Cholecystitis

Hepato-Pancreatico-Biliary

Clinicals - History

Fact Explanation
Sudden onset pain Is the commonest and most distressing symptom. May develop even without preceding features of dyspepsia. Felt in the right hypochondrium and often radiates by encirclement to the tip of the right scapula. The pain is severe, continuous and lasts up to 6 hours. Exacerbated by breathing and movement. The pain occurs due to obstruction of the gallbladder at the cystic duct by a gallstone. This leads to distention of the gallbladder, subsequently impeding the vascular and lymphatic pathways. Leading to mucosal ischemia and necrosis, that stimulate nociceptive fibers to cause pain. The inspissisated bile becomes secondarily infected by gram negative bacteria such as E.coli, Klebsiella and Enterococci. As the inflammation spreads to the peritoneum the pain becomes sharper and more localized. Sudden onset pain
Is the commonest and most distressing symptom. May develop even without preceding features of dyspepsia. Felt in the right hypochondrium and often radiates by encirclement to the tip of the right scapula. The pain is severe, continuous and lasts up to 6 hours. Exacerbated by breathing and movement. The pain occurs due to obstruction of the gallbladder at the cystic duct by a gallstone. This leads to distention of the gallbladder, subsequently impeding the vascular and lymphatic pathways. Leading to mucosal ischemia and necrosis, that stimulate nociceptive fibers to cause pain. The inspissisated bile becomes secondarily infected by gram negative bacteria such as E.coli, Klebsiella and Enterococci. As the inflammation spreads to the peritoneum the pain becomes sharper and more localized.
Nausea May precede an attack of acute cholecystitis or even be associated with a high-fat meal in patients with gallstones. When occurring during an acute attack it is due to the severe pain. Nausea
May precede an attack of acute cholecystitis or even be associated with a high-fat meal in patients with gallstones. When occurring during an acute attack it is due to the severe pain.
Vomiting Is a fairly constant symptom. Occurs due to the severe pain that occurs as a result of inflammation. , Vomiting
Is a fairly constant symptom. Occurs due to the severe pain that occurs as a result of inflammation. ,
Belching An isolated symptom of the spectrum of 'flatulent dyspepsia' that often plague patients with gallstones. Often dyspeptic symptoms precede and worsen during an attack of acute cholecystitis. Dyspeptic symptoms may be the only complaint in chronic cholecystitis. Belching
An isolated symptom of the spectrum of 'flatulent dyspepsia' that often plague patients with gallstones. Often dyspeptic symptoms precede and worsen during an attack of acute cholecystitis. Dyspeptic symptoms may be the only complaint in chronic cholecystitis.
Fever Pyrexia occurs as inspissated bile becomes infected with bacterial pathogens. However a high swinging fever should raise the possibility of abscess formation, cholangitis or perforation. Fever
Pyrexia occurs as inspissated bile becomes infected with bacterial pathogens. However a high swinging fever should raise the possibility of abscess formation, cholangitis or perforation.
Jaundice One third of patients with cholecystitis will be jaundiced. This could be due to either Mirizzi's Syndrome or choledocholithiasis. Jaundice
One third of patients with cholecystitis will be jaundiced. This could be due to either Mirizzi's Syndrome or choledocholithiasis.
Risk factors for gallstone formation Obese individuals are at risk of gallstones due to high dietary cholesterol intake, with over 90 percent of stones being mixed cholesterol stones. Past medical or family history of a hemolytic disease is significant in the formation of pigment stones. Fertile, females, in their fifth decade are also at risk of gallstone as estrogen causes stasis of bile, that predisposes to stone formation. , Risk factors for gallstone formation
Obese individuals are at risk of gallstones due to high dietary cholesterol intake, with over 90 percent of stones being mixed cholesterol stones. Past medical or family history of a hemolytic disease is significant in the formation of pigment stones. Fertile, females, in their fifth decade are also at risk of gallstone as estrogen causes stasis of bile, that predisposes to stone formation. ,
Complications of gallstone diease Previous episodes of biliary colic, gallstone pancreatitis, gallstone ileus and obstructive jaundice are pointers to the diagnosis of acute calculous cholecystitis. ,, Complications of gallstone diease
Previous episodes of biliary colic, gallstone pancreatitis, gallstone ileus and obstructive jaundice are pointers to the diagnosis of acute calculous cholecystitis. ,,

