Acute cholecystitis pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2]

Overview

Acute calculous cholecystitis is usually caused by the mechanical obstruction of the gallbladder due to gallstones. Acute acalculous cholecystitis is caused predominantly by the gallbladder stasis. Gallstones are the most common cause of physical obstruction of the gallbladder usually at the neck or in the cystic duct. Cholesterol gallstones are the most common type of gallstones. The obstruction causes an increased pressure as the gallbladder mucosa continues to produce mucus. This raised pressure may cause the venous congestion which is followed by the arterial congestion. Eventually, the raised pressure and stasis leads to the gallbladder ischemia and necrosis. Mechanical obstruction of the gallbladder as a result of polyps, malignancy, an infestation of the gallbladder with parasites, foreign bodies, and trauma may also lead to the acute cholecystitis. Acute cholecystitis is more common in siblings and first degree relatives of affected persons. Lith gene is involved in the pathogenesis of cholecystitis. Mutations in the hepatic cholesterol transporter ABCG8 also predispose an individual to the develop gallstones. Acute cholecystitis is associated with diabetes, insulin resistance, cardiovascular diseases, non-alcoholic fatty liver disease (NAFLD) and gastrointestinal malignancies. Microscopic histopathology shows edematous and hemorrhagic gallbladder wall, mucosal necrosis with neutrophil infiltration. Bile infiltration of the gallbladder wall and bile and leucocyte margination of blood vessels are specific findings for acalculous cholecystitis.

Pathophysiology

Pathogenesis

Inflammation of the gallbladder is termed as cholecystitis. Acute calculous cholecystitis is usually caused by the mechanical obstruction due to gallstones. Acute acalculous cholecystitis is caused predominantly by the gallbladder stasis. The pathogenesis of acute cholecystitis involves the following:[1][2][3][4][5][6][7][8][9][10][11]

  • Obstruction of the gallbladder:
    • Gallstones are the most common cause of physical obstruction of the gallbladder usually at the neck or in the cystic duct. The obstruction causes an increased pressure as the gallbladder mucosa continues to produce mucus. This raised pressure may cause the venous congestion which is followed by the arterial congestion. Eventually, the raised pressure and stasis leads to the gallbladder ischemia and necrosis.
      • There are two major types of gallstones:
        • Cholesterol gallstones:
          • Cholesterol gallstones are the most predominant form of the gallstones. They account for approximately 80% of the total gallstones.
          • The formation of gallstones is dependant on the following factors:
            • Cholesterol supersaturation in the bile
            • Crystal nucleation
            • Gallbladder dysmotility
            • Gallbladder absorption
        • Pigmented gallstones:
          • There are two types of pigmented gallstones.
            • Black stones
            • Brown stones
              • Brown stones are usually associated with bacterial infection.
              • Brown stones are usually located elsewhere in the biliary tree as opposed to the gallbladder.
    • Mechanical obstruction of the gallbladder as a result of polyps, malignancy, an infestation of the gallbladder with parasites, foreign bodies, and trauma may also lead to the acute cholecystitis.
  • Gallbladder stasis:

Genetics

  • Acute cholecystitis is more common in siblings and first degree relatives of affected persons.[12][13]
  • Lith gene is involved in the pathogenesis of cholecystitis.[6]
  • Mutations in the hepatic cholesterol transporter ABCG8 also predispose an individual to the develop gallstones.[9]

Associated Conditions

The following conditions are associated with acute cholecystitis:[14]

Gross Pathology

Microscopic Pathology

Histological image of acute cholecystitis; Low magnification. By Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=30991393 Source:[21]
Histological image of acute cholecystitis; Intermediate magnification. By Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=30991393 Source:[21]


References

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  20. Yaylak F, Deger A, Bayhan Z, Kocak C, Zeren S, Kocak FE, Ekici MF, Algın MC (2016). "Histopathological gallbladder morphometric measurements in geriatric patients with symptomatic chronic cholecystitis". Ir J Med Sci. 185 (4): 871–876. PMID 26602767. doi:10.1007/s11845-015-1385-3. 
  21. 21.0 21.1 "Acute cholecystitis - Libre Pathology". 

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