Chronic cholecystitis pathophysiology: Difference between revisions

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{{Cholecystitis}}
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==Overview==
Inflammation of the [[gallbladder]] is termed as cholecystitis. Chronic calculous cholecystitis is usually caused by the mechanical obstruction due to gallstones. Chronic acalculous cholecystitis is caused predominantly by the gallbladder stasis. Lith gene is also involved in the pathogenesis of cholecystitis. Cholecystitis is more common in siblings and first degree relatives of affected persons. On gross pathology, chronic cholecystitis usually shows enlarged or distended [[gallbladder]] and serosal or mucosal exudates. [[Fibrosis]] of gallbladder may also be seen. Microscopic pathology shows [[lymphocytic]] inflammatory infiltrates, [[metaplasia]], and lipid or mucolipid accumulations in the gallbladder wall.
==Pathophysiology==
==Pathophysiology==
===Acute Cholecystitis===
===Pathogenesis===
Cholecystitis is caused by an obstruction of the bile duct due to impaction of a gall stone.<ref name="pmid7396076">{{cite journal |author=Roslyn JJ, DenBesten L, Thompson JE, Silverman BF |title=Roles of lithogenic bile and cystic duct occlusion in the pathogenesis of acute cholecystitis |journal=[[American Journal of Surgery]] |volume=140 |issue=1 |pages=126–30 |year=1980 |month=July |pmid=7396076 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9610(80)90428-6 |accessdate=2012-08-20}}</ref> Gall stone impaction leads to damage of the mucosal surface of the gallbladder and bile stasis.
Inflammation of the [[gallbladder]] is termed as cholecystitis. Chronic calculous cholecystitis is usually caused by the mechanical obstruction due to [[gallstones]]. Chronic acalculous cholecystitis is caused predominantly by the gallbladder [[stasis]]. The pathogenesis of chronic cholecystitis involves the following:<ref name="pmid11483446">{{cite journal |vauthors=Kalloo AN, Kantsevoy SV |title=Gallstones and biliary disease |journal=Prim. Care |volume=28 |issue=3 |pages=591–606, vii |year=2001 |pmid=11483446 |doi= |url=}}</ref><ref name="pmid10750875">{{cite journal |vauthors=Ahmed A, Cheung RC, Keeffe EB |title=Management of gallstones and their complications |journal=Am Fam Physician |volume=61 |issue=6 |pages=1673–80, 1687–8 |year=2000 |pmid=10750875 |doi= |url=}}</ref><ref name="urlAcute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf">{{cite web |url=http://www.ncbi.nlm.nih.gov/books/NBK6881/#A2780 |title=Acute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf |format= |work= |accessdate=2012-08-20}}</ref><ref name="pmid22662601">{{cite journal |author=Amr AR, Hamdy HM, Nasr MM, Hedaya MS, Hassan AM |title=Effect of pancreatic biliary reflux as a cofactor in cholecystitis |journal=[[Journal of the Egyptian Society of Parasitology]] |volume=42 |issue=1 |pages=121–8 |year=2012 |month=April |pmid=22662601 |doi= |url= |accessdate=2012-08-20}}</ref><ref name="urlThe management of chronic cholecystitis - The American Journal of Surgery">{{cite web |url=http://www.americanjournalofsurgery.com/article/S0002-9610(27)91450-0/abstract |title=The management of chronic cholecystitis - The American Journal of Surgery |format= |work= |accessdate=}}</ref><ref name="urlCholecystitis - ScienceDirect">{{cite web |url=https://www.sciencedirect.com/science/article/pii/S0039610914000061?via%3Dihub |title=Cholecystitis - ScienceDirect |format= |work= |accessdate=}}</ref>
Factors which induce cholecystits are
====Gallbladder obstruction====
* Lithogenic bile
The following are a few important features about the gallbladder obstruction leading to chronic cholecystitis:
* Duct obstruction
*[[Gallstones]] are one of the major causes of cholecystitis. These cause physical obstruction to the [[lumen]] of the neck or [[cystic duct]]. This results in an increase in the intraluminal pressure. The degree and duration of obstruction are the two main factors that determine its progression.
Acute inflammation is not always necessary for the development of acute cholecystitis.
* Partial obstruction of short duration may cause [[biliary colic]]. Long-term obstruction may progress to chronic cholecystitis.
* Some studies suggest that the [[Pancreas|pancreatic]] biliary reflux plays a role in the development of chronic cholecystitis.


