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Acute cholecystitis Diagnosis. History Triad of sudden onset – RUQ tenderness – Fever (low-grade) – Leukocystosis (10,000-15,000 cells/uL) Accompanying.

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Presentation on theme: "Acute cholecystitis Diagnosis. History Triad of sudden onset – RUQ tenderness – Fever (low-grade) – Leukocystosis (10,000-15,000 cells/uL) Accompanying."— Presentation transcript:

1 Acute cholecystitis Diagnosis

2 History Triad of sudden onset – RUQ tenderness – Fever (low-grade) – Leukocystosis (10,000-15,000 cells/uL) Accompanying symptoms – Nausea and vomiting – Abdominal pain (severe, persistent)

3 Physical Examination Vary with the severity – right hypochondrial tenderness – muscle guarding, rigidity, rebound tenderness – some degree of fever – tachycardia – Murphy’s sign: variable

4 Laboratory Laboratory finding: – ALT/AST: mildly raised – Alkaline phosphate: mildly elevated – Bilirubin: variable, may rise to 85 mol/l – CBC/DC: elevated due to acute inflammation

5 Imaging studies Ultrasound – Initial investigation of choice – Most useful diagnostic tool – Demonstrate calculi in 90-95% of cases – no intrahepatic or extrahepatic ducts dilatation – Useful in detection of gallbladder inflammation Thickening of the wall Pericholecystic fluid Dilation of the bile duct – Sonographic Murphy’s sign – Color doppler scan to r/o ischemia condition

6 Imaging studies Computed tomography – Typical CT findings: wall thickening, pericholecystic stranding, and distension – Other findings: pericholecystic fluid, gallstones, luminal membranes and gas in the gallbladder wall – Findings of mural or luminal gas, intraluminal membranes, irregular wall or pericholecystic abscess are strongly suggestive of gangrenous cholecystitis – r/o other differential diagnosis

7 Imaging studies ERCP (Endoscopic retrograde cholangiopancreatography) – Diagnostic Significantly dilated common bile duct – Therapeutic ERCP is now rarely performed without therapeutic intent

8 Imaging studies Radionuclide (HIDA) biliary scan – Evaluate health and function of gallbladder – usually technetium-99m – HIDA scan (Hepatobillary imino-diacetic acid scan) Sensitivity: 95%, specificity 93-96% Positive predictive value: 92.1%, negative predictive value: 99% – Adequate filling of the gallbladder Acute cholecystitis is effectively excluded – Cystic duct obstruction Failure to visualize the gallbladder up to 4 hours

9 Acute cholecystitis Treatment

10 Medical therapy In-hospital stabilization – Oral intake is eliminated – Nasogastric suction may be indicated – Extracellular volume depletion – Electrolyte imbalance

11 Medical therapy Meperidine or NSAIDs – For analgesia – Produce less spasm of the sphincter of Oddi Intravenous antibiotics – Severe acute cholecystitis – Piperacillin or mezlocillin, ampicillin sulbactam, ciprofloxacin, moxifloxacin and 3 rd gen cephalosporins – Reduce postoperative complications of wound infection, abscess formation, or sepsis

12 Surgical therapy Open or laparoscopic cholecystectomy Optimal timing of surgery – depends on stabilization of patient Urgent (emergency) cholecystectomy or cholecystostomy – appropriate for suspected or confirmed complications such as empyema, emphysematous cholecystitis, or perforation Delayed surgical intervention Early cholecystectomy (usually within 72hrs of admission) – treatment of choice


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