Acute Cholecystitis

Question 1

Definition: acute cholecystitis

Answer 1

An acute nonspecific inflammation of the gallbladder

Question 2

Epidemiology:

Acute Cholecystitis

Answer 2

A) Male-female gallstone incidence ratio is 1:6.

B) The most common age of onset from 30 to 55 years, in patients older than 60 years prevalence is 25-30%

Question 3

Examination of the gallbladder:

Answer 3

A) Ultrasonography - the main method of diagnosis of gallbladder disease, which can help to assess the state of gallbladder, the presence of stones in it, inflammatory changes and extracystic complications. In the absence of sonography radiography can be used for examination of the gallbladder.

B) Computed tomography - used for difficult diagnostic cases, when the ultrasound study is uninformative.

C) Endoscopic retrograde cholangiopancreatography (ERCP) - is used in the presence of jaundice, its episodes in anamnesis, ultrasound signs of extrahepatic bile ducts’ dilatation, laboratory signs of cholestasis. ERCP is performed using gastroduodenoscopy with cannula inserting through the ampulla of Vater and contrasting of the extrahepatic ductal system, the bile ducts of the liver and pancreatic duct.

Question 4

Leading factors in the occurrence of acute cholecystitis:

Answer 4

A) Microbial agents, which penetrate the cavity of the gall bladder through its wall.

B) Inflammatory changes, which are determined by the virulence of the infection, extent of infection and immune status reactivity

Question 5

Pathways of infection in the gallbladder and the factors contributing to the microbial contamination:

Answer 5

A) The main pathways of infection:

• hematogenous;
• lymphogenous;
• ascending infection from the duodenum.

B) Secondary causes of microbial contamination of the gallbladder :

• violation of blood flow in the cystic artery;
• reflux of pancreatic secretion;
• allergy.

Question 6

Factors contributing to the development of inflammation in the gallbladder:

Answer 6

A) Availability of microbial flora.

B) Violation of the drainage function of the gallbladder:

a) the presence of stones in the gallbladder (85-90%);
b) violation of the cystic duct patency.

C) Reflux of pancreatic secretion in common bile duct and gallbladder , resulting in the develoment of enzymatic cholecystitis.

D) cystic artery thrombosis.

Question 7

Clinical signs of acute cholecystitis depend on:

Answer 7

a) the form of the inflammatory process in the gallbladder;
b) the nature and virulence of the microbial flora;
c) the immunoreactivity of the organism;
d) the presence of complications.

Question 8

Pathomorphology of acute cholecystitis:

Answer 8

A) Catarhal form of acute cholecystitis - gallbladder is tense, it’s serosa is hyperemic, edematic mucousa, spots of erosion, presence of odorless serous fluid in the abdominal cavity.

B) Phlegmonous form of acute cholecystitis - tense gallbladder, hyperemic , covered with fibrin films, edematous bladder wall, foci of purulent destruction, in the cavity of the gallbladder there is modified bile or pus, presence of turbid fluid in the abdomen near the bladder or infiltrate in the gallbladder.

C) Gangrenous form of acute cholecystitis - necrosis of a section of the wall or the entire bladder as a result of cystic artery thrombosis , possible perforation of the bladder wall , which causes the release of pyonecrotic or gall detritus into the abdominal cavity .

Question 9

Clinical signs of acute cholecystitis:

Answer 9

A) Complaints:

a) pain, which is localized in the right upper quadrant:
- constant;
- intensive;
- intensity increases with disease progression;
- radiates to the right shoulder or the right scapula, the lumbar region, sometimes to the heart (cholecystocardial syndrome)

b) nausea;
c) repeated vomiting with bile content;
d) chills.

B ) Medical history:

a) acute onset;
b) the presence of provoking factors (fatty, fried and spicy foods);
c) the presence of similar painful onsets in history.

C) Objective evidence of disease:

a) general clinical signs of acute cholecystitis:
- general weakness;
- increase in body temperature to 38-39 °C;
- tachycardia;
- possible icterus of sclera and skin;

b) local clinical signs of acute cholecystitis:
- dry and coated tongue;
- abdominal wall in the right upper quadrant lags behind in breathing;
- at superficial palpation muscle tension and tenderness in the right upper quadrant;
- at deep palpation there is strengthening of local pain , possible palpation of the bottom of the gallbladder;
- at percussion and auscultation there are no changes.

• Pathognomonic pain symptoms of acute cholecystitis:

• Georgievskiy-Myussi’s sign (phrenic nerve sign) - pain when press between edges of the right sternocleidomastoid muscle;
• Ortner-Grekov’s sign - pain at tapping of the right costal arch;
• Partyure’s sign gallbladder is increased in size, stressed and painful;
• Murphy’s symptom - inability to breath deep due to increased pain during simultaneous palpation in projection of the gallbladder;
• Shchetkin-Blumberg’s sign - increased pain with a sharp withdrawal of the hand from the abdominal wall after pushing in the right upper quadrant (rebound tenderness, a sign of peritonitis).

Question 10

Formation of the preliminary diagnosis is based on clinical data.
(acute cholecystitis)

Answer 10

Preliminary diagnosis is formed on the basis of the patient’s complaints, anamnesis and objective manifestations, confirmed by physical methods of examination.

Diagnosis specified during ultrasound investigation and confirmed by laboratory tests.

Question 11

Diagnostic program in patients with suspected acute cholecystitis

Answer 11

Formed on the basis of the preliminary diagnosis:
A) Clinical signs:
a) complaints;
b) history of the disease;
c) objective data.

B) Laboratory tests:

a) complete blood count ( leukocytosis with a shift to the left);
b) biochemical analysis (bilirubin and its fractions, ALT, AST, serum electrolytes, blood coagulation tests);
c) urine analysis (the presence of protein, red blood cells, casts, bile pigments).

