-IBIS-1.5.0-
tx
digestive system
cholecystitis
diagnoses
definition and etiology
definition:
an acute or chronic inflammation of the gallbladder
etiology:
In 95% of patients, the cause is obstruction of the gallbladder outlet or cystic duct by a calculus. Other causes include chemical irritation and digestive factors (e.g. high fat foods, pork, onions and eggs). Cholecystitis is generally regarded to be a disease of the four "f's": female, fat, forty, and fertile (non-menopausal). Chronic cholecystitis is the most common illness associated with the gallbladder, and is defined as a chronic inflammatory reaction. It is almost always secondary to gallstones, and it is thought to be caused by persistent bouts of acute or subacute cholecystitis or from mechanical irritation by the stone(s). It may also develop insidiously without any acute attacks, although the patient will eventually present with symptoms similar to acute cholecystitis.
signs and symptoms
signs and symptoms: acute
pain in the acute disease often begins as biliary colic which gets progressively worse
approximately 60-70% of patients will have histories of previous attacks that cleared spontaneously
pain is usually in the right upper quadrant, although radiation can occur in the epigastric area and to the tip of the right scapula
pain often begins at night or in the early morning, with a sudden or gradual onset; the pain can be quite severe, and is usually constant
vomiting of a bilious nature is common, as well as anorexia, nausea, and flatulence
slight icterus may be present, especially in severe cases
fever, if present, is usually slight (around 101° F): a high fever leads to a suspicion of cholangitis
marked guarding and rigidity in the right upper quadrant of the abdomen
localized tenderness, a tender liver edge and inspiratory arrest on deep palpation (Murphy's sign)
gallbladder is palpable in 50% of cases, and thus can be a key to diagnosis
lab findings:
increased ESR
moderate leukocytosis (10,000 - 15,000 cu mm, if > 15,000 suspect empyema or perforation) with a slight shift to the left
serum amylase and lipase values will be elevated in approximately 15% of patients
serum bilirubin levels commonly reach 3-4 mg/dl; higher levels may indicate cholelithiasis or pancreatitis
X-rays: plain film may identify some gallstones; cholecystogram is much more reliable; negative finding doesn't rule out cholecystitis, as a marked number of patients presenting with the disease will not have discernible calculi
ultrasound is accurate and reliable, especially in the acute condition
intervenous cholangiography can be helpful by showing the bile ducts, although the gallbladder will not be visualized
radionuclide scanning with labeled HIDA is a highly sensitive and specific test and is extremely useful in gathering functional information concerning cystic duct patency; alone it can reliably confirm or rule out the diagnosis
serum AST elevated in 75% of patients
course and prognosis
complications of acute cholecystitis:
gangrene: total necrosis of one or many areas of the gallbladder, usually due to venous stasis and the loss of arterial blood flow following edema of the GB
perforation: usually a result of gangrene, it occurs in about 10% of patients presenting with acute cholecystitis; it is a medical emergency requiring surgery and carries high morbidity and mortality rates
empyema: frank infection of the gallbladder which contains thick purulent material, most commonly caused by E. coli; surgery is mandatory
postoperative acute cholecystitis: a type of acute cholecystitis that can occur following any type of abdominal surgery; the cause is unknown and the morbidity and mortality are extremely high.
internal biliary fistula: communication of the bile ducts or gallbladder with the surrounding hollow viscera
gallstone ileus: mechanical obstruction of the intestinal tract from the passage of a large gallstone into the bowel lumen
porcelain gallbladder: from calcium salt deposition in the walls of a chronically inflamed and irritated gallbladder; it has a high association with gallbladder cancer; cholecystectomy is indicated
Conventional treatment of the acute and chronic disease may initially be pharmacologic, but usually ends in cholecystectomy, as attacks frequently recur. 25% of patients treated conventionally without surgery will have a recurrence within one year; 60% will have a recurrence within 6 years.
differential diagnosis
biliary colic
inflamed or leaking duodenal ulcer
rupture of gallbladder or a biliary duct
torsion of the gallbladder
peptic ulcer
pancreatitis or pancreatic cancer
hepatitis
renal pain or colic
appendicitis
pleurisy or pleuropneumonia
myocardial ischemia
intestinal obstruction or disease
footnotes