ACUTE CALCULOUS CHOLE CYSTITIS ACUTE ACALCULOUS

REFERENCES
STRAS BERG SM. ACUTE CALCULOUS CHOLECYSTITIS
N ENGL J MED 2008; 358:2804-11
HUFFMAN JL, SCHENKER S. ACUTE ACALCULOUS CHOLECYSTITIS:
A REVIEW. CLIN GASTROENTEROL HEPATOL 2010; 8:15-22.
 A complication of Cholelithiasis
20 millions in USA/year
 Most Gallstones Asymptomatic
 Biliary colic develops 1% to 4%
 Acute cholecystitis in 20% of these symptomatic patients
 60% women
 Older
 With/without previous attacks
 More frequent in men relative to its incidence and more severe
 DM
 90% of acute cholecystitis is associated with gallstones
Figure 1. Ultrasonographic images of three Gallbladders.
A normal, sonolucent gallbladder (panel A) is characterized
by a thin wall and an absence of acoustic shadows. In a
patient with symptomatic gallstones (panel B), the
gallblader contains small echogenic objects with posterior
acoustic ghadows that are typical of gallstones (arrow),
with a normal wall thickness. In a patient with acute
calculous cholecystitis (panel c), thickening is visible in the
gallbladder wall (arrow), along with a lare gallstone
(arrowhead)
Figure 2. Hepatobiliary Scintigraphy.
FigureInPanel
2. Hepatobiliary
Scintigraphy.
A, a normal
liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid.
In InPanel
Panel B,A,
ata55
normal
minutes
liver
after
is visible
tracer10
injection,
minutesfilling
after of
thethe
intravenous
bile duct (arrow)
injection
and
of gallbladder
a technetium-labeled
(arrowhead)
analogue
can be seen.
of iminodiacetic
In Panel C, acid.
at
1 hour
In Panel
afterB,tracer
at 55injection
minutes in
after
a patient
tracer with
injection,
acutefilling
cholecystitis
of the bile
andduct
obstruction
(arrow) and
of the
gallbladder
cystic duct,
(arrowhead)
there is filling
can of
bethe
seen.
bile
Induct
Panel C, at
(arrow)
butafter
no filling
the gallbladder.
1 hour
tracerofinjection
in a patient with acute cholecystitis and obstruction of the cystic duct, there is filling of the bile duct
(arrow) but no filling of the gallbladder.
 Local symptoms and signs
Murphy's sign
Pain or tenderness in RUQ
Mass in RUQ
 Systemic signs
Fever
Leucocytosis
Elevated CRP
 Imaging findings
A confirmatory finding on US or HB scintography
Presence of one local signs or symptoms
One systemic sign, and
A confirmatory finding on an imaging test
acute cholecystitis not meeting criteria for a more severe grade
Mild gallbladder inflammation, no organ dysfunction
presence of one or more of following:
 WBC>18000
VA
VB
Palpable, tender mass in RUQ
Duration > 72h
Marked local in tlammarion: biliary peritonitis, pericholecystic abscess, hepatic
abscess, gangrenous cholecystitis, emphysematous cholecystitis
presence of one or more of following:

CVS dysfunction ( BP requiring dopamine at ≥ 5 microgr/kg/min or any dose of Dobutamine)

CNS dysfunction (level of consciousness)

Respiratory dysfunction (ratio of pO2 of arterial blood to the fraction of inspired oxygen<300)

Renal dysfunction (oliguria, Cr> 2mg/dL) Hepatic dysfunction (PT INR >1.5)

Hematologic dysfunction (platelet<100.000)
VC
Laparascopic VS open
Early VS delayed
From 24h to 7 days after initial attack
2-3 months after afte initial attack
Percutaneous
Operative
Fasting, obstruction, post surgical ileus, TPN
Inspissated bile  toxic to epithelium
Clinical findings
Radiology
Surgery
Setting (inpatient, out patient)
US
Aspiration of GB/ drainage
Fever, abdominal pain
CT
Laparatomy
Leucocytosis, abnormal LFT
HIDA SCAN
Figure 1. (A and B) Longitudinal and horizontal sonogram of a 64-year-old man with positive
Murphy sign, showing hydrops. (C) CT scan 6 hours later showing thickened GB wall
(white arrow), hydrops, and pericholecystic inflammation (asterisk). Figure courtesy
of Dr Shaile Choudhary, MD (Department of Radiology, University of Texas Health
Science at San Antonio, San Antonio, TX).