ACUTE CALCULOUS CHOLE CYSTITIS ACUTE ... - IAGH

REFERENCES
STRAS BERG SM. ACUTE CALCULOUS CHOLECYSTITIS
N ENGL J MED 2008; 358:2804-11
HUFFMAN 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.
Figure
InPanel
2. Hepatobiliary
A, a normal
Scintigraphy.
liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid.
In InPanel B, A, at a 55 normal minutes liver after is visible tracer 10 injection, minutes filling after of the the intravenous bile duct (arrow) injection and of gallbladder a technetium-labeled (arrowhead) analogue can be seen. of iminodiacetic In Panel C, acid. at
1 hour In Panel after B, tracer at 55 injection minutes in after a patient tracer with injection, acute filling cholecystitis of the bile and duct obstruction (arrow) and of the gallbladder cystic duct, (arrowhead) there is filling can of be the seen. bile In duct Panel C, at
(arrow) 1 hour but after no filling tracer of injection the gallbladder. 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 signs
Murphy's sign
Pain or tenderness in RUQ
Mass in RUQ
• Systemic signs
Fever
Leucocytosis
Elevated CRP
• Imaging findings
A confirmatory finding on US or HB scintography
Presence of one local signs or symptoms
One systemic sign, and
A confirmatory finding on an imaging test

acute cholecystitis not meeting criteria for a more severe grade
Mild gallbladder inflammation, no organ dysfunction
VA
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
VB
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 pO 2 of arterial blood to the fraction of inspired oxygen 2mg/dL) Hepatic dysfunction (PT INR >1.5)
• Hematologic dysfunction (platelet

Laparascopic VS open
Early VS delayed
From 24h to 7 days after initial attack
2-3 months after afte initial attack
Percutaneous
Operative

Fasting, obstruction, post surgical ileus, TPN
Inspissated bile toxic to epithelium

Clinical findings
Setting (inpatient, out patient)
Fever, abdominal pain
Leucocytosis, abnormal LFT
Radiology
US
CT
HIDA SCAN
Surgery
Aspiration of GB/ drainage
Laparatomy

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