An Overview of Pericholecystic Abscess

A Complication of Gallbladder Disease

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A pericholecystic abscess is an abscess (a swollen area within body tissue, containing an accumulation of pus) that is formed in response to acute cholecystitis (an inflammation of the gallbladder).

Pericholecystic abscess is considered a rare condition; it is one of several associated complications of gallbladder disease. The condition is linked with severe, sudden onset (acute) symptoms of inflammation that occur when a person has cholecystitis.

To get a clear picture of what’s happening when a person develops a pericholecystic abscess, here are some associated medical terms:

  • Liver: A large glandular organ which has an important function in several metabolic processes (such as breaking down fats to produce energy). Liver cells function to produce bile.
  • Gallbladder: A small sac-like organ that is located under the liver; it stores the bile that is produced in the liver and connects to the liver via the biliary tract.
  • Bile: A thick greenish liquid that is stored in the gallbladder, it’s comprised of electrolytes, bile acids, cholesterol, phospholipids, and conjugated bilirubin. The function of bile is to carry away wastes and help to break down and absorb ingested fats and fat-soluble vitamins (including vitamins D and K).
  • The biliary tract (also called the biliary tree or biliary system): A system of tube-like structures (bile ducts) that carry bile from the liver to the gallbladder, for storage. When a fatty meal is eaten, the gallbladder releases bile to travel through the biliary tract to the small intestine and go to work breaking down fats.

Through the biliary system, bile flows from the liver to:

  • The right and left hepatic ducts: Which transports bile out of the liver, it is split into a right and left tube, which drain into the common hepatic duct.
  • The common hepatic duct: A thin tube that transports bile from the liver; it joins the cystic duct (from the gallbladder) then goes on to form the common bile duct.
  • The common bile duct: The tube in which bile travels to the duodenum (the first section of the small intestine) where some of the bile is released to help breakdown fat and the rest of the bile travels to the gallbladder to be stored for later use.

When a person ingests a meal, the gallbladder is stimulated (by several physiological signals) to contract, squeezing the bile down into the biliary tract. A meal that is fattier results in the gallbladder being squeezed harder and, subsequently, a larger amount of bile being released.

pericholecystic abscess
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Pericholecystic Abscess Symptoms

In a small percentage of cases of acute cholecystitis, a pericholecystic abscess is known to develop. 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).

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.

Causes

The primary underlying cause of pericholecystitic 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 cystic duct.

The cystic duct is part of the biliary tree, which is a system of ducts that function to carry bile from the liver to the small intestine for proper digestion of fats.

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 iflammation 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 improved 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

Early diagnosis and intervention is the key to successful outcomes in the treatment of a pericholecystic abscess. 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.

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