Acute cholecystitis

Incidence

Age - any

Sex

Geography

Aetiology
- in > 90% of cases, the gallbladder contains gallstones
- obstruction to neck of gallbladder or cystic duct by an impacted stone -> distension and inflammation
- inflammation is usually sterile, but within 24 hours gut organisms can be cultured

- the inflammation may occasionally subside leaving a mucocele
- more commonly, the inflammation involves the whole wall of the gallbladder -> localized peritonitis and acute pain
- gallbladder may become distended by pus (empyema)
- rarely there may be acute gangrenous cholecystitis with perforation and more generalized peritonitis

Presentation
History
- severe pain in epigastrium and R hypochondrium
- continuous pain increasing in intensity over 24 hours
- may radiate to back and shoulder
- ± nausea and vomiting
- mild jaundice in 20% of cases

Examination
- patient is ill with fever and shallow respirations
- R hypocohondrial tenderness, worse on inspiration (Murphy's sign)
- guarding and rebound tenderness

Differential diagnosis
- other abdominal emergencies; peroforated peptic ulcer, retrocaecal appendicitis, acute pancreatitis
- R basal pneumonia
- MI

Investigations
FBC
- moderate leucocytosis

LFTs
- slightly raised bilirubin, ALP, AST/ALT

USS
- presence of gallstones (not diagnostic)
- sonographic Murphy's sign - focal tenderness directly over visualized gallbladder
- gallbladder wall thickening
- didtended gallbladder
- biliary sludge
- pericholecystic fluid

Iodida scintiscan
- blockage of cystic duct

Macro

Micro

Staging

Serum markers

Management
Medical
- bedrest, NBM and i.v. fluids
- antibiotic - amoxycillin or a cephalosporin
- pain relief - an opiate is usually required
- signs of complication, e.g. empyema, generalized peritonitis or gangrene of the gallbladder require USS reassessment ± immediate surgery

Surgical
- cholecystectomy within days of acute attack, as long as patient is not an anaesthetic risk; does not increase operative mortality or morbidity

Prognosis

Complications

Hepatobiliary medicine

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Incidence
Age	- any
Sex
Geography
Aetiology	- in > 90% of cases, the gallbladder contains gallstones - obstruction to neck of gallbladder or cystic duct by an impacted stone -> distension and inflammation - inflammation is usually sterile, but within 24 hours gut organisms can be cultured - the inflammation may occasionally subside leaving a mucocele - more commonly, the inflammation involves the whole wall of the gallbladder -> localized peritonitis and acute pain - gallbladder may become distended by pus (empyema) - rarely there may be acute gangrenous cholecystitis with perforation and more generalized peritonitis
Presentation	History - severe pain in epigastrium and R hypochondrium - continuous pain increasing in intensity over 24 hours - may radiate to back and shoulder - ± nausea and vomiting - mild jaundice in 20% of cases Examination - patient is ill with fever and shallow respirations - R hypocohondrial tenderness, worse on inspiration (Murphy's sign) - guarding and rebound tenderness Differential diagnosis - other abdominal emergencies; peroforated peptic ulcer, retrocaecal appendicitis, acute pancreatitis - R basal pneumonia - MI
Investigations	FBC - moderate leucocytosis LFTs - slightly raised bilirubin, ALP, AST/ALT USS - presence of gallstones (not diagnostic) - sonographic Murphy's sign - focal tenderness directly over visualized gallbladder - gallbladder wall thickening - didtended gallbladder - biliary sludge - pericholecystic fluid Iodida scintiscan - blockage of cystic duct
Macro
Micro
Staging
Serum markers
Management	Medical - bedrest, NBM and i.v. fluids - antibiotic - amoxycillin or a cephalosporin - pain relief - an opiate is usually required - signs of complication, e.g. empyema, generalized peritonitis or gangrene of the gallbladder require USS reassessment ± immediate surgery Surgical - cholecystectomy within days of acute attack, as long as patient is not an anaesthetic risk; does not increase operative mortality or morbidity
Prognosis
Complications