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Cholecystitis case conference
- 1. A sack of stones Saavedra, Martin Henry F.
- 2. Objectives To present a case of an eighteen year old with abdominal pain To discuss the pathophysiology, diagnostics, and therapeutics of a patient with an Acute Cholecystitis
- 3. Identifying Data: Patient A.C. 18 year old, female Filipino Roman Catholic From Sta. Mesa, Manila Chief Complaint: Intermittent epigastric pain of 9 days duration.
- 4. 9 Temporal Profile P A I N I N T E N S I T Y D A Y S O F I L L N E S S 10 9 8 7 6 5 4 3 2 1
- 5. 9 Temporal Profile P A I N I N T E N S I T Y D A Y S O F I L L N E S S 10 9 8 7 6 5 4 3 2 1
- 6. 9 Temporal Profile Domperidone Gaviscon P A I N I N T E N S I T Y D A Y S O F I L L N E S S 10 9 8 7 6 5 4 3 2 1
- 7. 9 Temporal Profile Omeprazole P A I N I N T E N S I T Y D A Y S O F I L L N E S S 10 9 8 7 6 5 4 3 2 1 Domperidone Gaviscon
- 8. 9 Temporal Profile Omeprazole Omeprazole P A I N I N T E N S I T Y D A Y S O F I L L N E S S 10 9 8 7 6 5 4 3 2 1 Omeprazole Domperidone Gaviscon
- 9. Pediatric History Birth and Maternal History Full term NSD delivery attended by medical staff No feto-maternal complications Feeding History Exclusively breastfed for 6 months then added complementary feeding Non-picky eater, 3 meals/day with snacks Likes fried, fatty, and salty foods as well as street food No known food allergies
- 10. Pediatric History Immunization History Has complete primary immunizations given at a local health center Developmental History The patient is at par for age. No developmental delays noted. She is currently a newly graduated highschool student with interest in entering collage and is said to have good interactions with her peers.
- 11. Past Medical History No know past illnesses. No recent trauma/accident/surgeries. No known allergies.
- 12. Family History Paternal – hypertension No history of blood disorders, asthma, allergies
- 13. Social History Lives with her parents and sibling 2-storey concrete house in Manila with a clean and safe environment, adequate ventilation, potable water, and regular waste disposal.
- 14. Pediatric History Adolescent Psychosocial History Education: Newly graduated high school student; good performance in school; good peer relationship; aims for an engineering course Activity: Likes social media; helps with housework; goes out with peers frequently; no particular sport or activity Drugs: Denies illicit drug use; no alcohol intake or smoking; Father is the only smoker at home Sexuality: No current relationship; heterosexual; no STD’s Suicide/Depression: Known to be cheerful and lively; denies feeling of helplessness or desire for self-harm; wishes quick recovery.
- 15. Physical Examination PHYSICAL EXAMINATION UPON ADMISSION General Survey Awake, alert, responsive, not in distress, in pain Vital Signs BP: 90/60 HR: 90 bpm RR: 18 cpm Temp: 36.0 oC O2 Sat: 98% RA Anthropometrics Weight 63 kg Weight for Age Z-Score: 0, Normal Height 159 cm Height for Age Z-Score: 0, Normal BMI 24.5 kg/m2 BMI for Age Z-Score: 0, Normal Skin Smooth, warm, pinkish conjunctiva, no cyanosis, no hematoma, no rashes, no jaundice HEENT Head: No deformities or malformations noted. Eyes: Pink palpebral conjunctivae, anicteric sclerae, non-sunken eyeballs Ears: Patent ear canals, both ears; well-curved pinna, formed with instant recoil, no discharge on