Clinicals - Examination

Fact Explanation
Appears ill, febrile and tachycardic The patient is often distressed by the severe pain and is extremely toxic in an attack of acute cholecystitis. Pyrexia and tachycardia can be attributed to the secondary bacterial infection of the inspissated bile. Appears ill, febrile and tachycardic
The patient is often distressed by the severe pain and is extremely toxic in an attack of acute cholecystitis. Pyrexia and tachycardia can be attributed to the secondary bacterial infection of the inspissated bile.
Jaundice Affects one third of patients with cholecystitis. Obstructive jaundice may manifest with pale stools and dark urine. Jaundice occurs due to extra hepatic impaction of a gallstone causing Mirizzi's syndrome, choledocholithiasis or super added acute cholangitis. ,, Jaundice
Affects one third of patients with cholecystitis. Obstructive jaundice may manifest with pale stools and dark urine. Jaundice occurs due to extra hepatic impaction of a gallstone causing Mirizzi's syndrome, choledocholithiasis or super added acute cholangitis. ,,
Zackary Cope Sign On inspection there may be fullness of the right hypochondrium. This is seen in the early stages of inflammation, occurs due to the impaction of a gallstone in the cystic duct or Hartmann's pouch. ,, Zackary Cope Sign
On inspection there may be fullness of the right hypochondrium. This is seen in the early stages of inflammation, occurs due to the impaction of a gallstone in the cystic duct or Hartmann's pouch. ,,
Murphy's Sign Elicited by palpation of the abdomen, just below the ninth costal cartilage. When the patients inhales, the gallbladder descends and strikes the examiner's thumb causing a sharp pain that halts further inspiration. This sign has a sensitivity of 97% and is highly predictive at 93%, for the diagnosis of cholecystitis. Murphy's Sign
Elicited by palpation of the abdomen, just below the ninth costal cartilage. When the patients inhales, the gallbladder descends and strikes the examiner's thumb causing a sharp pain that halts further inspiration. This sign has a sensitivity of 97% and is highly predictive at 93%, for the diagnosis of cholecystitis.
Boas Sign As gallbladder pain radiates circumferentially to the tip of the scapula, the affected dermatome is hyper aesthetic, this can be detected by lightly drawing a pin across the back of the patients chest. , Boas Sign
As gallbladder pain radiates circumferentially to the tip of the scapula, the affected dermatome is hyper aesthetic, this can be detected by lightly drawing a pin across the back of the patients chest. ,
Palpable gallbladder Usually presents in a later stage. When the inflammation has bee present for several days and the tenderness begins to subside, a tender mass may be palpable. This usually indicates the possibility of an empyema or abscess. Palpable gallbladder
Usually presents in a later stage. When the inflammation has bee present for several days and the tenderness begins to subside, a tender mass may be palpable. This usually indicates the possibility of an empyema or abscess.
Absent bowel sounds Absent bowel sounds are a sinister sign, as it indicates a perforated gallbladder causing biliary peritonitis. Absent bowel sounds
Absent bowel sounds are a sinister sign, as it indicates a perforated gallbladder causing biliary peritonitis.

