Acute cholecystitis Diagnosis

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

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

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

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

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

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

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

Acute cholecystitis Treatment

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

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

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