ACUTE CHOLECYSTITIS Flashcards
what is acute cholecystitis?
inflammation of gallbladder
what is the epidemiology of acute cholecystitis?
40-50 y/o
women
what are the 2 types of acute cholecystitis?
calculous (95%)
acalculous(5%)
what is calculous acute cholecystitis?
gallbladder inflammation as a complication of cholelithiasis
what is acalculous acute cholecystitis?
gallbladder inflammation d/t gallbladder stasis and ischemia
more common in critically ill and/or immunocompromised patients
what are the RF of acute cholecystitis?
the 6 F’S
fair
female
fat -> diabetes
>forty
fertile-> pregnancy or HRT
family history
also native american or hispanic
what is the patho of acute cholecystitis?
- cystic duct obstruction leads to bile stasis
- stasis triggers release of inflammatory enzymes that damage gallbladder mucosa
- mucosal damage causes more fluid to be secreted into gallbladder lumen than is absorbed leading to increased intraluminal pressure
4 increased pressure results in distention which furthers the release of inflammatory mediators (prostaglandins and lysolecithin) - as inflammation increases, mucosal damage worsens leading to ischemia
- bact infxn can ensue (gram neg bacteria: e. coli, enterococcus, klebisella)
what are the complications of acute cholecystitis?
gangrene (20%)
perforation (20%)
what are the s/sx of acute cholecystitis?
abdominal pain that is severe, sudden and in the RUQ
- often triggered by fatty meal
- duration >6 hours
- radiation of pain to RL scapula (BOAS SIGN)
N/V (75%)
low grade fever
MURPHYS SIGN
when does murphys sign develop and what is it?
develops within 2-3 hours
deep inspiration exacerbated pain during palpitation of RUQ subcostal region and halts inspiration
what will labs for acute cholecystitis show?
CBC: leukocytosis w/ left shift (12k-25k)
LIPASE: >3x normal suggest common bile duct obstruction
LIVER TESTS: elevation of bilirubin and alk phos should raise suspicion for complications (cholangitis, choledocolithiasis) ; mild eval of ALT and AST
what is the dx study of choice?
US
what will you find on US?
gallbladder wall thickening > 4 mm
gallbladder wall edema
pericholecystic fluid
presence of gallstones
air in GB wall indicates gangrene
can also have ultrasonographic murphys sign elicited w/ US probe pressing on abdomen
when is a HIDA scan done?
perfromed if US is equivocal
what must you do pre-HIDA?
4 hour fast
what does HIDA scan do?
use radioactive tracer to access filling of GB
- if cystic duct not obstructed, tracer will be excreted in bile
what are the indications for CT abd/pelvis?
used to identify extrabiliary abnormalities or complications of acute cholecystitis
what is the first step in tx of acute cholecystitis?
hospitalization
- supportive care: NPO, IV hydration, antiemetics, NG tube placed for vomiting or if an ileus is present
analgesics-> NSAIDs (ketorolac) or opioids
abx initiated to tx possible infxn, empiric coverage directed against gram neg bacteria
- ceftriaxone 1-2g IV every 12-24 hours +metronidazole 500 mg IV every 8 hours
- Piperacillin/tazobactam 3.375-4.5 g IV every 6 hours
what is the next step after hospitalization for acute cholecystitis tx?
cholecystectomy- DEFINITIVE TX
early cholecystectomy (within 24-48 hours is preferred)
approach:
laparoscopic is the standard of care d/t lower risk of infxn and shorter hospital stay
open surgery is reserved for complicated cases
what is chronic cholecystitis?
long-standing GB inflammation resulting from gallstones and prior episodes of acute cholecystitis. GB becomes fibrotic and contracted, and is not able to concentrate bile or empty normally
what are the s/sx of chronic cholecystitis?
recurrent biliary colic, usually w/o fever
RUQ pain less intense
what is the dx study of choice for chronic cholecystitis?
US
what is the tx of chronic cholecystitis?
laparoscopic cholecystectomy
what are some sx of cholecystitis in elderly?
malaise, anorexia, vomiting and possible absent fever