Gallstones are one of the major causes of cholecystitis. These cause physical obstruction to the lumen of the neck or cystic duct. This results in an increase in the intraluminal pressure. The degree and duration of obstruction are the two main factors that determine its progression. <ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last = | first = | title = Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784509/ | publisher = | date = | accessdate = 22 September 2012 }}</ref>
====Bile Stasis====
 
Bile stasis results in acute acalculous cholecystitis but can also lead to chronic acalculous cholecystitis.
* If the obstruction is partial and of short duration, the patient may experience biliary colic and in the long term, it may progress to chronic cholecystitis.
* Loss of fluids, [[opioid]] drugs, [[positive pressure ventilation]], and other factors cause an increased concentration of bile in the [[biliary tract]].
* If the obstruction is complete and of longer duration, the patient can develop acute cholecystitis.
* Bile contains [[phosphatidyl choline]], which in increased concentrations can cause mucosal disruption.


===Chronic Cholecystitis===
==Genetics==
Some studies suggest that the pancreatic biliary reflux plays a role as a co factor for the development of chronic cholecystitis. Occult pancreatic biliary reflux can be diagnosed by measuring the levels of biliary amylase. <ref name="pmid22662601">{{cite journal |author=Amr AR, Hamdy HM, Nasr MM, Hedaya MS, Hassan AM |title=Effect of pancreatic biliary reflux as a cofactor in cholecystitis |journal=[[Journal of the Egyptian Society of Parasitology]] |volume=42 |issue=1 |pages=121–8 |year=2012 |month=April |pmid=22662601 |doi= |url= |accessdate=2012-08-20}}</ref>
Following are a few important genetic aspects related to chronic cholecystitis:
*Cholecystitis is more common in siblings and first degree relatives of affected persons.<ref name="urlAn Increased Familial Frequency of Gallstones - Gastroenterology">{{cite web |url=http://www.gastrojournal.org/article/S0016-5085(83)80118-8/abstract |title=An Increased Familial Frequency of Gallstones - Gastroenterology |format= |work= |accessdate=}}</ref><ref name="pmid6517051">{{cite journal |vauthors=Weiss KM, Ferrell RE, Hanis CL, Styne PN |title=Genetics and epidemiology of gallbladder disease in New World native peoples |journal=Am. J. Hum. Genet. |volume=36 |issue=6 |pages=1259–78 |year=1984 |pmid=6517051 |pmc=1684666 |doi= |url=}}</ref>
*Lith gene is involved in the pathogenesis of cholecystitis.<ref name="pmid20478482">{{cite journal |vauthors=Wang HH, Portincasa P, Afdhal NH, Wang DQ |title=Lith genes and genetic analysis of cholesterol gallstone formation |journal=Gastroenterol. Clin. North Am. |volume=39 |issue=2 |pages=185–207, vii–viii |year=2010 |pmid=20478482 |doi=10.1016/j.gtc.2010.02.007 |url=}}</ref>
*Mutations in the hepatic cholesterol transporter [[ABCG8]] also predispose an individual to the develop gallstones.<ref name="pmid27121416">{{cite journal |vauthors=Lammert F, Gurusamy K, Ko CW, Miquel JF, Méndez-Sánchez N, Portincasa P, van Erpecum KJ, van Laarhoven CJ, Wang DQ |title=Gallstones |journal=Nat Rev Dis Primers |volume=2 |issue= |pages=16024 |year=2016 |pmid=27121416 |doi=10.1038/nrdp.2016.24 |url=}}</ref>
==Associated conditions==
The following conditions are associated with gallstones:<ref name="pmid27508070">{{cite journal |vauthors=Tiderington E, Lee SP, Ko CW |title=Gallstones: new insights into an old story |journal=F1000Res |volume=5 |issue= |pages= |year=2016 |pmid=27508070 |pmc=4962289 |doi=10.12688/f1000research.8874.1 |url=}}</ref>
*[[Diabetes]]
*[[Insulin resistance]]
*[[Cardiovascular diseases]]
*[[Non-alcoholic fatty liver disease]] (NAFLD)
*[[Gastrointestinal cancer|Gastrointestinal malignancies]]:
**[[Gastric cancer]]
**[[Hepatocellular carcinoma]]
**[[Cholangiocarcinoma]]
**[[Pancreatic cancer]]
**Cancer of the [[ampulla of Vater]]


