ACUTE CHOLECYSTITIS

Jane Chunwen Teng D.O. 12/5/12

ACUTE CHOLECYSTITIS

Acute Cholecystitis: symptoms of RUQ pain, fever,

and leukocytosis associated with gallbladder

inflammation that is usually related to gallstone

disease.

Acalculous Cholecystitis: Clinically identical to

acute cholecystitis but is not associated with

gallstones, and usually occurs in critically ill pts. It

accounts for approximately 10 % of cases of acute

cholecystitis and is associated with high morbidity

and mortality.

CHRONIC CHOLECYSTITIS

Chronic inflammatory cell infiltration of the

gallballdder seen on histopathology.

Almost invariably associated with the presence of

gallstones and is thought to be the result of

mechanical irritation or recurrent attacks of acute

cholecystitis leading to fibrosis and thickening of the

gallbladder.

PATHOGENESIS

In contrast to biliary colic, the development of acute

cholecystitis is not fully explained by cystic duct obstruction

alone.

Studies in animals have demonstrates that ligation of the

cystic duct does not result in acute cholecystitis.

However, acute cholecystitis can be produced

experimentally by blockade of the cystic duct followed by

deliberate irritation of the gallbladder mucosa.

PATHOGENESIS

Lysolecithin (normally absent in bile) maybe release

following trauma of the gallbladder wall from an impacted

gallstone.

Inflammatory mediators (e.g. PGE2 and 6 keto PG F1

alpha) synthesized by inflamed human gallbladder

microsomes increased four times above normal.

Prolonged impaction of stones in the cystic duct can lead

to hydrops.

CLINICAL MANIFESTATION

RUQ or epigastrium abdominal pain, may radiate

to the right shoulder or back. Pain is usually steady

and sever.

Nausea, vomiting, and anorexia.

Hx of fatty food ingestion about one hour or more

before the initial onset of pain.

PHYSICAL EXAM

Pt usually are ill appearing, febrile, tachycardic

and lie still on the examining table because any

movement can aggravate the pain.

Abdominal exam usually demonstrates voluntary

and involuntary guarding.

PHYSICAL EXAM

Positive “Murphy’s sign” While palpating the area

of the gallbladder fossa just beneath the liver edge,

the patient is asked to inspire deeply, causing the

gallbladder to descend toward the examining

fingers. Pt with acute cholecystitis commonly

experience increased discomfort and may have

associated inspiratory arrest.

Using cholescintigraphy as the gold standard, the

sensitivity and specificity of a positive Murphy’s sign

were 97 and 48 %, respectively.

COMPLICATION

Left untreated, symptoms of cholecystitis may

abate within 7-10 days.

Complication can occur at alarmingly high rate,

including the development of gallbladder gangrene

(up to 20%) and subsequent perforation (2%). Other

complications include cholecystoenteric fistula,

gallstone ileus, emphysematous cholecystitis.

DIAGNOSIS

Confirmation of the diagnosis must be based upon

a combination of physical findings, laboratory

studies, and imaging tests.

The most accurate physical findings were a

positive Murphy sign (positive likelihood ratio 2.8,

95% CI 0.8 to 8.6) and right upper quadrant

tenderness (negative LR 0.4, 95% CI 0.2 to 1.1)

Lab: CBC shows leukocytosis with a left shift.

DIAGNOSIS

Elevation in the serum total bilirubin and alkaline

phosphatase concentrations are NOT common in

uncomplicated cholecystitis, since biliary obstruction

is limited to the gallbladder; if present, they should

raise the concerns about complicating conditions

such as cholangitis, choledocholithiasis, or the

Mirizzi syndrome (a gallstone impacted in the distal

cystic duct causing extrinsic compression of the

common bile duct)

DIAGNOSIS

There have been reports of mild elevation of serum

aminotransferase and amylase, along with

hyperbilirubinemia and jaundice. These

abnormalities maybe due to the passage of small

stones, sludge, or pus.

IMAGING TESTS

Ultrasonograpy is usually the first test obtained

and can often establish the diagnosis.

Nuclear cholescintigraphy may be useful in cases

in which the diagnosis remains uncertain after

ultrasounography.

ULTRASOUND DIAGNOSIS

Gallbladder wall thickening (>4-5 mm) or edema (double wall sign)

A “sonographic Murphy’s sign”, which is similar to the Murphy’s

sign elicited during abdominal palpation, except that the positive

response is observed during palpation with the ultrasound transducer.

A particularly informative systematic review summarized the results

of 30 studies of ultrasonography for gallstones and acute

cholecystitis. Adjusted sensitivity and specificity for diagnosis of

acute cholecystitis were 88% and 80% respectively.

