The document provides a comprehensive overview of acute cholecystitis, detailing its causes, epidemiology, etiology, pathology, clinical features, investigations, complications, and treatment. It emphasizes the significance of gallstones and their relation to the condition, along with risk factors and management strategies, including the importance of timely surgical intervention. Clinical features and diagnostic approaches are also outlined to aid in the assessment and treatment of patients with acute cholecystitis.

1. ACUTE
CHOLECYSTITIS
RUQ PAIN
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. ACUTE CHOLECYSTITIS
 Causes for RUQ pain
 Epidemiology
 Etiology
 Pathology
 Clinical features
 Investigations
 Complications
 Treatment
 Mindmap
 Diagnostic Algorithm
 Treatment Algorithm

3. CASUES FOR RUQ PAIN

4. ACUTE CHOLECYSTITIS
-Epidemiology
 Cholecystitis is inflammation of the
gallbladder most commonly due to an
obstruction of the cystic duct by gallstones
arising from the gallbladder (cholelithiasis).
 Uncomplicated cholecystitis has an excellent
prognosis; the development of complications
such as perforation or gangrene renders a bad
prognosis.
 10%-20% of Americans have gallstones, and as
many as one third of these people develop
acute cholecystitis
 AGE: The incidence of cholecystitis increases
with age. Explanation for this is unclear.
 Sex distribution: Gallstones are 2-3 times
more frequent in females than in males,
resulting in a higher incidence of calculous
cholecystitis in females. Elevated progesterone
levels during pregnancy is the cause.
Acalculous cholecystitis is observed more often
in elderly men.
 Prevalence by race and ethinicity: More
common in people of Scandinavian descent,
Pima Indians, and Hispanic populations. In
the United States, white people have a higher
prevalence than black people.

5. ACUTE CHOLECYSTITIS
-ETIOLOGY
 Risk factors for Calculus Cholecystitis: 90%
- Female
- Fat- obese
- Fertile- Multigravida
- Forty- elderly
- Certain ethnic groups
- Certain drugs like HRT in females
 Risk factors for Acalculus Cholecystitis:
10%
- Critically ill patients
- Those who underwent major
surgery/trauma/Burns
- Severe Sepsis
- Prolonged fasting
- Long term TPN
- Sickle cell disease
- Immunocompromised patients- Diabetes & HIV
Admirand Triangle
 Percentages of saturation
of three elements in bile
lead to precipitation and
cholesterol stone formation
 These three elements are
cholesterol, lecithin and
bile salts.
 The normal ratio between
cholesterol and lecithin &
bille salt is 1: 30
 If this ratio comes below
1: 13 the cholesterol gets
precipitated and crystals
form.

6. ACUTE CHOLECYSTITIS
-PATHOLOGY
 90% of cases of cholecystitis involve
calculous cholecystitis, with the other
10% of cases representing acalculous
cholecystitis.
 Acute calculous cholecystitis is caused
by an obstruction of the cystic duct,
leading to distention of the gallbladder.
As the gallbladder becomes distended,
blood flow and lymphatic drainage are
compromised, leading to mucosal
ischemia and necrosis.
 Acalculous cholecystitis- exact
mechanism is unclear. Injury may be
the result of retained concentrated bile.
 Stage 1: stone lodges in cystic
duct; midepigastric colickypain
 Stage 2: stone impacts in cystic
duct; pain shift to RUQ;
radiation to right
scapula/shoulder
 Stage 3: bacterial invasion GB
wall; + Murphy sign; subsides if
stone falls out
 Stage 4: perforation

7. ACUTE CHOLECYSTITIS
- Clinical Features

8. ACUTE CHOLECYSTITIS
- INVESTIGATIONS
1. Gall stones with
posterior acoustic
shadow
2. Gall Bladder wall
thickness >4mms
3. Pericholecystic
fluid collection

9. ACUTE CHOLECYSTITIS
- INVESTIGATIONS
1. In Acalculus
Cholecystitis and
equivocal USG
2. Normal GB- will
take-up tracer
3. In Ac cholecystitis-
Tracer not taken
up by GB

10. ACUTE CHOLECYSTITIS
- INVESTIGATIONS

11. ACUTE CHOLECYSTITIS
- SEVERITY GRADING
A- American
A- Association
S- Surgery
T- Trauma

12. ACUTE CHOLECYSTITIS
- COMPLICATIONS

13. ACUTE CHOLECYSTITIS
- TREATMENT
 Most consider that it is safe to observe patients with
asymptomatic gallstones, with cholecystectomy
reserved for patients who develop symptoms or
complications
 If patients come within 3 days of onset of
symptoms Immediate Cholecystectomy
 If patients are going to come after 3 days of onset of
symptoms do conservative treatment to cool down
the inflammation first and do elective
Cholecystectomy after 45 days
 If severe Cholecystitis with comorbidities Do
percutaneous cholecystostomy. However, an interval
cholecystectomy will be required once the patient’s
condition has stablised.

14. ACUTE CHOLECYSTITIS
- MINDMAP

15. ACUTE RUQ PAIN
- DIAGNOSTIC ALGORITHM

16. ACUTE CHOLECYSTITIS
- TREATMENT ALGORITHM

17. Peripheral Arterial Diseases(PAD)