Acute Cholecystitis

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Acute Cholecystitis is a condition characterized by acute abdominal pain, fever and positive Murphy’s sign due to inflammation of the Gall bladder.

What causes the Acute Cholecystitis?

A) Gallstone, Ninety percent of cases involve stones in the cystic duct (i.e., calculous Cholecystitis).
B) Non Calculous includes:
1. Severely ill patients with nothing by mouth since long time
2. Burn Patients
3. Trauma
4. Post surgical patients
5. Pregnancy
6. Infection
7. Drugs (especially hormonal therapy in women)
8 Diabetes mellitus

What is the pathophysiolgy of acute Cholecystitis?

In calculous Cholecystitis there is obstruction of cystic ducts due to gall stone leading to biliary colic. If the cystic duct remains obstructed, the Gall stone wall distends and the gallbladder wall then becomes inflamed and edematous. In most common cases the gall stone dislodges and the inflammation gradually resolve but in some and severe cases there is ischemia and necrosis of the gall bladder wall.

What are the signs and symptoms of acute Cholecystitis?

• Biliary colic (right upper quadrant abdominal pain)
• Fever
• Nausea and vomiting
• Anorexia
• Tenderness or rebound tenderness
• Guarding and rigidity
• Jaundice
• Murphy’s sign positive, ie Inspiration arrest of during deep palpation of the right upper quadrant)

What are the complications of Acute Cholecystitis?

• Emphysematous Cholecystitis
• Empyema of gall bladder
• Acute cholangitis
• Acute pancreatitis

What is the differential diagnosis of acute Cholecystitis?

• Appendicitis
• Perforated peptic ulcer
• Acute pancreatitis
• Bowel obstruction
• Acute pyelonephritis
• Myocardial infraction
• Pneumonia right lower lobe

How to diagnosed acute Cholecystitis?

Diagnosis relies on patient’s history, physical examination, Radiological examination and Laboratory studies.

Laboratory studies shows leukocytosis (increased WBC count), Liver function tests; including serum bilirubin, alkaline phosphatase, alanine transaminase (ALT), asparate transaminase (AST) and serum amylase also may be abnormal.

Diagnostic Imaging includes:

1. Ultrasound: it is the most commonly used test for diagnosis acute Cholecystitis with the sensitivity and specificity of 84% and 99% respectively.
2. Radionuclide cholescintigraphy: Biliary radionuclide scanning is used less frequently but may be helpful in atypical cases. No filling of the gallbladder with the radiotracer (99m Tc-HIDA) after 4 hours indicates an obstructed cystic duct with a sensitivity and specificity of 95%.
3. Computed tomography (CT): Nowadays CT   is performed frequently in patient with abdominal pain, but is less sensitivity than ultrasound for acute Cholecystitis.

How to managed acute Cholecystitis?

• After the diagnosis of acute Cholecystitis hospitalized the patients and managed with giving iv fluid, parenteral antibiotic (eg. Piperacillin/ tazobactam) and analgesic.
• Patients with acute Cholecystitis should have gone cholecystectomy as definitive treatment. Cholecystectomy may perform in either an early (2 to 3 days of symptoms) or a delayed (6 to 10 weeks after initial medical therapy).
• Tube cholecystectomy should be performed in patients who have acute Cholecystitis and who are failing systemic therapy but are not candidates for cholecystectomy because of severity of illness or concomitant medical problems.

What is the prognosis of acute Cholecystitis?

After the proper treatment of acute Cholecystitis prognosis is excellent.

References:

• Sabiston textbook of surgery 18th edition
• Bailey and love, surgery 25th edition
• www.sciencedirect.com
• The Washington manual of surgery, 5th edition.
• emedicine.medscape.com

Filed Under: General

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