Acute Cholecystitis DR DILIP S.RAJPAL

ACUTE CHOLECYSTITIS
DR DILIP S.RAJPAL
MS, MAIS, FICS(USA), FMAS,
Dipl. In Laproscopic surgery,
Fellow in Robotic & Lap. Colo-Rectal Surgery(korea univ.)

CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

HON SURGEON NOVA MEDICAL CENTRE
HON SURGEON GODREJ MEMORIAL HOSPITAL
HON. ASS PROF GRANT MED. COLLEGE
HON.SURGEON JJ. HOSPITAL
EX-ASST. PROF L.T.M.GEN. HOSPITAL

ANATOMY OF GIT

FOREGUT
MIDGUT
HINDGUT

CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL

PATHOPHYSIOLOGY
OBSTRUCTION
STASIS
DISTENTION
INCREASE IN INTRALUMINAL PRESSURE
STIMULATION OF INFLAMATORY
MEDIATORS
COMMENSALS BECOME VIRULENT
INFECTION
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL

VISCERAL PAIN

DULL, CRAMPY OR ACHING PAIN.
GEOMETRIC FORCES SUCH AS
DISTENTION, STRETCHING,
TRACTION, CONTRACTION &
CERTAIN CHEMICALS GIVE RISE
TO PAIN.
ALWAYS FELT IN MIDLINE.


DEFINITION

Inflammation of gall bladder is
called
ACUTE CHOLECYSTITIS .


INCIDENCE
COMMON IN FERTILE

FATTY

ABOVE FORTY

FEMALES


AETIOLOGY
1 CALCULOUS
Obstruct cystic duct

ACALCULOUS
Cholesterosis(strawberry gall bladder)
Cholesterol polyposis of gall bladder
Cholecystitis glandularis proliferans
Diverticulosis of gall bladder
Typhoid of gall bladder

BACTERIAL INFECTION
E-coli
Klebsiella
S.faecalis
Salmonella
Clostridia Anaerobes


SEVERE ILLNESS
Ileus
Sepsis
Severe burns/injuries
Starvation
Multiple blood transfusions

CARCINOMA

PATHOLOGY
INFLAMMATION
LOCALIZATION
• Ileus
• Movement of omentum
• Loops of intestine
RESOLUTION
EMPYEMA
MUCOCELE
PERFORATION
 GENERALIZED PERITONITIS
LOCAL ABSCESS
FISTULA

CLINICAL FEATURES
PAIN
SITE - RIGHT HYPOCHONDRIUM
TYPE - COLICKY
ONSET – SUDDEN
DURATION – MORE THAN 12 hrs
RADIATION
 BACK
 SHOULDER
 RIGHT HYPOCHONDRIUM
 LEFT HYPOCHONDRIUM

PRECIPITATING FACTORS
 Fatty Food
 Movement
 Breathing
RELIEVING FACTORS
 Analgesics

FEVER
NAUSEA/VOMITING
DISTENTION/CONSTIPATION
JAUNDICE

SIGNS
GENERAL
 TACHYCARDIA
 PYREXIA
LOCAL
TENDERNESS - RT HYPOCHONDRIUM
RIGIDITY - RT HYPOCHONDRIUM
MURPHY’S SIGN
MASS

INVESTIGATIONS
BLOOD COMPLETE PICTURE
 LEUCOCYTOSIS
URINE
 BILIRUBIN
PLAIN X-RAY ABDOMEN
 Radioopaque gall stones
ULTRASONOGRAPHY
 Dilatation of billiary tree
 Stones
 Fluid

GALL BLADDER RADIONUCLIDE SCAN

ORAL CHOLECYSTOGRAM

PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTC)

ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)

MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)

ABDOMINAL ULTRASOUND SHOWING GALL DILIP S.RAJPAL
CONSULTANT GEN. SURGEON DR
STONES

DIFFERENTIAL DIAGNOSIS
COMMON
 ACUTE PANCREATITIS
 PERFORATED DUODENAL ULCER
 PERFORATED PEPTIC ULCER
 APPENDICITIS

RARE
ACUTE PYELONEPHRITIS
HEPATITIS
MYOCARDIAL INFARCTION
PNEUMONITIS

COMPLICATIONS
EMPYEMA
PERFORATION
 PERITONITIS
ABSCESS
FISTULA
MUCOCELE
ACUTE PANCREATITIS
GALL STONE ILEUS
OBSTRUCTIVE JAUNDICE


