Acute cholecystitis

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1. ACUTE CHOLECYSTITIS LT COL SM SHAHADAT HOSSAIN MCPS,FCPS( Surgery),FCPS(Thoracic Surgery) Adv Trg on Thoracoscopy,CNUH,South Korea

2. ACUTE CHOLECYSTITIS Commonly, it occurs in a patient with pre-existing chronic cholecystitis but often also can occur as a first presentation. Usual cause is impacted gallstone in the Hartmann’s pouch, obstructing cystic duct.

3. Causative bacteria E. coli—most common Klebsiella , Pseudomonas, Proteus Strep. faecalis Salmonella Clostridium welchii

4. Classification 1. Acute calculous cholecystitis . 2. Acute acalculous cholecystitis (10%).

5. Mode of Infection Haematogenous through hepatic artery—cystic artery. Portal vein. Through bile.

6. Pathology of Acute Cholecystitis Gallbladder distended with oedematous friable wall. Wall contains dilated v essels. Areas of necrosis and patchy gangrene may occur in severe cases. Mucosa shows ulceration and necrosis . Lumen contains infected fluid/infected b ile or frank pus.

7. Clinical Features Sudden onset of pain in the right hypochondrium , with tenderness, guarding, and rigidity. Fever, nausea (25%). Jaundice. Tachycardia. Palpable, tender, smooth, soft gallbladder. Area of hyperaesthesia between 9th and 11th ribs right posteriorly ( Boas’s sign). Murphy’s sign: positive.

8. Investigations Total blood count: neutrophilia . LFT increased serum bilirubin . Ultrasound abdomen—reveals presence or absence of gallstone s; and thickening of gallbladder wall. Plain X-ray abdomen—10% of gallstones are radio-opaque. HIDA radioisotope study; Non- visualisation of gallbladder. CT scan to identify perforation, impacted stone , wall thickness and oedema .

9. Differential diagnosis of radio-opaque shadow Kidney stone Gallstone Calcified 12th rib tip Phlebolith P ancreatic stone Radio-opaque foreign body Faecolith Calcified lymph node Calcified renal tuberculosis Adrenal tumour —calcification

10. Ultrasound

11. Complications of Acute Cholecystitis Perforation. Peritonitis. Empyema gallbladder. Cholecystoduodenal , cholecystobiliary fistula, mirrrizi's syndrome. Pericholecystitic abscess. Cholangitis and septicaemia .

12. Differential diagnosis Duodenal ulcer perforation Acute pancreatitis Acute appendicitis Acute pyelonephritis Lobar pneumonia, Myocardial infarction

13. Treatment Conservative treatment (95%): NPO-Nil per mouth. IV fluids. Analgesics and antispasmodics. Broad spectrum antibiotics ( i.e.cefuroxime , ceftriaxone, metronidazole). After 6 weeks elective cholecystectomy.

14. EMPYEMA GALLBLADDER It is a type of acute cholecystitis wherein the gallbladder is filled with pus. When mucocele of the gallbladder gets infected.

15. Treatment Antibiotics: cefotaxime , quinolones, ceftriaxone. Cholecystectomy —an emergency procedure. Cholecystostomy with foley’s or malecot’s catheter kept in situ. After 6 weeks, cholecystectomy is done.

16. MUCOCELE OF THE GALLBLADDER It is due to obstruction of the cystic duct by a stone in the neck ( Hartmann’s pouch) of the gallbladder, without infection or inflammation. This causes absorption of all bile and secretion of mucous allowing gallbladder to distend causing mucocele of the gallbladder. Content is usually sterile.

17. Features: Painless swelling in the right hypochondrium . Non-tender, smooth, soft, globular, palpable gallbladder. Treatment: Cholecystectomy