Pericholecystic Fluid and Abscess Due to Cholecystitis

A pericholecystic abscess is an abscess that forms in response to an inflammation of the gallbladder called acute cholecystitis. An abscess is a swollen, fluid-filled area within body tissue.

Pericholecystic fluid is one of the signs of cholecystitis. This is fluid that builds up around the gallbladder and is usually visible on an ultrasound.

According to a report by Radiopaedia, pericholecystic abscess only occurs in approximately 3% to 19% of cases of acute cholecystitis (severe inflammation of the gallbladder).

What Is a Pericholecystic Abscess?

Pericholecystic abscess is considered a rare complication of cholecystitis. Cholecystitis is an inflammation of the gallbladder that usually happens when the gallbladder's main duct, called the cystic duct, becomes blocked by a gallstone or a mixture of bile, cholesterol, and salt crystals. Cholecystitis is one of several associated complications of gallbladder disease.

The gallbladder is a small sac-like organ that is located under the liver. The gallbladder stores the bile that is produced in the liver and connects to the liver via a series of ducts. The function of bile is to carry away wastes and help to break down and absorb fats and fat-soluble vitamins like vitamins D and K.

Pericholecystic Abscess Symptoms

Often the signs and symptoms of pericholecystic abscess are difficult to differentiate from uncomplicated acute cholecystitis. Uncomplicated acute cholecystitis is a condition involving sudden, severe inflammation of the gallbladder without complications (such as a pericholecystic abscess).

Signs and symptoms of a pericholecystic abscess may include:

• Nausea
• Vomiting
• Fever
• Abdominal pain (located in the upper right region of the abdomen and frequently the most common symptom)
• Jaundice (yellowish tinge to the skin and white areas of the eye, caused by a build-up of bilirubin)
• A small area of fluid accumulation which can spread to the nearby liver tissue, causing a liver abscess
• An increase in leukocytes (white blood cells)
• Paralytic ileus (a decrease in contractions of the intestinal muscles which work to move food along the digestive tract)
• A mass that may be able to be palpated (felt) upon examination by the examining physician
• Sudden intense or dull cramp-like pain in the abdomen (often seen when gallstones are the underlying cause of cholecystitis/pericholecystic abscess)

Positive Murphy's Sign

When a patient with cholecystitis takes in a deep breath, holds it, then breathes out while the diagnostician palpates (feels) the right subcostal (below the ribs) area. When pain occurs upon inspiration as the gallbladder comes into contact with the examiner's hand, this is considered a positive Murphy's sign.

What Causes a Pericholecystic Abscess?

The primary underlying cause of pericholecystic abscess is a rupture or perforation of the gallbladder that usually occurs secondarily to an acute inflammation of the gallbladder (cholecystitis).

When cholecystitis symptoms are not treated promptly, there is a progression of the disease that can lead to complications, such as pericholecystic abscess and other conditions.

Underlying causes of pericholecystic abscess may include:

• Acute cholecystitis caused by gallstones (cholelithiasis)
• Acute acalculous cholecystitis (AAC): AAC is an inflammation of the gallbladder that is not caused by gallstones.
• Gallbladder perforation: This is a hole or a rupture (break in the wall of the gallbladder), often a result of untreated gallstones.

According to a 2015 study published in the Singapore Medical Journal, 95% of the acute cholecystitis cases resulted from an obstruction of gallstones in the neck of the gallbladder or in the duct that carries bile from the gallbladder.

Development of a Perichoecystic Abscess

The sequence of events that most commonly lead to a pericholecystic abscess include:

1. The occlusion (blockage) of the cystic duct, which occurs most often as a result of gallstones.
2. The overdistension of the gallbladder from the accumulation of excess bile resulting in an increase in pressure inside of the gallbladder
3. Gallbladder perforation resulting in leakage of bile from a small hole or a rupture in the gallbladder wall. This occurs secondarily to the build-up of pressure inside of the gallbladder.
4. Formation of a pericholecystic abscess

According to a 2015 study published by the Singapore Medical Journal, in approximately 20% of the cases of acute cholecystitis the development of a secondary bacterial infection occurs.

If the pericholecystic abscess is not treated properly, the result can be complications such as death of tissue (necrotizing cholecystitis), gangrenous cholecystitis (a severe complication involving death of tissue and ischemia from lack of oxygenation following loss of proper blood flow), or septicemia (an infectious condition caused by having bacteria in the bloodstream).

Types of Gallbladder Perforation

There are several different forms of perforation that can occur secondarily to acute cholecystitis, these include:

• Free perforation (type 1): This type of gallbladder perforation involves generalized biliary peritonitis, which is an inflammation caused by the leakage of bile into the peritoneal cavity. The peritoneal cavity is a sterile environment that lines the abdominal cavity. Free perforation is associated with a very high death rate of 30%.
• Localized perforation with the formation of pericholecystic abscesses (type 11): This is the most common type of gallbladder perforation in which a mass may be palpable (felt) upon examination. A localized perforation involves an abscess that is contained within the gallbladder itself and has not spread to the peritoneal cavity.