===Acute Acalculous Cholecystitis===
==Gross Pathology==
====Gallbladder Ischemia/Reperfusion Injury<ref name="urlAcute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf">{{cite web |url=http://www.ncbi.nlm.nih.gov/books/NBK6881/#A2780 |title=Acute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf |format= |work= |accessdate=2012-08-20}}</ref>====
On gross pathology, chronic cholecystitis may have the following features:<ref name="pmid20818819">{{cite journal |vauthors=Huang SM, Yao CC, Pan H, Hsiao KM, Yu JK, Lai TJ, Huang SD |title=Pathophysiological significance of gallbladder volume changes in gallstone diseases |journal=World J. Gastroenterol. |volume=16 |issue=34 |pages=4341–7 |year=2010 |pmid=20818819 |pmc=2937116 |doi= |url=}}</ref><ref name="pmid29083717">{{cite journal |vauthors=Jones MW, Ferguson T |title=Gallbladder, Cholecystitis, Acalculous |journal= |volume= |issue= |pages= |year= |pmid=29083717 |doi= |url=https://www.ncbi.nlm.nih.gov/books/NBK459182/#article-17050.s1}}</ref><ref name="Chronic cholecystitis">{{cite web |url=http://www.tandfonline.com/doi/full/10.1080/01913120490489441 |title=Chronic cholecystitis}}</ref>
* Prolonged periods of ischemia to the gall bladder leads to disruption of the normal mucosal surface.
*Enlarged or distended of [[gallbladder]]
* Lipopolysaccharides are exposed leading to activation of various coagulation cascades.
*Serosal or mucosal exudates
* Reperfusion leads to an increased humoral response which leads to further damage causing cholecystitis.
*[[Gallbladder wall thickening|Thickened wall]] with [[hemorrhage]] and [[edema]]
====Bile Stasis<ref name="urlAcute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf">{{cite web |url=http://www.ncbi.nlm.nih.gov/books/NBK6881/#A2780 |title=Acute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf |format= |work= |accessdate=2012-08-20}}</ref>====
==Microscopic Pathology==
* Loss of fluids, opioid drugs, [[positive pressure ventilation]], and other factors cause an increased concentration of bile in the [[biliary tract]]s.
On microscopic pathology, chronic cholecystitis has the following features:<ref name="Chronic cholecystitis">{{cite web |url=http://www.tandfonline.com/doi/full/10.1080/01913120490489441 |title=Chronic cholecystitis}}</ref><ref name="urlCholecystitis - ScienceDirect">{{cite web |url=https://www.sciencedirect.com/science/article/pii/S0039610908000972?via%3Dihub |title=Cholecystitis - ScienceDirect |format= |work= |accessdate=}}</ref>
* Bile contains [[phosphatidyl choline]], which in increased concentrations can cause mucosal disruption.
* [[Lymphocytic]] infiltrates and [[metaplasia]]
* [[Fibrosis]] (due to [[collagen]] deposition)
* Lipid and mucolipid acuumulation in gallbladder wall
*[[Granulation tissue]]


===Pathology===
====Chornic Cholecystitis====
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{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
| background: " #FFFFFF; |[[File:Gallbladder cholesterolosis micro.jpg|400px|thumb|center|Histological image of chronic cholecystitis; Low magnification. <small> By Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=30991393 Source: Libre Pathology<ref name="urlFile:Acute cholecystitis -- very low mag.jpg - Wikimedia Commons">{{cite web |url=https://commons.wikimedia.org/w/index.php?curid=30991393 |title=File:Acute cholecystitis -- very low mag.jpg - Wikimedia Commons |format= |work= |accessdate=}}</ref>]]
<br clear="left" />
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==References==
==References==
{{Reflist|2}}
{{reflist|2}}
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Latest revision as of 21:54, 19 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2] Aditya Govindavarjhulla, M.B.B.S. [3]

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Overview

Inflammation of the gallbladder is termed as cholecystitis. Chronic calculous cholecystitis is usually caused by the mechanical obstruction due to gallstones. Chronic acalculous cholecystitis is caused predominantly by the gallbladder stasis. Lith gene is also involved in the pathogenesis of cholecystitis. Cholecystitis is more common in siblings and first degree relatives of affected persons. On gross pathology, chronic cholecystitis usually shows enlarged or distended gallbladder and serosal or mucosal exudates. Fibrosis of gallbladder may also be seen. Microscopic pathology shows lymphocytic inflammatory infiltrates, metaplasia, and lipid or mucolipid accumulations in the gallbladder wall.

