Cholecystitis

From Wikipedia, the free encyclopedia - View original article

Cholecystitis
Classification and external resources

Micrograph of a gallbladder with cholecystitis and cholesterolosis.
ICD-10K81
ICD-9575.0, 575.1
DiseasesDB2520
MedlinePlus000264
eMedicinemed/346
MeSHD002764
 
Jump to: navigation, search
Cholecystitis
Classification and external resources

Micrograph of a gallbladder with cholecystitis and cholesterolosis.
ICD-10K81
ICD-9575.0, 575.1
DiseasesDB2520
MedlinePlus000264
eMedicinemed/346
MeSHD002764

Cholecystitis is inflammation of the gall bladder.

Contents

Signs and symptoms

Cholecystitis usually presents as a pain in the right upper quadrant. This is known as biliary colic. This is initially intermittent, but later usually presents as a constant, severe pain. During the initial stages, the pain may be felt in an area totally separate from the site of pathology, known as referred pain. The pain is originally located in the right upper quadrant but the referred pain may occur in the right scapula region (Boas' sign).

This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies, and fried foods.

This is usually accompanied by a low-grade fever, diarrhea, vomiting, nausea and granulocytosis. The gallbladder may be tender and distended.

More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.

Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, and diarrhea.

Causes

Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species.[citation needed]

The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.

Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis. This can arise in patients with anorexia nervosa, as the lack of stimulation of the gallbladder leads to an infectious process.

Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.

Diagnosis

Cholecystitis is usually diagnosed by a history of the above symptoms, as well as examination findings:

Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes.

Ultrasound can assist in the differential.[1][2]

Differential diagnosis

Acute cholecystitis

Acute cholecysitis as seen on ultrasound. Closed arrow points to gall bladder wall thickening. Open arrow points to stones in the GB

This should be suspected whenever there is acute right upper quadrant or epigastric pain, other possible causes include:

Chronic cholecystitis

The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:

Quick Differential

Cholangitis is a medical emergency as it may be life threatening and patients can rapidly succumb to acute liver failure or bacterial sepsis. The classical sign of cholangitis is Charcot's triad, which is right upper quadrant pain, fever and jaundice. Liver function tests will likely show increases across all enzymes (AST, ALT, ALP, GGT) with raised bilirubin. As with choledocholithiasis, diagnosis is confirmed using cholangiopancreatography.

It is worth noting that bile is an extremely favorable growth medium for bacteria, and infections in this space develop rapidly and may become quite severe.[citation needed]

Investigations

Blood

Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC count. CRP (C-reactive protein) is often elevated. The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.

Radiology

Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The diagnostic criteria are gallbladder wall thickening greater than 3mm, pericholecystic fluid and sonographic Murphy's sign. Gallstones are not part of the diagnostic criteria as acute cholecystitis may occur with or without them.

The reported sensitivity and specificity of CT scan findings are in the range of 90–95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.

Management

X-Ray during laparoscopic cholecystectomy

For most patients diagnosed with acute cholecystitis, the definitive treatment is surgical removal of the gallbladder, cholecystectomy. Until the late 1980s surgical removal was usually accomplished by a large incision in the upper right quadrant of the abdomen under the rib cage. Since the advent of laparoscopic surgery in the early 1990s, laparoscopic cholecystectomy has become the treatment of choice for acute cholecystitis.[4] Laparoscopic cholecystectomy is performed using several small incisions located at various points across the abdomen. Several studies have demonstrated the superiority of laparoscopic cholecystectomy when compared to open cholecystectomy. Patient undergoing laparoscopic surgery report less incisional pain postoperatively as well as having fewer long term complications and less disability following the surgery.[5][6] Additionally, laparoscopic surgery is associated with a lower rate of surgical site infection.[7]

During the days prior to laparoscopic surgery, studies showed that outcomes were better following early removal of the gallbladder, preferably within the first week.[8] Patients receiving early intervention had shorter hospital stays and lower complication rates. In the era of laparoscopic surgery, a similar approach is still advocated. In a 2006 Cochrane review, early laparoscopic cholecystectomy was compared to delayed treatment. The review consisted of 5 trials with 451 patients randomized to either early (223 patients) or delayed (228) surgical management.[9] There was no statistically significant difference in terms of negative outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) or conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34).[9] However, the early group was found to have shorter hospital stays.[9] For early cholecystectomy, the most common reason for conversion to open surgery is inflammation obscuring Calot's triangle. For delayed surgery, the most common reason was fibrotic adhesions.[9]

Supportive measures are usually instituted prior to surgery. These measures include fluid resuscitation and antibiotics. Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e.g.ceftriaxone) and an antibacterial with good coverage (fluoroquinolone such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic patients, aztreonam and clindamycin may be used.

In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. A cholecystectomy may then be warranted if the patient's condition improves.

Complications

Cholecystectomy

Gall bladder perforation

Gall bladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis. The early diagnosis and treatment of GBP are crucial to decrease patient morbidity and mortality.