both ears Nose: Patent nares, no flaring, septum at midline, no discharge Mouth and Throat: no tonsillopharyngeal congestion, no cervical lymphadenopathy Chest and Lungs Equal chest expansion, no retraction, equal tactile fremitus, resonant on all lung fields, clear breath sounds Cardiovascular Adynamic precordium, normal rate, regular rhythm, distinct s1 and s2, no murmurs, no heaves and thrills Abdomen Flat, non-distended, normoactive bowel sounds (+) guarding on palpation, (+) Direct tenderness, epigastric area, (-) rebound tenderness, (-) Dunphy’s sign, (-) Psoas or Obturator’s sign, (+) Murphy’s sign; gallbladder palpable below the right subcostal margin, liver non-palpable Extremities Full and equal pulses, CRT<2s, no cyanosis, edema
- 16. Diagnostic Examination CBC Normal Values 05.26.20 Hemoglobin 120 - 140 g/L 124 Hematocrit 37-47% 38 RBC 4.5-5.5 x 10^12/L 4.7 MCHC 32-37% 32 MCH 27.5 -33.2 pg 26.3 MCV 80 -94 fl 81 RDW 11.0-15.0% 12.6 WBC 5.0-10.0x10^9/L 17.6 Neutrophils 37 -92% 94 Lymphocytes 20 -50% 6 Monocytes 0-14% 0 Eosinophils 0-6% 0 Basophils 0-1% 0 Platelet 150-440 324 MPV 7.5-11.5 9.8 Blood Type A+ RBC Morphology Normochromic, normocytic Normochromic, normocytic Urinalysis 05.26.2020 Color Yellow Turbidity Turbid Reaction Acidic Specific Gravity 1.030 Protein Trace Sugar Negative RBC 3-5/hpf WBC 15-25/hpf Bacteria Many Epithelial Cells Many Mucus Thread Many Blood Chem Reference Value 05.23.2020 Alkaline Phosphatase 10 Amylase 60-160 u/L 40 Lipase 0-110 Iu/L 6
- 17. Initial Diagnosis Acute Abdomen, T/C Acute Cholecystitis
- 18. Additional Diagnostic Exams Chest X-ray 05.26.20 Normal Chest Upper Abdomen Ultrasound 05.26.20 • Mild hepatic fibrosis by shear wave elastography. Negative for mass lesions • Gallbladder hydrops and cholecystolithiasis lodged at the neck and cystic duct • Non-dilated biliary tree • Normal sonogram of the pancreas and spleen Test Reference Value 05.26.2020 Protime 10-13 12.1 Control 12.0 INR 1.01 % Activity 87.4 PTT 29-34 25.3 Control 30.0 Blood Chem Reference Value 05.23.2020 Sodium 135-155mmol/L 140 Potassium 3.5-5.3 mmol/L 3.8 Chloride 103-116 mmol/L 109 Liver Function Reference Value 05.24.2020 SGPT 10-30 Iu/L 12 SGOT 6-37 Iu/L 13 Direct Bilirubin 5.0 Total Bilirubin 7.9 Indirect Bilirubin 2.9
- 20. One of the most common complaints in a child Diagnosis is dependent on history and clinical features Majority of abdominal pain is from a benign cause Most common medical cause is gastroenteritis; surgical is appendicitis Wide and varies with age group Challenge is to identify the correct diagnosis or disease with possibly life-threatening consequences
- 21. Joon Sung Kim. Acute Abdominal Pain in Children. Pediatr Gastroenterol Hepatol Nutr 2013 December 16(4):219-224
- 22. History Onset pattern, progression, location, intensity, characters, precipitating and relieving factors of abdominal pain, and associated symptoms Age, recent trauma, previous surgery
- 23. Joon Sung Kim. Acute Abdominal Pain in Children. Pediatr Gastroenterol Hepatol Nutr 2013 December 16(4):219-224
- 24. Physical Examinations General appearance Resists movement – peritoneal Frequent positioning – visceral pain Vital Signs Fever – underlying infection Tachycardia – hydration status Tachypnea - pneumonia Abdominal Examination degree of abdominal tenderness, location, rebound tenderness, rigidity, distension, masses, or organomegaly.