Pathophysiology

Pathogenesis

Inflammation of the gallbladder is termed as cholecystitis. Chronic calculous cholecystitis is usually caused by the mechanical obstruction due to gallstones. Chronic acalculous cholecystitis is caused predominantly by the gallbladder stasis. The pathogenesis of chronic cholecystitis involves the following:[1][2][3][4][5][6]

Gallbladder obstruction

The following are a few important features about the gallbladder obstruction leading to chronic cholecystitis:

  • Gallstones are one of the major causes of cholecystitis. These cause physical obstruction to the lumen of the neck or cystic duct. This results in an increase in the intraluminal pressure. The degree and duration of obstruction are the two main factors that determine its progression.
  • Partial obstruction of short duration may cause biliary colic. Long-term obstruction may progress to chronic cholecystitis.
  • Some studies suggest that the pancreatic biliary reflux plays a role in the development of chronic cholecystitis.

Bile Stasis

Bile stasis results in acute acalculous cholecystitis but can also lead to chronic acalculous cholecystitis.

Genetics

Following are a few important genetic aspects related to chronic cholecystitis:

  • Cholecystitis is more common in siblings and first degree relatives of affected persons.[7][8]
  • Lith gene is involved in the pathogenesis of cholecystitis.[9]
  • Mutations in the hepatic cholesterol transporter ABCG8 also predispose an individual to the develop gallstones.[10]

Associated conditions

The following conditions are associated with gallstones:[11]

Gross Pathology

On gross pathology, chronic cholecystitis may have the following features:[12][13][14]

Microscopic Pathology

On microscopic pathology, chronic cholecystitis has the following features:[14][6]

{{#ev:youtube|gxGvP3GV_1E}}

Histological image of chronic cholecystitis; Low magnification. By Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=30991393 Source: Libre Pathology[15]


References

  1. ↑ Kalloo AN, Kantsevoy SV (2001). "Gallstones and biliary disease". Prim. Care. 28 (3): 591–606, vii. PMID 11483446.
  2. ↑ Ahmed A, Cheung RC, Keeffe EB (2000). "Management of gallstones and their complications". Am Fam Physician. 61 (6): 1673–80, 1687–8. PMID 10750875.
  3. ↑ "Acute acalculous cholecystitis - Surgical Treatment - NCBI Bookshelf". Retrieved 2012-08-20.
  4. ↑ Amr AR, Hamdy HM, Nasr MM, Hedaya MS, Hassan AM (2012). "Effect of pancreatic biliary reflux as a cofactor in cholecystitis". Journal of the Egyptian Society of Parasitology. 42 (1): 121–8. PMID 22662601. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. ↑ "The management of chronic cholecystitis - The American Journal of Surgery".
  6. ↑ 6.0 6.1 "Cholecystitis - ScienceDirect".
  7. ↑ "An Increased Familial Frequency of Gallstones - Gastroenterology".
  8. ↑ Weiss KM, Ferrell RE, Hanis CL, Styne PN (1984). "Genetics and epidemiology of gallbladder disease in New World native peoples". Am. J. Hum. Genet. 36 (6): 1259–78. PMC 1684666. PMID 6517051.
  9. ↑ Wang HH, Portincasa P, Afdhal NH, Wang DQ (2010). "Lith genes and genetic analysis of cholesterol gallstone formation". Gastroenterol. Clin. North Am. 39 (2): 185–207, vii–viii. doi:10.1016/j.gtc.2010.02.007. PMID 20478482.
  10. ↑ Lammert F, Gurusamy K, Ko CW, Miquel JF, Méndez-Sánchez N, Portincasa P, van Erpecum KJ, van Laarhoven CJ, Wang DQ (2016). "Gallstones". Nat Rev Dis Primers. 2: 16024. doi:10.1038/nrdp.2016.24. PMID 27121416.
  11. ↑ Tiderington E, Lee SP, Ko CW (2016). "Gallstones: new insights into an old story". F1000Res. 5. doi:10.12688/f1000research.8874.1. PMC 4962289. PMID 27508070.
  12. ↑ Huang SM, Yao CC, Pan H, Hsiao KM, Yu JK, Lai TJ, Huang SD (2010). "Pathophysiological significance of gallbladder volume changes in gallstone diseases". World J. Gastroenterol. 16 (34): 4341–7. PMC 2937116. PMID 20818819.
  13. ↑ Jones MW, Ferguson T. "Gallbladder, Cholecystitis, Acalculous". PMID 29083717.
  14. ↑ 14.0 14.1 "Chronic cholecystitis".
  15. ↑ "File:Acute cholecystitis -- very low mag.jpg - Wikimedia Commons".


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