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View Full Version : Acute Cholecystitis (Etiology-Pathology-Clinical picture-Complications-Investigations-Treatment)



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06-04-2008, 09:44 AM
mAetiology:
(1) Infection: ¯ Direct spread
Ÿ Via bile duct Ÿ From the liver
Ÿ Usually B.coli, strept.
¯ Lymphatic born.
¯ Blood born. e.g. Typhoid cholecystitis
(2) Obstruction: By: ¯ Impacted stone in the cystic duct.
¯ Stricture of previous inflammation.
¯ Stasis of bile salts and acids.
(3) ChemicalIrritation:By bile salts and acids usually a sequelae of obstruction.
The accepted circle is as follow: obstruction ® chemical irritation ® inflammation ® Bacterial invasion ® infection ® oedema ® obstruction.
mPathology: ¯ Non obstructive type 5% ¯ Obstructive type 95%
(I) Non obstructive type:
a) Catarrhal ®localised to mucous membrane
b) Suppurative ® pus either in the lumen or the wall
c) Gangrenous ® due to septic thrombosis of the wall, increase tension in the gall bladder, and direct effect of bacterial toxins.
(II) Obstructive:
a) Mucocele only incarcerated mucous with bile salts.
b) Empyema ®Gangrene ® Perforation ®
- If the perforation occurs in rapid course ® biliary peritonitis.
- If it occurs gradually it may give external or internal fistula.

mClinical Picture:
Ÿ Incidence is more with 5F: Female, Fatty, Fertile, Forty years with Fatty dyspepsia
Ÿ Symptoms: General constitutional symptoms.
q Pain: severe colicky pain in the Rt. hypochondrium refered to Rt. Shoulder (through phrenic nerve) and interscapular region (through intercostal nerve).
q Vomiting: Excessive and repeated.
Ÿ Signs:
q Fever, tachycardia.
q Mild jaundice if ascending cholangitis occurs "after 24 h"
q Marked tenderness and rigidity in Rt. hypochondrium, maximum over the tip of 9th costal cartilage.
q Boas' sign: "hyperaesthesia in interscapular region"
q Gall bladder may be felt as a tense tender mass in cases of mucocele
q Murphy's sign : The patient catches his/her breath on pressure on the right hypochondrium during inspiration.
m Fate and Complications:
· Resolution: usually in nonobstructive type.
· Muccocele of the gall bladder.
· Empyema of the gall bladder.
· Perforation and generalized peritonitis or localized peritonitis.
· Gradual perforation to a nearby viscous, internal fistula formation e.g. fistula to the duodenum.
· Gradual perforation and trickling of pus through the falciform ligament, external fistula to the umbilicus.
· Ascending infection through bile duct ® ascending cholangitis.
· Chronicity and toxemia.
mDifferential Diagnosis:
· From causes of acute abdomen in upper abdomen & chest ® See before.

m Investigations:
1- Blood picture: Leucocytosis.
2- Liver function: may reveal increase bilirubin.
3- Ultrasonography: can detect thick wall, turbed bile, and stones if present.
4- Plain X-ray to reveal stones in the gall bladder, (acute on top of chronic) or emphysematous gall bladder (due to gas infection or fistula to a viscus containing gas e.g. duodenum).
5- Radioisotope scanning: Tecnetium 99m labeled derivatives of imino-diacetic acid (HIDA scanning) are excreted in the bile and are used to visualize the biliary tree. In acute cholecystitis the gall bladder is not visualized due to cystic duct obstruction.
6- I.V. Cholangiography: If the gall bladder is visualised ® cholecystitis is safely excluded.
mTreatment:
(I) Delayed surgical treatment:
* Conservative treatment at first then cholecystectomy ."after 4 weeks".
1- Hospitalization and conservative treatment is composed of:
Nasogastric suction. I.V. fluids. Antibiotics.
Hot fomentation.
Sedative (Avoid morphia as it may cause spasm in the sphincter of Oddi).
Antispasmodics.
2- After 4 weeks infection will subside with no oedema or congestion cholecystectomy can be done.
(II) Early surgical treatment:
q Indications:
1- Failure of conservation for 48 hs.
2- Presence of tense mass, for fear of perforation.
3- If perforation occurs.
4- Doubtful diagnosis.
q Operations: Cholecystectomy, if possible, or Cholecystostomy.
Cholecystostomy is a simple operation done even under local anaesthesia to drain the gall bladder content and relieve jaundice occured due to obst. of C. B. D.
It is indicated in:
a) Cases with oedema & adhesions ® disturbed anatomy.
b) Presence of peritonitis or jaundice.
c) Poor general condition.
@ Laparoscopic cholecystectomy during acute attack is now feasible, nevertheless, the conversion rate to open surgery is five times higher in acute than in elective cases.
SOURCE: DR. AYMAN SALEM'S BOOK
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