'Lecture: Dr.Mohammad Kamal Aktar

1. Cholecystitis

2. Cholecystitis
usually presents
as a pain in the
right upper
quadrant or
epigastric region.

3. Symptomatically it differs from
biliary colic by the presence of an
inflammatory component (fever,
increased white cell count
).

4. This pain is initially
intermittent, but later usually
presents as constant and
severe

5. During the initial stages,
the pain may be felt in an
area totally separate from
the site of pathology,
known as referred pain.

6. The pain is originally
located in the right upper
quadrant but the referred
pain may occur in the
right scapula region (Boas'
sign).

7. This may also present with the
above mentioned pain after
eating greasy or fatty foods
such as pastries, pies, and fried
foods.

8. This is usually
accompanied by diarrhea,
vomiting and nausea. The
gallbladder may be tender
and distended.

9. More severe symptoms such as high
fever, shock and jaundice indicate the
development of complications such
as abscess formation, perforation or
ascending cholangitis. Another
complication, gallstone ileus, occurs if
the gallbladder perforates and forms
a fistula with the nearby small bowel,
leading to symptoms of intestinal
obstruction.

10. Chronic cholecystitis
manifests with non-
specific symptoms such
as nausea, vague
abdominal pain, belching,
and diarrhea.

11. Causes
Cholecystitis is often caused by
cholelithiasis (the presence of
choleliths, or gallstones, in the
gallbladder), with choleliths most
commonly blocking the cystic duct
directly. This leads to inspissation
(thickening) of bile, bile stasis, and
secondary infection by gut organisms,
predominantly E. coli and Bacteroides

12. The gallbladder's wall becomes
inflamed. Extreme cases may
result in necrosis and rupture.
Inflammation often spreads to its
outer covering, thus irritating
surrounding structures such as
the diaphragm and bowel.

13. Less commonly, in debilitated and
trauma patients, the gallbladder may
become inflamed and infected in the
absence of cholelithiasis, and is
known as acute acalculous
cholecystitis. This can arise in
patients with anorexia nervosa, as
the lack of stimulation of the
gallbladder leads to an infectious
process.

14. Stones in the gallbladder may
cause obstruction and the
accompanying acute attack. The
patient might develop a chronic,
low-level inflammation which
leads to a chronic cholecystitis,
where the gallbladder is fibrotic
and calcified.

15. Diagnosis
Cholecystitis is usually
diagnosed by a history of the
above symptoms, as well as
examination findings:

16. fever (usually low
grade in
uncomplicated
cases)

17. tender right upper
quadrant with or
without Murphy's sign

18. Ortner's sign —
tenderness when hand
taps the edge of right
costal arch

19. Georgievskiy — Myussi's sign
(phrenic nerve sign) — pain
when press between edges
of sternocleidomastoid

20. Boas' sign — Increased
sensitivity below the right
scapula (also due to phrenic
nerve irritation).

21. Subsequent laboratory and
imaging tests are used to
confirm the diagnosis and
exclude other possible causes.
Ultrasound can assist in the
differential

22. Differential diagnosis
[edit] Acute cholecystitis
Differential diagnosis
Acute cholecystitis
Acute cholecysitis as seen on ultrasound.
This should be suspected whenever there
is acute right upper quadrant or epigastric
pain,

23. other possible causes
include:
Perforated peptic ulcer
Acute peptic ulcer
exacerbation
Amoebic liver abscess
Acute amoebic liver colitis

24. Acute pancreatitis
Acute intestinal obstruction
Renal colic
Acute retro-colic appendicitis

25. Chronic cholecystitis
The symptoms of chronic cholecystitis are
non-specific, thus chronic cholecystitis may
be mistaken for other common disorders:
Peptic ulcer
Hiatus hernia
Colitis
Functional bowel syndrome, is defined
pathologically by the columnar epithelium
reaching down to the muscular layer.

26. Quick Differential
Biliary colic — Caused by obstruction of the
cystic duct. It is associated with sharp and
constant epigastric pain in the absence of fever,
and there is usually a negative Murphy's sign.
Liver function tests are within normal limits
since the obstruction does not necessarily
cause blockage in the common hepatic duct,
thereby allowing normal bile excretion from
the liver. An ultrasound scan is used to visualise
the gallbladder and associated ducts, and also
to determine the size and precise position of

27. Cholecystitis — Caused by blockage of the cystic duct with
surrounding inflammation, usually due to infection.
Typically, the pain is initially 'colicky' (intermittent), and
becomes constant and severe, mostly in the right upper
quadrant. Infectious agents that cause cholecystitis
include E. coli, Klebsiella, Pseudomonas, B. fragilis and
Enterococcus. Murphy's sign is positive, particularly
because of increased irritation of the gallbladder lining,
and similarly this pain radiates (spreads) to the shoulder,
flank or in a band like pattern around the lower abdomen.
Laboratory tests frequently show raised hepatocellular
liver enzymes (AST, ALT) with a high white cell count
(WBC). Ultrasound is used to visualise the gallbladder and
ducts.

