Acute cholecystitis overview
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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]
Overview
Historical Perspective
Gallstones are found in 3500 years old Egyptian mummies during the autopsies. In 1420, Antonio Benivieni was the first to describe gallstones. Carl Langenbuch performed the first cholecystectomy of a 43-year-old man who had suffered from biliary colic for sixteen years. Historically, open cholecystectomy was the treatment employed for the treatment of acute cholecystitis. Laparoscopic cholecystectomy was developed to treat acute cholecystitis and the shift from open to laparoscopic cholecystectomy occurred in the late 1980s.
Classification
Acute cholecystitis may be classified according to causes into two major subtypes: Acute calculous cholecystitis and acute acalculous cholecystitis.
Pathophysiology
Acute calculous cholecystitis is usually caused by the mechanical obstruction of the gallbladder due to gallstones. Acute acalculous cholecystitis is caused predominantly by the gallbladder stasis. Gallstones are the most common cause of physical obstruction of the gallbladder usually at the neck or in the cystic duct. Cholesterol gallstones are the most common type of gallstones. The obstruction causes an increased pressure as the gallbladder mucosa continues to produce mucus. This raised pressure may cause the venous congestion which is followed by the arterial congestion. Eventually, the raised pressure and stasis leads to the gallbladder ischemia and necrosis. Mechanical obstruction of the gallbladder as a result of polyps, malignancy, an infestation of the gallbladder with parasites, foreign bodies, and trauma may also lead to the acute cholecystitis. Acute cholecystitis is more common in siblings and first degree relatives of affected persons. Lith gene is involved in the pathogenesis of cholecystitis. Mutations in the hepatic cholesterol transporter ABCG8 also predispose an individual to the develop gallstones. Acute cholecystitis is associated with diabetes, insulin resistance, cardiovascular diseases, non-alcoholic fatty liver disease (NAFLD) and gastrointestinal malignancies. Microscopic histopathology shows edematous and hemorrhagic gallbladder wall, mucosal necrosis with neutrophil infiltration. Bile infiltration of the gallbladder wall and bile and leucocyte margination of blood vessels are specific findings for acalculous cholecystitis.
Causes
The most common cause of acute cholecystitis is gallstones. Less common causes of acute cholecystitis include gallbladder stasis, gallbladder polyp, gallbladder malignancy, parasites, and foreign
Differentiating Acute cholecystitis from Other Diseases
Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant abdominal pain and nausea/vomiting such as biliary colic, acute cholangitis, and viral hepatitis.