Definitions

Symptomatic Wax/waning postprandial epigastric/RUQ
cholelithiasis pain due to transient cystic duct
obstruction by stone, no fever/WBC,
normal LFT
Acute Acute GB inflammation due to cystic duct
cholecystitis obstruction. Persistent RUQ pain +/-
fever, ↑WBC, ↑LFT, +Murphy’s =
inspiratory arrest


Chronic cholecystitis -Recurrent bouts of colic/acute
chol’y leading to chronic GB wall inflamm/fibrosis. No
fever/WBC.

Acalculous cholecystitis -GB inflammation due to biliary
stasis(5% of time) and not stones(95%). Seen in
critically ill pts

Choledocho-lithiasis -Gallstone in the common bile duct
(primary means originated there, secondary = from
GB)

Cholangitis -Infection within bile ducts usu due to
obstrux of CBD. Charcot triad: RUQ pain, jaundice,
fever (seen in 70% of pts), can lead to septic shock

Case 1
46yo F w RUQ pain x4hr, after a fatty
meal, radiating to the R scapula, also w
nausea. Pt is pain-free now.
No prior episodes
Minimal RUQ tenderness, no Murphy’s
WBC 8, LFT normal
RUQ U/S reveals cholelithiasis without GB
wall thickening or pericholecystic fluid
Diagnosis: ?

Case 1
→ denotes
gallstones

→
→ ► denotes the
acoustic
shadow due to
► absence of
reflected sound
waves behind
the gallstone


Symptomatic cholelithiasis
aka “biliary colic”
The pain occurs due to a stone
obstructing the cystic duct, causing wall
tension; pain resolves when stone passes
Pain usually lasts 1-5 hrs, rarely > 24hrs
Ultrasound reveals evidence at the crime
scene of the likely etiology: gallstones
Exam, WBC, and LFT normal in this case
Treatment: Laparoscopic
cholecystectomy

Spectrum of Gallstone Disease
Cholelithiasis Symptomatic
cholelithiasis
can be a herald
to:
Asymptomatic Symptomatic – an attack of
cholelithiasis cholelithiasis acute
cholecystitis
– or ongoing
chronic
Chronic Acute cholecystitis
calculous calculous
cholecystitis cholecystitis May also resolve

Case 2
Same case, except pt has had
multiple prior attacks of similar RUQ
pain
No fever or WBC
Ultrasound reveals gallstones,
thickened GB wall, no pericholecystic
fluid

Diagnosis: ?

Chronic calculous cholecystitis
Recurrent inflammatory process due
to recurrent cystic duct obstruction,
90% of the time due to gallstones
Overtime, leads to scarring/wall
thickening

Treatment: laparoscopic
cholecystectomy

Case 3
Same pt, now > 24hrs of RUQ pain
radiating to the R scapula, started after
fatty meal, a/w nausea, vomiting, fever
Exam: Palpable, tender gallbladder,
guarding, +Murphy’s = inspiratory arrest
WBC 13, Mild ↑LFT
U/S: gallstones, wall thickening (>4mm),
GB distension, pericholecystic fluid,
sonographic Murphy’s sign (very specific)
Diagnosis: ?

Case 3
Curved arrow
– Two small stones
at GB neck
◄
Straight arrow
– Thickened GB wall

◄
– pericholecystic fluid
= dark lining
outside the wall

Case 3

→ denotes the
→ GB wall
► thickening

► denotes the
fluid around the
GB

GB also appears
distended

Acute calculous cholecystitis
Persistent cystic duct obstruction leads to
GB distension, wall inflammation &edema
Can lead to:empyema, gangrene, rupture
Pain usu. persists >24hrs & a/w
N/V/Fever
Palpable/tender or even visible RUQ mass
Nuclear HIDA scan shows nonfiling of GB
– If U/S non-diagnostic, obtain HIDA
Tx: NPO, IVF, Abx (GNR & enterococcus)
Sg: Cholecystectomy usu within 48hrs
DR DILIP S.RAJPAL

Case 4
87yo M critically ill, on long-term
TPN w RUQ pain, fever, ↑WBC
Ultrasound: GB wall thickening,
pericholecystic fluid, no gallstones

Diagnosis: ?


