Acute cholecysitis is inflammation of the gallbladder that causes severe abdominal
pain. It is usually a complication of cholelithiasis that involves the gallbladder with various degrees of severity. Physiology of the gallbladder: The gallbladder stores and concentrates bile. Bile flow is controlled by hepatic secretory pressure, the tone of Sphincter of Oddi, gallbladder contraction and the rate of gallbladder fluid absorption. The gallbladder also releases bile in to the common hepatic duct. Anatomy of gallbladder: Fundus or tip Corpus Infundibulum called Hartmanns pouch Neck Cystic duct (2-4 cm long) Biliary tract The Biliary tract includes the intra-hepatic bile duct, the extra-hepatic biel dut, the gallbladder and the sphincter of Oddi. Intra-hepatic bile duct: Bile canaliculi Segmental bile duct Lobal bile duct Right or left hepatic duct Extra-hepatic bile duct: Left and right hepatic bile duct Common hepatic duct, ductus hepaticus communis Common bile duct, ductus choleduchus Cystic duct of gallbladder, Sphincter of Oddi Classification of acute cholecystitis Types of acute cholecystitis: acute calculous cholecystitis 90-95% acute acalculous cholecystitis Forms of acute cholecystitis: Simple or catarrhal Phelgmonous Gangrenous Perforated
Acute calculous cholecystitis
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-involves a gallstone; is a complication of cholelithiasis.
-the gallstone blocks the pathway from the gallbladder to the cystic duct leading ultimately to inflammation of the gallbladder. -obstruction of cystic duct increase intraluminal pressure in the gallbladder. -is associated with arterial dilation and entesive venous filling Acute acalculous cholecystitis, AAC -is inflammation of the gallbladder without stone formation -is associated with arterial occlusion and minimal or no vneous filling . The critical factor in acute acalculous cholecystis is gallbladder ischemia or reperfusion injury. -bile stasis due to volume depletion is also a factor in AAC (lysophospholipid choline I bile can cause local injury of the gallbladder wall/mucosa; other bile components like -glucuronidase can induce AAC Clinical picture of acute cholecystitis Sudden pain in the rugiht upper quadrant (RUQ) NB: sudden pain is also in biliary colic but the onset of the pain in biliary colic is food-related. Pain in acute cholecystitis is not connected with meals and begins as a dull, poorly localized pai in the mid-epigastrium. Tenderness and n rigidity of RUQ Nausea, vomiting Signs of acute cholecystitis in acute calculous and acalculous cholecystitis Murphys sign press the right upper quadrant region while the patient is inspiring deeply. Murphys sign is positive when patient stops breathing during inspiration because your pressing caused pain. Kers sign- kers point is where the right lateral edge of the rectus abdominis muscle meets the right costal arch. Kers point is the projection of the gallbladder. Kers sign is positive if pain is felt by the patient when you percuss Kers point. Ortners sign - is positive when pain is felt if you strikKers point with edge of the palm. De Mussy-Georgievskys sign or the phrenic sign- pressing the clavicular edge of the sternocleidomastoid muscle causes pain in the right upper quadrant. Boas sign- area of hyperesthesia between 9 th and 11th rib posteriorly on the right side Laboratory investigations CBC = leukocytois 12,000-15,000 cells Check liver function, serum bilirubin, serum alkaline phosphatase and serum amylase Instrumental methods 3
-US to demonstrate gallstones
-CT to show thickening of the gallbladder wall. Management Conservative treatment: Admit the ptient to the hospital Diet Iv hydration Systemic antibiotics Monitor the patient Other drugs ie spasmolytics, anithistamines, but do not give pain killers. If you do give pain killers you wont be able to tell when the inflammation spreads 9pain intensifies) and you wont know when to use surgical treatment. Surgical treatment -Open or laparoscopic cholecystectomy Open cholecystectomy: usually a midline incision is used; is of 2 types antegrade and retrograde -Surgery s contraindicated in carcinoma, choledocholithiasis, biliary stenosis, sever abdominal infection, pregnancy Differential diagnosis Appendicitis Cholangitis Cholelithiasis Diverticulitis Gastroenteriritis hepatitis