Gallstones can lead to a painful inflammation of the gallbladder.
Inflamed gallbladder symptoms are usually caused by gallstones in the gallbladder. These stones, also known as choleliths, can cause the bile to thicken and lead to infection by bacteria like E. coli that normally inhabit the intestines. It is this secondary infection that actually causes the inflammation, which typically begins in the wall of the gallbladder. Inflammation may then spread to other areas such as the surface of the gallbladder, which can irritate adjacent structures like the diaphragm and intestines. In extreme cases, the infection may also cause tissue to die (necrosis) and the gallbladder to rupture.
Gallstones usually block the cystic duct of the gallbladder directly which can obstruct the bile stored in the gallbladder and trigger an acute attack. Gallstones which do not obstruct the bile duct may cause the gallbladder to become calcified and chronically inflamed. Inflammation may also occur without gallstones on rare occasions, most commonly in debilitated patients or trauma victims.
To understand gallbladder inflammation, it's helpful to understand the organ's structure and how it functions. The process begins with the liver, which produces bile. The bile is released through both the hepatic and cystic ducts to the gallbladder, where it becomes more concentrated. During digestion, the gallbladder releases the bile through the common bile duct, which joins with the pancreatic duct and flows into the top of the small intestine. If the gallbladder has been surgically removed, bile flows directly from the liver into the duodenum but is no longer concentrated, which can cause diarrhea and gas when eating meals with high fat content.
The bile then breaks down fats, which are insoluble in water, and neutralizes the acids secreted by the stomach during digestion. Although these are its main functions, bile also stimulates the release of cholecystokinin (CCK), an important enzyme involved in the digestion of fats and proteins.
As stated by the Mayo Clinic, one of the most common initial symptoms of gallbladder inflammation is upper abdominal pain. The pain may be intermittent at first, but it nearly always becomes constant and is often accompanied by nausea, vomiting and fever. Patients with an inflamed gallbladder not caused by gallstones generally have similar symptoms, but they may present only with fever and sepsis, a dangerous inflammation of the entire body caused by the infection.
Other symptoms may be revealed during a physical examination, including a sensation of fullness, a palpable gallbladder and jaundice. However, many patients with chronic inflamed gallbladder have diffuse pain without any other physical findings, especially elderly patients and patients with diabetes.
Hepatobiliary scintigraphy (HBS) is the preferred test for diagnosing acute gallbladder inflammation and is typically between 85 and 95 percent accurate, making it superior to ultrasonography. HBS is an imaging method that uses a radioactive tracer to measure the time required for the gall bladder to fill. A healthy gallbladder with a clear cystic duct will begin to fill within 10 minutes and be fully visible within 30 minutes. An inflamed gallbladder with a blocked cystic duct may not appear on the scan for over an hour.
Although less accurate than HBS, ultrasonography is useful in detecting gallstones larger than 2 mm in diameter and has the distinct advantage of requiring minimal training. In addition to gallstones, ultrasonography can find other signs of inflammation, including a gallbladder wall thicker than 4 mm. Generally, patients should fast for about 8 hours before undergoing an ultrasonogram so the gallbladder is easier to detect.
A chronically inflamed gallbladder that does not cause any symptoms may not warrant any treatment. However, early treatment for an acute inflamed gallbladder is essential due to its potential for rapidly progressing to gangrene which can subsequently perforate the gallbladder. The initial treatment for an acute inflamed gallbladder is nutrition from a feeding tube along with intravenous antibiotics and fluids. Antibiotic therapy with a single broad-spectrum antibiotic against intestinal bacteria is usually adequate for mild cases of an acute inflamed gallbladder.
According to Emergency Medicine, a number of antibiotics are commonly used to treat an inflamed gallbladder. These antibiotics may be classified according to their spectrum of activity. An antibiotic that has a broad spectrum of activity is effective against a wide range of microorganisms. However, it also tends to have more adverse side effects due to the greater number of beneficial microorganisms it eradicates. For this reason, physicians usually prefer to use the antibiotic with the narrowest spectrum of activity that will still be effective against the desired microorganism. Of the drugs used to treat an inflamed gallbladder, ampicillin has a moderate spectrum of activity, piperacillin has a broad spectrum of activity and meropenem has a very broad spectrum of activity. Imipenem is an extremely broad spectrum antibiotic and should only be used in life threatening cases.
Intravenous pain killers such as meperidine (Demerol) may be administered for severe pain. Ketorolac (Acular) is a powerful non-steroidal, anti-inflammatory drug, which may be used as an alternative if the patient is not likely to need surgery. Both of these drugs have adverse side effects such as drowsiness, nausea and vomiting. Morphine tends to have fewer side effects than these drugs, but not all physicians recommend their use for patients with an inflamed gallbladder because it causes a significant delay in emptying the gallbladder.
Supportive medical care should include continued maintenance of fluid levels and antibiotic treatment, but only in cases involving infection of the biliary tract. Vomiting is treated with antiemetics such as Promethazine (Prorex) or Prochlorperazine (Compazine) and draining the stomach through nasogastric suction. Patients receiving long-term nutrition through a feeding tube may also require intravenous CCK to prevent the formation of gallbladder sludge.
The standard surgical treatment for an inflamed gallbladder is a laparoscopic cholecystectomy within three days of admission. During a laparoscopic cholecystectomy, surgeons make four small incisions and use a small camera to guide them through the removal of the gallbladder. Prompt surgery results in a shorter hospital stay in most cases, and an inflamed gallbladder rarely requires open surgery in non-life threatening cases. The need for open surgery dramatically increases in cases involving perforation of the gallbladder or gangrene.
A laparoscopic cholecystectomy should not be performed if the patient is at high risk for complications of general anesthesia or morbidly obese. This procedure is also contraindicated for patients with very large gallstones or end-stage liver disease. Doctors may drain the gallbladder with a sonographically guided drainage tube and use antibiotics to treat patients with a high surgical risk. Most patients with an acute inflamed gallbladder not caused by a gallstone can also be treated with a drainage tube.