Acute calculous cholecystitis

Dr Noor
Dr Ramadhani
Acute calculous cholecystitis
• Occulusion of the cystic duct by gallstones
• Results in gallblader wall inflamation and eventually to ischaemic
necrosis or perforation

Nb –acalculous cholecystitis
- accounts for 5 to 10% of all patients with acute cholecystitis.
-occurs most frequently in critically ill patients following insults
such as trauma, large surface burns, long-term parenteral nutrition, and
after major nonbiliary operations
Pathogenesis
• Cystic duct obstruction
• Irritants can lead to gallbladder inflamation ;
lysolecithin ,prostaglandins .
• Infection of bile within the biliary system probably has a role in the
development of cholecystitis.
• The main species isolated were Escherichia coli, Enterococcus,
Klebsiella, and Enterobacter.
• Histologic changes of the gallbladder in acute cholecystitis can range
from mild edema and acute inflammation to necrosis and gangrene.
• Occasionally, prolonged impaction of a stone in the cystic duct can
lead to a distended gallbladder that is filled with colourless, mucoid
fluid.

• This condition, known as a mucocele with white bile (hydrops), is due

to the absence of bile entry into the gallbladder and absorption of all
the bilirubin within the gallbladder.
Clinical presentation
• sharp RUQ pain unremitting which lasts hours to days
• May radiate to the rt shoulder or back
• May have hx of ingestion of fatty meal before the pain onset
• Fevers ,nausea ,vomiting and lack of appetite
p/e ; ill appearing ,febrile , tachy
positive Murphys sign (sensitivty 97% specificity 48%)
voluntary or involuntary guarding
Patients with complications may have signs of sepsis (gangrene),
generalized peritonitis (perforation), abdominal crepitus
(emphysematous cholecystitis), or bowel obstruction (gallstone ileus).
• Lab works ; WBC – normal /mild leukocytosis (12000-15000),mild
increase in ALP ,transaminase and bilirubin (<6mg/dl)

• Elevation in the serum total bilirubin and ALP concentrations

are not common in uncomplicated acute cholecystitis since
obstruction is limited to the gallbladder.
• if present, they should raise concerns about biliary obstruction and
conditions such as cholangitis, choledocholithiasis, or Mirizzi
syndrome
Diagnostic imaging
U/S;
• Sensitivity 84% and specificity 99%
• Features ;
Gallbladder wall thickening (greater than 4 to 5 mm), pericholecystic
fluid, or edema (double wall sign)
sonographic murphys sign
Cholescintigraphy (hepatic iminodiacetic acid
)(HIDA)
• Uses 99m Tc sensitivity 90-97% specifity 77-90%
• Done when diagnosis is uncertain after u/s
• Used to check patency of the cystic duct ,CBD , and ampulla
• Normally, visualization of contrast within the common bile duct,
gallbladder, and small bowel occurs within 30 to 60 minutes.
• When the gallbladder is not visualized within 60 minutes, delayed
images (at three to four hours) or morphine augmentation is obtained.
• Nonvisualization of the gallbladder 30 minutes post-morphine or on
delayed images is diagnostic of acute cholecystitis.
CT scan
• Not routinely done

• To rule out complications of acute cholecystitis in patients

with sepsis (gangrene), generalized peritonitis (perforation),
abdominal crepitus (emphysematous cholecystitis), or bowel
obstruction (gallstone ileus).
MRI
• MRI/MRCP is useful for diagnosing acute cholecystitis. It
is recommended if abdominal US does not provide a
definitive diagnosis. (Recommendation 2, level B)
Complication
• Gangrenous cholecystitis ; most common complication (20%)
mostly in older px ,pxs with DM,delay in presentation
• Perforation ;(10%) occurs in patients with a delay in diagnosis or failure to
respond to initial therapy.
occurs at the fundus
• Emphysematous cholecystitis ; caused by secondary infection of the
gallbladder wall with gas-forming organisms (such as Clostridium welchii)
Affected patients are often men in their 50 - 70 decade, and approximately
1/3 to 1/2 have diabetes
Rarely would you get crepitus on the abdominal wall
• Cholecystoenetric fistula ; may result from perforation of the gallbladder
directly into the intestinal lumen.
While the majority of fistulas are cholecystoduodenal fistulas,
approximately 15 percent are cholecystocolonic, most commonly to the
hepatic flexure
Symptoms of a cholecystocolonic fistula include bile acid diarrhea and
rarely intestinal obstruction due to gallstone ileus.

• Gallstone ileus ; Passage of a gallstone, usually larger than 2.5 cm, through a
cholecystoenteric fistula may lead to the development of mechanical bowel
obstruction,
usually in the narrowest part of the terminal ileum which is approximately
two feet proximal to the ileocecal valve
 Diagnosis criteria TG 18
A. Local signs of inflammation etc.

(1) Murphy's sign, (2) RUQ mass/pain/tenderness

B. Systemic signs of inflammation etc.

(1) Fever, (2) elevated CRP, (3) elevated WBC count

C. Imaging findings

Imaging findings characteristic of acute cholecystitis

Suspected diagnosis: one item in A + one item in B

Definite diagnosis: one item in A + one item in B + C

Management
Supportive ;
• Patients diagnosed with acute calculous cholecystitis (ACC) should be
admitted to the hospital and provided with supportive care including ;
-Intravenous hydration.
-Correction of any electrolyte abnormalities.
-Pain control.
-Intravenous antibiotics.
-Patients should be kept fasting, and although uncommonly needed,
those who are vomiting should have placement of a nasogastric tube
 TG 18
Grade III (severe) acute cholecystitis
“Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:

1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of norepinephrine

2. Neurological dysfunction: decreased level of consciousness

3. Respiratory dysfunction: PaO2/FiO2 ratio <300
4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT-INR >1.5
6. Hematological dysfunction: platelet count <100,000/mm3
Grade II (moderate) acute cholecystitis
“Grade II” acute cholecystitis is associated with any one of the following conditions:

1. Elevated WBC count (>18,000/mm3)

2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 ha
4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Grade I (mild) acute cholecystitis

“Grade I” acute cholecystitis does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a
healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative
procedure
 THANK YOU
REF ;
- Uptodate
- Deckermed
- Tokyo guidelines 2018