28. Choledocholithiasis — This refers to blockage of the common
bile duct where a gallstone has left the gallbladder or has
formed in the common bile duct (primary cholelithiasis). As
with other biliary tree obstructions it is usually associated
with 'colicky' pain, and because there is direct obstruction of
biliary output, obstructive jaundice. Liver function tests will
therefore show increased serum bilirubin, with high
conjugated bilirubin. Liver enzymes will also be raised,
predominately GGT and ALP, which are associated with biliary
epithelium. The diagnosis is made using endoscopic
retrograde cholangiopancreatography (ERCP), or the nuclear
alternative (MRCP). One of the more serious complications of
choledocholithiasis is acute pancreatitis, which may result in
significant permanent pancreatic damage and brittle
diabetes.

29. Cholangitis — An infection of entire biliary tract,
and may also be known as 'ascending cholangitis',
which refers to the presence of pathogens that
typically inhabit more distal regions of the bowel[3]
Cholangitis is a medical emergency as it may be life
threatening and patients can rapidly succumb to
acute liver failure or bacterial sepsis. The classical
sign of cholangitis is Charcot's triad, which is right
upper quadrant pain, fever and jaundice. Liver
function tests will likely show increases across all
enzymes (AST, ALT, ALP, GGT) with raised bilirubin.
As with choledocholithiasis, diagnosis is confirmed
using cholangiopancreatography.

30. Investigations
Blood
Laboratory values may be notable for an elevated
alkaline phosphatase, possibly an elevated
bilirubin (although this may indicate
choledocholithiasis), and possibly an elevation of
the WBC count. CRP (C-reactive protein) is often
elevated. The degree of elevation of these
laboratory values may depend on the degree of
inflammation of the gallbladder. Patients with
acute cholecystitis are much more likely to
manifest abnormal laboratory values, while in
chronic cholecystitis the laboratory values are
frequently normal.

31. Radiology
Sonography is a sensitive and specific modality for diagnosis
of acute cholecystitis; adjusted sensitivity and specificity for
diagnosis of acute cholecystitis are 88% and 80%,
respectively. The diagnostic criteria are gallbladder wall
thickening greater than 3mm, pericholecystic fluid and
sonographic Murphy's sign. Gallstones are not part of the
diagnostic criteria as acute cholecystitis may occur with or
without them.
The reported sensitivity and specificity of CT scan findings are
in the range of 90–95%. CT is more sensitive than
ultrasonography in the depiction of pericholecystic
inflammatory response and in localizing pericholecystic
abscesses, pericholecystic gas, and calculi outside the lumen
of the gallbladder. CT cannot see noncalcified gallbladder
calculi, and cannot assess for a Murphy's sign.

32. Hepatobiliary scintigraphy with technetium-
99m DISIDA (bilirubin) analog is also sensitive
and accurate for diagnosis of chronic and
acute cholecystitis. It can also assess the
ability of the gall bladder to expel bile (gall
bladder ejection fraction), and low gall
bladder ejection fraction has been linked to
chronic cholecystitis. However, since most
patients with right upper quadrant pain do
not have cholecystitis, primary evaluation is
usually accomplished with a modality that can
diagnose other causes, as well.

33. Treatment for cholecystitis will
depend on your symptoms and
your general health. People who
have gallstones but don't have any
symptoms may need no treatment.
For mild cases, treatment includes
bowel rest, fluids and antibiotics
given through a vein, and pain
medicine.

34. The main treatment for acute
cholecystitis is surgery to remove
the gallbladder (cholecystectomy).
Often this surgery can be done
through small incisions in the
abdomen (laparoscopic
cholecystectomy), but sometimes it
requires a more extensive operation

35. Sometimes acute cholecystitis is caused
by one or more gallstones getting stuck
in the main tube leading to the
intestine, called the common bile duct.
Treatment may involve an endoscopic
procedure (endoscopic retrograde
cholangiopancreatography, or ERCP) to
remove the stones in the common bile
duct before the gallbladder is removed.

36. Supportive measures are usually instituted prior to
surgery. These measures include fluid
resuscitation and antibiotics. Antibiotic regimens
usually consist of a broad spectrum antibiotic such
as piperacillin-tazobactam (Zosyn), ampicillin-
sulbactam (Unasyn), ticarcillin-clavulanate
(Timentin), or a cephalosporin (e.g.ceftriaxone)
and an antibacterial with good coverage
(fluoroquinolone such as ciprofloxacin) and
anaerobic bacteria coverage, such as
metronidazole. For penicillin allergic patients,
aztreonam and clindamycin may be used.

37. In cases of severe inflammation, shock, or if
the patient has higher risk for general
anesthesia (required for cholecystectomy), the
managing physician may elect to have an
interventional radiologist insert a
percutaneous drainage catheter into the
gallbladder ('percutaneous cholecystostomy
tube') and treat the patient with antibiotics
until the acute inflammation resolves. A
cholecystectomy may then be warranted if the
patient's condition improves.

38. THANK YOU