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Infectious Disease and Microbiology – Cholecystitis and Cholangitis
Cholecystitis refers to acute or chronic inflammation of the gallbladder. Cholangitis is a clinical syndrome characterized by systemic infection originating in the biliary tract, usually due to obstruction. Emphysematous cholecystitis is a severe form of gallbladder inflammation in which gas forms within the gallbladder lumen, wall, or surrounding tissues.
Acute cholecystitis accounts for 3–10% of patients presenting with abdominal pain, increasing to approximately 20% among individuals older than 50 years. Among patients with gallstones (cholelithiasis), 1–4% annually develop biliary colic, and if untreated, about 20% of symptomatic individuals may later develop acute cholecystitis.
In 90–95% of cases, acute cholecystitis results from gallstone obstruction. Risk factors for gallstone formation include obesity, rapid weight loss, hemolytic diseases (such as sickle cell disease and G6PD deficiency), and certain ethnic backgrounds (e.g., Pima Indians). Gallstones are more than twice as common in women as in men, although cholecystitis tends to be more severe in men.
Acalculous cholecystitis occurs without gallstones and is associated with serious medical conditions such as diabetes mellitus, sepsis, ischemia, trauma, burns, prolonged total parenteral nutrition, vasculitis, collagen vascular diseases, sarcoidosis, HIV/AIDS, and certain infections (e.g., tuberculosis and parasitic infections). It is slightly more common in men and is associated with higher complication rates. Emphysematous cholecystitis is more frequent in elderly patients and those with diabetes.
Acute calculous cholecystitis results from obstruction of the cystic duct by gallstones. Acalculous cholecystitis develops due to gallbladder stasis and bile stagnation. Acute cholangitis occurs when obstruction of the common bile duct leads to increased biliary pressure, facilitating bacterial translocation into the bloodstream and resulting in systemic infection.
Common pathogens in biliary infections are polymicrobial and include Escherichia coli, Klebsiella species, Enterococcus species, Enterobacter species, and Pseudomonas species. Anaerobes are more common in elderly patients, diabetics, and those with prior biliary surgery. Obstructive causes of cholangitis include choledocholithiasis, malignant strictures, iatrogenic bile duct injury, primary sclerosing cholangitis, congenital biliary abnormalities, and parasitic infections such as Clonorchis, Opisthorchis, and Ascaris.
Clinically, biliary disease often presents with right upper quadrant abdominal pain that may radiate to the right scapular or infrascapular area. Acute cholecystitis typically begins with biliary colic and fever that progressively worsen. Unlike biliary colic, the pain is continuous. Approximately 60–70% of patients report prior self-limited episodes. Acalculous cholecystitis may present with unexplained fever or vague abdominal discomfort, particularly in critically ill patients.
Acute cholangitis classically presents with Charcot’s triad: fever with chills, jaundice, and right upper quadrant pain. However, only 50–70% of patients exhibit all three features. Severe cases may present with Reynolds’ pentad, which includes hypotension and altered mental status in addition to Charcot’s triad, indicating sepsis and possible organ failure.
On physical examination, right upper quadrant tenderness is highly sensitive for biliary tract disease. A positive Murphy’s sign—pain during inspiration while palpating the right upper quadrant—is suggestive of acute cholecystitis.
Laboratory findings in acute cholecystitis often include fever and leukocytosis. A temperature above 38.5°C or white blood cell count greater than 12,500/mm³ suggests infection. Mild elevations in serum bilirubin and aminotransferases are common. Elevated amylase may indicate concomitant gallstone pancreatitis. Abnormal renal function, thrombocytopenia, or coagulopathy suggest more severe disease. Bile cultures are frequently positive in cases of obstruction and jaundice.
Ultrasonography is the primary imaging modality for diagnosing cholecystitis. Findings include gallbladder wall thickening (>2 mm), pericholecystic fluid, intramural gas, ductal dilation, and a sonographic Murphy’s sign. Hepatobiliary scintigraphy may be used if ultrasound is inconclusive; failure of gallbladder filling suggests cystic duct obstruction. CT scanning can identify bile duct dilation, pneumobilia, or complications and may assist in diagnosing cholangitis.
Management includes prompt administration of antibiotics targeting Enterobacteriaceae. For mild-to-moderate community-acquired acute cholecystitis, recommended regimens include cefazolin, cefuroxime, or ceftriaxone. In severe cases, elderly or immunocompromised patients, or in acute cholangitis, broad-spectrum therapy such as piperacillin–tazobactam, carbapenems, cefepime plus metronidazole, or fluoroquinolones plus metronidazole is indicated. Vancomycin may be added in healthcare-associated infections. Anti-enterococcal coverage is generally not required in uncomplicated community-acquired infections.
Supportive care includes bowel rest, intravenous fluids, correction of electrolyte imbalances, and analgesia. Antibiotics are typically initiated within one hour before cholecystectomy and discontinued within 24 hours postoperatively if infection is confined to the gallbladder.
Early laparoscopic cholecystectomy is preferred over delayed surgery due to lower complication rates and shorter recovery. In severe cases or when surgery is contraindicated, biliary decompression may be achieved through percutaneous drainage or endoscopic retrograde cholangiopancreatography (ERCP). Acute cholangitis often requires urgent biliary drainage in addition to antibiotics.
Prognosis for acute cholecystitis is generally favorable with timely treatment, although recurrence is common if the gallbladder is not removed. Acute cholangitis carries a mortality rate of 10–30%, especially in elderly patients or those with severe sepsis.
Complications include chronic cholecystitis, empyema of the gallbladder, perforation, fistula formation, hepatic abscess, sepsis, and recurrent biliary obstruction. Severe acute cholangitis may result in shock, organ failure, and disseminated infection if not promptly treated.
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