C) Imaging and instrumentation workup:

a) ultrasonography (to assess the state of the gallbladder, bile duct , pancrease and liver);
b) plain abdominal X-ray if indicated (in case of necessity to differentiate from obstruction of intestine, perforated ulcer);
c) computed tomography ( indicated in difficult diagnostic cases );
d) endoscopic retrograde cholangiopancreatography (ERCP) indicated, for assessment of pathological changes of the extrahepatic bile ducts;
e) diagnostic laparoscopy may be used to confirm the diagnosis in difficult diagnostic cases; in presence of technical possibilities it turns into a medical procedure, completing with a laparoscopic cholecystectomy.

Question 12

Differential diagnosis:

acute cholecystitis

Answer 12

A) With urgent surgical diseases of the abdominal cavity:

• acute appendicitis;
• ulcer of stomach and duodenum complicated with perforation;
• acute pancreatitis;
• acute obstruction of the bowel.

B) With urgent urological diseases:
- right-sided renal colic

C) With therapeutic diseases:

• right lower lobe pneumonia;
• right sided intercostal neuralgia;
• myocardial infarction.

D) With chronic abdominal diseases:

• duodenal ulcer, complicated with penetration;
• tumor of hepatic flexure of the colon.

Question 13

Complications of acute cholecystitis :

Answer 13

A) Paravesical infiltrate.

B) Perivesical abscess.

C) Gallbladder empyema.

D) Perforation of the gallbladder.

E) Peritonitis.

F) Mechanical jaundice.

G) Cholangitis.

I) Hydrocholecystis.

J) Acute pancreatitis.

Question 14

Organizational principles of providing medical care to patients with acute cholecystitis

Answer 14

A) When there are clinical manifestations of acute cholecystitis the patient is hospitalized in the surgical department.

B) If the ultrasound presents clinical signs of acute cholecystitis without the involvement of the peritoneum in the pathological process the medication therapy is aimed at the relief of pain and inflammatory syndromes.

C) If the ultrasound presents clinical signs of destructive cholecystitis without extracystic complications and with localized ones, the drug therapy is directed towards the reduction of pain and inflammatory syndromes for 24-48 hours.

D) In cases of relief of the inflammatory process, clinical ultrasound signs of which are listed in paragraphs B) and C ), and the presence of stones planned surgery in 10-12 days indicated. With the progression of inflammation of the gall bladder to the peritoneum and ineffectiveness of conservative treatment there is a justified indication for urgent surgery in 24-48 hours after admission.

Е) If the ultrasound presents clinical signs of destructive cholecystitis with extracystic generalized complications emergency surgery within 2-3 hours after the diagnosis and preoperative preparation is indicated.

Question 15

Nature of surgical interventions in acute cholecystitis:

Answer 15

A) Emergency surgery (2-3 hours from the time of admission) - in case of the signs of destructive cholecystitis complicated with peritonitis.

B) Urgent surgery (24-48 hours from the time of hospitalization) - in the absence of effectiveness of medication.

B) Delayed operation (48-72 hours from the time of admission) - if there are indications for emergency or urgent surgery , but the patient refuses surgery in the earlier period.

D) Рlanned surgery - in relieving effects of acute cholecystitis and confirming the presence of gallbladder stones.

Question 16

Medical therapy of acute cholecystitis:

Answer 16

A) Fasting 2-3 days.

B) Drinking alkaline fluids.

C) Local hypothermia.

D) Management of pain ( nonnarcotic analgesics, antispasmodics).

E) Antiinflammatory therapy ( broad spectrum antibiotics).

F) Desintoxication infusion transfusion therapy

Question 17

Surgical treatment of acute cholecystitis:

Answer 17

A) Open cholecystectomy:

• supramedian laparotomy;
• inspection of the abdominal cavity and extrahepatic bile ducts;
• cholecystectomy from the neck or from the bottom with separate ligation of the cystic duct and cystic artery;
• drainage of the abdominal cavity;
• laparotomic suturing of wounds.

B) Laparoscopic cholecystectomy:

• the introduction of trocars in four standard points (above the navel , under the xiphoid process of the sternum, under the right costal arch on the midclavicular and the anterior axillary lines);
• visual inspection of the abdominal cavity;
• cholecystectomy from the neck (of the gallbladder) with a separate clipping of the cystic duct and artery;
• removing the gallbladder from the abdomen;
• drainage of the abdominal cavity;
• suturing wounds of the abdominal wall

Question 18

Clinico-statistical classification of acute cholecystitis:

Answer 18

K80.0 Calculus of gallbladder with acute cholecystitis
Layout clinical diagnosis: Acute calculous cholecystitis {MX form}, {complicated with OX}

Morphological form:
M1 catarrhal
M2 phlegmonous
M3 gangrenous

Complications:
O1  gallbladder empyema
O2  hydrocholecystis
O3  paravesical infiltrate
O4  perivesical abscess
O5  peritonitis
O6  vesicointestinal fistula
O7  jaundice
O8  cholangitis
O9  acute pancreatitis

Question 19

Examination of disability and rehabilitation of patients:

acute cholecystitis

Answer 19

A) In uncomplicated postoperative period -the sutures are removed after laparotomy operations on 9-10th day , and after laparoscopic operation on 5-6th days.

B) Outpatient treatment after surgery: 4-5 weeks after laparotomy and 2-3 weeks after laparoscopic surgery.

C) If the professional activities of the patient is related to heavy physical work, medical control commission restricts physical activity for 4-6 months.

D) For 2-3 months after surgery recommended diet with restriction of fatty, fried and spicy foods.