- 26. Diagnostic Exams CBC and urinalysis usually indicated in all acute abdominal pain Other labs based on index of suspicion Ex. Amylase and lipase for pancreatitis Pregnancy test in postmenarchal girls Appropriate imaging Ultrasound, radiographs, CT/MRI
- 28. Differential Diagnosis Acute Cholecystitis Acute Appendicitis Acute Pancreatitis Rule in (+) Direct tenderness on RUQ Small palpable RUQ mass Murphy’s sign (+)Guarding (+)Nausea/Vomiting Leukocytosis Left shift (+) Gallstones on UTZ (+)Nausea/Vomiting (+)Guarding (+)Many WBC in urinalysis Leukocytosis Left shift RUQ pain (+)Nausea/Vomiting (+)Guarding Leukocytosis Left shift Rule out (-)aggravating factors for pain (-)Fever (-)Fever (-) RLQ shift of pain (+) Direct tenderness on RUQ (-)Appendiceal findings on UTZ Normal Lipase/Amylase No pancreatic findings on UTZ (-)Fever (-)pain radiation to back (-)aggravating factors for pain (-)trauma (-) binge alcohol intake (-)Cullen sign
- 29. Course in the Wards: Day of Admission At the ER 9-10/10 pain, squeezing in character on the epigastric area radiating to the RUQ Pain unrelieved by Omeprazole, Gaviscon; nausea controlled by plasil Leukocytosis with neutrophilic predominance on CBC and urinalysis; other labs normal Gallbladder hydrops and cholecystolithiasis seen on ultrasound Evaluated by surgery and advised admission as a case of Acute Cholecystitis with Cholecystolithiasis
- 30. Course in the Wards: Day of Admission At the Ward Started on Cefazolin Venoclysis started Additional diagnostics done with normal results Emergency open cholecystectomy done, procedure tolerated IOP: Non-dilated gallbladder; Non-thickened wall; Multiple subcentimeter stones; No pericholecystic fluid. Other Vital signs stable with good pain control Surgical site well coapted with no bleed or discharge Tramadol/Paracetamol for pain control
- 32. Course in the Wards: 1st HD Afebrile, stable vital signs Good pain control Post-operative site well coapted, purulent no discharge Shifted to soft diet Fair to good appetite
- 33. Course in the Wards: 2nd HD Afebrile, stable vital signs Good pain control Post-operative site well coapted, purulent no discharge Cefazolin IV shifted to oral Cephalexin Venoclysis discontinued Shifted low fat, regular diet Good appetite
- 34. Course in the Wards: 3rd HD Afebrile, stable vital signs Good pain control Post-operative site well coapted, purulent no discharge Discharged well and stable
- 35. Final Diagnosis Acute Cholecystitis with Cholecystolithiasis S/P Emergency Open Cholecystectomy (05.27.20)
- 37. Acute Cholecystitis Inflammation of the gallbladder Obstruction, inflammation, or infection Obstruction at the cystic duct is prolonged Uncommon in children and incidence increases with age Right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation.
- 38. Epidemiology Incidence increases with age Uncommon in children and is usually caused by infection Female > Male Recently cholesterol stones are more common Scandinavian descent, Pima Indians, and Hispanic populations; less common in sub-Saharan Africa and Asia
- 39. Risk Factors Fat (Stature and Diet) Female Fertile (Multigravid) Forty Fair Skinned Contraceptive pills or hormonal therapy Metabolic illness (Ex. Diabetes) Blood Disorders Sedentary
- 41. Features of the Patient Female gender Reproductive age Likes fatty and oily foods No particular sport or activity
- 42. Etiology Obstruction Inflammation (mechanical or chemical) Bacterial invasion E. coli Klebsiella spp. Clostridium spp. Salmonella spp.
- 43. Cholelithiasis Most common biliary pathology Mostly asymptomatic (>80%) 1-2% of asymptomatic patients will develop symptoms Most common point of origin is within the gallbladder.
