Acute Cholecystitis

1. Acute Cholecystitis Group A

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

3. Inflammatory response can be evoked by three factors

6. 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

7. 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

8. Emphysematous Cholecystitis Common in the elderly and those with DM Clinical manifestations similar to nongaseous cholecystitis

9. Diagnosis with plain abdominal film Gas within gall bladder lumen Gaseous ring Prompt surgical intervention with antibiotic therapy mandatory Considerable morbidity Emphysematous Cholecystitis

10. 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

11. Complications of Cholecystitis

14. Treatment

15. 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

16. 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

17. 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.

18. 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

19. 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.

20. Postcholecystectomy Complications

21. 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.

22. 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

23. 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

24. 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.

25. 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.

26. 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

27. 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

28. 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

29. 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.

30. 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.

31. 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.

32. 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