Gangrenous cholecystitis

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 Gangrenous Cholecystitis

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Gangrenous cholecystitis is a severe, potentially life-threatening complication of acute cholecystitis, characterized by the progressive necrosis of the gallbladder wall. It is typically caused by ischemia and infection, leading to tissue death and possibly perforation of the gallbladder. Below is a comprehensive explanation of the different aspects of gangrenous cholecystitis.


1. Cause and Etiology:

  • Primary cause: The most common cause of gangrenous cholecystitis is acute cholecystitis, which is caused by gallstones (cholelithiasis). These stones obstruct the cystic duct, leading to gallbladder distention, inflammation, and stasis of bile.
  • Infection: Bacterial infection plays a crucial role. The most common organisms include Escherichia coli, Klebsiella, Enterococcus, and Pseudomonas. The inflammation and ischemia caused by the obstructed bile flow predispose the gallbladder to infection.
  • Ischemia: Prolonged obstruction of the cystic duct reduces blood flow to the gallbladder, leading to ischemia, necrosis, and eventually gangrene. This ischemia can be exacerbated by factors like diabetes, advanced age, and immunocompromised states.
  • Risk factors:
    • Gallstones (the leading cause of cholecystitis)
    • Diabetes mellitus
    • Male gender
    • Age (elderly are more prone)
    • Immunocompromised states (e.g., cancer, chronic steroid use)
    • Severe sepsis
    • Trauma or surgery near the gallbladder


2. Pathophysiology:

  • Obstruction: The cystic duct is obstructed by gallstones or sludge, leading to increased intraluminal pressure in the gallbladder. This pressure interferes with blood supply and lymphatic drainage, causing ischemia.
  • Ischemic injury: Lack of blood flow leads to tissue necrosis and reduced ability to fight bacterial infection, which worsens the inflammation and leads to further tissue damage.
  • Infection: Infection sets in, and bacteria thrive in the ischemic and stagnant environment. The infection produces toxins that further exacerbate the tissue damage.
  • Gangrene and perforation: If the ischemia and infection are not treated, the gallbladder wall may become necrotic and eventually perforate, leading to peritonitis or biliary leakage.


3. Epidemiology:

  • Prevalence: Gangrenous cholecystitis is a relatively uncommon complication of acute cholecystitis. It is seen in 5-15% of patients with acute cholecystitis.
  • Age: Most commonly affects older adults, typically those over 50 years of age.
  • Gender: Males are at higher risk than females, which is the opposite of typical acute cholecystitis, where females are more frequently affected.
  • Comorbidities: Diabetes, immunosuppression, and cardiovascular disease increase the risk of developing gangrenous cholecystitis.


4. Clinical Presentation:

The symptoms of gangrenous cholecystitis are similar to acute cholecystitis but are often more severe and may include:

  • Severe right upper quadrant (RUQ) pain: This is the hallmark symptom, usually sharp and persistent.
  • Fever: Often high-grade, indicating infection.
  • Jaundice: May be present, especially if there is a concomitant bile duct obstruction or choledocholithiasis.
  • Nausea and vomiting: Common due to the severity of the condition.
  • Tachycardia and hypotension: These may be signs of systemic sepsis.
  • Abdominal tenderness: Severe tenderness in the RUQ, often with guarding or rebound tenderness.
  • Murphy's sign: A positive Murphy's sign (pain on palpation of the right upper abdomen during inspiration) may be present, but it is often less reliable in gangrenous cholecystitis due to the extent of tissue necrosis.


5. Imaging Features:

  • Ultrasound: The first-line imaging technique for diagnosing cholecystitis. In gangrenous cholecystitis, the ultrasound may show:

    • Gallbladder wall thickening.
    • Distention of the gallbladder.
    • Presence of sludge or stones.
    • Hypervascularity on Doppler (suggesting inflammation).
    • Pericholecystic fluid collections (suggesting abscess or perforation).
  • CT scan: A more sensitive method for detecting gangrenous cholecystitis. CT can reveal:

    • Gallbladder wall necrosis (lack of contrast enhancement).
    • Air within the gallbladder wall (a sign of gangrene).
    • Perforation, abscess formation, or signs of peritonitis.
  • MRI: Less commonly used, but may be useful in unclear cases or when other imaging modalities are inconclusive.


6. Treatment:

  • Surgical intervention:
    • Cholecystectomy: The definitive treatment for gangrenous cholecystitis is surgical removal of the gallbladder (cholecystectomy). This is typically done as an emergency procedure.
    • Laparoscopic vs. open: Laparoscopic cholecystectomy is preferred when feasible, but in severe cases (e.g., perforation, extensive necrosis), open surgery may be required.
  • Antibiotic therapy: Broad-spectrum intravenous antibiotics should be started immediately, particularly to cover Gram-negative bacteria and anaerobes. Common choices include:
    • Piperacillin-tazobactam or a combination of ceftriaxone with metronidazole.
  • Supportive care:
    • Intravenous fluids and electrolytes to manage dehydration and shock.
    • Pain control with analgesics.
    • Monitoring for signs of sepsis and managing appropriately.
  • Perforation: If perforation occurs, it is treated as a surgical emergency with drainage and possible repair of the gallbladder or peritoneum.


7. Prognosis:

  • Early intervention: The prognosis is generally favorable with timely diagnosis and treatment. Patients who undergo early cholecystectomy and appropriate antibiotic therapy can recover well.
  • Delayed diagnosis: If treatment is delayed, the risk of complications such as peritonitis, sepsis, and multi-organ failure increases significantly.
  • Mortality: The mortality rate for gangrenous cholecystitis can range from 10-30%, depending on factors such as the patient’s age, comorbidities (especially diabetes or cardiovascular disease), and the presence of complications (e.g., perforation or abscess).
  • Complications: These may include gallbladder perforation, sepsis, liver abscess, and bile duct injury during surgery.


Gangrenous cholecystitis is a severe complication of acute cholecystitis caused by gallstone obstruction leading to ischemia, infection, and gallbladder necrosis. It requires prompt surgical intervention, usually in the form of cholecystectomy, along with broad-spectrum antibiotics and supportive care. Early treatment is key to reducing the high mortality associated with this condition.

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