecystitis. Here it comes to an infection with the gas-forming bacteria E. coli and clostridia. Although very rare (about one percent of all acute cholecystitis), this form of gallbladder inflammation is highly dangerous. It is associated with a significantly increased risk of serious complications. In addition to bacteria, parasites such as amoebae or water-borne worms can cause akalkulöse gallbladder inflammation.

Gallbladder inflammation: diagnosis and examination

If you have a suspicion of gallbladder inflammation, you should always see a doctor. For mild symptoms, a family doctor or a specialist in internal medicine (internist) can help. However, severe pain and high fever associated with acute cholecystitis require hospitalization. Once you have visited your doctor, he will immediately refer you to a clinic.

Medical history (anamnesis)

The history (history) is as crucial as any disease. It provides the doctor with first indications of the correct diagnosis. He first asks for possible symptoms of gallbladder inflammation. The doctor may ask the following questions:

• Since when and where are your complaints?
• Did the pain occur in spasmodic attacks, especially at the beginning?
• Have you recently measured elevated body temperature?
• Did you have gallstones in the past? Or did your family members often have gallstones?
• Have you been fasting lately?
• Which medications do you take (possibly hormone preparations from the gynecologist)?

Physical examination

After the detailed questioning, your doctor will examine you physically. Risk factors such as excessive overweight or fairness can be seen at first glance. The same applies to a possible yellowing of the eyes or the skin. He will also measure your body temperature. Pulse buttons and heart-tapping show the doctor if the heart beats over-rapidly, as is typical of an infection.

Probably the most important role is played by the examination of the abdomen. The doctor first listens to the abdomen (auscultation). Reduced bowel sounds may indicate an inflammation of the peritoneum (peritonitis), especially in the advanced stage.

Then he palpates the stomach with his hands (palpation). Typical of gallbladder inflammation is the so-called Murphy sign (named after an American surgeon). The doctor presses on the right upper abdomen under the costal arch. Now he will ask you to take a deep breath. As a result, the gallbladder moves under the oppressive hand. If the gall bladder is inflamed, the pressure from the doctor causes severe pain. You will involuntarily tense the abdomen (defense tension) and stop inhaling. In 30 to 40 percent of gall bladder infections, the doctor can also palpate the bulging gallbladder.

laboratory tests

In order to detect inflammation of the gallbladder, the doctor will take blood samples. Some blood levels may be altered by gallbladder inflammation. For example, white blood cells (leukocytosis) are increasingly found. Inflammation in the body is indicated by C-reactive protein (CRP) and an increased blood sedimentation rate. In addition, certain proteins of the liver (enzymes AST, ALT) may be increased by gallbladder inflammation. The doctor also checks the bilirubin (red blood pigment), the enzyme gamma-GT and the so-called alkaline phosphatase (protein enzyme, increased in 25 percent).

Furthermore, the urine is examined. The doctor wants to exclude damage to the kidneys. Because sometimes even pyelonephritis (pyelonephritis) or kidney stones (nephrolithiasis) can cause similar symptoms as gallbladder inflammation. In addition, all women of fertile age are tested for a possible pregnancy. In high fever and poor general condition (tachycardia, low blood pressure) doctors take blood for so-called blood cultures. It is possible that the bacteria have already spread throughout the body via the blood (bacterial toxemia, sepsis).

Imaging procedures

There are many ways to visualize the gallbladder and its possible inflammation using imaging techniques. A simple and safe method is the abdominal ultrasound (abdominal ultrasound). In case of doubt, a CT or so-called hepatobiliary scintigraphy is initiated. The latter complex procedure shows the production of bile and its discharge pathways using radioactively labeled substances. An X-ray is rarely performed.

Ultrasound (sonography)

With the help of an ultrasound device, the doctor can detect both gallstones (which are larger than two millimeters) and gallbladder inflammation. Thickened, crystallized bile (bile) can also be seen and is called “sludge”. In addition, the Murphy character can be triggered on this exam. An acute gallbladder inflammation manifests itself in the ultrasound by the following characteristics:

• The wall thickness is greater than four millimeters.
• The gallbladder wall shows up in three layers.
• Around the gallbladder a dark fluid hemisphere is visible.
• The gallbladder is significantly enlarged.

