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Cholecystitis

  1. ACUTE CHOLECYSTITIS

Epidemiology/Etiology

  • Most common in patients with pre-existing chronic cholecystitis
  • Highest frequency in 50-70 years old
  • Most common cause is due to impacted gallstone in Hartmann’s pouch, obstructing the cystic duct

Pathogenesis

  • Stone causes obstruction at Hartmann’s pouch or in cystic duct
    • Obstruction leas to stasis, oedema of the wall and bacterial infection
    • Most common bacteria – E. coli, Klebsiella, Pseudomonas, Clostridium welchii
  • Impacted stone also causes mucosal erosion
    • Exposes the submucosal tissues to bile salts which are toxic to them
    • Leads to necrosis, further infection and perforation of the gallbladder at Hartmann’s pouch
  • Gall bladder is distended with edematous wall
    • Lumen contains infected fluid/bile or pus

Emphysematous cholecystitis (surgical emergency)

  • Form of acute cholecystitis where gallbladder wall necrosis causes gas formation in the lumen
  • More common in patients who are elderly, diabetic or immunocompromised
  • Causative organism is C. welchii
  • Can result in gangrene, perforation, peritonitis and septicaemia
  • Emergency cholecystectomy is needed

Clinical features

  • Sudden onset of pain in right hypochondrium with tenderness, guarding, rigidity
  • Palpable, tender, smooth gallbladder
  • Boa’s sign – area of hyperaesthesia between 9th and 11th rib posteriorly on the right side
  • Murphy’s sign – patient is in sitting position, on deep inspiration while palpating in right hypochondrium the patient winces with pain
  • Jaundice
  • Fever, nausea, tachycardia

Investigations

  • US abdomen – can reveal gallstones and thickening of gallbladder wall
  • 99mTc-HIDA scintigraphy – non-visualisation of the gallbladder is diagnostic
  • CT – shows gallstone, distension, wall thickening
  • Plain XR – gas seen in emphysematous cholecystitis
  • Neutrophilia
  • Liver function tests – elevated serum bilirubin signifies cholangitis or stone in CBD

Treatment

  • Conservative treatment
    • Nasogastric aspiration
    • IV, analgesics, antispasmodics
    • Broad spec antibiotics – ceftriaxone, cefotaxime, amikacin
    • Observation and follow-up US
  • After 3-6 weeks elective cholecystectomy
  • Immediate cholecystectomy
    • Indications – empyema gallbladder, emphysematous gallbladder or persisting/worsening symptoms

Complications

  • Perforation – most common in the fundus or neck (Hartmann’s pouch)
    • Can cause cholecystoduodenal or cholecystobiliary fistula
  • Peritonitis
  • Pericholecystitic abscess
  • Empyema gallbladder
  • Cholangitis and septicaemia

2. ACUTE ACALCULOUS CHOLECYSTITIS

  • Development of cholecystitis in the absence of gallstones
  • Most common in
    • Patients who have undergone major surgeries, traumas or burns
    • Patients who are hospitalised and critically ill i.e. ICU patients
    • Patients with vasculitis and congestive heart failure
  • Thought to occur due to biliary stasis or gallbladder ischaemia
  • Pathology – oedema and necrosis of the gallbladder wall with features of acute inflammation
  • Investigations – US abdomen, HIDA scan
  • Treatment – cholecystectomy

3. CHRONIC CHOLECYSTITS

Epidemiology/Etiology

  • Occurs after repeated episodes of acute cholecystitis
  • Most often due to gallstones
  • Can also result from acalculous cholecystitis

Pathology

  • Chronically inflamed, non-functioning and nondistending gallbladder
    • Gallbladder is shrunken, contracted, small and fibrotic with thickened wall
  • Mucosa proliferates into the lumen creating deep clefts in the wall of the gallbladder – Rokitansky-Ashcoff’s sinuses
  • Muscular wall is atrophied and replaced by fibrous tissue
  • Histologically – dense chronic inflammation with fibrous tissue

Clinical features

  • Can be asymptomatic
  • Pain in right hypochondrium – colicky or persistent
  • Murphy’s sign
  • Flatulent dyspepsia
  • Intolerance to fatty meals

Investigations

  • US abdomen – stone, thickened GB
  • HIDA
  • LFT

Treatment

  • Cholecystectomy

Complications

  • CBD stone
  • Cholangitis
  • Pancreatitis
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