acute cholecystitis

1. ACUTE CHOLECYSTITIS
Usual cause is impacted gallstone in the Hartmann's pouch,
obstructing cystic duct.

2. Definition
Acute bacterial inflammation of the
gall bladder with or without stone.

3. Typs
• Calculous: Obstructive cholecystitis. It is the
commonest
variety. Calculi cause bile stasis.
• Acalculous: Nonobstructive cholecystitis. It is not
uncommon and is seen in patients who are recovering
from
major illness .
• Acute emphysematous cholecystitis.

4. Mode of Infection
•Haematogenous through hepatic artery-cystic
artery.
•Portal vein.
•Through bile after filtering in the liver via portal
circulation.

5. Pathogenesis of Acute Cholecystitis
• Stone causes obstruction at Hartmann's pouch or in cystic
duct. Obstruction causes stasis, oedema of the wall, bacterial
infection, acute cholecystitis and its effects.
• Impacted stone also causes mucosal erosion allowing bile
salts to act over the submucosal tissues as bile is toxic to
these tissues. It leads into necrosis, further infection and
often perforation of the gallbladder usually at Hartmann's
pouch.

6. Pathology
• Gallbladder will be distended with oedematous friable wall.
• Wall contains dilated vessels.
• Areas of necrosis and patchy gangrene may occur in severe
cases.
• Mucosa shows ulceration and necrosis.
• Lumen contains infected fluid/infected bile or frank pus.
shows features of acute inflammation with neutrophils,
oedema, and areas of necrosis and cell death.

7. Complications
Acute cholecystitis can lead to:
• Perforation-5-10% which usually occurs in the fund us or
in the neck (Hartmann's). It can cause cholecystoduodenal,
cholecystointestinal or cholecystobiliary fistula, Mirrri zi 's
syndrome.
• Peritonitis; Pericholecystitic abscess.
• Cholangitis and septicaemia.
• Empyema gallbladder; gangrenous gallbladder.

8. Clinical Features
• Sudden onset of pain in the right hypochondrium, with
tenderness, guardi ng, and rigidity.
• Palpable, tender, smooth, soft gallbladder.
• Area of hyperaesthesia between 9th and 11th ribs posteriorly
on the right side (Boas's sign).
• Jaundice may be present.
• Fever, nausea, palpable tender mass in GB region (25%).
• Tachycardia and toxic features.
• Murphy's sign may be positive (mid-inspiratory arrest).

9. investigations
• Ultrasound abdomen-very useful, reveals presence or absence of gallstones;
and thickening of gallbladder wall. Sonographic Murphy's sign may be
positive.
• Plain X-ray abdomen- 10% of gallstones are radio-opaque; also rules out other
causes of acute pain abdomen. Gas is seen in emphysematous GB.
• Total count shows neutrophilia.
• HIDA/PIPIDA radioisotope study- very useful. Non-visuali_x0002_sation of
gallbladder is diagnostic.
• LFT is important. Increased serum bilirubin often signifies cholangitis or stone
in the CBD.
CT scan is useful in identifying the perforation, impacted stone, gallbladder wall
thickness and oedema.

10. Treatment
• Advised hospitalisation.
• Initially (nonoperative) conservative treatment (95%):
• Nasogastric aspiration.
• IV fluids.
• Analgesics and antispasmodics.
• Broad spectrum antibiotics
• Observation.
• Follow-up UIS scan.
• Later after 3-6 weeks, elective interval cholecystectomy,

11. cholecystostomy
• Empyema gallbladder; Persisting symptoms; Progressing
symptoms.
• Here the gallbladder is opened and all stones and pus are
removed. Either a Foley's or Malecot's catheter is placed in the
• gallbladder and is exteriorised. US-guided percutaneous
cholecystostomyalso can be used.
• After 3 weeks, elective cholecystectomy is done.

12. INDICATIONS FOR CHOLECYSTOSTOMY OR EMERGENCY
CHOLECYSTECTOMY (5%)
• Persisting symptoms/failure of medication
• Empyema GB
• Emphysematous cholecystitis
• Perforation/peritonitis; elderly.