In the case of emphysematous gallbladder inflammation, the physician may also detect air retention in the gallbladder (Stage 1), in the gallbladder wall (Stage 2), or even in the surrounding tissue (Stage 3). Free air in the abdominal cavity indicates a tear or a hole in the gallbladder and represents an emergency. In this case, surgery is performed as soon as possible. The same applies to other complications of gallbladder inflammation, which can be detected by ultrasound (for example, accumulation of pus).

CT

In ultrasound, the gallbladder and the common bile duct are difficult or impossible to visualize. Even the pancreas, the doctor often difficult to assess. If gallbladder inflammation can not be reliably diagnosed or if there is a suspicion of pancreatitis, the doctors perform computed tomography (CT).

roentgen

An x-ray is rarely induced. Only very few gallstones can be visualized with this technique. However, the x-ray of emphysematous gallbladder inflammation is usually much more noticeable. In this case, there is an accumulation of air in the area of ​​the gallbladder. The air is generated by gas-forming bacteria. This form of cholecystitis affects especially older, diabetic men with a non stone-related (akalkulösen) gallbladder inflammation.

In addition, a so-called porcelain bubble can be seen in both ultrasound and x-ray. This disease is the result of chronic gallbladder inflammation. Because of scarred remodeling and lime deposits, the gallbladder wall hardens visibly and becomes whitish like porcelain.

ERCP

With a ERCP (Endoscopic retrograde cholangiopancreatography), the bile ducts, gallbladder and ducts of the pancreas are visualized using X-ray contrast media and a special endoscope. This examination is performed under short-term anesthesia and is only initiated when physicians suspect gallstones in the common bile duct. During an ERCP these stones can be removed directly. The junction of the bile duct to the intestine (Papilla vateri) is widened with a cut so that the stone can pass into the intestine and be excreted with the stool.

Sometimes the gallstones have to be removed with the help of wire loops (Dormiakörbchen). However, ERCP also increases the risk of pancreatitis or bile duct inflammation.

Gallbladder inflammation: treatment

The treatment of cholecystitis is carried out according to today’s standards mostly surgically. The gallbladder and stones are completely removed. The medical term for this surgical procedure is cholecystectomy.

Usually, this operation is performed by means of laparoscopy: small abdominal incisions are used to insert instruments into the abdomen and cut out the gallbladder (laparoscopic cholecystectomy). In some cases, the gallbladder is also removed directly through a cut in the abdominal wall. This open cholecystectomy, for example, is necessary if the stone mass contained in the gallbladder is too large.

According to a study published by the University of Heidelberg in 2013, patients with acute gallbladder inflammation have particular benefit from an operation that occurs within the first 24 hours after hospitalization. However, the study was limited to those who were generally ill or moderately ill. US experts also advocate early surgery within the first 72 hours. The current guidelines of the German Society of Visceral Surgery recommend surgery within the first five days.

Both the akalkulösen (not stone-related) and in the emphysematous gallbladder inflammation is usually treated immediately surgically. Because both forms of cholecystitis have a high risk of complications. In patients with a high surgical risk (many previous illnesses, severe underlying disease, old age), the jammed, sometimes infected bile (possibly also pus) can be temporarily drained through the skin via a tube (cholecystotomy and percutaneous drainage). According to the German guidelines, the gallbladder should then be removed after six weeks. More recent studies suggest another option for these risk patients: inserting a stent (metal tube) into the bile duct to relieve the gallbladder.

Non-operative treatment measures

The spasmodic pain of gallbladder inflammation treated the doctor with painkillers (analgesics) and anticonvulsant drugs (spasmolytics). In addition to painkillers, the administration of antibiotics is often necessary. These drugs work against the pathogens of bacterial gallbladder inflammation. Recent studies also show that non-steroidal anti-inflammatory drugs (NSAIDs) can lower the risk of gallbladder inflammation in existing gallstones.

In addition, medics recommend not to eat for at least 24 hours. Through this abstinence the gallbladder should be relieved. However, it is also important that patients with gallbladder inflammation take enough liquid. In the hospital, the fluid is usually supplied as an infusion via the vein. In addition, physicians pay attention to the electrolyte balance (for example, potassium and sodium levels in the blood).

Resolution of risky gallstones

In cases of gallstone disease with only mild discomfort, it can be attempted to dissolve the gallstones with medication (litholysis). This also reduces the risk of gallbladder inflammation. Doctors usually use ursodeoxycholic acid (UDCA) as a capsule for litholysis. However, this substance can only dissolve cholesterol-containing stones that are not seen in the X-ray image (X-ray negative stones). Furthermore, the gallbladder still has to function and the bile duct must be continuous for UDCA to be used. The success of the treatment is checked by ultrasound. The guidelines recommend that UDCA intake be continued for three months thereafter.

