Epidemiology
The distribution and incidence of acute cholecystitis follow that of cholelithiasis because of the close relationship between the two.
Cholelithiasis occurs in approximately 10% to 15% of adults, meaning more than 20 million Americans are estimated to have gallstones, and approximately 750,000 cholecystectomies are performed annually.[8] Most patients with gallstones do not develop symptoms. About 1% to 2% of people with asymptomatic gallstones become symptomatic each year.[9][10][11][12] Acute cholecystitis occurs in about 10% of patients with symptomatic gallstones.[1][13] It is 3 times more common in women than in men up to the age of 50 years, and is about 1.5 times more common in women than in men thereafter.[7]
The incidence of acute acalculous cholecystitis is higher in the intensive care population, particularly patients in burn and trauma units.
Risk factors
Gallstones cause 90% of cases by becoming impacted within the cystic duct, leading to gallbladder inflammation.[7] Gallstones become more common with age in both sexes. American Indians have the highest prevalence of gallstones compared with other ethnic groups in the US.[20] Studies have indicated an increased frequency of gallstone disease in families, twins, and relatives of gallstone patients.[20]
Factors leading to biliary tract disease in critically ill patients include gallbladder dysmotility, gallbladder ischemia, and total parenteral nutrition.[20] Vascular compromise, especially in critically ill patients who experience episodes of hypotension, is thought to be a contributing factor.[21] Recent severe illness, including trauma and burns, puts the patient at risk of acalculous cholecystitis.
Fasting causes gallbladder hypomotility. Prolonged TPN causes gallbladder stasis, biliary sludge, and gallstones due to decreased gallbladder emptying. Around 60% of patients receiving TPN exhibit sludge after only 3 weeks.[20] It is thought that bile stasis leads to accumulation of toxic agents in the gallbladder lumen, causing gallbladder mucosa damage.[21]
There is an increased risk of gallbladder disease in people with diabetes.[24]
Risk factor for developing gallstones.
Risk factor for developing gallstones.
Related to bile stasis, ischemia, bacterial infection, sepsis, and activation of factor XII.[22]
Patients with extensive burns commonly have multiple risk factors for developing acalculous cholecystitis, such as sepsis, dehydration, total parenteral nutrition use, and positive pressure ventilation.[23]
Secreted into bile; can precipitate with calcium, forming biliary sludge and stones.[20]
Can decrease bile acid secretion, which may predispose to sludge or stone formation.[13]
Ischemia occurs as a primary event (e.g., small vessel vasculitis) or as a complication of hepatic chemoembolization, such as inadvertent embolization of the cystic artery causing acalculous acute cholecystitis.[25]
Cytomegalovirus, Cryptosporidium, and Salmonella typhi can infect the biliary system and produce cholecystitis. Can occur in AIDS patients as part of the spectrum of AIDS-related cholangiopathy due to infections with microsporidia species.
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