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Acute cholecystitis

Most common complication of gallstones.

Associated with gallstones in greater than 90% of cases.

Occurs when a stone becomes impacted in the cystic duct and inflammation develops behind the obstruction.

 

Blocked bile accumulates, and pressure on the gallbladder wall may lead to the release of substances that cause inflammation, such as phospholipase. 

 

There is a risk of bacterial infection with acute cholecystitis 

 

An inflamed gallbladder is likely to cause pain, fever, and tenderness in the upper, right corner of the abdomen, and may have a positive Murphy’s sign. 

 

Cholecystitis is often managed with rest and antibiotics, particularly cephalosporins and, in severe cases, metronidazole.

Acalculus cholecystitis is considered in a patient with fever, right upper quadrant pain in a critically ill patient with no intake for a prolonged period of time, or in a patient with recent major surgery, and in the presence of multiple organ failure.

May occur in patients with AIDS caused by infectious agents.

Commonly associated with fever and sudden appearance of pain in the epigastrium or right upper quadrant.

Abdominal pains may gradually subside over 12-18 hours, and may be associated with vomiting, and that 75% of the patients.

Right upper quadrant abdominal pain may be associated with a Murphy’s sign, guarding and rebound tenderness may be present.

The gallbladder is palpable in about 15% of cases.

25% of patients have jaundice.

Leukocytosis is typical, and bilirubin is generally between one and 4 mg/dL, while AST and output phosphatase are often elevated.

May be associated with moderately elevated amylase level.

Abdominal plain films they demonstrate an radiopaque gallstone in 15% of cases.

Hepatobiliay scanning with technetium or hepatic iminodiacetic acid (HIDA) can demonstrate and obstructive cystic duct, which is the cause of the process in most patients.

The HIDA scan is reliable if the bilirubin is less than 5 mg/dL and has a 98% sensitivity and an 81% specificity for acute cholecystitis.

False positive HIDA scans can result from liver disease, chronic cholecystitis, and prolonged fasting.

Abdominal ultrasound may show the presence of gallstones and has a sensitivity of 67%, and a specificity of 82% for the diagnosis of acute cholecystitis by showing gallbladder thickening, pericholecystic fluid, and positive sonographic Murphy’s sign.

HIDA is more sensitive test than ultrasound in diagnosing acute cholecystitis and should be the first diagnostic test in patients with suspected acute cholecystitis.

Differential diagnosis: peptic ulcer disease, acute pancreatitis, colonic carcinoma, diverticulitis, liver abscess, hepatitis, pneumonia with pleurisy, perforated viscous, and myocardial infarction.

Complications include gangrene of the gallbladder manifesting by continued or progressive right upper quadrant abdominal pain, tenderness, regarding, fever, leukocytosis from ischemia of the gallbladder.

Gangrene of the gallbladder leads to gallbladder perforation, with abscess formation and rarely peritonitis.

Patients may develop chronic cholecystitis from repeated episodes of acute inflammation, or chronic irritation of the gallbladder by stones.

Chronicle cholecystitis may lead to villi enlargements from cholesterol deposition grossly appearing as a strawberry gallbladder, hyperplasia of the gallbladder wall may give it the appearance of a myoma, and hydrops may occur.

Cholelithiasis with chronic cholecystitis may result in repeated episodes of gallbladder inflammation, bile duct stone formation, pancreatitis, fistulization to the bowel and rarely gallbladder cancer.

Porcelain or calcified gallbladders highly associated with gallbladder cancer and are an indication for cholecystectomy.

Acute cholecystitis can be treated conservatively by withholding feedings, injured venous fluids, analgesics and intravenous antibiotics.

Early cholecystectomy is treatment of choice rather than delaying the process, because of a high risk of recurrent attacks with up to 10% by one month, and over 30% one by one year.

Cholecystectomy can generally be performed within 2 to 4 days after resolution of the acute process.

Immediate cholecystectomy is required if there is evidence of gangrene or perforation.

Mortality rate 0.5%.

Early laparoscopic cholecystectomy compared to initial antibiotic treatment and delayed cholecystectomy associated with a significant reduced hospital stay, no major complications, and no significant difference in open surgical conversion rates (Cassilas).

Overall mortality rate for cholecystectomy is less than 0.2%.

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