FN: Acute and Chronic Cholecysitis

Question 1

Pathogeneisis

Answer 1

Stone or sludge impaction in HArtmanns pouch
– chemical and/or bacterial inflammation
5% are acalculous: sepsis, burns, DM

Question 2

Sequelae

Answer 2

1. resolution ± recurrence
2. Gangrene and rarely perforation
3. Chronic cholecystitis
4. Empyema

Question 3

Presentation

Answer 3

Severe RUQ pain

• continuous
• Radiates to right scapula and epigastrium

Fever
Vomiting

Question 4

Examination

Answer 4

1. Local peritonism in RUQ
2. Tachycardia w/ shadow breathing
   ±jaundice
   Murphys sign
   Phlegmon
   Boas sign

Question 5

Murphys signs

Answer 5

2 fingers over the GB and ask pt. to breath in

Pain and breath catch, Must be -ve on the left hand side

Question 6

Phlegmon

Answer 6

May be palpable - mass of adherent omentum and bowel

Question 7

Boas sign

Answer 7

Hyperaesthesia below the right scapula

Question 8

Investigation

Answer 8

Urine
Bloods
Imaging

Question 9

Urine shows

Answer 9

Bilirubin, urobilinogen

Question 10

Bloods

Answer 10

FBC: raised WCC
U+E: dehydration form vomiting
Amylase, LFTs, G+S, clotting, CRP

Question 11

Imaging

Answer 11

AXR: gallstone, percelain, gallbladder
Erect CXR: look for perforation
Us:
1. Stones: acoustic shadow
2. Dilated ducts (>6mm)
Inflamed GB: wall oedema

Question 12

MRCP

Answer 12

If dilated ducts seen on

Question 13

Management Conservative

Answer 13

NBM
Fluid resuscitation
ANalgesiaL paracetaol, diclofenac, codeine
Abx: cefuroxime and metronidazole
80-90% settle over 24-48h
Detertioration: perforation . empyem

Question 14

Surgical

Answer 14

May be elective surgery @ 6-12 wks (reduced inflammation)

If

Question 15

Empyema management

Answer 15

High fever
RUQ mass
Percutaneous drainage: cholecystostomy

Question 16

Chronic Cholecustitis symptoms

Answer 16

Flatulent Dyspepsia
1. Vague upper abdominal discomfort
Distension, bloating
Nausea
Flatulena, burping
Symptoms exacerbated by fatty foods - CCK release stimulated gallbaldder

Question 17

Differential

Answer 17

PUD
IBS
Hiatus HErnia
Chronic pancreatitis

Question 18

Investigation

Answer 18

AXRL porcelain gallbladder
US: stones, fibrotic, shrunken gallbladder
MRCP

Question 19

Management medical

Answer 19

Bile salts (not very effective)

Question 20

Surgica lmamagement

Answer 20

Elective cholecystectomy

ERCP first if US shows dilated ducts and stones

Question 21

Rare gallstone disease

Answer 21

Mucocela
Gallbladder
Mirizzis syndrome
Gallstone ileus