acute calculous chole cystitis acute acalculous chole cystitis seid

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Transcript of acute calculous chole cystitis acute acalculous chole cystitis seid

  • REFERENCES

    STRAS BERG SM. ACUTE CALCULOUS CHOLECYSTITISN ENGL J MED 2008; 358:2804-11HUFFMAN JL, SCHENKER S. ACUTE ACALCULOUS CHOLECYSTITIS:

    A REVIEW. CLIN GASTROENTEROL HEPATOL 2010; 8:15-22.

  • A complication of Cholelithiasis

    20 millions in USA/year

    Most Gallstones Asymptomatic

    Biliary colic develops 1% to 4%

    Acute cholecystitis in 20% of these symptomatic patients

    60% women

    Older

    With/without previous attacks

    More frequent in men relative to its incidence and more severe

    DM

    90% of acute cholecystitis is associated with gallstones

  • Figure 1. Ultrasonographic images of three Gallbladders.

    A normal, sonolucent gallbladder (panel A) is characterized

    by a thin wall and an absence of acoustic shadows. In a

    patient with symptomatic gallstones (panel B), the

    gallblader contains small echogenic objects with posterior

    acoustic ghadows that are typical of gallstones (arrow),

    with a normal wall thickness. In a patient with acute

    calculous cholecystitis (panel c), thickening is visible in the

    gallbladder wall (arrow), along with a lare gallstone

    (arrowhead)

  • Figure 2. Hepatobiliary Scintigraphy.

    InPanel A, a normal liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid. In Panel B, at 55 minutes after tracer injection, filling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, at 1 hour after tracer injection in a patient with acute cholecystitis and obstruction of the cystic duct, there is filling of the bile duct (arrow) but no filling of the gallbladder.

    Figure 2. Hepatobiliary Scintigraphy.

    InPanel A, a normal liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid. In Panel B, at 55 minutes after tracer injection, filling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, at 1 hour after tracer injection in a patient with acute cholecystitis and obstruction of the cystic duct, there is filling of the bile duct (arrow) but no filling of the gallbladder.

  • Local symptoms and signsMurphy's signPain or tenderness in RUQMass in RUQ

    Systemic signsFeverLeucocytosisElevated CRP

    Imaging findingsA confirmatory finding on US or HB scintography

    Presence of one local signs or symptomsOne systemic sign, andA confirmatory finding on an imaging test

  • acute cholecystitis not meeting criteria for a more severe grade

    Mild gallbladder inflammation, no organ dysfunction

    presence of one or more of following: WBC>18000

    Palpable, tender mass in RUQ

    Duration > 72h

    Marked local in tlammarion: biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis

    presence of one or more of following:

    CVS dysfunction ( BP requiring dopamine at 5 microgr/kg/min or any dose of Dobutamine)

    CNS dysfunction (level of consciousness)

    Respiratory dysfunction (ratio of pO2 of arterial blood to the fraction of inspired oxygen 2mg/dL) Hepatic dysfunction (PT INR >1.5)

    Hematologic dysfunction (platelet

  • Laparascopic VS openEarly VS delayedFrom 24h to 7 days after initial attack2-3 months after afte initial attack

    PercutaneousOperative

  • Fasting, obstruction, post surgical ileus, TPN

    Inspissated bile toxic to epithelium

  • SurgeryRadiologyClinical findings

    Aspiration of GB/ drainageUSSetting (inpatient, out patient)

    LaparatomyCTFever, abdominal pain

    HIDA SCANLeucocytosis, abnormal LFT

  • Figure 1. (A and B) Longitudinal and horizontal sonogram of a 64-year-old man with positiveMurphy sign, showing hydrops. (C) CT scan 6 hours later showing thickened GB wall(white arrow), hydrops, and pericholecystic inflammation (asterisk). Figure courtesyof Dr Shaile Choudhary, MD (Department of Radiology, University of Texas HealthScience at San Antonio, San Antonio, TX).