Cholecystitis is inflammation of the gall bladder.

Causes and pathology Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species. The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel. Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis. Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified. Symptoms Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first. This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies and fried foods. This is usually accompanied by a low grade fever, vomiting and nausea. More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction. Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, and diarrhea. Diagnosis Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:

fever (usually low grade in uncomplicated cases)

tender right upper quadrant +/- Murphy's sign Ortner's sign - tenderness when hand taps the edge of right costal arch. Georgievskiy-Myussi's sign (phrenic nerve sign) - pain when press between edges of sternocleidomastoid muscle. [1]

Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes. Ultrasound can assist in the differential.[2][3] Differential diagnosis Acute cholecystitis

This should be suspected whenever there is acute right upper quadrant or epigastric pain. o Other possible causes include: Perforated peptic ulcer Acute peptic ulcer exacerbation Amoebic liver abscess Acute amoebic liver colitis Acute pancreatitis Acute intestinal obstruction Renal colic Acute retrocolic appendicitis

Chronic cholecystitis The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:

Peptic ulcer Hiatus hernia Colitis Functional bowel syndrome

It is defined pathologically by the columnar epithelium has reached down the muscular layer. THERAPY For most patients, in most centres, the definitive treatment is surgical removal of the gallbladder. Supportive measures are instituted in the meantime and to prepare the patient for surgery. These measures include fluid resuscitation and antibiotics. Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-

sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e.g.ceftriaxone) and an antibacterial with good coverage (fluoroquinolone such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic patients, aztreonam and clindamycin may be used.cis Gallbladder removal, cholecystectomy, can be accomplished via open surgery or a laparoscopic procedure. Laparoscopic procedures can have less morbidity and a shorter recovery stay. Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. A laparoscopic procedure may also be 'converted' to an open procedure during the operation if the surgeon feels that further attempts at laparoscopic removal might harm the patient. Open procedure may also be done if the surgeon does not know how to perform a laparoscopic cholecystectomy. In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. The patient may later warrant cholecystectomy if their condition improves.