FN: Acute and Chronic Cholecysitis Flashcards
Pathogeneisis
Stone or sludge impaction in HArtmanns pouch
– chemical and/or bacterial inflammation
5% are acalculous: sepsis, burns, DM
Sequelae
- resolution ± recurrence
- Gangrene and rarely perforation
- Chronic cholecystitis
- Empyema
Presentation
Severe RUQ pain
- continuous
- Radiates to right scapula and epigastrium
Fever
Vomiting
Examination
- Local peritonism in RUQ
- Tachycardia w/ shadow breathing
±jaundice
Murphys sign
Phlegmon
Boas sign
Murphys signs
2 fingers over the GB and ask pt. to breath in
Pain and breath catch, Must be -ve on the left hand side
Phlegmon
May be palpable - mass of adherent omentum and bowel
Boas sign
Hyperaesthesia below the right scapula
Investigation
Urine
Bloods
Imaging
Urine shows
Bilirubin, urobilinogen
Bloods
FBC: raised WCC
U+E: dehydration form vomiting
Amylase, LFTs, G+S, clotting, CRP
Imaging
AXR: gallstone, percelain, gallbladder Erect CXR: look for perforation Us: 1. Stones: acoustic shadow 2. Dilated ducts (>6mm) Inflamed GB: wall oedema
MRCP
If dilated ducts seen on
Management Conservative
NBM Fluid resuscitation ANalgesiaL paracetaol, diclofenac, codeine Abx: cefuroxime and metronidazole 80-90% settle over 24-48h Detertioration: perforation . empyem
Surgical
May be elective surgery @ 6-12 wks (reduced inflammation)
If
Empyema management
High fever
RUQ mass
Percutaneous drainage: cholecystostomy
Chronic Cholecustitis symptoms
Flatulent Dyspepsia 1. Vague upper abdominal discomfort Distension, bloating Nausea Flatulena, burping Symptoms exacerbated by fatty foods - CCK release stimulated gallbaldder
Differential
PUD
IBS
Hiatus HErnia
Chronic pancreatitis
Investigation
AXRL porcelain gallbladder
US: stones, fibrotic, shrunken gallbladder
MRCP
Management medical
Bile salts (not very effective)
Surgica lmamagement
Elective cholecystectomy
ERCP first if US shows dilated ducts and stones
Rare gallstone disease
Mucocela
Gallbladder
Mirizzis syndrome
Gallstone ileus
