Acute cholecystitis pathophysiology

Acute cholecystitis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The exact pathogenesis of [disease name] is not fully understood.

OR

It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].

OR

[Pathogen name] is usually transmitted via the [transmission route] route to the human host.

OR

Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.

OR

[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].

OR

The progression to [disease name] usually involves the [molecular pathway].

OR

The pathophysiology of [disease/malignancy] depends on the histological subtype.

Pathophysiology

Pathogenesis

The pathogenesis of acute cholecystitis involves the following:

• 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.
  • 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
              • Black stones consist of calcium bilirubinate and mucin glycoproteins.
              • Black stones are predominantly associated with hemolytic conditions or cirrhosis (as a result of increased levels of unconjugated bilirubin).
              • These stones are usually located in the gallbladder.
            • 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:
    • Gallbladder stasis is usually due to the lack of gallbladder stimulation and contractility.
    • This leads to concentration of the bile salts with a build-up of pressure within the organ. An increased intraluminal pressure results in ischemia and necrosis of the gallbladder.
    • The gallbladder stasis also facilitates the proliferation of the bacterias such as Escherichia coli, Klebsiella, Bacteroides, Proteus, Pseudomonas, and Enterococcus faecalis. This can also cause an inflammatory reaction in the gallbladder.

Genetics

• [Disease name] is transmitted in [mode of genetic transmission] pattern.
• Genes involved in the pathogenesis of [disease name] include [gene1], [gene2], and [gene3].
• The development of [disease name] is the result of multiple genetic mutations.

Associated Conditions

The following conditions are associated with acute cholecystitis:

• Diabetes
• Insulin resistance
• Cardiovascular diseases
• Non-alcoholic fatty liver disease (NAFLD)
• Gastrointestinal malignancies
  • Gastric cancer
  • Hepatocellular carcinoma
  • Cholangiocarcinoma
  • Pancreatic cancer
  • Cancer of the ampulla of Vater

Gross Pathology

• On gross pathology, acute cholecystitis has the following features:
  • Enlarged/distended gallbladder
  • Serosal or mucosal exudates
  • Thickened wall with hemorrhage and edema
  • Ulcers, pus, bile, and gallstones

Microscopic Pathology

• On microscopic histopathological analysis, acute cholecystitis has the following features:
  • Edematous and hemorrhagic gallbladder wall
  • Mucosal necrosis with neutrophil infiltration
  • Eosinophilic infiltration of the gallblader mucosa
• Specific microscopic features of acalculous cholecystitis:
  • Bile infiltration and leucocyte margination of blood vessels
  • Lymphatic dilation