Approaches to this complication will vary based on the condition of an individual patient, the evaluation of the treating surgeon or physician, and the facilities' capability. Perforation can happen at the neck from pressure necrosis due to the impacted calculus, or at the fundus. It can result in a local abscess, or perforation into the general peritoneal cavity. If the bile is infected, diffuse peritonitis may occur readily and rapidly and may result in death A retrospective study looked at 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis. Patients were treated with analgesics and antibiotics within the first 36 hours after admission (with a mean of 9 hours), and proceeded to surgery for a cholecystectomy. Two patients died and 6 patients had further complications. The morbidity and mortality rates were 37.5% and 12.5%, respectively in the present study. The authors of this study suggests that early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance.[10]

Xanthogranulomatous cholecystitis

Xanthogranulomatous cholecystitis (XGC) is a rare form of gallbladder disease which mimics gallbladder cancer although it is not cancerous.[11][12] It was first discovered and reported in the medical literature in 1976 by J.J. McCoy, Jr., and colleagues.[11][13]

See also

References

  1. ^ Shea JA, Berlin JA, Escarce JJ, et al. (November 1994). "Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease". Arch. Intern. Med. 154 (22): 2573–81. doi:10.1001/archinte.154.22.2573. PMID 7979854. http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=7979854. 
  2. ^ Fink-Bennett D, Freitas JE, Ripley SD, Bree RL (August 1985). "The sensitivity of hepatobiliary imaging and real-time ultrasonography in the detection of acute cholecystitis". Arch Surg 120 (8): 904–6. doi:10.1001/archsurg.1985.01390320028004. PMID 3893388. http://archsurg.ama-assn.org/cgi/pmidlookup?view=long&pmid=3893388. 
  3. ^ Sung JY; Costerton JW; Shaffer EA (1992). "Defense system in the biliary tract against bacterial infection". World J. Gastroenterol. 37 (5): 689–96. doi:10.1007/BF01296423. PMID 1563308. 
  4. ^ Strasberg, S. M. (2008). "Acute Calculous Cholecystitis". New England Journal of Medicine 358 (26): 2804–2811. doi:10.1056/NEJMcp0800929. PMID 18579815.  edit
  5. ^ Velanovich, V. (2000). "Laparoscopic vs open surgery: A preliminary comparison of quality-of-life outcomes". Surgical endoscopy 14 (1): 16–21. doi:10.1007/s004649900003. PMID 10653229.  edit
  6. ^ Chen, L.; Tao, S. F.; Xu, Y.; Fang, F.; Peng, S. Y. (2005). "Patients' quality of life after laparoscopic or open cholecystectomy". Journal of Zhejiang University SCIENCE 6B (7): 678–681. doi:10.1631/jzus.2005.B0678. PMC 1389804. PMID 15973772. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1389804/.  edit
  7. ^ Richards, C.; Edwards, J.; Culver, D.; Emori, T. G.; Tolson, J.; Gaynes, R.; National Nosocomial Infections Surveillance (Nnis) System, C. F. D. C. P. (2003). "Does Using a Laparoscopic Approach to Cholecystectomy Decrease the Risk of Surgical Site Infection?". Annals of Surgery 237 (3): 358–362. doi:10.1097/01.SLA.0000055221.50062.7A. PMC 1514308. PMID 12616119. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1514308/.  edit
  8. ^ Banz, V.; Gsponer, T.; Candinas, D.; Güller, U. (2011). "Population-Based Analysis of 4113 Patients with Acute Cholecystitis". Annals of Surgery 254 (6): 964–970. doi:10.1097/SLA.0b013e318228d31c. PMID 21817893.  edit
  9. ^ a b c d Gurusamy, K. S.; Samraj, K. (2006). Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. In Gurusamy, Kurinchi Selvan. "Cochrane Database of Systematic Reviews". Cochrane database of systematic reviews (Online) (4): CD005440. doi:10.1002/14651858.CD005440.pub2. PMID 17054258.  edit
  10. ^ Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E (2006). "Diagnosis and treatment of gallbladder perforation". World J. Gastroenterol. 12 (48): 7832–6. PMID 17203529. 
  11. ^ a b Makino I, Yamaguchi T, Sato N, Yasui T, Kita I (August 2009). "Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET". World J. Gastroenterol. 15 (29): 3691–3. doi:10.3748/wjg.15.3691. PMC 2721248. PMID 19653352. http://www.wjgnet.com/1007-9327/full/v15/i29/3691.htm. 
  12. ^ Rao RV, Kumar A, Sikora SS, Saxena R, Kapoor VK (2005). "Xanthogranulomatous cholecystitis: differentiation from associated gall bladder carcinoma". Trop Gastroenterol 26 (1): 31–3. PMID 15974235. 
  13. ^ McCoy JJ, Vila R, Petrossian G, McCall RA, Reddy KS (March 1976). "Xanthogranulomatous cholecystitis. Report of two cases". J S C Med Assoc 72 (3): 78–9. PMID 1063276.