Cholecystitis & Complex Gallbladder Infection
Gallbladder infection is a common diagnosis but it can sometimes be more complicated than just an acute gallbladder infection secondary to gallstones or sludge. Nausea, vomiting, right upper abdominal pain, and sometimes fever are the most common presenting symptoms for gallbladder infection.
Diagnosis of gallbladder infection requires an ultrasound to evaluate the thickness of the gallbladder wall and presence of pericholecystic fluid indicating swelling/edema around the gallbladder wall. Gallstones are often seen within the gallbladder in patients with gallbladder infection. CT scan may be needed to further evaluate the area around the gallbladder and adjacent liver. Severe gallbladder infection can cause liver abscess, fever, sepsis, and even death. The adjacent stomach and duodenum can also be affected by the severely inflamed/infected gallbladder.
Once diagnosed, the treatment for acute gallbladder infection (cholecystitis) is gallbladder removal, also known as laparoscopic cholecystectomy. When the gallbladder infection is so severe, gallbladder removal surgery is sometimes technically very difficult and it is associated with high risk of potential complications. When technical difficulty is encountered by a general surgeon, a referral to a liver surgeon or liver specialist is necessary to avoid unforeseen major complications such as bile duct leak, bile duct transection/injury, or vascular injury. Recognizing the technical difficulty is important to avoid unnecessary harm to the patients.
Mirizzi syndrome (impacted stone in the cystic duct causing external compression and obstruction of the common hepatic duct) and empyema of the gallbladder (complicated cholecystitis with purulent content into the gallbladder) are two conditions that should ideally be treated by highly experienced biliary surgeons.
Concomitant liver diseases such as significant liver cirrhosis, abdominal ascites, portal hypertension, liver abscess, and liver tumors are sometimes found in patients with gallbladder infection requiring cholecystectomy. In this situation, the cholecystectomy is associated with significantly higher intra-and postoperative complications. An extensive experience in liver surgery is needed to avoid further complications. This type of patients are often referred to a liver surgeon or liver specialist for gallbladder removal surgery.
In about 5-10% of patients with cholelithiasis, stones can travel down into the common bile duct causing choledocholithiasis. This can present with yellowness of the eyes and skin (obstructive jaundice), biliary infection (acute cholangitis), and sometimes acute pancreatitis when the pancreatic duct is obstructed. Choledocholithiasis requires an advance endoscopic procedure to retrieve gallstones from the common bile duct (ERCP) prior to the gallbladder removal surgery. When the endoscopic procedure fails to retrieve gallstones from the common bile duct, a percutaneous transhepatic tube placement by an interventional radiologist becomes necessary.
When both techniques fail, then surgical operation is necessary to remove the gallstone from the common bile duct by direct opening of the the bile duct wall. This is called common bile duct exploration. This biliary surgery can be done via traditional open operation or minimally invasive technique. Dr. Papoulas has become a referral surgeon for complex gallbladder and biliary diseases in Cyprus. We work in close collaboration with our interventional radiologists and interventional gastroenterologist to deliver the best care for our patients.
Chronic cholecystitis is a very common diagnosis leading to a visit to a primary care physician or gastroenterologist. It affects women more than men, commonly obese patients above the age of 40. Chronic intermittent right upper quadrant abdominal pain, nausea following fatty meals, episodic epigastric discomfort, and unintentional weight loss are usual symptoms of chronic cholecystitis. Imaging such as abdominal ultrasound and nuclear medicine scan (HIDA scan) to measure the contractility of the gallbladder are sometimes necessary to confirm the diagnosis.
Most patients with chronic cholecystitis were found to have gallstones within the gallbladder. It is important to obtain a complete history and physical examination to rule out other potential causes of pain, such as peptic ulcer disease, gastritis, duodenitis, or even right-sided colon infection. A subset of benign gallbladder disease called biliary dyskinesia is diagnosed when the ejection fraction of the gallbladder falls less than 35% on HIDA scan. This means, the gallbladder has an inadequate/poor emptying which leads to bile stasis, pain, and subclinical gallbladder inflammation.
Once the diagnosis of chronic cholecystitis is confirmed, gallbladder removal surgery is indicated. It is crucial to see an experienced general surgeon or a liver surgeon to minimize potential risk of complications during laparoscopic cholecystectomy. Laparoscopic cholecystectomy is undertaken via four small incisions. Dr. Papoulas and his team perform routinely laparoscopic cholecystectomy and have the expertise to deal with complex gallbladder conditions.
Gallbladder polyps are found in approximately 5% of the general population. Gallbladder polyps are often discovered incidentally during a right upper quadrant ultrasound examination for abdominal pain. It presents as a solid growth within the wall of the gallbladder or protruding into the lumen of the gallbladder. Among all the “gallbladder polyps”, only 5% are true polyps. The majority of gallbladder polyps are benign and asymptomatic, with cholesterol polyp being the most common type. The type of gallbladder polyp with malignant potential is the adenomatous polyp. Rarely, gallbladder polyps can cause symptoms such as abdominal discomfort, nausea, and early satiety. Right upper quadrant ultrasound is the diagnostic tool for identifying gallbladder polyps. Biopsy of the gallbladder polyps is not technically feasible in many situation, therefore, it is not a part of diagnostic workup. It is important to differentiate between gallstones and gallbladder polyps.