CHOLESCINTIGRAPHY (HIDA SCAN)

Indicated if the diagnosis remain uncertain following

ultrasonography.

Technetium labeled hepatic iminodiacetic acid (HIDA) is

injected intravenously and is then taken up selectively by

hepatocytes and excreted into bile.

If the cystic duct is patent, this agent will enter the

gallbladder, leading to its visualization without the need

for concentration.

CHOLESCINTIGRAPHY (HIDA SCAN)

HIDA scan is also useful demonstrating patency of the

common bile duct and ampulla.

Visualization of the contrast within the common bile duct,

gallbladder, and small bowel occurs within 30 to 60 mins.

The test is positive if the gallbladder does not visualize,

which is invariably due to cystic duct obstruction, usually

from edema associated with acute cholecystitis or an

obstructing stone.

CHOLESCINTIGRAPHY (HIDA SCAN)

Cholescintigraphy has a sensitivity and specificity of

approximately 97 and 90 %, respectively.

Cystic duct obstruction with a stone or tumor in the absence

of acute cholecystitis can cause a false positive test.

Other conditions that can cause false positive results include:

- Severe liver disease, Fasting pt receiving TPN, Biliary

sphincterotomy and Hyperbilirubinemia.

MORPHINE CHOLESCINTIGRAPHY

A modified version of the HIDA scan, in which pts are

given IV morphine during the exam.

Morphine increases sphincter of Oddi pressure, thereby

causing a more favorable pressure gradient for the

radioactive tracer to enter the cystic duct.

This modification is thought to be particularly useful in

critically ill pts, in whom standard HIDA scans may be

associated with false positive results.

M A G N E T I C R E S O N A N C E C H O L A N G I O G R A P H Y ( M R C H O L A N G I O G R A P H Y )

Noninvasive technique for evaluating the intrahepatic and

extrahepatic bile ducts.

In a series that included 35 pts with symptoms of acute

cholecystitis who underwent both ultrasound and MR

cholangiography prior to cholecystectomy. MR cholangiography

was superior to ultrasound for detecting stones in the cystic duct

(sensitivity 100 vs. 14 %) but was less sensitive than ultrasound

for detecting gallbladder wall thickening (sensitivity 69 vs. 96 %)

CT

Abdominal CT is usually unnecessary in the diagnosis of acute

cholecystitis, although it can easily demonstrate gallbladder wall

edema associated with acute cholecystitis.

Other CT findings include pericholecystic stranding and fluid,

and high-attenuation bile.

However, CT may fail to detect gallstones because many stones

are isodense with bile.

CT can be useful when complications of acute cholecystitis are

suspected or when other diagnosis are considered.

TREATMENT

Pts diagnosed with acute cholecystitis required hospital admission

for IV hydration, correction of electrolyte disorders, and pain

control (IM ketorolac 30-60 mg adjusted for age and renal function).

Pts should be kept NPO and those who are vomiting may need

NGT placement.

The guidelines of the Infectious Diseases Society of America

(IDSA) recommend that antimicrobial therapy be instituted if

infection is suspected on the basis of lab (>12,5000 WBC) or clinical

findings (temp ≥38.5 degree) , and radiographic findings .

TREATMENT

Routine antibiotics are also recommended in pts of

advanced age or who have diabetes or

immunodeficiency, and for prophylaxis in patients

undergoing cholecystectomy to reduce septic

complications even when infection is not suspected.

Empiric antibiotic therapy should induce activity

against the most common pathogens.

TREATMENT

In a study of 467 pts, including a control group of 42

pts, including a control group of 42 with normal biliary

tress, positive bile cultures were found in 22 % pts with

symptomatic gallstones and 46 & of pts with acute

cholecystitis. The most frequent isolates from the

gallbladder or common bile duct were

- E.Coli (12%), Klebsiella (11%) , and Enterobacter (9%).

TREATMENT

Empiric antibiotic Treatment for gram negative and anaeronic

bateria

1st choice:

Monotherapy with a beta-lactam or beta-lactamase inhibitor (e.g.

pipercillin tazobactam 3.375 or 4.5 g IV q6hr or ticarcillin-

clauvulanate 3.1 g q4hr)

Or Combination of 3rd generation cephalosporin PLUS

metronidazole (ceftriaxone 1g q 24 hr or 2g q 12 hr for CNS

infection and metronidazole 500mg q8hr)

TREATMETN

The duration of antibiotic therapy is tailored to clinical

improvement.

For pts requiring prompt surgical intervention, antibiotics may

be warranted for 24 to 48 hours following cholecystectomy,

although longer or shorter courses may be appropriate depending

on individual circumstances.

Pts for whom surgical intervention is initially deferred ay

warrant antibiotic therapy over 48 to 72 hours pending resolution

of clinical signs and symptoms.

