Cholecystitis

 ICD9           = 575.0, 575.1|
 ICDO           = |
 Image          = |
 Caption        = |
 OMIM           = |
 MedlinePlus    = |
 eMedicineSubj  = med |
 eMedicineTopic = 346 |
 DiseasesDB     = 2520 |

}} Cholecystitis is inflammationof the gallbladder. It is commonly due to impaction (sticking) of a gallstonewithin the neck of the gall bladder, leading to inspissationof bile, bile stasis, and infection by gut organisms. Cholecystitis may be a cause of right upper quadrant pain. The pain may actually manifest in the right flank or scapularregion at first. In severe cases, the gall bladder can rupture and form an abscess. In severe cases, it may lead to a life-threatening infection of the livercalled cholangitis. In other cases, it may lead to a stable inflammatory state termed chronic cholecystitis.

Diagnosis

The classic patient with acute cholecystitis presents with acute right upper quadrant pain, nausea/vomiting, and fever. On physical examination, he or she has a Murphy's sign, which is a diaphragm spasm (due to the intense pain) when the region of the gall bladder is palpatedby the examiner.

Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin(although this could indicate choledocholithiasis), and possibly an elevation of the white blood cellcount. The degree of elevation of these laboratory values can be dependent 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

Sonographyis 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 2 major diagnostic criteria are cholelithiasisand sonographic Murphy's sign. Minor criteria include gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation.

The reported sensitivity and specificity of CT scanfindings 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 calculioutside the lumenof the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphywith 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.

References

• Shea, JA, Berlin, JA, Escarce, JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154:2573.
• Fink-Bennett, D, Freitas, JE, Ripley, SD, Bree, RL. The sensitivity of hepatobiliary imaging and real time ultrasonography in the detection of acute cholecystitis. Arch Surg 1985; 120:904.

Therapy

Image:Laprascopy-Roentgen.jpg Although antibioticswill often help reduce the inflammation of the gallbladder, acute cholecystitis is an indication for gallbladder removal (cholecystectomy). This can be accomplished with an open surgery or a laparoscopicprocedure. Laparoscopic procedures can have less morbidityand a shorter recovery stay. An open procedure is preferred by many surgeons if the gallbladder is so inflamed that it could fall apart with the manipulations that could be needed with a laparoscopic procedure. A laparoscopic procedure may also be 'converted' to an open procedure during the operation if the surgeon feels that further attempts at laparoscopic removal might harm the patient.

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 radiologistinsert a percutaneousdrainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. The patient may later warrant cholecystectomyif their condition improves.

Gallbladder ruptureis a possible but an unusual complication of cholecystitis. 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.

Complications

of cholecystitis

• Rupture
• Ascending cholangitis

of cholecystectomy

• bile leak ("biloma")
• bile duct injury (about 5-7 out of 1000 operations. Open and laparoscopic surgeries have essentially equal injuries, but the recent trend is towards fewer injuries with laparoscopy, probably because the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
• abscess
• wound infection
• bleeding (liver surface and cystic artery most common sites)
• hernia
• organ injury (intestine and liver at highest risk, especially if gallbladder through inflammation has become adherent/scarred to other organs[eg transverse colon])
• deep vein thrombosis/pulmonary embolism(unusual- risk can be decreased through use of sequential compression devices on legs during surgery)

ja:??? pt:Colecistite

This article is licensed under the GNU Free Documentation License.
It uses material from the http://en.wikipedia.org/wiki/Cholecystitis Wikipedia article Cholecystitis.