Cholelithiasis - complications: cholecystitis, cholangitis
Cholecystitis
This is the most common complication for gallstones. Acute cholecystitis results when a stone becomes lodged in the gallbladder-cystic duct junction where it prevents gallbladder emptying. In the most severe cases this can lead to ischemia and necrosis of the gallbladder, although more commonly we will spontaneous resolution as the gallstone gets dislodged. It is an inflammatory process, where 50% have secondary bacteria such as E.coli.
Symptoms present similarly to biliary colic (above), however generally pain is unremitting and will last several days with nausea, anorexia and fever. Murphy sign (patient breathes out and then place hand below costal margin on R mid-clav, patient then breathes in, if there is pain, murphy sign +ve) is often present and mild jaundice may occur. Where there is a high fever, this suggests concomitant bacterial infection.
Image: “Acute cholecystitis as seen on ultrasound axial view” by Cerevisae, CC BY-SA 4.0, via Wikimedia Commons.
Complications of cholecystitis include empyema of gallbladder (suppurative infection of gallbladder), emphysematous cholecystitis (acute infection by gas organism e.g. clostridium), and gangrene of the gallbladder. Perforation and the formation of fistulas is also a risk. In cases of repeated acute cholecystitis we can develop what is known as porcelain gallbladder where the gallbladder calcifies.
Treatment is that of stabilisation with IV fluids and broad-spectrum antibiotics (e.g. piperacillin-tazobactam, ceftriaxone) along with analgesics. The main curative treatment is that of cholecystectomy.
Cholangitis
Also known as ascending cholangitis, this is inflammation of the bile ducts caused by bacteria ascending from the ampulla of the duodenum. It is often a complication of partial obstruction of the bile duct by gallstones.
Duodenoscopy view of the ampulla of Vater with pus extruding from it, a sign of ascending cholangitis.
Image: “Cholangitis” by The original uploader was Samir at English Wikipedia ., Public domain, via Wikimedia Commons.
Clinical presentation is right upper abdominal pain, fever, rigors, malaise and possibly jaundice.
Cause is any kind of stenosis of the bile ducts, often this is from gallstones, but it can also be hereditary narrowing or tumours. As bacteria enter the biliary tree, the increased pressure within the biliary system due to the narrowing combines to cause the ductal inflammation.
Diagnosis is based on increased WBC and C-reactive protein, along with usually abnormal LFTs, increased bilirubin and alkaline phosphatase along with the above clinical presentation.