TIMING FOR SURGERY

Although there is consensus that incidentally discovered asymptomatic

gallstones should not be treated. Once a pt develops symptoms or

complications related to gallstones (such as biliary colics or acute

cholecystis), treatment to eliminate the gallstones should be

recommended, because the likelihood of subsequent symptoms or

complications is high.

The National Cooperative Gallstone Study, a trial of nonsurgical

treatment with chenodiol for biliary tract pain, demonstrated that the

risk for recurrent symptoms was approximately 70 % during the two yrs

following initial presentation.

TIMING FOR SURGERY

The selection of treatment and timing of definitive

therapy for acute cholecystitis depends upon the

severity of symptoms and the pts overall risk of

surgery.

The aim of definitive therapy is to eliminate the

precipitating cause of acute cholecystitis (ie,

gallstones in the case of calculous cholecystitis) to

prevent recurrent attacks.

TREATMENT

The benefit of prompt surgical intervention was also

illustrated in a subsequent study of 29,818 Medicare

pts with acute cholecystitis. Compared to pts who

underwent cholecystectomy in the initial

hospitalization, pts who were discharged without

surgery were more likely to require readmission (38

vs. 4 %) and had higher mortality (hazard ratio 1.56,

95% CI, 1.47-1.65) over the following two yrs.

TREATMENT

Lows-risk pts - The physical status scale

established by the American Society of

Anesthesiologists (ASA) is commonly used to

determine the risk of surgery.

Although previously considered to be at higher

risk, pts with DM who do not have substantial

microvascular or macrovascular disease have an

outcome after acute cholecystitis similar to the

nondiabetic population.

TREATMENT

The ASA physical status classification system is a system for

assessing the fitness of patients before surgery .

1. A normal healthy patient.

2. A patient with mild systemic disease.

3. A patient with severe systemic disease.

4. A patient with severe systemic disease that is a constant threat to life.

5. A moribund. patient who is not expected to survive without the surgery

6. A declared brain-dead patient whose organs are being removed for

donor purposes.

TREATMENT IN LOW RISK PTS

Immediate Cholecystectomy is preferred for pts who are at low

risk (ASA class I and II)

Several studies have indicated that cholecystectomy performed

for low surgical risk pts during the initial hospitalization can

reduce morbidity and costs.

Early Surgery is also easier to perform as local inflammation

increases 72 hr past the initial onset of symptoms making

dissection less precise, increasing the severity of surgical

complications, and open conversion more likely.

TREATMENT IN HIGH RISK PTS

High-risk pts - Pts who are in ASA classes III, IV, or V have a surgical

mortality ranging from 5-27%, and are considered high-risk for

cholecystectomy.

This category generally includes pts with severe chronic illnesses, such

as cardiovascular or pulmonary disease, or advanced malignancy.

High risk pts, or pts who present late in the course of their disease

process(>3-5 days), who continue to have severe symptoms and show no

appreciable improvement despite one to two days of medical

management require further intervention.

TREATMENT IN HIGH RISK PTS

Gallbladder drainage by percutaneous cholecystostomy

in conjunction of antibiotic is the initial treatment of

choice for high risk pts.

The goal of cholecystostomy is to drain purulent material

from the obstructed gallbladder.

Tube decompression of the gallbladder allows for

resolution of edema which often “opens” up the

obstructed cystic duct.

TREATMENT IN HIGH RISK PTS

Endoscopic transpapillary gallbladder drainage has also been

reported in pts with acute cholecystitis in whom percutaneous

approaches are contraindicated or anatomically impossible.

A limitation of the technique is that it can be technically

challenging to place a guidewire and drainage tube into the

gallbladder.

In addition, this procedures carries all the inherent

complications of ERCP.

TREATMENT – SURGERY

When the acute cholecystits has resolved, pts who are surgical

candidates should undergo cholecystectomy.

Surgery may also be required when the pt does not improve

following percutaneous drainage, which suggests that the

gallbladder has already progressed to gangrene.

Pts who are particularly unstable will benefit from open

cholecystostomy tube drainage achieved through a limited

lapratomy. This can be performed at the bedside in the ICU

setting if necessary.

NONSURGICAL TREATMENT

Pts who stabilize but continue to be at high risk for

surgery can be considered for percutaneous

gallstone extraction with or without mechanical

lithotripsy.

REFERENCE

http://www.uptodate.com/contents/pathogenesis-cli

nical-features-and-diagnosis-of-acute-cholecystitis?

source=search_result&search=acute+cholecystitis

&selectedTitle=2%

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http://www.uptodate.com/contents/treatment-of-ac

ute-cholecystitis?source=search_result&search=ac

ute+cholecystitis&selectedTitle=1%

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