Acute emphysematous cholecystitis

This is a severe and fulminant form of acute cholecystitis which accounts for less than 1 per cent of cases. Stones are absent in 30 to 50 per cent of patients, who are usually elderly men, and 40 per cent have diabetes mellitus. It is caused by a mixture of bacteria which includes gas-forming organisms, and the pathognomonic diagnostic sign is gas within the wall or the lumen of the gallbladder seen on a plain radiograph. The onset of the disease is abrupt and the condition of the patient deteriorates rapidly. There is a high incidence of gangrene and perforation, and emergency cholecystectomy is needed.

 

Xanthogranulomatous cholecystitis

This is a rare but severe form of chronic cholecystitis in which the gallbladder is thickened and irregular with extensions of yellow xanthogranulomatous inflammation to adjacent organs. Foamy macrophages and giant cells are seen within connective tissue in the wall of the gallbladder. The condition is thought to be due to bile penetrating deeply into the gallbladder wall. The appearances both on investigation and at operation resemble carcinoma of the gallbladder; frozen section histology at operation may be necessary because the two conditions are associated.

 

Acute acalculous cholecystitis

Acute cholecystitis can develop in the absence of gallbladder stones. It is most often seen in the intensive care unit and is associated with severe illness such as multiple trauma, extensive burns, major surgery, and sepsis, often in an elderly person. The aetiology is unknown, but is thought to be related to gallbladder distension and bile stasis. The normal contraction of the gallbladder is inhibited in patients with sepsis and those on total parenteral nutrition, especially if opiate analgesics are administered. This allows the development of biliary sludge, which may be demonstrated in the gallbladder of many patients with major illness, not all of whom develop acalculous cholecystitis.

 

Pathology

Pathological examination of the gallbladder reveals oedema of the serosa and muscular layers, with patchy thrombosis of arterioles and venules. Areas of necrosis develop and may affect the underlying mucosa. One possibility is that activation of factor VII by trauma may lead to thrombosis of blood vessels in the seromuscular layer of the gallbladder.

 

Diagnosis

In a severely ill patient, the development of acute acalculous cholecystitis is usually insidious. The clinical features are similar to those of acute calculous cholecystitis but they are often masked by the underlying condition. Ultrasound is the most useful investigation, and may show biliary sludge in a tender thickened gallbladder, but fails to demonstrate stones. All the indicators of liver function deteriorate, and a HIDA scan will fail to demonstrate the gallbladder.

 

Treatment

Once the diagnosis is made an immediate cholecystectomy is necessary because of the high incidence of gangrene of the gallbladder. The mortality rate varies with the nature of the underlying condition but is generally higher than that in patients with acute calculous cholecystitis.

 

Cholesterolosis

This is caused by the deposition of cholesterol in the mucosa and submucosa of the gallbladder wall and produces the classical & lsquo; strawberry gallbladder& rsquo;. Microscopy shows macrophages loaded with cholesterol. Ultrasound identifies the cholesterol in the wall as bright shiny spots, and there may also be cholesterol stones within the lumen. Cholesterolosis may cause pancreatitis, perhaps as a result of small cholesterol crystals passing down the bile duct and briefly occluding the ampulla, so that symptomatic patients should be advised to undergo cholecystectomy.

 

Adenomyomatosis

Adenomyomatosis or cholecystitis glandularis proliferans is characterized by hypertrophic smooth muscle bundles and epithelial sinus formation. The gallbladder has a thickened wall which may be divided into two separate sections by a stricture of incomplete septum (Fig. 28) 1251. Granulomatous polyps develop in the lumen at the fundus. Inflammation develops later and gallstones are sometimes present. Symptomatic patients require a cholecystectomy. Others in whom the diagnosis is made but not treated require surveillance since adenomyomatosis may predispose to carcinoma.

 

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