m89-Acute Calculous Chole Cystitis 1-2

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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.


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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


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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 posterioracoustic 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)


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Figure 2. Hepatobiliary Scintigraphy.

InPanel A, a normal liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid.

In Panel B, at 55 minutes after tracer injection, filling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, at

1 hour after tracer injection 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.

Figure 2. Hepatobiliary Scintigraphy.

InPanel A, a normal liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid.

In Panel B, at 55 minutes after tracer injection, filling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, at

1 hour after tracer injection 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.


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Local symptoms and signsMurphy's sign

Pain or tenderness in RUQ

Mass in RUQ

Systemic signsFever

Leucocytosis

Elevated CRP

Imaging findingsA 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


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acute cholecystitis not meeting criteria for a more severe grade

Mild gallbladder inflammation, no organ dysfunction

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

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 pO2 of arterial blood to the fraction of inspired oxygen 2mg/dL) Hepatic dysfunction (PT INR >1.5)

Hematologic dysfunction (platelet


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Laparascopic VS open

Early VS delayed

From 24h to 7 days after initial attack

2-3 months after afte initial attack

Percutaneous

Operative


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Fasting, obstruction, post surgical ileus, TPN

Inspissated bile toxic to epithelium


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SurgeryRadiologyClinical findings

Aspiration of GB/ drainageUSSetting (inpatient, out patient)

LaparatomyCTFever, abdominal painHIDA SCANLeucocytosis, abnormal LFT


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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 HealthScience at San Antonio, San Antonio, TX).

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m89-Acute Calculous Chole Cystitis 1-2