f Post graduate mcqs and discussion : ACUTE CHOLECYSTITIS

Saturday, March 31

ACUTE CHOLECYSTITIS

Commonly it occurs in a patient with pre-existing chronic cholecystitis but often also can occur as a first presentation.
Usual cause is impacted gallstone in the Hartmann’s pouch, obstructing cystic duct.

 Classification

1. Acute calculous cholecystitis.
2. Acute acalculous cholecystitis.


Mode of Infection

Haematogenous through hepatic artery—cystic artery.
Portal vein.
Through bile after filtering in the liver via portal circulation.

Fig: ACUTE CHOLECYSTITIS


Pathogenesis of Acute Cholecystitis

Stone causes obstruction at Hartmann’s pouch or in cystic duct. Obstruction causes stasis, oedema of the wall, bacterial infection, acute cholecystitis and its effects.
Impacted stone also causes mucosal erosion allowing bile salts to act over the submucosal tissues as bile is toxic to these tissues.

It leads into necrosis, further infection and often perforation of the gallbladder usually at Hartmann’s pouch.

Pathology of Acute Cholecystitis


Gallbladder will be distended with oedematous friable wall. Wall contains dilated vessels.

Areas of necrosis and patchy gangrene may occur in severe cases.

Mucosa shows ulceration and necrosis.

Lumen contains infected fluid/infected bile or frank pus.

Histology shows features of acute inflammation with neutrophils, oedema, and areas of necrosis and cell death.


Complications of Acute Cholecystitis

1. Perforation, which usually occurs in the fundus or in the neck (Hartmann’s). It can cause cholecystoduodenal, cholecystointestinal or cholecystobiliary
fistula.

2. Peritonitis.

3. Pericholecystitic abscess, empyema GB.

4. Cholangitis and septicaemia.

5. Empyema gallbladder, gangrenous gallbladder.



Clinical Features

Sudden onset of pain in the right hypochondrium, with tenderness, guarding, and rigidity.

Palpable, tender, smooth, soft gallbladder.

Area of hyperaesthesia between 9th and 11th ribs posteriorly on the right side (Boas’s sign).

Jaundice may be present.

Fever, nausea, palpable tender mass in GB region.

Tachycardia and toxic features.


Investigations


Ultrasound abdomen—very useful, reveals presence or absence of gallstones; and thickening of gall bladder wall.

Plain X-ray abdomen— gallstones are radio-opaque; also rules out other causes of acute pain abdomen. Gas is seen in emphysematous gallbladder.

Total count shows neutrophilia.

Plain X-ray abdomen is not very relevant but is often important to rule out duodenal ulcer perforation, peritonitis. Only 10% of gallstones are radio-opaque. In emphysematous cholecystitis gas shadow may be seen in the region of gallbladder. Porcelain gallbladder may be seen as opacifi ed area in gallbladder region.


Differential diagnosis

Duodenal ulcer perforation
Acute pancreatitis
Acute appendicitis
Acute pyelonephritis
Lobar pneumonia, myocardial infarction
Ruptured ectopic pregnancy


Treatment


Advised hospitalisation.

Initially (nonoperative) conservative treatment : Nasogastric aspiration. IV fl uids. Analgesics and antispasmodics. Broad spectrum antibiotics (cefoperazone, ceftazidime, ceftria xone, cefotaxime + amikacin, tobramycin + metro￾nidazole {antimicrobial}). Observation. Follow-up
Ultrasound  scan.

Later after 3-6 weeks, elective cholecystectomy, either by open method through right subcostal (Kocher’s) incision or through laparoscopy is done.


Cholecystostomy is done immediately if patient is having:
1. Empyema gallbladder.
2. Persisting symptoms.
3. Progressing symptoms.

Here the gallbladder is opened and all stones and pus are removed. Either a Foley’s or Malecot’s catheter is placed in the gallbladder and is exteriorised. After 3 weeks, elective cholecystectomy is done.


Indications for cholecystostomy or emergency cholecys tectomy .

Empyema GB
Persisting symptoms/failure of medication Emphysematous cholecystitis
Perforation/peritonitis
Elderly .