3. CHOLECYSTITIS

4. CASE REVIEW

5. A 71-year-old man presented to the ED with right upper quadrant pain of two day’s duration. The pain began as a dull ache in the midepigastrium and then moved to the right upper quadrant and right flank. He vomited several times and was unable to eat. The emesis was a watery brown material. He had a small bowel movement earlier that day. He had a history of diabetes and hypertension and was taking glyburide and lisinopril. He had not had prior abdominal surgery. On examination, he was overweight and in mild distress due to abdominal discomfort. His blood pressure was 148/100 mm Hg, pulse 110 beats/min, respiratory rate 24 breaths/min, temperature 100.4°F (rectal). He was alert and oriented. His oral mucosa was dry and sclera was anicteric. His lungs were clear and his heart wasr apid and regular without a murmur

6. Abdominal examination revealed diminished bowel sounds, moderate tenderness in the right upper quadrant, and a Murphy’s sign. There was no tenderness on rectal examination and stool was guiac negative. An intravenous line was started and blood specimens were obtained. Intravenous fluids, insulin, and ampicillin/sulbactam were administered Blood test results (units for electrolytes, mEq/L and chemistry values, mg/dL, except where noted): WBC 19,700/mm3, hematocrit 49%, platelets 246,000/mm3. Na 132, K 4.1, Cl 101, CO2 22, BUN 24, creatinine 1.4, glucose 406. ALT 100 U/L (normal: 7–37), AST 65 U/L, alkaline phosphatase 61 U/L (normal: 39–117), total bilirubin 1.6 (normal: 0.2–1.2), lipase 110 U/L (normal). A bedside sonogram was performed and the gallbladder could not be confidently identified. The patient was sent to the radiology department for another abdominal ultrasound study. Selected ultrasound images, including the right upper quadrant, are shown in Figure 1.

9. TYPICAL SONOGRAPHIC APPEARANCE OF GALLSTONE

12. UNDER WHAT CIRCUMSTANCES WOULD THE GALLBLADDER NOT HAVE ITS TYPICAL APPEARANCE?

13. When patient has recently eaten. Multiple episodes of cholecystitis (scarred and shrunken) Filled w/stones or contracted around gallstones Air filled gallblader (empysematouse cholecystitis)

14. WALL-ECHO-SHADOW (WES) OR DOUBLE ARC

18. EMPHYSEMATOUS CHOLECYSTITIS

19. Emphysematous cholecystitis < 1% ATC: elderly, male, dbt Mortality rate: 15% (1.4 cholecystitis) TTO: CX because of perforation Test of choice: Abdominal RX

21. Air in the biliary system also occurs w/ enteric- biliary fistula (gallstone ileus or surgical anastomosis) – Gallbladder is collpased rather than distended

22. GAS IN THE GALLBLADDER WALL IS PATHOGNOMONIC FOR EMPHYSEMATOUS CHOLECYSTITIS

23. BEST INITIAL TEST? ULTRASONOGRAPHY : bright echogenic crescent in the gallbladder fossa with dirty shadowing and ring down artifacts. – Similar: Contracted stone-filled gallbladder (WES) Porcelain gallbladder w/ calcified wall due to chronic cholecystitis CONFIRMATION: – Abdominal rx or CT

25. IMAGING DIAGNOSIS OF ACUTE CHOLECYSTITIS Abdominal rx: 15% stones calcified Ultrasound : > sensitive Symptomatic: – 80% without

27. DIAGNOSIS OF ACUTE CHOLECYSTITIS CLINICAL PRESENTATION SIGNS OF GALLBLADDER INFLAMATION ON SONOGRAPHY OR CT – GALLBLADDER WALL THICKENING (>3 TO 5MM) – PERICHOLECYSTIC FLUID – SONOGRPHIC MURPHY’S SIGN

29. CLINICAL PRESENTATION! Persitant pain Focal tenderness Murphy sign Leukocytosis Fever