ACUTE CHOLECYSTITIS

Pableo, Rachel M.

General data

• C.D• 43 y.o.• Female• Married• Roman Catholic• August 4, 1966• Solana,Cagayan• July 29, 2010

Chief complaint

• Right upper quadrant pain

History of Present Illness

• 1 year PTA - recurrent RUQ colicky pain• UTZ – cholecystolithiasis• 3 months PTA - consulted a PMD and

Omeprazole was prescribed• Still with RUQ pain - admission

Past Medical History

• August 2009 – surgery due to a laryngeal cyst at SPH

Family History

• unremarkable

Personal and Social History

• Non-cigarette smoker• Non-alcoholic beverage drinker

Review of Systems

• Integumentary: (-) pruritus• CNS: (-) seizure, (-) h/a, (-) dizziness• Cardiorespiratory: (-) cough, (-) chest pain• GIT: (-) vomiting, (-) diarrhea, (-) constipation• GUT: (-) oliguria, (-) hematuria, (-) dysuria

• Hematologic: (-) gum bleeding, (-) easy bruisability

• Muskuloskeletal: (-) myalgia, (-) arthralgia• Endocrine: (-) weight loss, (-) loss of appetite,

(-) fever

Physical Examination:

• General Survey: Px is conscious, coherent and not in cardiorespiratory distress

Vital Signs:• BP: 120/90• CR: 98 bpm• RR: 20 bpm• Temp: 36.8 C

• Skin: (-) pallor, good skin turgor• HEENT: pink palpebral conjunctiva• Chest and Lungs: (-) rales, (-) wheezes• Heart: AP, NRRR, (-) murmur• Abdomen: flabby, (+) Murphy’s sign• Extremities: (-) edema, FEP

Impression

• Acute Cholecystitis

Date Diagnostics IVF/Meds

7/29/10 11:45 am CBC, UA, UTZ, Na, K, creatinine, RBS, CXR, 12L ECG Sodium : 149 mmol/L (138-145) Potassium: 4.06 mmol/L (3.5-5.4)Glucose : 5.36 mmol/L (4.10 – 5.90) Creatinine: 60 umol/L (53 – 115)Chloride: 104 mmol/L (96 – 110) ALT: 15 u/L (9 – 72)ALKP: 82 u/L (38 – 126)

•Admit to surgery ward•Secure consent for admission and management•NPO•IVF D5LRS 1L q 8 hrs•Medicines: Ampi-Sulbactam 1.5 mg q 12 hrs ANST• Ranitidine 50 mg IV q 12 hrs• Ketorolac 30 mg IV q 8 hrs•For “E” cholecystectomy•Refer to Medicine for eval’n prior to cholecystectomy

Date Diagnostics IVF/ MedsCBC:Hgb: 109 g/L (120-160)Hct: 0.33 (0.38 – 0.47)Erythrocyte no. conc.: 4.9 (4.5 to 6.0 x 109/L)Thrombocyte no. conc.: 243 (150-400 x 109/L)WBC Diff. Ct.: Neutrophils – 38.4 (35-65)Lymphocytes – 41.3 (20-40)Monocytes – 19.3 (2-8)Eosinophils – 0 (0-5)Basophils – 1 (0-1)U/A:Yellow, sl. TurbidpH 6.0SG 1.030(-) chemical testWBC – 12-15/hpf, RBC 6-9 Bacteria - few

Date Diagnostics IVF/ Meds

7/29/10 3:45 pmBP: 130/90, HR: 81 bpm, RR: 18 bpm

UTZ of of Hepatobiliary tree and PancreasResult: CholelithiasisCXR: no cardiomegaly, no infiltration12L ECG : sinus rhythm, non-specific ST-T wave changes

Patient seen and examinedPatient was referred for eval’n due to cholecystectomyA: stable cardiopulmonary status at the time of examinationP: no absolute CI for the contemplated procedure

Date Diagnostics IVF/ Meds7/30/10 1:00 am Post –op orders

Status post cholecystectomyNPOMonitor VS q 15 mins. Until stableOR @ 5-6 pm via face maskIVF: Plain NSS x 30 gtts/ min , D5LRS x 30 gtts/minMeds: Intrathecal morphine given Ketorolac 30 mg IV q g hrs after negative skin testTramadol 50 mg IV PRN - moderate to severe painRanitidine 50 mg IV q 8 hrs while on NPO

