Acute cholecystitis

Acute cholecystitis

Presentation- RUQ pain(4~6hrs), Murphy’s sign, leukocytosis, fever, Mirizzi syndrome(stone at cystic duct, compress common hepatic/common bile duct from external)

Imaging

Ultrasound- Wall>4~5mm, double wall sign
Cholescintigraphy(HIDA scan)- 30~60 mins present at CBD, gallbladder. Positive if absent
Morphine cholescintigraphy- Morphine increased sphincter of Oddi pressure, decreased false positive of HIDA scan
MRCP- Detect stone better than ultrasound, but ultrasound detect wall thickening better
CT

DDx- Biliary colic( Pain after fat-meal, no gallbladder wall thickening, normal lab, pain less than 4~6hrs, less fever)

Diagnosis

A. Local signs of inflammation(1) Murphy’s sign, (2) RUQ mass/pain/tenderness
B. Systemic signs of inflammation(1) Fever, (2) elevated CRP, (3) elevated WBC count
C. Imaging findings
*Suspected diagnosis: one item in A + one item in B*Definite diagnosis: one item in A + one item in B + C

Severity

Grade INot fulfill criteria of grade II and III
Grade II1. Elevated WBC count (>18,000/mm3)
2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 hr
4. Marked local inflammation (gangrenous cholecystitis,pericholecystic abscess, hepatic abscess, biliary peritonitis,emphysematous cholecystitis)
*Present one of these
Grade III1. Cardiovascular dysfunction: hypotension requiring treatment withdopamine ≥5 μg/kg per min, or any dose of norepinephrine
2. Neurological dysfunction: decreased level of consciousness
3. Respiratory dysfunction: PaO2/FiO2 ratio <300
4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT‐INR >1.5
6. Hematological dysfunction: platelet count <100,000/mm3
* Present one of these

Management- Grade I(Early LC within 72hrs), Grade II&III(PTGBD<3 days or >6wks → LC, PTGBD only showed recurrence rate of12.9%)

Complication

Gangrenous cholecystitisMost common → aging people, DM
PerforationAfter gangrene,present of pericholecystic abscess
Cholecystoenteric fistulaFistule from gallbladder to duodenum/jejunum
Gallstone ileusFistula make the stone enter terminal ileum and lead to ileus
Emphysematous cholecystitisSecondary infection of the gallbladder wall with gas-forming organisms (such as Clostridium welchii), Escherichia coli, staphylococci, streptococci, Pseudomonas, and Klebsiella

Treatment:

1.Pain control- ketolorac(30 to 60 mg, IM)→  morphine

2.Antibiotic-

a)Community acquired(mild to moderate severity)→ cefazolin, cefuroxime, or ceftriaxone)

b)Community acquired with severe → Doripenem/ertapenem/imipenem, piperacillin+tazobactam, ciprofloxacin/levofloxacin/cefepime+ metronidazole

c)Healthcare associated → Doripenem/ertapenem/imipenem+ vancomycin, piperacillin+tazobactam+vancomycin,  ciprofloxacin/levofloxacin/cefepime+ metronidazole+vancomycin)

3.NPO, IV fluid, UDCA

Risk stratification- American Society of Anesthesiologists (ASA)- ASA I&II→ early laparoscopic cholecystectomy within 3 days

Prophylactic cholecystectomy- Porcelain GB or > 2cm gallstone

Cholecystectomy indication- Symptomatic, cancer risk, acalculous cholecystitis, polyp>0.5cm, Porcelain gallbladdder

Published by Steve Johnson

I am a doctor who like to organise knowledges and share ideas with others. As a doctor, a lot of knowledges influx everyday and need some patient to organise and absorb. Here was my notes to share with you and hope to save your time to know it.

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