However, the risk remains very high that stones form again and cause gallbladder inflammation. If a patient suffers from gallstones or cholecystitis symptoms after non-operative treatment, the gallbladder is surgically removed.

The use of so-called extracorporeal shockwave lithotripsy is also no longer recommended in the guidelines. In this procedure, the gallstones are bombarded with sound waves from the outside via an applied transmitter and thereby comminuted. The debris can then be excreted through the intestine. However, new gallstones (high risk of recurrence) usually form very quickly even after this treatment, which in turn increases the risk of gallbladder inflammation. In addition, the cost-benefit ratio is worse than with a cholecystectomy.

Gallbladder inflammation: disease course and prognosis

The prognosis of acute gallbladder inflammation is good if treated early. In particular, rapid surgical removal of the gallbladder reduces the risk of complications. In addition, studies show that patients can leave the hospital more quickly if they are operated on within the first few days.

The gallbladder is not a vital organ, which is why worrying about surgical removal is often unfounded. Patients may tolerate spicy and fatty foods worse after gallbladder inflammation with cholecystectomy. Often, however, this improves over the years.

complications

If the diagnosis of gallbladder inflammation is made late, some life-threatening complications are threatened. In the early stages of gall bladder inflammation, this includes, in particular, accumulations of pus in the gallbladder (empyema) as well as greater tissue damage due to a blood supply (gangrene). Such complications of gallbladder inflammation increase the risk of life-threatening disease and must always be treated surgically.

Perforated gallbladder inflammation

Especially in the case of stone-induced gall bladder inflammation threatens in the further course of the breakthrough of the gallbladder wall. As a result, bile empties into surrounding organs or body cavities and the inflammation spreads. As a result, it can, for example, to abscesses around the gallbladder (pericholezystitischer abscess) or come in the liver.

Arrives inflammatory bile in the abdominal cavity, doctors speak of a free perforation. The result is usually a peritonitis (bilious peritonitis). In contrast, there is the covered perforation. The crack in the gallbladder wall is covered by intestinal loops, for example.

fistulas

In addition, gallbladder inflammation can break up in the gastrointestinal tract. It may then form ganglike connections in the stomach, small or large intestine, so-called bilioenteric / biliodigestive fistulas. As a result, air bubbles in the biliary system can be detected in X-rays, CT or ultrasound (the air passes through the fistula from the intestine into the biliary tract). Doctors speak in this case of Aerobilie. In addition, stones can enter the intestine in the opposite way and close it (gallstone ileus). In rare cases, the gall bladder infection forms a connection to the skin (biliokutane fistula).

Bacterial septicemia

In a gall bladder infection with bacteria, the pathogens can enter the bloodstream and cause a dangerous bacterial toxemia (sepsis). This complication is especially feared in emphysematous gallbladder inflammation. However, the akalkulöse, so non-stone-related gallbladder inflammation is usually the result of such sepsis. It can ultimately worsen the clinical picture, as abscesses and perforations threaten here as well.

Chronic gallbladder inflammation

The transition from acute to chronic gallbladder inflammation is fluid: chronic cholecystitis follows an incompletely healed acute gall bladder infection. Some patients complain of occasional pain when it comes to an acute inflammatory thrust. However, chronic gallbladder inflammation usually causes no symptoms. As the disease progresses, the gallbladder may shrink. If lime accumulates in the gallbladder wall, this leads to the so-called porcelain bubble.

It 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 gallbladder inflammation and its complications are also treated by complete cholecystectomy.

Prevent gallbladder inflammations

Gallbladder inflammation is difficult to prevent. First and foremost is the prevention of gallstone disease as the main risk factor. Eat a high fiber content and be active in sports. This also counteracts the risk factor overweight. Avoid low-fat diets or fasting. If you are overweight, you should ask your doctor for advice on how to reduce it.

Even a rapid weight loss after abdominal surgery (gastric bypass, gastric banding) increases the risk of gallstones and thus a gall bladder infection. Studies have shown that taking UDCA six months after surgery reduces stone risk. It is also important that you trust your doctor. The complaints of gallbladder inflammation usually improve after the first intake of medication (spasmolytics, analgesics). Nevertheless, the doctor will recommend you an operative cholecystectomy. Follow the advice of your treating physician to find serious complications cholecystitis to avoid.