Acute calculous cholecystitis: Difference between revisions
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Even though the infection is not necessarily bacterial, antibiotics are used in the acute phase (in Norway ampicillin + gentamycin + metronidazole is used). If the patient is really ill or antibiotics are insufficient to clear the infection, we must achieve source control by gallbladder drainage or emergency surgery. Gallbladder drainage can be achieved percutaneously or endoscopically (with ERCP). | Even though the infection is not necessarily bacterial, antibiotics are used in the acute phase (in Norway ampicillin + gentamycin + metronidazole is used). If the patient is really ill or antibiotics are insufficient to clear the infection, we must achieve source control by gallbladder drainage or emergency surgery. Gallbladder drainage can be achieved percutaneously or endoscopically (with ERCP). | ||
The definitive treatment for acute calculous cholecystitis is laparoscopic subtotal cholecystectomy, to prevent both complications and recurrence. There are two approaches to the timing of cholecystectomy, early surgery (during the same hospital admission) and delayed surgery (elective surgery after 6+ weeks). | The definitive treatment for acute calculous cholecystitis is laparoscopic subtotal [[cholecystectomy]], to prevent both complications and recurrence. There are two approaches to the timing of cholecystectomy, early surgery (during the same hospital admission) and delayed surgery (elective surgery after 6+ weeks). | ||
In most cases, we opt for early surgery. In complicated cases, one may opt for delayed surgery. This allows the inflammation to heal, making surgery less risky. | In most cases, we opt for early surgery. In complicated cases, one may opt for delayed surgery. This allows the inflammation to heal, making surgery less risky. | ||
Revision as of 20:24, 8 November 2023
Acute calculous cholecystitis is one manifestation of complicated gallstone disease characterised by inflammation of the gallbladder secondary to cystic duct obstruction by a gallstone. It's not necessarily infected by bacteria, but it may be.
Acute calculous cholecystitis may be complicated by gallbladder gangrene, perforation, or emphysema.
Clinical features
Cholecystitis usually presents with right upper quadrant pain which lasts longer than biliary colic, fever, nausea/vomiting, and positive Murphy sign (may be negative in elderly). The patient usually appears ill and may have abnormal vital signs.
Murphy sign refers to the patient abruptly stopping a deep inspiration during palpation of the upper right quadrant due to sudden pain. This occurs because during inspiration, the tender gallbladder is pushed caudally by the expanding lungs, eventually hitting the palpating hand. Note that Murphy sign is not sensitive in elderly.
Diagnosis and evaluation
Laboratory tests show elevated inflammatory parametres. Ultrasound shows gallbladder wall thickening or oedema, and it will likely show gallstones as well. There is usually no evidence of cholestasis, unless there is concomitant choledocholithiasis.
Treatment
Left untreated, most symptoms of cholecystitis are self-limiting. However, the risk of developing complications is high, so treatment is indicated.
Even though the infection is not necessarily bacterial, antibiotics are used in the acute phase (in Norway ampicillin + gentamycin + metronidazole is used). If the patient is really ill or antibiotics are insufficient to clear the infection, we must achieve source control by gallbladder drainage or emergency surgery. Gallbladder drainage can be achieved percutaneously or endoscopically (with ERCP).
The definitive treatment for acute calculous cholecystitis is laparoscopic subtotal cholecystectomy, to prevent both complications and recurrence. There are two approaches to the timing of cholecystectomy, early surgery (during the same hospital admission) and delayed surgery (elective surgery after 6+ weeks).
In most cases, we opt for early surgery. In complicated cases, one may opt for delayed surgery. This allows the inflammation to heal, making surgery less risky.
Complications
Gangrenous cholecystitis
Some people (around 20% of cholecystitides) develop gangrenous cholecystitis, which is more severe than "regular" acute cholecystitis and which may cause sepsis.
Gallbladder perforation
10% of cholecystitis cases are complicated by gallbladder perforation, which may form an abscess or cause peritonitis.
Emphysematous cholecystitis
Cholecystitis complicated by secondary infection with gas-forming bacteria like clostridium may cause cholecystitis with gas in the gallbladder wall. This increases the risk for gangrene or perforation. It's difficult to distinguish from "regular" acute cholecystitis, but crepitus in the abdominal wall may be present.