Gallbladder & extrahepatic bile ducts

Cholecystitis

Acute cholecystitis


Editorial Board Member: Monika Vyas, M.D.
Deputy Editor-in-Chief: Catherine E. Hagen, M.D.
Tiffany Sheganoski, D.O.
Aaron R. Huber, D.O.

Topic Completed: 29 November 2021

Minor changes: 29 November 2021

Copyright: 2003-2021, PathologyOutlines.com, Inc.

PubMed Search: Acute cholecystitis[TI] pathology "last 5 years"[DP]

See also: Acute calculous cholecystitis

Tiffany Sheganoski, D.O.
Aaron R. Huber, D.O.
Page views in 2020: 12,003
Page views in 2021 to date: 15,037
Cite this page: Sheganoski T, Huber AR. Acute cholecystitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/gallbladderacutecholecystitis.html. Accessed December 3rd, 2021.
Definition / general
  • Abrupt destructive process of gallbladder
    • Not typical inflammation; neutrophils often absent
    • Most often due to stones blocking cystic duct
    • ~50% of cases complicated by aerobic bacterial infection
Essential features
  • Inflammation of gallbladder induced by choleliths, ischemia or substances
  • Gallbladder wall thickening and pericholecystic fluid seen on transabdominal ultrasound
  • Complications, such as perforation, seen most often in acalculous cholecystitis
  • Cholecystectomy within 72 hours is typically curative
ICD coding
  • ICD-9:
    • 574.00 - calculus of gallbladder with acute cholecystitis, without mention of obstruction
    • 574.01 - calculus of gallbladder with acute cholecystitis with obstruction
    • 574.30 - calculus of bile duct with acute cholecystitis, without mention of obstruction
    • 574.31 - calculus of bile duct with acute cholecystitis with obstruction
    • 574.60 - calculus of gallbladder and bile duct with acute cholecystitis, without mention of obstruction
    • 574.61 - calculus of gallbladder and bile duct with acute cholecystitis, with obstruction
    • 575.0 - acute cholecystitis
  • Reference: Gastroenterol Rep (Oxf) 2017;5:36
Epidemiology
Sites
  • Gallbladder
Pathophysiology
  • Calculous
    • Blockage of neck or cystic duct
      • Typically by gallstones or biliary sludge
      • Continued production of mucus by gallbladder with no outlet
    • Increased pressure within gallbladder
    • Venous stasis
    • Arterial stasis
    • Gallbladder ischemia and necrosis (Surg Clin North Am 2014;94:455)
  • Acalculous
    • Bile stasis and ischemia not provoked by a physical blockade of cystic duct
Etiology
Clinical features
  • Classic: right upper quadrant pain, nausea, vomiting, anorexia, fever
Diagnosis
Laboratory
Radiology description
  • Transabdominal ultrasound
    • Gallbladder wall > 4 mm
    • Pericholecystic fluid
  • Cholescintigraphy
Radiology images

Images hosted on other servers:

Acalculous choleystitis imaging

Prognostic factors
Case reports
Treatment
Clinical images

Images hosted on other servers:

Inflamed gallbladder with exudate

Gross description
  • Distention / edema of gallbladder
  • Serosa
    • Exudate
    • Color alteration
    • Hemorrhagic
  • Wall
    • Thickened up to 2 cm
    • Edematous
    • Hemorrhagic
  • Mucosa
    • May see ulcers
  • Cholelith(s)
    • In neck or cystic duct
  • Lumen
Gross images

Images hosted on other servers:

Red mucosa

Acute (with
empyema) and
chronic cholecystitis
with gallstone

Microscopic (histologic) description
  • May not see acute inflammatory cells unless there is a secondary bacterial infection or choledocholelithiasis
  • Erosion of mucosa
  • Edema
  • Myofibroblasts, lymphocytes, plasma cells, eosinophils and pigment laden macrophages
  • Fibrin
Microscopic (histologic) images

Contributed by Aaron Huber, D.O.
Hemorrhagic mucosa

Hemorrhagic mucosa

Acute inflammation and erosion

Acute inflammation and erosion

Inflamed and reactive epithelium

Inflamed and reactive epithelium

Videos

Overview of acute cholecystitis

Imaging findings in cholelithiasis and acute cholecystitis

Sample pathology report
  • Gallbladder, cholecystectomy:
    • Acute calculous cholecystitis
Differential diagnosis
Board review style question #1

A patient undergoes removal of the pictured organ. What symptoms or presentation would suggest that the etiology of the condition that leads to removal of this organ is related to cocaine use?

  1. Amaurosis fugax
  2. Hematemesis
  3. Melena
  4. Vascular thrombosis
Board review style answer #1
D. Cocaine induced cholecystitis is seen in young, otherwise healthy patients and should be suspected when there is vascular thrombosis along with involvement of other parts of the gastrointestinal tract.

Comment Here

Reference: Acute cholecystitis
Board review style question #2

What imaging finding would suggest that the pictured organ should be surgically removed in the appropriate clinical context?

  1. Focal fat stranding
  2. Gallbladder wall > 4 mm
  3. Inflamed appendix > 6 mm in diameter
  4. Round / ovoid collection of barium in the stomach
Board review style answer #2
B. Thickening of the gallbladder wall > 4 mm as well as pericholecystic fluid may be seen on ultrasound imaging in a case of acute cholecystitis.

Comment Here

Reference: Acute cholecystitis
Board review style question #3

What factors make the pictured organ susceptible to ischemia necessitating removal, even in the absence of physical blockade of the duct?

  1. Location in zone 3, furthest from the hepatic artery
  2. Location within a watershed zone
  3. No collateral blood supply
  4. Sensitivity to atherosclerosis of the inferior mesenteric artery
Board review style answer #3
C. Cases of acalculous cholecystitis may occur because the gallbladder is completely reliant on the cystic artery, with no collateral blood supply.

Comment Here

Reference: Acute cholecystitis
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