Cholecystitis

Definition

• Inflammation of the gallbladder

Pathogenesis

• Stone impaction in the cystic duct causing obstruction

• Acalculous cholecystitis due to gallbladder stasis and ischemia — inflammatory response; occurs mainly in ill. hosp. Pts [TPN. sepsis, trauma, burns, opiates, immunosuppression, infxn (eg. CMV. Crypto. Campylobacter, typhoid fever)]

_ Clinical manifestations

• History: RUQ epigastric pain - radiation to R shoulder or back, nausea vomiting, fever

• Physical examination: RUQ tenderness. Murphy's sign = t RUQ pain and inspiratory arrest with deep breath during palpation of R subcostal region. - palpable gallbladder

• Laboratory evaluation: i WBC, • mild T bilirubin. A«. ALT AST. and amylase;

AST/ALT -500 U. bili >4 mg dl. or amylase -1000 U L — choledocholithiasis Diagnostic studies (jama 2003.289 80)

• RUQ U/S: high Se and Sp for gallstones; specific signs of cholecystitis include pericholecystic fluid, gallbladder wall thickening, and a sonographic Murphy's sign

• Cholescintigraphy (HIDA scan): most sensitive test for acute cholecystitis. IV

injection of radiolabeled HIDA is selectively secreted into biliary tree. In acute cholecystitis. HIDA enters CBD but not the gallbladder.

Treatment

• NPO. IV fluids, nasogastric tube if intractable vomiting, analgesia

• Antibiotics (£. coli. Klebsiella, enterococcus. and Enterobacter are usual pathogens)

3rd-generation cephalosporin (or quinolone) • metronidazole; or piperacillin-tazobactam

• Semiurgent cholecystectomy (usually w in 72 h)

• Cholecystostomy and percutaneous drainage if too sick for surgery

• Intra-operative cholangiogram or ERCP to r o choledocholithiasis in Pis w jaundice.

cholangitis, or stone in CBD on U S

Complications

I • Emphysematous gallbladder due to infection by gas-forming organisms

• Cholecystoenieric fistula (to duodenum, colon, or stomach): ran see air in biliary tree I • Gallstone ileus: bowel obstruction (usually at terminal ileum) due to stone in intestine that passed through a fistula

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