Acute acalculous cholecystitis
In 5-10% of cases of acute cholecystitis
Seen in critically ill pts or prolonged TPN
More likely to progress to gangrene,
empyema, perforation due to ischemia
Caused by gallbladder stasis from lack of
enteral stimulation by cholecystokinin
Tx: Emergent cholecystectomy usu open
If pt is too sick, perc cholecystostomy
tube and interval cholecystectomy later
on & COLOPROCTOLOGIST
CONSULTANT GEN. SURGEON
LAPROSCOPIST
DR DILIP S.RAJPAL

Complications of acute cholecystitis
Empyema of Pus-filled GB due to bacterial
gallbladder proliferation in obstructed GB. Usu.
more toxic, high fever

Emphysematous More commonly in men and diabetics.
cholecystitis Severe RUQ pain, generalized sepsis.
Imaging shows air in GB wall or lumen

Perforated Occurs in 10% of acute chol’y, usually
gallbladder becomes a contained abscess in RUQ

Less commonly, perforates into adjacent
viscus = cholecystoenteric fistula & the
stone can cause SBO (gallstone ileus)

Case 5
46yo F p/w RUQ pain, jaundice, acholic
stools, dark tea-colored urine, no fevers
Known history of cholelithiasis
Exam: unremarkable
WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg
Ultrasound: Gallstones, CBD stone,
dilated CBD > 1cm
Diagnosis: ?

Choledocholithiasis
Can present similarly to cholelithiasis,
except with the addition of jaundice
DDx: cholelithiasis, hepatitis, sclerosing
cholangitis, less likely CA with pain
Tx: Endoscopic retrograde
cholangiopancreatography (ERCP)
– Stone extraction and sphincterotomy
Interval cholecystectomy after recovery
from ERCP


Case 6
46yo F p/w fever, RUQ pain, jaundice
(Charcot’s triad)
If also altered mental status and signs
of shock = Raynaud’s pentad
VS tachycardic, hypotensive
ABC’s, Resuscitate
– 2 large bore IV, Foley, Continuous monitor
– 1-2L fluid bolus, repeat until resuscitated
Diagnosis: ?

Cholangitis
Infection of the bile ducts due to CBD
obstruction 2ndary to stones, strictures
Charcot’s triad seen in 70% of pts
May lead to life-threatening sepsis and
septic shock (Raynaud’s pentad)
Tx: NPO, IVF, IV Abx
Emergent decompression via ERCP or
perc transhepatic cholangiogram (PTC)
Used to require emergency laparotomy

Case 7
46yo F p/w persistent epigastric & back
pain
Known history of symptomatic gallstones
No EtOH abuse
Exam: Tender epigastrum
Amylase 2000, ALT 150
Ultrasound: Gallstones
Diagnosis: ?


Gallstone pancreatitis

35% of acute pancr 2ndary to stones
Pathophysiology
– Reflux of bile into pancreatic duct and/or
obstruction of ampulla by stone
ALT > 150 (3-fold elevation) has 95%
PPV for diagnosing gallstone pancreatitis
Tx: ABC, resuscitate, NPO/IVF, analgesic
Once pancreatitis resolving, ERCP w
stone extraction/sphincterotomy
Cholecystectomy before hosp discharge

Take Home Points
As always, ABC & Resuscitate before Dx
Understanding the definitions is key
Is this acute cholecystitis? (fever, WBC,
tender on exam with positive Murphy’s)
Or simply cholelithiasis vs ongoing chronic
cholecystitis? (no fever/WBC)
Is patient sick or toxic-appearing, to suspect
empyema, gangrene or even perforation?
Elicit h/o jaundice, acholic stools, tea-colored
urine
Rule out cholangitis, because this will kill the
patient unless dx & tx early

Acute Cholecystitis DR DILIP S.RAJPAL

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