ACUTE/CHRONIC CHOLECYSTITIS.

  • Acute: Acute inflammation of the gall bladder that may caused by distention, edema, inflammation, or infection.
  • Chronic: Recurring non-acute gall bladder inflammation and symptoms caused primarily by the presence of gallstones.

ETIOLOGY/ PATHOGENESIS

  • Cholelithiasis accounts for nearly 90% of acute cholecystitis cases.
  • Acalculous Cholecystitis accounts for the remainder of the causes: Tumor, Post surgical complication, Biliary sludge, Critically ill patient without oral intake for prolonged period.
  • Microorganisms: Salmonella,Vibrio Cholera, Leptospira, Listeria

PERTINENT HISTORICAL FINDINGS/ CLINICAL SYMPTOMS

  • Risks of gall stone disease: More common in females, Ages 30 – 39 more common, Pregnancy major risk factor for younger women (1.3% nulliparous vs. 13% multiparous), Obesity, Estrogen Use
  • Acute: Hallmark symptom includes sudden onset of upper abdominal pain that lasts for several hours. This pain gradually intensifies and localizes to hyopgastrium or right upper quadrant. Pain may radiate to right scapular area or to shoulder. Nausea Vomiting is common, Anorexia is common, Fever is common
  • Chronic: Chronic recurrent pain in the right upper quadrant or epigastrium. Episodic recurrent pain in right upper quadrant, Lack of fever, Nausea and Vomiting, Referred pain to right scapula, Indigestion, Fatty food intolerance, Bloating and belching.

PERTINENT PHYSICAL EXAM FINDINGS

  • Pain to palpation of right upper quadrant
  • Cessation of inspiration with palpation of right upper quadrant (Murphy’s sign)
  • Febrile
  • less commonly, jaundice and a palpable gall bladder
  • Chronic: Absence of palpable mass in contrast to acute cholecystitis

DIFFERENTIAL DIAGNOSIS

  • Perforated peptic ulcer
  • Pancreatitis
  • Hepatic abscess or diverticulum
  • Hepatitis
  • Pneumonia
  • Cardiac ischemia

DIAGNOSTIC EVALUATIONS

  • Radionuclide Scan (most accurate) showing filling defect of isotope into the GB
  • Ultrasound showing gall stones, pericholecystic fluid, gall bladder wall thickening, and tenderness to right upper quadrant on ultrasound scanning (ultrasonic murphy’s sign)
  • Plain Abdominal Radiograph will show gall stones in nearly 15%
  • Leukocytosis common
  • Liver Studies (not commonly elevated in uncomplicated cholecystitis)
  • Chronic: Evidence of gallstones on plain abdominal films

MEDICAL MANAGEMENT

  • Observation of patients who are not good surgical candidates
  • IV Hydration helpful
  • IV Antibiotics for 7 – 10 days: Ampicillin 2g every 6h. Choice of Cephalosporin and Ampicillin – Sublactam can also be used
  • Immunosuppressed patients: Addition of Metrocidazole 500mg IV  every 8 hours, Zosyn 3.375mg IV every 6 hours, Levaquin 500mg IV once daily.
  • Uncomplicated, may be D/C’d with antibiotics, Analgesics, and close follow up.
  • Acute Cholecystitis: Surgical cholecystectomy is recommended within 24 – 48 hours after presentation of acute cholecystitis due high risk of recurrence
  • Laparoscopic Cholecystectomy is procedure of choice. Most serious complication is bile duct injury (0.25%), ERCP
  • Diabetic patients may have fewer symptoms due to neuropathy and more frequently have ganegrene
  • Gall Stone Dissolution Therapy: Dissolution of stones less than 5mm. For patients with absolute or relative contraindication for surgery, Continuous therapy may be necessary. Recurrence rate is about 10% in 5 years and unusual after 5 years.

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Dr. Zachary Lahlou

 

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