Ho Teaching- Acute Cholecystitis

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acute cholecystitis

Transcript of Ho Teaching- Acute Cholecystitis

Acute cholecystitis

Acute cholecystitis

Inflammation of gallbladderTypes:Calculous90% of cases Acalculous

CalculousCholesterolPigment (brown/black) Less than 30% cholesterolBlack (insoluble bilirubin pigment layers+calcium+Chole)Brown (calcium+cholesterol)Mixed stones

US/Europe 80% cholesterol/mixed stonesAsia80% pigment stones

AcalculousSeen in pt with prolong immobilisation30% mortality rate, rapid progressSecondary toDecrease mesenteric blood flowBile stasisSalmonella infectionRisk Factors6FFemaleFatFertileFortyFatty food intoleranceFlatulence

Presenting complainAcute right upper quadrant pain steady and severe pain, worsened by movement and deep breathingMay radiate to the backFever FlatulenceNausea and vomitinganorexia

Physical examinationUsually appears ill, febrile and tachycardicJaundice in few casesGuardingTenderness more over RHCPositive murphy's sign

InvestigationFBC, LFT, amylaseFindingsLeukocytosisSlight elevation of liver enzymes

Imaging studies (to confirm diagnosis)XraysAbdominal radiographs demonstrate 10% of all gallstonesenlarged GB shadowRadio-opaque: calciumRadiolucent: cholesterol stones

UltrasoundOperator dependantSensitivity: 96% Specificity: 95%Suboptimal in fat ptFindings+ Murphys signwall thickening (> 4-5mm)wall edema

CT Abdomen

Radioisotope scanningHIDA (HPB iminodiacetic acid) given IVSelectively takene by liver cells and excreted into bile90% normal individual GB visualized within 30minsNon visualisation sign suggestive of acute cholecystitis

DifferentialsAcute peptic ulcerAcute cholecystitisAcute appendicitisAcute pancreatitisAcute pyelonephritisPneumoniaFitz-Hugh-curtis syndrome

TreatmentSymptoms subsides in 90% of cases withh conservative measureFour principlesNBM and IVDAnalgesicsAntibioticsSubsequent MxAntibioticsThe current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h)ampicillin/sulbactam (Unasyn, 3 g IV q6h)meropenem (Merrem, 1 g IV q8h)third-generation cephalosporin plus metronidazole (Flagyl, 1 g IV loading dose followed by 500 mg IV q6h).

Subsequent MxIf inflammation subsiding-> start feeding accordinglyUSGMRCP for jaundice ptCT if suspected perforationCholecystectomy done electively. High risk pt can proceed with percutaneous transhepatic cholecystostomy drainageConservative mx to be abandoned if pain and tenderness increaseCholecystectomy to be done if pt becoming more septicCholecystectomyOpen and laparascopicStudy done in "Virgen de la Arrixaca" University Hospital, El Palmar (Murcia), Spain. 1998Patients 114 underwent LC, and 110 underwent OCResultsConversion from LC to OC was necessary in 15% op.Complications occurred in 14% of the patients in the LC group and in 23% of the patients in the OC group, with no significant differences between the 2 groups (P=.06)The length of the hospital stay averaged 8.1 days for the OC group and 3.3 days for the LC group (P