Cholecystitis and Cholelithiasis - Erler Zimmer

Cholecystitis and Cholelithiasis - Erler Zimmer

Clinical History

A 60-year-old man with a history of four episodes of severe gripping abdominal pain in the past year, each lasting two hours and associated with meals, presented with a similar attack accompanied by vomiting and fever. As this episode did not resolve spontaneously, he underwent cholecystectomy.

Pathology

The opened gallbladder, with a thickened wall, reveals a haemorrhagic mucosa and numerous irregular faceted calculi. A large calculus is impacted in the neck of the gallbladder. The serosal surface of the gallbladder is congested and has lost its normal sheen. This illustrates cholecystitis complicating cholelithiasis (gallstones).

Further Information

Acute cholecystitis manifests as the clinical syndrome of right upper quadrant pain, fever, and jaundice. Gallstones are the primary cause, accounting for the majority of cases, with only 5-10% attributed to other pathology. Chronic cholecystitis may develop due to recurrent attacks, leading to fibrosis and thickening of the gallbladder wall. Approximately 6-11% of patients with symptomatic gallstones progress to acute cholecystitis. Serum biochemistry typically shows leucocytosis with or without obstructive liver function test abnormalities. Ultrasound reveals gallstones, wall thickening, and a sonographic Murphy's sign (tenderness from ultrasound probe pressure). Other imaging modalities include nuclear medicine cholescintigraphy scans, MRCP (magnetic cholangiopancreatography), and CT. ERCP provides diagnostic information on biliary obstruction and may serve as a therapeutic intervention. Causative organisms, if present, usually stem from gut flora, with common culprits being E. coli, Enterococcus, Klebsiella, and Enterobacter. Complications may include gangrenous cholecystitis, perforation, cholecystoenteric fistula, or gallstone ileus. The definitive treatment is surgical cholecystectomy.