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BILIARY COLIC and ACUTE CHOLECYSTITIS

 

BILIARY COLIC and ACUTE CHOLECYSTITIS

BILIARY COLIC (or CHRONIC CHOLECYSTITIS)

 

  1. many patients with acute cholecystitis have a history of episodic biliary colic
  2. mechanism: gallstone temporarily impacted in cystic duct, no infection

 

Signs and symptoms

 

  1. steady pain (not colic) in epigastrium or RUQ for minutes to hours
  2. frequently occurs at night or after fatty meal
  3. can radiate to right shoulder or scapula
  4. associated nausea/vomiting
  5. no peritoneal findings
  6. no systemic signs

 

Differential diagnosis

  1. Pancreatitis
  2. PUD
  3. hiatus hernia with reflux
  4. gastritis

 

Diagnostic investigation

  1. normal blood work
  2. U/S shows gallstones

 

Treatment  : elective cholecystectomy (95% success)

 

 

 

ACUTE CHOLECYSTITIS

 

Mechanism

  1. inflammation of gallbladder resulting from obstruction of cystic duct by gallstone (80%)
  2. no cholelithiasis in 20% (acalculous - see below)

 

Signs and symptoms

 

  1. severe constant epigastric or RUQ pain
  2. systemic signs - fever, tachycardia
  3. focal peritoneal findings - Murphy's sign (sudden cessation of inspiration with deep RUQ palpation)
  4. palpable gallbladder in one third of patients

 

Differential diagnosis

 

  1. perforated or penetrating peptic ulcer
  2. myocardial infarction
  3. pancreatitis
  4. hiatus hernia
  5. right lower lobe pneumonia
  6. appendicitis
  7. hepatitis
  8. herpes zoster

 

Diagnostic investigation

 

  1. Elevated WBC, left shift
  2. mildly elevated bilirubin, ALP
  3. sometimes slight elevation AST, ALT
  4. U/S shows distended, edematous gallbladder, pericholecystic fluid, large stone stuck in gallbladder neck, sonographic Murphy's sign

 

Complications

  1. Hydrops: mucus accumulation in gallbladder due to cystic duct obstruction; may lead to necrosis
  2. gangrene and perforation: may cause localized abscess or generalized peritonitis (can occur 3 days after onset)
  3. empyema of gallbladder (suppurative cholangitis)
  4. cholecystoenteric fistula from repeated attacks of cholecystitis gallstone ileus
  5. choledocholithiasis - 15% of patients with gallstones

Mortality 5%

Treatment

  1. admit, hydrate, NG tube, antibiotics if high risk (elderly, mmunosuppressed)
  2. lack of improvement with conservative treatment ---->operate within 24-48 hours (cholecystectomy)
  3. earlier O.R. if high risk (DM, steroids) or severe disease
  4. Laparoscopic tube cholecystostomy if general anesthetic contraindicated

 

BILIARY COLIC and ACUTE CHOLECYSTITIS BILIARY COLIC and ACUTE CHOLECYSTITIS Reviewed by Radiology Madeeasy on September 01, 2010 Rating: 5
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