Etiology and pathogenetic mechanisms
The onset of chronic gallbladder inflammation is closely associated with cholelithiasis (gallstone disease). It has been statistically proven that the vast majority of patients (from 90 to 95%) suffer specifically from the calculous variant of the disease, in which the presence of calculi acts as the primary damaging factor.
The remaining 5% account for the acalculous form. Severe stress factors acting on the patient's body serve as triggers for this type of inflammation. Provoking factors include extensive surgical interventions (e.g., cardiac surgery), major mechanical trauma, and ischemic damage to the vascular network of the gallbladder wall itself.
The infectious factor deserves special attention. Pathogenic bacteria generally do not act as the primary trigger initiating chronic inflammation. Nevertheless, the involvement of microbial flora is critically important—it is precisely what causes the development of severe purulent-inflammatory complications, such as gallbladder empyema and ascending cholangitis.
Clinical manifestations and pathological anatomy
The clinical presentation of the chronic inflammatory process is often mild or masked. Dyspeptic syndrome usually comes to the forefront of the patient's complaints, while pain in the right hypochondrium is moderately expressed. However, when an exacerbation develops, the symptoms and laboratory parameters become completely identical to those of acute cholecystitis.
From the perspective of pathological anatomy, repeatedly recurring episodes of inflammation lead to pronounced structural remodeling of the gallbladder. Morphologically, the following changes are observed:
- Thickening and progressive sclerosis of the organ wall.
- Formation of connective tissue adhesions with surrounding tissues.
- Reduction in the size of the organ and its marked deformation.
For intravital verification of these pathological changes in clinical practice, ultrasound examination (ultrasound) and cholecystography are successfully used.
Management tactics during exacerbation
Treatment of a patient in the stage of pronounced exacerbation requires mandatory hospitalization. The therapeutic strategy is based on the same standards as the management of patients with an acute inflammatory process.
Basic principles of conservative therapy include:
- Prescription of strict bed rest.
- Compliance with therapeutic fasting followed by a transition to a specialized diet.
- Use of antispasmodic drugs for pain relief.
- Prescription of antibacterial therapy strictly according to indications.
The further patient management strategy directly depends on the severity of the disease: the frequency of relapses and the body's response to ongoing conservative therapy. The issue of further treatment, including the need for surgery, is generally decided collegially in conjunction with a surgeon.
Prevention and management in the remission stage
When the acute phase has passed, the main task of the clinician is the implementation of an anti-relapse strategy. The primary goal of this stage is the reliable prevention of new flare-ups of the chronic process. To achieve a sustained result, patients are prescribed scheduled courses of treatment 1–2 times a year.
The basis of drug support outside of exacerbation is enzyme replacement therapy. Medications containing pancreatic enzymes are prescribed in a course lasting 3–4 weeks. This tactic significantly improves digestion processes and effectively reduces the functional load on all gastrointestinal organs.
An additional, yet extremely important stage of rehabilitation is sanatorium-resort treatment in specialized gastroenterological (gastrointestinal) institutions.
Briefly: answers to topical questions
Which groups of antibacterial drugs are the drugs of choice in the exacerbation of chronic cholecystitis?
During an exacerbation of chronic cholecystitis, treatment is carried out in a hospital setting and complies with the management standards for acute cholecystitis. When prescribing systemic antibiotics, priority is given to drugs with good penetration into the biliary tract. Recommended groups:
- Penicillins in combination with beta-lactamase inhibitors: piperacillin+tazobactam.
- III or IV generation cephalosporins: cefepime, ceftazidime; possibly in combination with metronidazole.
- Carbapenems: imipenem+cilastatin, meropenem, doripenem.
- Monobactams: aztreonam; possibly in combination with metronidazole.
- Fluoroquinolones: ciprofloxacin, levofloxacin, moxifloxacin; possibly in combination with metronidazole.
What specific diet (Pevzner diet table number) is prescribed during exacerbation and in the remission stage of cholecystitis?
During the exacerbation phase of cholecystitis, therapeutic diet tables No. 5 and No. 5a according to Pevzner are prescribed. In the acute phase, daily caloric intake is reduced relative to the age norm; meals are fractionated, 5–6 times a day, in small portions. The diet is adapted taking into account individual tolerance and gastrointestinal tract status.
In the remission phase, the patient continues to follow diet No. 5.
What are the indications for surgical treatment (cholecystectomy) in chronic calculous cholecystitis?
In chronic calculous cholecystitis, indications for surgical intervention and the choice of the surgical hospital level are determined by the surgeon. The decision is made individually based on examination data and the presence of comorbidities.
Scheduled cholecystectomy is recommended for patients with chronic cholecystitis in the form of hyalinizing cholecystitis or with signs of a "non-functioning gallbladder" in the presence of low operative and anesthetic risk. The goal of the surgery is to prevent the development of gallbladder adenocarcinoma; pronounced gallbladder fibrosis increases the risk of its development.
To memorize the morphology of chronic cholecystitis, imagine an old scar: the gallbladder wall thickens, the tissue contracts (sclerosis), adheres to neighbors (adhesions), and loses its original appearance (deformation and shrinkage).
Class and exam questions
Is chronic cholecystitis always accompanied by stone formation?
No, not always. In 5% of cases, the acalculous variant is diagnosed. It can be triggered by gallbladder wall ischemia, past cardiac surgeries, or severe trauma.
What is the role of bacterial flora in this disease?
Bacteria are rarely the root cause of the disease. However, their involvement becomes the main factor in the development of severe complications—ascending cholangitis and empyema.
What examinations can confirm morphological changes in the gallbladder wall?
The main methods for verifying wall thickening, organ deformation, and the presence of adhesions are ultrasound examination (ultrasound) and cholecystography.
What else to study on this topic
- Features of dyspeptic syndrome in a masked clinical presentation.
- Indications for prescribing antibacterial therapy during exacerbation.
- Mechanisms of ischemic damage to the gallbladder wall during severe stress situations.
- Criteria for the severity of the disease course and indications for a surgical consultation.
- Enzyme replacement therapy: mechanism of reducing the functional load on the gastrointestinal tract.
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