Gall bladder stone disease is a common problem in India. Gall stones are hardened deposits of the digestive fluid in the gall bladder. The gallbladder is a pear-shaped organ on the right side of the abdomen, just beneath the liver. It is a pouch that stores bile, a green-yellow liquid that helps with digestion. Inflammation of the gall bladder is called cholecystitis. Gall stones are responsible for 90% of cholecystitis which is called calculous cholecystitis.
Gall bladder gangrene is defined as necrosis of the gall bladder wall as a result of ischemia (inadequate blood supply to an organ) followed by progressive vascular insufficiency. Untreated cholecystitis can cause tissue in the gallbladder to die. Factors such as male sex, advanced age, delayed surgery, cardiovascular diseases, and diabetes mellitus increase the likelihood of developing gangrenous cholecystitis. Compared with uncomplicated acute cholecystitis, gangrene carries a significantly higher mortality rate, which has been reported to be between 15% and 50%.
In India, a few cases reports described that patients developed gallbladder gangrene after recovering from coronavirus disease (covid 19). During the peak of the second wave, there were incidences of gangrene of the gall bladder discovered in patients who had recovered from covid. The covid – 19 infection primarily affects the lungs as it has the highest number of ace 2 receptors that the virus uses to bind the human cells. After lungs, bile duct, and gallbladder have the highest number of ace 2 receptors. A high concentration of ace 2 receptors is conducive to the entry of the virus. When the virus enters cells, it causes a dysregulated immune response. These dysregulated abnormal immune responses due to covid antigen produce severe inflammation and increasing intraluminal pressure. If the pressure is not relieved, the gall bladder wall will become progressively ischemic eventually resulting in gangrenous changes. This will lead to sepsis and shock. The other reason may be the immunocompromised state of the covid patient against the virus results in severe inflammation of the gall bladder.
The median duration between covid 19 symptoms and diagnosis of acalculous cholecystitis is 2 months. These patients complain of high fever with chills, pain in the right upper quadrant of the abdomen, nausea, vomiting, loss of appetite, and low blood pressure which could be a sign of septic shock (a life-threatening condition). Patients may start abdominal pain from time to time when eating foods that are high in fat, such as fried foods. The pain does not usually last more than a few hours, some patients may have jaundice (yellowing of skin and eyes). All the patients who had recovered from covid-19 do not have the common and conventional predisposing factors mentioned above.
This condition is diagnosed through ultrasound and CT scan of the abdomen. Acalculous cholecystitis with the gangrenous gallbladder is a serious condition associated with high morbidity and much high mortality than calculous cholecystitis.
In this pandemic, a high index of suspicion of this entity in a patient with fever and right upper quadrant pain especially with a history of recent recovery from covid-19 infection besides timely diagnosis and early intervention with broad-spectrum antibiotics may prevent the development of complication and perforation of the gall bladder.
Acute gangrenous cholecystitis due to covid-19 must be addressed urgently because rapid progression and deterioration may result if untreated. The best definitive therapy is cholecystectomy, either laparoscopic or open. People with a history of covid-19 have pain in the right upper abdomen suspect gall bladder inflammation, they should start the treatment soon.
Acalculous cholecystitis is an inflammatory disease without evidence of gallstones.it accounts for the remaining 10 % of cholecystitis.it is most observed in patients on mechanical ventilation, with severe sepsis, after severe trauma and burn injuries. Long periods of fasting, total parenteral nutrition (TPN), and drastic weight loss can increase the incidence of acalculous cholecystitis. In addition, acalculous cholecystitis is associated with a higher incidence of gangrene and perforation than calculous cholecystitis.
Consultant- General & Laparoscopic Surgeon