Themorphologicchangesinchronic cholecystitis areextremelyvariableandsometimessubtle.Themerepresenceofstoneswithinthegallbladder,evenintheabsenceofacuteinflammation,oftenistakenassufficientjustificationforadiagnosis.Thegallbladdermaybecontracted,ofnormalsize,orenlarged.Mucosalulcerationsareinfrequent;thesubmucosaandsubserosaoftenarethickenedfromfibrosis.Intheabsenceofsuperimposedacutecholecystitis,collectionsoflymphocytesinthewallaretheonlysignofinflammation(
Fig.16.41A ).Outpouchingsofmucosalepitheliumthroughthewallofthegallbladder(Rokitansky-Aschoffsinuses)maybequiteprominent(see
Fig.16.41B
Acute calculous cholecystitis presents with biliary pain that lasts for more than 6 hours. The pain is severe, usually steady, upper abdominal in location, and often radiates to the right shoulder. Fever, nausea, leukocytosis, and prostration are classic; the presence of conjugated hyperbilirubinemia suggests obstruction of the common bile duct. The right subcostal region is markedly tender and rigid as a result of spasm of the abdominal muscles; occasionally a http://ebooksmedicine.net
Fig. 16.41 Chroniccholecystitis.(A)Thegallbladdermucosaisinfiltratedbychronicinflammatorycells.(B)ARokitansky-Aschoffsinuscontaininga fragmentedbilepigmentstone.
tender, distended gallbladder can be palpated. Mild attacks usually subside spontaneously over 1 to 10 days; however, recurrence is common. Approximately 25% of symptomatic patients are sufficiently ill to require surgical intervention.
The diagnosis of acute cholecystitis usually is based on the detection of gallstones by ultrasonography, typically accompanied by evidence of a thickened gallbladder wall. Attention to this disorder is important because of the potential for the following serious complications:
Bacterial superinfection leading to cholangitis or sepsis
Gallbladder rupture leading to diffuse peritonitis
Biliary enteric (cholecystenteric) fistula, with drainage of bile into adjacent organs, entry of air and bacteria into the biliary tree, and potentially gallstone-induced intestinal obstruction (ileus)
Aggravation of preexisting medical illness, with cardiac, pulmonary, renal, or liver decompensation
Symptoms arising from acute acalculous cholecystitis usually are obscured by another serious medical or surgical condition, which sets the stage for the development of cholecystitis. The diagnosis therefore rests on a high index of suspicion. Chronic cholecystitis lacks the striking manifestations of the acute forms and is usually characterized by recurrent attacks of steady epigastric or right upper-quadrant pain. Nausea, vomiting, and intolerance for fatty foods are frequent accompaniments. Chronic cholecystitis is a pathologic diagnosis based on the examination of the resected gallbladder. Beyond signs and symptoms mentioned above, its principal importance may lie in the association of gallstones and chronic inflammation with carcinoma of the gallbladder (discussed next).