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ACALCULOUS CHOLECYSTITIS REVISITED

ACALCULOUS CHOLECYSTITIS. 5-10% acute cholecystitisChronic form: biliary symptoms without gallstones Often called biliary dyskinesiaUp to 10-15% laparoscopic cholecystectomies. BILIARY DYSKINESIA. HYPERTONIC -discoordinate gallbladder neck con

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ACALCULOUS CHOLECYSTITIS REVISITED

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    2. ACALCULOUS CHOLECYSTITIS REVISITED Anthony J Dowell MB,BS, MSc, FACS, FRCS(C) Nanaimo Regional General Hospital

    3. ACALCULOUS CHOLECYSTITIS 5-10% acute cholecystitis Chronic form: biliary symptoms without gallstones Often called biliary dyskinesia Up to 10-15% laparoscopic cholecystectomies The symptoms of Irritable Bowel Syndrome are well known. The cause remains obscure, and treatments unsatisfactory. Prokinetic and antikinetic agents give some symptomatic relief for variable periods. This suggests the condition is a motility disorder And either neuronally (through the autonomic) or hormonally mediated. The symptoms of Irritable Bowel Syndrome are well known. The cause remains obscure, and treatments unsatisfactory. Prokinetic and antikinetic agents give some symptomatic relief for variable periods. This suggests the condition is a motility disorder And either neuronally (through the autonomic) or hormonally mediated.

    4. BILIARY DYSKINESIA HYPERTONIC -discoordinate gallbladder neck contraction -cystic duct obstruction -sphincter of Oddi obstruction HYPOTONIC - less than 35% contraction after CCK

    7. CAUSES Likely a motility disorder of gallbladder possibly causing a relative obstruction of cystic duct May be related to Irritable Bowel Syndrome Could be neuronally or humorally mediated Nerves: hepatic branches of left/anterior vagus Hormones: prokinetic: CCK, gastrin, motilin inhibitory: VIP, somatostatin, pancreatic p polypeptide Histamine - contraction via H1 receptors - relaxation via H2 receptors

    8. DIAGNOSIS ULTRASOUND: >95% sensitive for stones CHOLECYSTOGRAM: >95% sensitive. Telepaque HIDA SCAN: - functioning/non - contraction >35% - pain with CCK (Sincalide) BILE ANALYSIS:>95% sensitive for cholecystitis - cholesterol crystals - WBCs - bile microspheroliths ENDOSCOPY: rule out other mucosal pathology

    10. CCK CHOLECYSTOGRAPHY, BILE ANALYSIS & GASTROSCOPY Retrospective study of 140 CCK cholecystograms GI Clinic St Paul’s seemed unreliable alone. Prospective, 1976-81, 5yr follow up 76 patients, mostly female over 40, biliary symptoms, normal cholecystogram or ultrasound Endoscopy: reflux 33 (43%), other 9 (12%) Acalculous cholecystitis: 25/76 (32%)

    11. RESULTS CCK Cholecystography Function –reliable Pain – unreliable: 44% correct, 33% equivocal 24% false pos, 28% false neg Contraction – reliable, 72% predictive Bile Analysis identified both calculous cases identified 76% (19 of 25) of acalculous 16% false neg, 9% false pos Combined predicted 84% (21/25) subsequently cured by cholecystectomy 8% (2)false negative, no false positive

    12. DISCUSSION These 3 investigations produce greater diagnostic accuracy than clinical judgement alone (33% better, 33% same, 33% worse) Overall rate of detecting patients subsequently improved by specific therapy after all 3 investigations 67/77 (87%) Subsequent experience in 32 cases over 20 years in Nanaimo with CCK injection and bile collection with endoscopy, subsequent HIDA scan. 27 correctly predicted (84%)

    13. CONCLUSIONS Endoscopy first. Over half (55%) will have other pathology Add CCK injection to endoscopy to collect bile increases yield to three quarters (76%) CCK cholecystography subsequent to endoscopy, about the same (72%), but if combined with bile collection, increases diagnostic accuracy a further 10%, to 84%, and minimises false positives.

    14. PRACTICAL CONSIDERATIONS Rule out other problem especially malignancy Informed consent – 80% success - 15-20% continuing symptoms bile salt diarrhoea, reflux, irritable bowel syndrome ERCP for postcholecystectomy syndrome, sphincterotomy for papillary stenosis, sphincter of Oddi dysfunction

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