Acute Cholecystitis

Group A

• Gallbladder wall inflammation usually follows obstruction of the cystic duct by a stone

Inflammatory response can be evoked by three factors

Acalculous Cholecystitis

• Characteristic of acalculous disease: Acute gallbladder inflammation complicating severe underlying illness

• Ultrasound, CT, or radionuclide examinations: Large, tense, static gallbladder without stones and with evidence of poor emptying over a prolonged period

• Management: Early diagnosis and surgical intervention, with meticulous attention to postoperative care

Acalculous Cholecystopathy

• Disordered motility of the gallbladder• The following criteria can be used for

identification:• Recurrent episodes of typical RUQ pain characteristic of

biliary tract pain• Abnormal CCK cholescintigraphy demonstrating a

gallbladder ejection fraction of <40%• Infusion of CCK reproduces the pain

• Ultrasound: Large gallbladder• Sphincter of Oddi dysfunction: Recurrent RUQ

pain and CCK-scintigraphic abnormalities

Emphysematous Cholecystitis

• Common in the elderly and those with DM

• Clinical manifestations similar to nongaseous cholecystitis

Diagnosis with plain abdominal filmGas within gall bladder lumenGaseous ring

Prompt surgical intervention with antibiotic therapy mandatoryConsiderable morbidity

Emphysematous Cholecystitis

Chronic Cholecystitis

• Repeated bouts of subacute or acute cholecystitis• Persistent mechanical irritation of gallbladder wall by

gall stones• Bacteria in bile in >25% of patients with chronic

cholecystitis• May be asymptomatic for years• May progress to symptomatic gallbladder disease or

to acute cholecystitis, or present with complications

Complications of Cholecystitis

Complication Pathogenesis Clinical presentation Treatment

Empyema of the galbadder Progression of acute cholecystitis with persistent cystic duct obstruction to superinfection of the stagnant bile with pus- forming bacterial organism

Resembles cholangitis; high fever, severe RUQ pain, marked leukocytosis and often prostration

Emergency surgical intervention with antibiotic therapy

Hydrops or Mucocele Obstructed gall bladder lumen is distended by mucus (mucocele) or clear transudate (hydrops) produced by mucosal epithelial cells

Visible, palpable non-tender mass extending from RUQ to the iliac fossaHydrops- frequently asymptomatic or occasional chronic RUQ pain

Cholecystectomy to avoid superimposed complications

Gangrene and Perforation Ischemia of the wall with patchy or complete tissue necrosisLocalized perforations are due to recurrent inflammation of the gall bladder Baterial superinfection- abscess formation

RUQ pain Cholecystectomy with abscess drainage for seriously ill patients

Fistula formation Results from inflammation and and adhesion formation (Fistula of the duodenum are the most common)

Usually asymptomatic Symptomatic patients: cholecystectomy, CBD exploration, closure of the fistulous tract

Gallstone ileus Mechanical intestinal obstruction resulting from the passage of a large gallstone in the bowel lumen (ileocecal valve- common site)

Usually asymptomatic Laparotomy with stone extraction

Limey bile Calcium secretion into the lumen of the gallbladder in sufficient concentration to produce precipitation, diffuse and hazy opacification of bile

Clinically innocuous Cholecystectomy

Porcelain gallbladder Calcium salt deposition within the wall of a chronically inflammed gallblader

Clinically innocuous Cholecystectomy

Treatment

Treatment

• Surgical intervention - mainstay therapy for acute cholecystitis and its complications

• In-hospital stabilization may be required before cholecystectomy• oral intake is eliminated• nasogastric suction may be indicated• extracellular volume depletion and

electrolyte abnormalities are repaired

Medical Therapy• Meperidine or NSAIDs• analgesic – decrease spasm of the Spinchter of Oddi

• Intravenous Antibiotic• indicated in patients with severe acute cholecystitis• for E. coli, Klebsiella spp., and Streptococcus spp.• ex. Ureidopenicillins (piperacillin), ampicillin sulbactam,

ciprofloxacin, moxifloxacin, and 3rd gen cephalosporins• Metronidazole - added if gangrenous or emphysematous

cholecystitis is suspected• Imipenem/Meropenem – for bacteria causing ascending

cholangitis

Surgical Therapy

• Early cholecystectomy is the treatment of choice for most patients with acute cholecystitis

• Urgent cholecystectomy/cholecystostomy is appropriate in most patients in whom a complication of acute cholecystitis such as empyema, emphysematous cholecystitis, or perforation is suspected or confirmed.

