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Acute Cholecystitis

Discuss acute cholecystitis?
Patients with acute cholecystitis experience severe pain that persists for several hours (6hrs or more), until they finally seek help at a local emergency department. Whereas in biliary colic the cystic duct obstruction is transient, in acute cholecystitis it is persistent. Persistent cystic duct obstruction, in combination with chemical irritants in the bile, results in inflammation and edema of the gallbladder wall. Nausea and vomiting are common.

Physical examination usually reveals marked tenderness in the right upper quadrant, often associated with a definite mass or fullness. Murphy’s sign is positive. Fever and local peritoneal signs are common.

Discuss the diagnosis?
Diagnosis is suspected based on the clinical presentation above.
Blood tests reveal leukocytosis with neutrophilia. A mild elevation in bilirubin, liver enzymes and amylase occur even in the absence of cholangitis or choledocholithiasis. These abnormalities may be due to the passage of small stones, sludge, or pus.
USS- is the investigation of choice. Positive findings particularly indicative of acute cholecystitis are stones, thickening of the gallbladder wall, pericholecystic fluid, and a positive Murphy sign on contact with the ultrasonographic probe.

Cholescintigraphy (HIDA scan)
- may be needed if the diagnosis remains uncertain following USS. It has no role in the diagnosis of gallstones but is very useful in excluding acute cholecystitis in patients who present with acute biliary colic. The test is positive if the gallbladder does not visualize which is invariably due to cystic duct obstruction, usually from edema associated with acute cholecystitis or an obstructing stone.

Discuss the treatment?

  • Supportive care- Fluid and electrolyte correction and pain relief
  • Antibiotics- most patients with acute cholecystitis are given antibiotics, although clear evidence of benefit is lacking.
  • Cholecystectomy-
    • Patients who are at low-risk (ASA classes I and II) benefit from early cholecystectomy during the same hospital admission. Several studies have indicated that cholecystectomy performed for low surgical risk patients during the initial hospitalization can reduce morbidity and costs
    • High-risk patients — Patients who are in ASA classes III, IV, or V have a surgical mortality ranging from 5 to 27 percent, and are considered high-risk for cholecystectomy. In such patients, treatment should be aimed at stabilizing symptoms only. They are discharged once stable.

Discuss the complications of acute cholecystitis?
The symptoms of cholecystitis may abate spontaneously within 7 to 10 days. However, complications rates are alarmingly high with this approach; hence treatment should be started on an emergent basis. He complications of acute cholecystitis are:

  • Gangrenous cholecystitis is the most common complication of cholecystitis especially in elderly and diabetics.
  • Perforation of the gallbladder usually occurs after the development of gangrene. It may lead to a localised abscess or lead to a generalized peritonitis.
  • Cholecystoenteric fistula may result from perforation of the gallbladder directly into the duodenum or jejunum.
  • Gallstone ileus — Passage of a gallstone through a cholecystoenteric fistula may lead to the development of mechanical bowel obstruction, usually in the terminal ileum (gallstone ileus)

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