Once a pericholecystic abscess is formed, it can lead to other complications, including:

• Chronic cholecystoenteric fistulation (type III): This involves a hole that forms in the gallbladder (perforation), which causes the formation of a fistula or abnormal passageway into the small intestine. This could potentially result in a bowel obstruction if a gallstone is involved and it moves through the fistula.
• Cholecystobiliary fistula formation (type IV): This type of fistula most commonly formed in the cystic duct or the neck of the gallbladder as a result of an impacted gallstone. The gallstone erodes into the common hepatic duct.

Diagnosis

Although a few different types of imaging tests are commonly used to diagnose complications of gallbladder disease, a computed tomography (CT) scan is considered the most useful diagnostic tool for detecting a localized perforation with pericholecystic abscesses.

 A CT scan (also referred to as a CAT scan) is a type of imaging test that involves taking a series of images of the inside of the body from various angles. It can show pictures that are very detailed of various body parts. Sometimes an iodine-based contrast material is injected into the vein before the scan. This is done to make the images easier to read.

Due to the fact that many emergency departments are equipped with CT scanners these days, there is an increase in the number of patients given CT examinations for suspected acute cholecystitis, according to a 2015 study. This has helped to improve the incidence of early diagnosis and prompt intervention for people with acute cholecystitis.

Other types of imaging tools for diagnosing pericholecystic abscesses include:

MRI (magnetic resonance imaging): A type of imaging test that involves strong magnetic fields and radio waves to produce very detailed pictures of various parts of the body, an MRI can often show more detailed images and is known to be more instrumental in diagnosing specific types of diseases than a CT scan.

Ultrasonography (US) or diagnostic ultrasound: This is a type of imaging test that utilizes high frequency sound waves to produce images of structures inside of the body.

Many diagnosticians consider ultrasound the preferred initial test for evaluating gallbladder stones because it is relatively low in cost, quick to perform, and is highly sensitive in detecting gallstones.

But an ultrasound is not as successful in detecting complications—such as pericholecystic abscesses—and other underlying complications. For diagnosing pericholecystic abcesses, a CT scan or an MRI is preferred.

Treatment

To treat a pericholecystic abscess, early diagnosis and intervention is the key to successful outcomes. The initial treatment for gallbladder perforation may be percutaneous cholecystostomy.

This is a minimally invasive, image-guided procedure involving the placement of a catheter into the gallbladder to help with stabilization until surgery can be performed to remove the gallbladder if possible. However, in some individuals, gallbladder surgery is not recommended.

There are many reasons that surgery may not be an option for many people with pericholecystic abscess. For example, the advanced stage of cholecystitis (such as when a pericholecystic abscess is present) tends to occur in older people or in those with comorbidity (the presence of two or more diseases or conditions at one time) who have an increased risk of morbidity and mortality.

Gallbladder perforations are a serious complication of acute cholecystitis and represent an advanced stage of the disease. They tend to occur in older people and/or people with comorbidities and carry higher rates of morbidity and mortality.

In many instances, pericholecystic abscesses are not discovered until surgery has begun. But the use of CT scans of the upper abdomen has contributed to the number of people who have received a diagnosis of gallbladder perforation before a standard cholecystectomy (surgery to remove the gallbladder) is performed.

Common treatment modalities for pericholecystic abscesses may include:

• Percutaneous catheter drainage to remove pus: For those with localized disease such as type II (localized) perforation, this type of treatment is considered a primary modality for those who are unable to undergo surgery.
• IV (intravenous) fluids: For hydration
• Nothing by mouth (NPO): To rest the gallbladder by restricting food intake
• Antibiotic therapy: Usually administered via an IV (intravenous) route
• Medication to reduce inflammation (such as indomethacin), as well as pain medication: Note, indomethacin can also help promote emptying of the gallbladder in those with gallbladder disease.

Prognosis

Gallbladder perforation with pericholecystic abscess is a rare disorder. It is considered a life-threatening, emergency complication of acute cholecystitis.

With a delay in diagnosis, acute cholecystitis may have an equal mortality (death) rate. This is because prompt treatment modalities are not employed, resulting in progression of the disease.

Study on Pericholecystic Abcess Outcomes

A study involving 238 patients who had a removal of the gallbladder due to gangrenous cholecystitis discovered that:

• 30 people had gallbladder perforation
• 9 people had a contained perforation (pericholecystic abscess)
• 21 people had free intraabdominal perforation
• 3% of the patients were suspected of having gallbladder perforation before surgery.

The study reports that there is a high morbidity (illness) and mortality (death) rate linked with perforation of the gallbladder. In addition, the researchers found that those who were male and those who were at an advanced age were more likely to have perforation of the gallbladder as well as complications after surgery (cholecystectomy).

In conclusion, the study found that early diagnosis and treatment are imperative to improving the prognosis (outcome) of pericholecystic abscess and other complications of gallbladder disease.