29 Acalculus Cholocystitis
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29 Acalculus Cholocystitis

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29 Acalculus Cholocystitis 29 Acalculus Cholocystitis Document Transcript

  • Acalculous Cholecystitis Further reading : http://emedicine.medscape.com/article/187645-overview 1. Epidemiology 1. Incidence: 5-10% of patients with Acute Cholecystitis 2. Risk factors 1. Elderly 2. Diabetes Mellitus 3. Multiple trauma 4. Extensive burn injury 5. Prolonged labor 6. Major surgery 7. Gallbladder torsion 8. Systemic Vasculitis 9. Biliary tract infection (Bacterial or parasitic) 3. Symptoms and Signs 1. Indistinguishable from calculous Acute Cholecystitis 2. Patient ill on initial presentation 4. Diagnostics 1. RUQ Ultrasound or CT Abdomen 1. Large, tense, static gallbladder 2. No evidence of Gallstones 2. Radionuclide Cholescintography (HIDA scan) 1. Poor gallbladder filling 2. Gallbladder ejection fraction <50% 5. Management 1. Cholecystectomy 1. Offers satisfactory symptom relief in 96% of cases 2. Brosseuk (2003) Am J Surg 186:1
  • RUQ Ultrasoun = Gallbladder Ultrasound 1. Efficacy in Cholelithiasis 1. Test Sensitivity for Gallstones: 95% 2. Test Specificity high 3. Can visualize Gallstones >= 2 mm 2. Evaluation of Cholecystitis 1. Findings suggestive of Cholecystitis 1. Presence of Gallstones 2. Thickened gallbladder wall 3. Gallbladder distension 4. Pericholecystic fluid 5. Positive sonographic Murphy Sign 2. Interpretation: Above findings present 1. Cholecystitis Positive Predictive Value (PPV) 90% 3. Interpretation: Above findings absent 1. Cholecystitis unlikely RIGHT UPPER QUADRANT
  • Radionuclide Cholescintography =: HIDA scan, DISIDA scan 1. Technique 1. Technetium-iminodiacetic acid analog injected IV 1. HIDA scan used for Serum Bilirubin < 5-7 mg/dl It is most commonly observed in the setting of very ill 2. DISIDA scan used for Serum Bilirubin patients (eg, on mechanical ventilation, with sepsis or >7 mg/dl 1 2 severe burn injuries, after severe trauma ). In addition, 2. Absorbed and secreted into biliary tract by acalculous cholecystitis is associated with a higher hepatocytes incidence of gangrene and perforation compared to calculous disease. The usual finding on imaging studies is a distended 2. Interpretation acalculous gallbladder with thickened walls (>3-4 mm) with 1. Normal Billiary tract and Gallbladder or without pericholecystic fluid. Acalculous cholecystitis can 1. Clear outline gallbladder and cystic be observed in patients with human immunodeficiency virus duct in 1 hour (HIV) infection, although it is a late manifestation of this 2. Cystic duct obstruction disease. Acalculous cholecystitis can also be found in 1. Failure to outline Gallbladder within 1 patients on total parenteral nutrition (TPN), typically those hour on TPN for more than 3 months. Pathophysiology The main cause of this illness is thought to be due to bile stasis and increased lithogenicity of bile. Critically ill patients are more predisposed because of increased bile viscosity due to fever and dehydration and because of prolonged absence of oral feeding resulting in a decrease or absence of cholecystokinin- induced gallbladder contraction. Gallbladder wall ischemia that occurs because of a low-flow state due to fever, dehydration, or heart failure may also play a role in the pathogenesis of acalculous cholecystitis. View slide
  • Management should be instituted promptly, especially in critically ill patients. After blood cultures are obtained, intravenous broad spectrum antibiotics should be started. Once acalculous cholecystitis is established, secondary infection with enteric pathogens, including Escherichia coli, Enterococcus faecalis, Klebsiella, Pseudomonas, Proteus species, and Bacteroides is common. Antibiotic therapy should be directed against these organisms. Workup Laboratory Studies The choice of antibiotics should take into consideration  CBC count, liver function tests, and blood culture tests are recent use of antibiotics. Patients who were previously on some of the main laboratory tests that should be broad-spectrum antibiotics can be treated with a third performed. Bile culture results are negative in nearly 50% generation cephalosporin plus metronidazole or of patients with acalculous cholecystitis, probably imipenem/cilastatin plus or minus antifungal therapy (usually because of concurrent antibiotic therapy in these patients with fluconazole) depending upon the duration and intensity of prior broad spectrum antibiotic therapy. Vancomycin can be added when the incidence of nosocomial infection with MRSA is known or suspected to be likely. Diet Patients in the acute stage of acalculous cholecystitis should receive nothing by mouth. Hydration with intravenous fluids should be Those who have not previously received antibiotics can provided. receive empiric therapy with piperacillin/tazobactam, ampicillin/sulbactam, or imipenem. Aminoglycosides should be avoided when possible in the elderly or those with renal Medication insufficiency, although one or two doses can be given empirically pending microbiological results in most patients Administer broad-spectrum antibiotics for enteric and biliary without serious risk. pathogen coverage. Definitive treatment is cholecystectomy in patients who are surgical candidates or cholecystostomy in patients who are not surgical candidates. Follow-up Complications  Perforation or gangrene of the gallbladder and extrabiliary abscess formation may occur. Prognosis  Prognosis is guarded. Miscellaneous Medicolegal Pitfalls  Delay in diagnosis or treatment may result in higher mortality rates. View slide
  • MY NEXTBIO DATA IMPORT COMMUNITY CORPORATE HOME Sign In Register for free Acalculous cholecystitis Overview Search Term: Acalculous cholecystitis (disease) Overview Print page RESEARCH Inflammation of the GALLBLADDER wall in the absence of GALLSTONES. Data Correlations View Complete Description PUBLICATIONS Literature Clinical Trials Literature | 939 results View All Clinical Trials | 4 trials View All News Acute acalculous cholecystitis in The Influence of Ezetimibe on juvenile systemic lupus erythematosus. Gallbladder Function NEXTBIO COMMUNITY Authors: J A Mendonça, J F Marques- conditions: Chronic Acalculous Users Neto, P Prando, S Appenzeller Cholecystitis Lupus 2009 May interventions: ezetimibe ; Placebo Groups T-cell PTLD presenting as acalculous cholecystitis. Role of Routine on-Table Cholangiography in Laparoscopic Bookmark this page Authors: Tamir Miloh, Margret Magid, Cholecystectomy Alyssa Yurovitsky, James Strauchen, Forward this page Ronen Arnon, Nanda Kerkar, Henrietta conditions: Common Bile Duct Stones E-mail feedback Rosenberg, Umesh Joashi, Deepa interventions: on table cholangiography Bhojwani Pediatric transplantation 2008 Sep Community Associated Researchers NextBio Users Thought leaders and organizations working on research involving Acalculous No NextBio users were found for “Acalculous cholecystitis. cholecystitis”. Complete your user profile with your interests, Authors View All if you want others to find you within the NextBio community. H Syrjälä T I Ala-Kokko P A Laurila J Saarnio NextBio Groups Alexia Prassouli No NextBio groups were found for “Acalculous cholecystitis”. Clinical Trials Sponsors View All Be the first to start a group and share your interests with others within the NextBio Royal Brompton & Indiana University community. Harefield NHS Foundation Trust Covidien Yale University Organizations View All Oulu University Jordan University of Hospital Science and Technology Hospital Vera Cruz Medical University of Gdansk University of Ilorin Teaching Hospital Resources Contact Us Customer Support © 2009 NextBio | privacy policy | terms of service | site map