Surgical Therapy

• Delayed surgical intervention is probably best reserved for:• patients in whom the overall medical

condition imposes an unacceptable risk for early surgery

• patients in whom the diagnosis of acute cholecystitis is in doubt

Surgical Therapy

• Operative risks increase with:• age-related diseases of other organ systems • presence of long or short-term

complications of gallbladder disease• Seriously ill or debilitated patients with

cholecystitis may be managed with cholecystostomy and tube drainage of the gallbladder.

Postcholecystectomy Complications

Complications• Early complications:• atelectasis and other pulmonary disorders• abscess formation• external or internal hemorrhage• biliary-enteric fistula• bile leaks• jaundice

• Routine performance of intraoperative cholangiography during cholecystectomy has helped to reduce the incidence of these early complications.

Complications

• The most common cause of persistent postcholecystectomy symptoms is an overlooked symptomatic nonbiliary disorder.

• Postcholecystectomy syndromes may be due to:• biliary strictures• retained biliary calculi• cystic duct• stump syndrome• stenosis or dyskinesia of the sphincter of Oddi• bile salt–induced diarrhea or gastritis

Cystic Duct Stump Syndrome

• Disease in a long (>1 cm) cystic duct remnant

• Symptoms resembling biliary pain or cholecystitis in the absence of cholangiographically demonstrable retained stones

Symptoms of biliary colic accompanied by signs of recurrent, intermittent biliary obstruction may be produced by papillary stenosis, papillary dysfunction, spasm of the sphincter of Oddi, and biliary dyskinesia.

Papillary Stenosis

• Defined by:• Upper abdominal pain, usually RUQ or epigastric• abnormal liver tests• dilatation of the common bile duct upon ERCP examination• delayed (>45 min) drainage of contrast material from the

duct• increased basal pressure of the sphincter of Oddi

• Treatment consists of endoscopic or surgical sphincteroplasty to ensure wide patency of the distal portions of both the bile and pancreatic ducts.

Dyskinesia of the Sphincter of Oddi

• Proposed mechanisms:• spasm of the sphincter• denervation sensitivity resulting in hypertonicity• abnormalities of the sequencing or frequency rates of

sphincteric contraction waves• Medical treatment with nitrites or anticholinergics to

attempt pharmacologic relaxation of the sphincter has been proposed

• Endoscopic biliary sphincterotomy or surgical sphincteroplasty may be indicated in patients who fail to respond to a 2- to 3-month trial of medical therapy

Bile Salt-Induced Diarrhea and Gastritis

• Cholecystectomy shortens gut transit time by accelerating passage of the fecal bolus through the colon with marked acceleration in the right colon, thus causing an increase in colonic bile acid output and a shift in bile acid composition toward the more diarrheagenic secondary bile acids.

• Treatment with bile acid sequestering agents such as cholestyramine or colestipol

Hyperplastic Cholecystoses

• Group of disorders of the gallbladder characterized by excessive proliferation of normal tissue components

• Adenomyomatosis - a benign proliferation of gallbladder surface epithelium with glandlike formations, extramural sinuses, transverse strictures, and/or fundal nodule formation

Hyperplastic Cholecystoses

• Rokitansky-Aschoff sinuses - outpouchings of mucosa

• Cholesterolosis (strawberry gallbladder) - abnormal deposition of lipid, especially cholesteryl esters within macrophages in the lamina propria of the gallbladder wall

• Cholecystectomy is indicated in both adenomyomatosis and cholesterolosis when symptomatic or when cholelithiasis is present.

Hyperplastic Cholecystoses

• Gallbladder polyps:• Prevalence in adults is ~5%, with a marked

male predominance• Cholecystectomy is recommended in

symptomatic patients, as well as in asymptomatic patients >50 years of age, or in those whose polyps are >10 mm in diameter or associated with gallstones or polyp growth on serial ultrasonography.

Clinical Correlation• Patient• Epigastric pain for 48

hours• Steady, boring, severe,

sudden onset, radiating to the interscapular area

• Had the same severe attack 2 years ago that spontaneously relieved after 2 hours

• Acute cholecystits• Biliary pain that

progressively worsens• Becomes generalized the

RUQ, may radiate to the interscapular area, right scapula, or shoulder

• Approximately 60-70% of patients report having experience prior attacks resolves spontaneously.

Clinical Correlation

• Patient• Icteric sclerae• Temp = 38 Celcius• Abdomen• Slightly distended,

tympanitic, with hypoactive bowel sounds, tender epigastrium, no mass

• Acute cholecystitis• Jaundice is unusual• Low grade fever• Abdomen• RUQ tender with rebound

tenderness, enlarged and tensed gallbladder, abdominal distension, hypoactive bowel sounds