Date Diagnostics IVF/ Meds7/30/10 8:50 am

7/31/10 (+) BMSoft, non tender

Soft dietIVF: D5LRS 1L q 8 hrsContinue medsProbable discharge tomorrow D/C TramadolMGHDulcolax 2 adult suppository nowBladder draining prior to dischargeHome Meds:Cefuroxime 500 mg TID for 7 daysKetomed 10 mg 1 tab TIDOmeprazole 20 mg BIDFollow-up - Aug. 5, 2010Discharge

GALLSTONE DISEASE

Discussion

Prevalence and Incidence

• one of the most common problems affecting the digestive tract

• Factors : -age- gender- ethnic background

Predisposing conditions:

- Obesity- pregnancy- dietary factors- Crohn's disease- terminal ileal resection

- gastric surgery- hereditary spherocytosis- sickle cell disease- thalassemia

Prevalence and Incidence

• 3x more in women than men• first-degree relatives - twofold greater

prevalence

NATURAL HISTORY

• asymptomatic throughout life• Some progress to a symptomatic stage, with

biliary colic caused by a stone obstructing the cystic duct - may progress to complications related to the gallstones.

• Approximately 3% of asymptomatic individuals become symptomatic per year.

• Complicated gallstone disease develops in 3 to 5% of symptomatic patients per year.

Gallstone Formation

• result of solids settling out of solution• major organic solutes in bile are:

*bilirubin*bile salts* phospholipids*cholesterol

• classified by their cholesterol content as either:* cholesterol stones * pigment stones – black or brown

CHOLESTEROL STONES

• single large stones with smooth surfaces

• contain variable amounts of bile pigments and calcium, but are always >70% cholesterol by weight

• Most cholesterol stones are radiolucent

• Whether pure or of mixed nature: common primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol.

PIGMENT STONES

• contain <20% cholesterol • dark because of the presence of calcium

bilirubinate• Black pigment

stones are usually small, brittle, black,

and sometimes spiculated

• formed by supersaturation of calcium bilirubinate, carbonate, and phosphate

• Brown stones are usually <1 cm in diameter, brownish-yellow, soft, and often mushy

• usually secondary to bacterial infection caused by bile stasis

• major part of the stone: *Precipitated calcium bilirubinate *bacterial cell bodies

ACUTE CHOLECYSTITIS

• secondary to gallstones in 90 to 95% of cases• Obstruction of the cystic duct by a gallstone

is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall

• It is an inflammatory process, probably mediated by:* lysolecithin*bile salts* PAF

CLINICAL MANIFESTATIONS

• Attack of biliary colic - unremitting and may persist for several days

• Usually right upper quadrant or epigastrium• Radiate to the right upper part of the back or

the interscapular area - more severe

CLINICAL MANIFESTATIONS

• Febrile• Complains of anorexia, nausea, and vomiting • Reluctant to move

• Focal tenderness (RUQ)• A Murphy's sign, an

inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis

Laboratory Findings

• mild to moderate leukocytosis (12,000 to 15,000 cells/mm3

• high WBC (above 20,000) - gangrenous cholecystitis, perforation, or associated cholangitis

• mild elevation of serum bilirubin, < 4 mg/mL, with mild elevation of ALP, transaminases, and amylase

• Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts

• by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct (Mirizzi's syndrome)

DIAGNOSIS

• Ultrasonography is the most useful radiologic test for diagnosing acute cholecystitis

TREATMENT

• IV fluids, antibiotics, and analgesia• Gram (-) aerobes, anaerobes• Typical regimens:

* 3rd generation cephalosporin with good anaerobic coverage * 2nd generation cephalosporin combined with metronidazole

TREATMENT

• aminoglycoside with metronidazole – if the patient is with allergies

• Cholecystectomy – definitive treatment for acute cholecystitis

Laparoscopic cholecystectomy - procedure of choice for acute

cholecystitis

• When patients:* present late (after 3 to 4 days of illness)*unfit for surgery- they can be treated with antibiotics with laparoscopic cholecystectomy scheduled for approximately 2 months later

THANK YOU