Investigations - Diagnosis

Fact Explanation
Full blood count Can observe a neutrophilic leukocytosis with a sharp left shift. This occurs due to the secondary bacterial infection of the inspissated bile. Full blood count
Can observe a neutrophilic leukocytosis with a sharp left shift. This occurs due to the secondary bacterial infection of the inspissated bile.
Serum aspartate aminotransferase Is used to evaluate the presence of hepatitis, and may even be mildly elevated in isolated cholecystitis and common bile duct obstruction. Serum aspartate aminotransferase
Is used to evaluate the presence of hepatitis, and may even be mildly elevated in isolated cholecystitis and common bile duct obstruction.
Serum alanine aminotransferase Is used to evaluate the presence of hepatitis, and may even be mildly elevated in isolated cholecystitis and common bile duct obstruction. Serum alanine aminotransferase
Is used to evaluate the presence of hepatitis, and may even be mildly elevated in isolated cholecystitis and common bile duct obstruction.
Serum bilirubin Obstruction in common hepatic duct or bile duct causes hyperbilirubinemia. Serum bilirubin
Obstruction in common hepatic duct or bile duct causes hyperbilirubinemia.
Alkaline phosphatase Is elevated in acute calculous cholecystitis, may even herald a common bile duct stone. Alkaline phosphatase
Is elevated in acute calculous cholecystitis, may even herald a common bile duct stone.
Ultrasound scan Is the investigation of choice in patient suspected to have acute cholecystitis. Will demonstrate pericholecystic fluid, distended gallbladder with an edematous wall and gall stones. In addition it is possible to elicit Murphy's sign during ultrasound examination(sonographic Murphy's), this increases sensitivity of the sign, as direct visualization of the gallbladder is possible. ,,, Ultrasound scan
Is the investigation of choice in patient suspected to have acute cholecystitis. Will demonstrate pericholecystic fluid, distended gallbladder with an edematous wall and gall stones. In addition it is possible to elicit Murphy's sign during ultrasound examination(sonographic Murphy's), this increases sensitivity of the sign, as direct visualization of the gallbladder is possible. ,,,
Endoscopic retrograde cholangio pancreaticography (ERCP) Useful in visualizing the common bile duct in patients with high risk of stones, if common bile duct obstruction is present. Endoscopic retrograde cholangio pancreaticography (ERCP)
Useful in visualizing the common bile duct in patients with high risk of stones, if common bile duct obstruction is present.
Hepatobiliary scintigraphy Biliary scintigraphy (HIDA scan) is the gold standard investigation if the diagnosis remains in doubt after ultrasound scanning. Hepatobiliary scintigraphy
Biliary scintigraphy (HIDA scan) is the gold standard investigation if the diagnosis remains in doubt after ultrasound scanning.
Computed tomography (CT) CT used if obesity or gaseous distention limits the use of ultrasonography. Gallbladder wall thickening, pericholecystic fluid, subserosal edema and intramural gas are suggestive of the diagnosis. Computed tomography (CT)
CT used if obesity or gaseous distention limits the use of ultrasonography. Gallbladder wall thickening, pericholecystic fluid, subserosal edema and intramural gas are suggestive of the diagnosis.
Magnetic Resonance Imaging (MRI) An alternative to CT if Ultrasonography is inconclusive; may demonstrate the same morphologic changes as CT scanning. Magnetic Resonance Imaging (MRI)
An alternative to CT if Ultrasonography is inconclusive; may demonstrate the same morphologic changes as CT scanning.

Investigations - Management

Fact Explanation
Ultrasound scan To exclude the presence of common bile duct stones, in patients with features that are suggestive: obstructive jaundice. If not identified and treated may cause a post-cholecystectomy cystic duct leak. (stump blow-out). , Ultrasound scan
To exclude the presence of common bile duct stones, in patients with features that are suggestive: obstructive jaundice. If not identified and treated may cause a post-cholecystectomy cystic duct leak. (stump blow-out). ,
Endoscopic retrograde cholangio pancreaticography (ERCP) Has both diagnostic and therapeutic value in the presence of common bile duct stones. Such stones should be removed prior to or during cholecystectomy to avoid a post-cholecystectomy cystic duct leak. (stump blow-out). , Endoscopic retrograde cholangio pancreaticography (ERCP)
Has both diagnostic and therapeutic value in the presence of common bile duct stones. Such stones should be removed prior to or during cholecystectomy to avoid a post-cholecystectomy cystic duct leak. (stump blow-out). ,
Assessment of fitness for general anesthesia Open, laparoscopic cholecystectomy are performed under general anesthesia, therefore fitness for general anesthesia should be established. This should include : Electrocardiogram (ECG), baseline renal functions, chest X ray and venous plasma glucose. , Assessment of fitness for general anesthesia
Open, laparoscopic cholecystectomy are performed under general anesthesia, therefore fitness for general anesthesia should be established. This should include : Electrocardiogram (ECG), baseline renal functions, chest X ray and venous plasma glucose. ,

