ACUTE CHOLECYSTITIS
DR. OLAOGUN J. GBENGA
• Cholecystitis is the inflammation of the gall
bladder
• It can be acute or chronic
• Both are parts of the same spectrum of disease
and are related to inflammation within the gall
bladder secondary to cystic duct obstruction by
stones
Acute cholecystitis
• Types
• Acute obstructive (calculous) cholecystitis – 90%. In <1% of acute cholecystitis, the
cause is a tumour obstructing the cystic duct
• Acute non-obstructive (acalculous) cholecystitis: 5-10%. It is seen in critically ill
patients
• Patients recovering from major surgery- abdominal aortic aneurysm repair and
cardiopulmonary bypass.
• Multiple trauma
• Burns
• Prolonged hyperalimentation
• Starvation
• The etiology of acute acalculous cholecystitis remains unclear, although gallbladder stasis
and ischemia have been implicated as causative factors
• Bacteriology
• Common organisms- E. coli, Klebsiella spp. and
Streptococcus spp.
• Others- salmonella, staphylococcus, aerobacter
aerogenes, clostridium welchi and bacteroides
spp
Clinical presentation
• Right upper quadrant pain- lasts longer than biliary colic
• Nausea /vomiting
• Fever
• anorexia
• Jaundice
• Features of perforation (rare)
• Physical exam- tenderness /rebound tenderness
• Murphy’s and Boas signs
• A tender palpable mass in the right subcostal region
may be found in 25% of cases and signifies one of the
following:
• Empyema of the gallbladder
• Omental phlegmon
• Abscess due to localized perforation
• Carcinoma of the gallbladder (elderly)
Differential diagnosis
• Acute appendicitis
• Perforated peptic ulcer
• Acute pancreatitis
• Hepatitis
• Acute pyelonephritis
• Myocardial infarction
• Pneumonia
Investigations
• Abdominal scan- most useful radiologic
investigation
• HIDA scan- helpful in atypical case
• Plain abd radiograph
• Intravenous cholangiogram
• Computerized tomography
• Others- FBC, LFT
Treatment
• Conservative measures- symptoms subside in > 90% of cases
• Rest the gall bladder- NPO, NGT, anticholinergic drugs
• Relax sphincter of Oddi- propantheline, atropine
• Intravenous fluids
• Analgesic- Pethidine, NSAIDs
• Antibiotics
• When symptoms improve, commence oral fluid/ fat-free
diet
• 10-20% will fail to respond
Contraindications
• Progression of the disease despite conservative treatment
• Failure to improve within 24 h especially in patients > 60 years old
• Presence of an inflammatory mass in the right hypochondrium
• Detection of gas in the gallbladder/biliary tract
• Established generalized peritonitis
• Development of intestinal obstruction
Operative treatment
• Cholecystectomy- definitive treatment
• Laparoscopic/ open
• Emergency/early/elective
• Percutaneous cholecystostomy
Prognosis
• Mortality- 2-3%
• 10% in >70 yrs.
Chronic cholecystitis
• It implies an ongoing or recurrent inflammatory
process involving the gallbladder
• Frequently associated with gall stones (>90%)
leading to recurrent episodes of cystic duct
obstruction and manifest as biliary pain or colic
but may arise from repeated episodes of acute
cholecystitis
• Pathology
• There is much thickening of the gall bladder wall
• There is increase in mononuclear cell infiltration and
subepithelial and subserosal fibrosis , the latter
completely destroying the pattern of the mucosa
• Buried crypts of mucosa (Aschoff-Rokitansky sinuses)
are common and characteristic feature
Clinical features
• The primary symptom is pain (biliary colic)-
frequently radiates to the right upper back, right
scapula, or between the scapulae and typically
lasts 1 to 5 hours.
• Nausea/vomiting- 60-70% cases
• Bloating and belching (50% of patients)
• Fever and jaundice occur much less frequently
• The physical examination
• Completely normal in patients with
chronic cholecystitis, particularly if they
are pain free.
• Mild right upper quadrant tenderness-
during an episode of biliary colic.
• Laboratory values such as serum bilirubin,
transaminases, and alkaline phosphatase are also
usually normal in patients with uncomplicated
gallstones.
• Oral cholecystogram- non-functioning gall bladder
• Abd ultrasound- 95-98% sensitive
• Abd radiograph (10-15%)
• Abd CT (50%)
• Treatment
• Laparoscopic cholecystectomy- treatment of choice
• Morbidity and mortality are similar to open procedure.
• The mortality rate for both procedures is approximately < 1%
• The most significant complication following laparoscopic
cholecystectomy is injury to the biliary tract.
• Overall complication: < 10% of patients.
• Conversion to an open cholecystectomy is necessary in < 5% of
patients
• A few patients have symptoms after operation (post-
cholecystectomy syndrome) which could arise from:
• Residual common bile duct stones
• Residual cystic duct stump
• Autonomic nerve neuroma of the stump
• Peri-operative cholangiography should be considered
an integral part of the operation
• Cholecystoses
• These are group of conditions affecting the gall bladder in which there
are chronic inflammatory changes with hyperplasia of all tissue
elements
• The basis of this reaction is unknown
• They are:
• Cholesterosis (strawberry gall bladder)
• Cholesterol polyposis
• Cholecystitis glandularis proliferans
• Treatment- cholecystectomy
•QUESTIONS