Size of the gallbladder polyp determines treatment. Malignant gallbladder in general tend to be larger than benign polyps. Multiple studies have shown the risk of malignancy rises sharply with polyp size larger than 10 mm. The general consensus is to proceed with gallbladder removal surgery (laparoscopic cholecystectomy) for polyps larger than 10 mm. A rapid growth is a factor to consider when contemplating a laparoscopic cholecystectomy. Number of gallbladder polyps is also a point of discussion/debate among gastroenterologists and general surgeons. Annual follow-up for gallbladder polyps smaller than 10 mm is recommended.
Coexistence of gallbladder polyps (independent of size) and gallstone disease is an indication to undergo laparoscopic cholecystectomy due to the increased risk for malignancy.
A consultation with a liver surgeon or liver specialist or gallbladder specialist is necessary in cases of gallbladder polyps, especially when they are larger than 10 mm. Laparoscopic cholecystectomy is undertaken to remove the gallbladder polyps. Pathological examination during the operation (frozen section) is important to determine presence of malignancy. It is our practice to plan for a gallbladder cancer resection at the same time, when malignancy is found within the gallbladder polyp. This operation is performed using minimally invasive laparoscopic technique. This way, the patient can avoid a second unnecessary operation. Dr. Papoulas and his team treat lots of patients with gallbladder polyps found on an ultrasound for abdominal symptoms.
Gallbladder cancer may appear as a focal mass, thickening of the gallbladder wall, or infiltrative mass that fills the inside of the gallbladder and extends into the adjacent liver and bile ducts. Gallbladder cancer is a deadly disease, often insidious, with poor overall prognosis when it is discovered at advanced stages. Some patients present with right upper quadrant abdominal pain, persistent discomfort, bloatedness, jaundice (yellowing of skin and eyes), and unexplainable weight loss.
Chronic inflammatory state of the gallbladder from gallstones, parasitic infection, or other causes are believed to trigger the development of gallbladder cancer. Almost all patients with gallbladder cancer was found to have gallstones. Most patients are between 60 and 80 years of age at the time of diagnosis with slightly male predominance. Gallbladder cancer is frequently misdiagnosed as chronic cholecystitis by primary care physician or even general surgeons. Liver biopsy should not be performed when suspicion for gallbladder cancer is present to avoid bile spillage and peritoneal spread (peritoneal carcinomatosis).
Mucosal plaque and wall irregularity caused by gallbladder cancer can sometimes be differentiated from other causes of gallbladder wall thickening using a high-quality CT scan or MRI/MRCP scan. Direct invasion into the adjacent liver parenchyma is common. Gallbladder cancer can also extend into the hepatic hilum, causing biliary obstruction and jaundice secondary to direct involvement of the common hepatic duct. Regional lymph node enlargement may also be present indicating more advanced cancer stage and worse overall survival.
A high-quality CT scan is necessary to accurately determine resectability, distant disease spread, and peritoneal spread. Gallbladder cancer can cause metastasis to the lungs, brain, distant lymph nodes, bones, and other organs. PET scan is helpful when distant metastasis is suspected. Presence of distant metastasis and extrahepatic multiorgan invasion are contraindications to surgical resection. It is our practice to evaluate the gallbladder (cholecystectomy) specimen in the operating room to exclude occult gallbladder cancer in the specimen.
Approximately 47% of gallbladder cancers are detected incidentally during and after laparoscopic cholecystectomy (routine gallbladder surgery) for benign indications. When this occurs, an immediate consultation with a liver surgeon or liver specialist is necessary to ensure proper treatment, which affects overall prognosis.
The standard gallbladder cancer treatment includes central liver resection to remove part of liver segment 4 and 5, as well as excision of the regional lymph nodes along the bile ducts and porta hepatis. When found incidentally after a routine laparoscopic cholecystectomy, return to the operating room for re-resection of the central part of the liver and regional lymph nodes should be undertaken after 4-6 weeks. This operation should be done by an experienced liver surgeon or liver specialist to ensure proper oncological outcomes. In about 40% of patients, residual cancer cells were found in the adjacent liver segment 4 and 5 or in the regional lymph nodes. Liver transplant surgery does not have any role in the treatment of gallbladder cancer.
Majority of the liver resection for gallbladder cancer is undertaken via traditional open operation. In the last few years, minimally invasive surgical techniques (laparoscopic and robotic liver resection) have been applied to gallbladder cancer resection. Postoperative chemotherapy is often needed based on the final pathology findings. Significant improvement in long-term overall survival was seen in gallbladder cancer patients receiving postoperative chemotherapy.
Dr. Michail Papoulas has significant experience in performing gallbladder cancer operations using minimally invasive techniques with excellent outcomes. Dr. Papoulas has published a systematic review in the role of neoadjuvant treatment for advanced gallbladder cancer and was invited to give a talk at the International Hepato-Pancreato-biliary meeting in 2018 on the same topic.