Management - Supportive

Fact Explanation
Conservative management Most patients respond to conservative management. During this period the gall stone falls back into the gall bladder allowing the cystic duct to empty. Measures to rest the gallbladder should be instituted: nil oral regime, intravenous fluid resuscitation and adequate analgesia. Conservative management
Most patients respond to conservative management. During this period the gall stone falls back into the gall bladder allowing the cystic duct to empty. Measures to rest the gallbladder should be instituted: nil oral regime, intravenous fluid resuscitation and adequate analgesia.
Analgesia Can be provided with NSAIDS or opioids. Indometacin can reverse the inflammation and the prokinetic action of indometacin will also improve postprandial emptying of the gall bladder in patients with gallbladder disease. Analgesia
Can be provided with NSAIDS or opioids. Indometacin can reverse the inflammation and the prokinetic action of indometacin will also improve postprandial emptying of the gall bladder in patients with gallbladder disease.
Intravenous antibiotics Started empirically due to the risk of bacterial infection. A second generation or newer (Cefuroxime) cephalosporin should be used with metronidazole, since commonly encountered organisms are gram negative. , Intravenous antibiotics
Started empirically due to the risk of bacterial infection. A second generation or newer (Cefuroxime) cephalosporin should be used with metronidazole, since commonly encountered organisms are gram negative. ,

Management - Specific

Fact Explanation
Emergency surgery About 20% of patients require emergency surgery. It is indicated if the patient deteriorates and when generalized peritonitis or emphysematous cholecystitis is present as these are suggestive of gangrene/perforation of the gall bladder. , Emergency surgery
About 20% of patients require emergency surgery. It is indicated if the patient deteriorates and when generalized peritonitis or emphysematous cholecystitis is present as these are suggestive of gangrene/perforation of the gall bladder. ,
Open cholecystectomy Open cholecystectomy traditionally has been performed 6-12 weeks after the acute episode to allow the inflammatory process to resolve. , Open cholecystectomy
Open cholecystectomy traditionally has been performed 6-12 weeks after the acute episode to allow the inflammatory process to resolve. ,
Laparoscopic cholecystectomy Early laparoscopic cholecystectomy within (72-96 hours of symptoms) have lower complication rates and conversion rates, in addition to shorter hospital stays, early intervention 'edema planes' allow the gall bladder to be dissected laparoscopically. If inflammation has been present for more than 72 hours, features of chronic inflammation (such as fibrosis) predominate and make it more difficult to dissect the gall bladder. Thus, optimal treatment should be initial resuscitation, followed by laparoscopic cholecystectomy on the next surgical list. ,, Laparoscopic cholecystectomy
Early laparoscopic cholecystectomy within (72-96 hours of symptoms) have lower complication rates and conversion rates, in addition to shorter hospital stays, early intervention 'edema planes' allow the gall bladder to be dissected laparoscopically. If inflammation has been present for more than 72 hours, features of chronic inflammation (such as fibrosis) predominate and make it more difficult to dissect the gall bladder. Thus, optimal treatment should be initial resuscitation, followed by laparoscopic cholecystectomy on the next surgical list. ,,
Percutaneous cholecystostomy Percutaneous cholecystostomy is a minimally invasive procedure that can be performed at the bedside under local anesthesia. It is suitable for patients with multiple co morbidities and are thus, poor candidates for general anesthesia. ,, Percutaneous cholecystostomy
Percutaneous cholecystostomy is a minimally invasive procedure that can be performed at the bedside under local anesthesia. It is suitable for patients with multiple co morbidities and are thus, poor candidates for general anesthesia. ,,
Non operative management Solvent dissolution therapy or extracorporeal shockwave lithotripsy is used in chronic cholecystitis for patients unfit for surgery. However it has no place in the management of acute cholecystitis. , Non operative management
Solvent dissolution therapy or extracorporeal shockwave lithotripsy is used in chronic cholecystitis for patients unfit for surgery. However it has no place in the management of acute cholecystitis. ,

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