cholecystitis Flashcards
definition of cholecystitis
inflammation of the gallbladder
acute - frequent complication of gallstones obstructing the CBD (in minority of cases can occur w/o gallstones
chronic - outdated term for recurrent episodes of biliary colic
aetiology of cholecystitis
follows stone or sludge impaction in the neck of the gallbladder
cholelithiasis (passage of gallstones into the cystic duct = cystic duct obstruction = distension and inflammation of the gallbladder
secondary bacterial infection may present - not necessary for development of cholecystitis
some people dont have gallstones - acalculous cholecystitis - 5-10% of acute cholecystitis, may effect people admitted to hospital with multiple trauma or acute non-biliary illness
aetiology of chronic cholecystitis
chronic irritation of gallbladder mucosa by cholelithiasis
recurrent attacks of acute cholecystitis
RF for gallstones
obesity
age
female
high TG and low HDL
weight cycing - intentionally losing weight then gaining it
dm
OCP
HRT
smoking
crohns
genetic and ethnic factors
RF for acute acalculous cholecystitis
- trauma
- burns
- immpobility
- starvation
- sepsis
- acute renal failure
- dm
- vascular disease
- TPN
- narcotic analgesics
epidemiology of cholecystitis
female more
most common complication of cholelithiasis
peak incidence >50yrs
sx of cholecystitis
acute history
colicky pain in epigastrum and RUQ post prandial - referred to the R shoulder
vomiting
dyspepsia and abdo discomfor over several years
high temp and pulse
local peritonism
obstructive jaundice
sx of chronic cholecystitis
flatulent dyspepsia
- vague abdo discomfort
- distension
- nausea
- flatulence
- fat intolerance - fat stimulates cholecystokinin release and GB contraction
signs of cholecystitis
- inflammation
- temperature
- guarding - tender RUQ
- intermittent pain
- triggered by fatty food
- quiet bowel sounds
- high WCC
- urine dipstick shows ketones only
- gall bladder mass
- A phlegmon (RUQ mass of inflamed adherent omentum and bowel) may be palpable.
murphy’s sign
lay 2 fingers over the RUQ, ask pt to breathe in = pain and arrest of inspiration as an imflamed GB impinges on fingers
only +ve if same test in LUQ doesn’t cause pain
ix for cholecystitis
US, needed for definite diagnosis - thick walled, shrunken GB with multiple calculi with pericholecystic fluid - signs of inflammation, CBD dilated
normal LFTs and a non-dilated biliary tree are important - make CBD stone unlikely
CT is mainly used to assess complications of cholecystitis e.g. abscess. The need for CT should be kept under regular review.
If ultrasound findings are inconclusive, consider HIDA scan, abdominal MRI, or abdominal CT to confirm the diagnosis
Assess for choledocholithiasis
look at CRP and WCC - high in inflammation
ix for chronic cholecystitis
- US to image stones and assess CBD diameter - thickened gall bladder wall
- MRCP used to find CBD stones
- lab studies may be normal
- no evidence of acute inflammatory changes eg pericholecystic fluid
- cholelithiasis commonly present
- HIDA scan - delayed visualization of the gallbladder
- should be assessed for choledocholithiasis before treatment
ix for acute cholecystitis
leukocytosis
raised CRP
blood cultures
bile cultures
test severity - blood gas analysis, basic metabolic panel (electrolyte derangement may be present), PT/INR
mx of cholecystitis
system relief
IV fluid
analgesia
AB - broad spectrum to cover anaerobic and gram positive
USS
surgery - laproscopic cholecystectomy - can do while in hospital or get pt stable and then plan for in 6wks
- timing - if <4days from presentation there is inflammation so fluid around the organ = easier surgery. if >4days the fibrinous tissue becomes fibrous adhesions = tough inflammatory mass - difficult to do laproscopy so have to come back in 6wks
- LFTs - has the stone slipped into CBD, if it has and you try to do a cholecystectomy and and put a clip on the CBD, the increased pressure because of the stone will cause the clip to come off = bile leak into the peritoneum
- also can be changed by inflamm around the CBD = oedema = mild obstruction
- therefore do MRCP to see if stone or not - diagnostic
- presence of jaundice/history of obstructive jaundice - make sure there is no obstructed biliary system before the operation
open surgery required if GB perforation
If elderly or high risk/unsuitable for surgery, consider percutaneous cholecystostomy; cholecystectomy can still be done later.
ERCP is treatment not diagnostic - has morbidity: pancreatitis, perforation of the duodenum ascending cholangitis, bleeding
NBM
mx of chronic cholecystitis
cholecystectomy
if US showsdilated CBD with stones - ERCP and sphincterectomy before surgery
If symptoms per-sist post-surgery consider hiatus hernia/IBS/peptic ulcer/chronic pancreatitis/tumour.
