1. Treatment

2. Surgical intervention - mainstay therapy for acute cholecystitis and its complications In-hospital stabilization may be required before cholecystectomy – oral intake is eliminated – nasogastric suction may be indicated – extracellular volume depletion and electrolyte abnormalities are repaired

3. Medical Therapy Meperidine or NSAIDs – analgesic – decrease spasm of the Spinchter of Oddi Intravenous Antibiotic – indicated in patients with severe acute cholecystitis – for E. coli, Klebsiella spp., and Streptococcus spp. – ex. Ureidopenicillins (piperacillin), ampicillin sulbactam, ciprofloxacin, moxifloxacin, and 3 rd gen cephalosporins – Metronidazole - added if gangrenous or emphysematous cholecystitis is suspected – Imipenem/Meropenem – for bacteria causing ascending cholangitis

4. Surgical Therapy Early cholecystectomy is the treatment of choice for most patients with acute cholecystitis Urgent cholecystectomy/cholecystostomy is appropriate in most patients in whom a complication of acute cholecystitis such as empyema, emphysematous cholecystitis, or perforation is suspected or confirmed.

5. Surgical Therapy Delayed surgical intervention is probably best reserved for: – patients in whom the overall medical condition imposes an unacceptable risk for early surgery – patients in whom the diagnosis of acute cholecystitis is in doubt

6. Surgical Therapy Operative risks increase with: – age-related diseases of other organ systems – presence of long or short-term complications of gallbladder disease Seriously ill or debilitated patients with cholecystitis may be managed with cholecystostomy and tube drainage of the gallbladder.

7. Postcholecystectomy Complications

8. Complications Early complications: – atelectasis and other pulmonary disorders – abscess formation – external or internal hemorrhage – biliary-enteric fistula – bile leaks – jaundice Routine performance of intraoperative cholangiography during cholecystectomy has helped to reduce the incidence of these early complications.

9. Complications The most common cause of persistent postcholecystectomy symptoms is an overlooked symptomatic nonbiliary disorder. Postcholecystectomy syndromes may be due to: – biliary strictures – retained biliary calculi – cystic duct – stump syndrome – stenosis or dyskinesia of the sphincter of Oddi – bile salt–induced diarrhea or gastritis

10. Cystic Duct Stump Syndrome Disease in a long (>1 cm) cystic duct remnant Symptoms resembling biliary pain or cholecystitis in the absence of cholangiographically demonstrable retained stones

11. Symptoms of biliary colic accompanied by signs of recurrent, intermittent biliary obstruction may be produced by papillary stenosis, papillary dysfunction, spasm of the sphincter of Oddi, and biliary dyskinesia.

12. Papillary Stenosis Defined by: – Upper abdominal pain, usually RUQ or epigastric – abnormal liver tests – dilatation of the common bile duct upon ERCP examination – delayed (>45 min) drainage of contrast material from the duct – increased basal pressure of the sphincter of Oddi Treatment consists of endoscopic or surgical sphincteroplasty to ensure wide patency of the distal portions of both the bile and pancreatic ducts.

13. Dyskinesia of the Sphincter of Oddi Proposed mechanisms: – spasm of the sphincter – denervation sensitivity resulting in hypertonicity – abnormalities of the sequencing or frequency rates of sphincteric contraction waves Medical treatment with nitrites or anticholinergics to attempt pharmacologic relaxation of the sphincter has been proposed Endoscopic biliary sphincterotomy or surgical sphincteroplasty may be indicated in patients who fail to respond to a 2- to 3-month trial of medical therapy

14. Bile Salt-Induced Diarrhea and Gastritis Cholecystectomy shortens gut transit time by accelerating passage of the fecal bolus through the colon with marked acceleration in the right colon, thus causing an increase in colonic bile acid output and a shift in bile acid composition toward the more diarrheagenic secondary bile acids. Treatment with bile acid sequestering agents such as cholestyramine or colestipol

15. Hyperplastic Cholecystoses Group of disorders of the gallbladder characterized by excessive proliferation of normal tissue components Adenomyomatosis - a benign proliferation of gallbladder surface epithelium with glandlike formations, extramural sinuses, transverse strictures, and/or fundal nodule formation

16. Hyperplastic Cholecystoses Rokitansky-Aschoff sinuses - outpouchings of mucosa Cholesterolosis (strawberry gallbladder) - abnormal deposition of lipid, especially cholesteryl esters within macrophages in the lamina propria of the gallbladder wall Cholecystectomy is indicated in both adenomyomatosis and cholesterolosis when symptomatic or when cholelithiasis is present.

17. Hyperplastic Cholecystoses Gallbladder polyps: – Prevalence in adults is ~5%, with a marked male predominance – Cholecystectomy is recommended in symptomatic patients, as well as in asymptomatic patients >50 years of age, or in those whose polyps are >10 mm in diameter or associated with gallstones or polyp growth on serial ultrasonography.