Cholecystitis Flashcards
Types of gall stones
- Pigmented: hemolysis
- Cholesterol: large->+age, obesity
- Mixed: calcium salt + cholesterol 90% asymptomatic
Risk factors cholecystitis
- Calculous
Cholesterol gall stones: Female, fat, forty, fertile, pregnant, OCP, rapid weight loss
Pigmented gall stones: hemolytic disease, salmonella, infection
- Acalculous (stasis)
Severe illness, sepsis
Cardiac
TPN, prolonged fasting
Physical inactivity
Low fibre
Trauma
Severe burns
Ceftriaxone
Infections
- Other
Sickle cell
Diabetes
AIDS->CMV, cryptococcus
Clinical features
RUQ pain
Previous biliary pain
+ve murphy’s
Abdominal mass
Right shoulder pain,
Anorexia, nausea, fever, vomiting
Investigations
FBC->+WBC
CRP->elevated
LFTs->elevated ALP, GGT, bilirubin
Amylase->pancreatitis
RUQ USS->pericholecystic fluid, distended gall bladder, thickened wall, +ve murphy’s sign
Criteria
- Local signs of inflammation
- Systemic signs of inflammation->fever, CRP, WCC
- Imaging findings
Management
- ABC, assess severity
- NBM
- IVF, investigations->FBC, UEC, CRP, USS, AXR/ECXR (depending on presentation)
- Antibiotics: Gentamicin + amoxycillin
- Analgesia (diclofenac) + antiemetic
- Monitoring->BP, pulse/RR, urinary output
- Surgical consult
- Admit, book and consent . Complete pre-op workup
- Laparoscopic cholecytectomy within 48 hours
USS findings
- Bright echoic with acoustic shadowing
- Thickened wall
- Halo 4. May show stones, dilation of the duct
When in ERCP indicated
- Not in uncomplicated gall stone disease
- Recurrent biliary pain/pancreatitis when gall stones suspected of being underlying cause but not identified on USS
Possible clinical situations with gall stones
- Incidental gall stones on USS
- Incidental at laparotomy
- Biliary colic 4. Cholecystitis
- Obstructive jaundice
- Cholangitis
- Gallstone ileus
- Pancreatitis
- Mucocele/empyema
- Mirizzi’s
- Perforation
Management of incidental gall stone on USS, cumulative incidence of requiring a lap chole
- Unless evidence of biliary pain- do nothing
- Cumulative incidence of requiring a lap chole is 1% per year
Management when incidental at laparotomy
- +risk of becoming symptomatic, 75% at 12 months
- If adequate exposure, tolerating anaesthesia, can add cholecystectomy and cholangiography
Management of biliary colic
- Once pain, increased risk of ongoing
- At 5 years, all will have recurrence and 20% will develop a complication
- Unless operative risk ++, or low life expectancy operation
- Analgesia, hydration, NBM, elective cholecystectomy
Pre-operative treatment
- Fasting
- Prophylactic Antibiotics->cefazolin
- DVT prophylaxis
Post operative when laparoscopic
- 2 weeks until return of activity
- Less pain and ileus
- Ambulant day of surgery
- Narcotics 1 day, simple oral analgesia for 10 days
Post-operative when open
- ++Pain
- DVT prophylaxs
- 5 day hospital stay
- PCA
- NBM for 24-48 hours->+ileus
- IVF two days
- Four weeks until normal return of activity