Cholecystitis

Question 1

Acute Cholecystitis

Answer 1

acute inflammation of the gallbladder by obstruction of the cystic duct by a small stone causing gallbladder distension, chemical inflammation of its wall and eventually secondary infection

Question 2

Risk Factors

Clinical features

Answer 2

RF: 5F, history of gallstone

CF:
S: RHC
O: Sudden
C: continous and lasting more 6 hours
R: radiate to the back close to the tip of the right scapula
A: nausea, vomiting, if ass with obstructive jaundice: dark urine, pale stool and itchy skin
T: -
E: aggravated by moving and breathing, only relieved by analgesics
S: -
previous hx: without any chronic indigestion

Question 3

Physical findings

Answer 3

General: in pain, breathing slowly, tachycardia and pyrexia, jaundice may be present and sweating

Abdomen:
I: fullness in the RHC in early stages of the inflammation (Zackary Cope's sign)
Palpation:
RHC tenderness and guarding
Murphy's sign positive
Boas' sign

Percusssion: dull area just beneath the costal margin, guarding prevents deep palpation

Auscultation: normal bowel sounds are heard, unless the gallbladder has infarcted or ruptured causing biliary peritonitis

Question 4

Murphy’s sign

Answer 4

1. Palpate from the RIF and ask the patient to take a deep breath
2. the liver and the attached gallbladder descend when inhalation
3. keep moving the palpating hand upwards to the RHC
4. the attached gallbladder will strikes the palpating hand due to descending with inhalation
5. sharp pain is produced and prevents further inspiration in patient

Question 5

Boas’ sign

Answer 5

the gallbladder pain often radiates through to the tip of the scapula, the affected dermatome may be hyperaesthetic, a change detected by lightly drawing a pin down the back of the patient’s back

Question 6

Chronic cholecystitis

Answer 6

chronic or recurrent infection in the gallbladder which is always associated with gallstones

Question 7

Clinical features

Answer 7

middle aged women with obese
flatulent dyspepsia (the belching can relieve the pain)
acute pain in RHC
gradually increase in pain, 15-30 mins after meals
radiate to the back
pain worsen after eating fatty meals (fatty meal intolerance)
postprandial belching

Question 8

Investigation

Answer 8

FBC:

• Hb
• WCC (leukocytosis)
• CRP (inflammatory response)

LFT (elevated)

• raised ALP
• normal of AST, ALT
• normal total bilirubin

LPT (cholesterol)
Serum amylase (evidence of pancreatitis)

USS

• presence of gallstone
• gallbladder wall thickened
• bile duct dilatation

MRCP (if TAUS is inconclusive)

Question 9

How to manage?

Answer 9

advised on lifestyle fx : low fat diet, weight loss and increase exercise
IV analgesics
IV antibiotics (metronidazole)
Acute cholecystectomy (within 48-72 hours of symptoms commencement)
Elective cholecytectomy after 6 weeks