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

The signs and symptoms of a pericholecystic abscess are often hard to distinguish from uncomplicated acute cholecystitis. Uncomplicated acute cholecystitis is sudden, severe inflammation of the gallbladder without additional complications like an abscess.

Symptoms of a pericholecystic abscess may include:

• Nausea
• Vomiting
• Fever
• Pain in the upper right part of the abdomen, which is a common symptom
• Jaundice, a yellowish tint to the skin and eyes caused by a buildup of bilirubin
• An area of fluid buildup that can spread to the liver, possibly causing a liver abscess
• Higher white blood cell count (leukocytes)
• Paralytic ileus, which is reduced movement in the intestines that helps move food along the digestive tract
• A mass that may be felt during a physical exam
• Sudden intense or cramp-like abdominal pain, especially when gallstones cause the condition

Positive Murphy’s Sign

A positive Murphy’s sign is noted when someone with cholecystitis takes a deep breath and holds it while a healthcare provider presses below the ribs on the right side. Pain during this process, as the gallbladder makes contact with the examiner’s hand, indicates a positive result.

What Causes a Pericholecystic Abscess?

A pericholecystic abscess usually results from a rupture or hole in the gallbladder following acute inflammation known as cholecystitis.

If cholecystitis is not treated quickly, it can progress and lead to complications like a pericholecystic abscess.

Potential causes of a pericholecystic abscess include:

• Acute cholecystitis due to gallstones (cholelithiasis)
• Acute acalculous cholecystitis (AAC), which is gallbladder inflammation not caused by gallstones
• Gallbladder perforation, a hole or rupture in the gallbladder wall, often due to untreated gallstones

A 2015 study in the Singapore Medical Journal found that 95% of acute cholecystitis cases were due to gallstones blocking bile flow in the neck of the gallbladder or nearby ducts.

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.