Acute cholecystitis and its risks
Acute inflammation of the gallbladder is dangerous due to its complications. The most critical is wall perforation, which inevitably leads to the development of biliary peritonitis. Also common is empyema, a condition in which the cystic duct becomes blocked and the organ cavity fills with pus. In addition, the pathology may be accompanied by biliary colic, purulent cholangitis, cholangiolitis, and obstructive jaundice. With prolonged inflammation, adhesions form around the gallbladder — pericholecystitis.
Chronic process: morphological changes
Chronic cholecystitis is usually the outcome of acute inflammation. Macroscopically, the organ appears altered: the gallbladder wall becomes dense and thickened, and the mucosa acquires a characteristic cord-like appearance.
The microscopic picture includes:
- Atrophy of the mucosa;
- Sclerosis of the lamina propria and muscular layer;
- Lymphomaxrophage infiltration;
- Presence of Rokitansky-Aschoff sinuses.
During exacerbation of the chronic process, leukocytes are detected in the infiltrate.
Briefly: answers to topical questions
What morphological forms of acute cholecystitis are distinguished in pathological anatomy?
Pathological anatomy distinguishes the following morphological forms of acute cholecystitis:
- Catarrhal.
- Fibrinous — a fibrinous exudate forms on the mucosal surface, with possible foci of necrosis.
- Purulent (phlegmonous) — characterized by neutrophilic infiltration of the wall, possible abscess formation, and the presence of purulent exudate in the lumen.
- Gangrenous — may be accompanied by mucosal ulceration, sloughing membranes, and gas accumulation in the gallbladder wall.
- Eosinophilic — a rare form in which more than 90% of the leukocytes in the infiltrate are eosinophils.
What are Rokitansky-Aschoff sinuses?
Rokitansky-Aschoff sinuses (Rokitansky–Aschoff sinuses) are cystic epithelial invaginations into the thickness of the gallbladder wall. They form as a result of epithelial and smooth muscle hyperplasia, leading to thickening of the organ wall. Small calculi may form within these spaces. These structures are a characteristic feature of gallbladder adenomyomatosis and are also detected in microscopic examination of chronic cholecystitis along with mucosal atrophy, lymphomacrophage infiltration, and sclerosis.
What are the main causes (etiology) for the development of acute cholecystitis?
The main causes of acute cholecystitis are cholelithiasis and secondary infection. The following etiological factors are distinguished:
- Cholelithiasis — the main cause, provoking bile outflow blockade by a calculus and smooth muscle spasm.
- Infection — bacterial agents penetrating via ascending or descending pathways.
- Enzymatic damage — reflux of pancreatic juice into the gallbladder with mucosal injury.
- Parasitic invasion — helminthes infestation (e.g., ascarids).
- Viral origin — viral involvement, proven recently.
- Other factors — toxic and allergic effects.
What is the mechanism of development of obstructive jaundice in complicated cholecystitis?
The mechanism of mechanical (subhepatic) jaundice in complicated cholecystitis is based on impaired bile outflow into the duodenum. The outflow obstruction may be caused by biliary tract blockage due to calculi in cholelithiasis or external compression resulting from acute cholecystitis with a pericholecystic process. The pathogenesis includes the following stages:
- Impaired transport — occurs due to biliary tract obstruction.
- Biliary system overload — accumulation of bile in the proximal sections.
- Biliary hypertension — increased pressure in the bile capillaries.
- Capillary damage — stretching and rupture of their walls.
Prolonged ductal hypertension causes epithelial proliferation, which further exacerbates cholestasis.
Chronic cholecystitis is defined by the "three S's": Sclerosis, Sinuses (Rokitansky–Aschoff), and Synechiae (adhesions).
Class and exam questions
What is the main cause of chronic cholecystitis?
The chronic form of the disease develops as a direct consequence of a previous episode of acute cholecystitis.
Why is gallbladder empyema dangerous?
Empyema occurs due to cystic duct obstruction, leading to pus accumulation in the organ cavity and a high risk of perforation.
What cells appear in the infiltrate during an exacerbation of chronic cholecystitis?
During an exacerbation, leukocytes are added to the inflammatory infiltrate.
What else to study on this topic
- Mechanisms of Rokitansky–Aschoff sinus formation
- Differential diagnosis of biliary and purulent peritonitis
- Pathogenesis of purulent cholangitis in cholecystitis
- The relationship between muscularis sclerosis and impaired gallbladder function
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