- 44. Cholesterol Stones Most common type up to 80% Pure cholesterol or mixed with other substances Female > Male Smooth and whitish, or yellow to tan color; oval shape 80% by weight in cholesterol
- 45. Pigment Stones Small, dark, usually numerous. Comprised mostly of bilirubin and calcium <20% by weight in cholesterol
- 46. Supersaturation of bile with cholesterol or calcium Precipitation of solutes to form solid crystals Crystals fuse and form stonesOutlet obstruction Pressure builds within the gallbladder and begins to impair venous and lymphatic drainage of the gallbladder wall and mucosa Mucosal Erosion by the stones Further destruction of the mucosa and epithilium by toxic bile salts Bacterial Proliferation Necrosis and eventual perforation
- 47. Clinical Manifestation RUQ or epigastric pain radiating to back or right scapula Colicky or dull, constant pain associated with nausea, vomiting, or anorexia Usually severe lasting a few minutes but typically prolonged Fever, nausea, vomiting, and anorexia. Pain after fatty food ingestion Jaundice X X X X _ _ P A T I E N T F E A T U R E S
- 48. Clinical Manifestation Patient may lie still due to pain Voluntary or involuntary guarding Murphy’s sign Palpable mass on the RUQ X X X X P A T I E N T F E A T U R E S
- 50. Diagnostics Based on the History and physical examination and confirmatory radiologic studies
- 51. Diagnostics Ultrasound Most sensitive and specific test Information of adjacent structures Radiologic signs of Acute Cholecystities 1. Pericholecystic fluid 2. Thickened gallbladder wall >4mm 3. Murphy’s sign during sonographic examination
- 54. PATIENT UTZ HERE
- 55. Diagnostics Hepatic Iminodiacetic Acid (HIDA) Scan HIDA agent is excreted in the biliary tree within 1 hour of administration Normal gallbladder will uptake the dye Absence of dye in the gallbladder is diagnostic Sensitivity of 80-90%
- 57. Normal HIDA Scan Acute Cholecystitis Contrast is seen in the glllbladder Gallbladder is not appreciated
- 58. Diagnostics Computed Tomography Scan Accuracy similar to that in UTZ Findings Wall edema Pericholecystic stranding and fluid High attenuation bile Rule out complications Gangrene leading to sepsis Generalized peritonitis (perforation) Abdominal crepitus (emphysematous cholecystitis) Bowel obstruction (gallstone ileus) May fail to detect gallstones as many are isodense
- 59. Diagnostics X-ray 15% of gallstones are radiopaque Obtained primarily to exclude other diagnoses Perforated viscus, bowel obstruction, calcific pancreatitis, and renal stones.
- 61. Diagnostics Laboratory findings Leukocytosis with left shift Elevated serum bilirubin or Alkaline phosphatase in CBD obstructions ALT (SGPT) and AST (SGOT) increased in liver involvement Amylase and Lipase to rule in/out pancreatitis Coagulation profiles to assess liver involvement
- 62. Features of the Patient Leukocytosis and Neutrophilic predominance on CBC Other laboratory findings normal
- 63. ✓ ✓ ✓ ✓ ✓
- 64. Surgical Management Cholecystectomy is curative Only gallstones causing symptoms/complications require treatment Generally no reason for prophylactic cholecystectomy in asymptomatic patients unless: Gallbladder is calcified Gallstones are >3cm in diameter
- 65. Surgical Management Two surgical options: Open: performed with an abdominal incision below the lower right rib areas; Recovery typically requires 3-5 days; Return to normal diet typically in a week; More invasive but less expensive Laparoscopic: performed with 3-4 small puncture holes for instruments; Same day discharge or single night stay is possible. Less invasive but more expensive.
- 66. Medical Management Antimicrobial Instituted if infection is suspected Prophylaxis prior surgery to reduce septic complications Broad spectrum effective vs Gr (-) aerobes (ex. Cefazoline, Gentamicin, Cefuroxime) Analgesia Antiemetics IV hydration
- 67. Conservative Management NPO for 2-3 days with initiation of IV hydration Broad spectrum antibiotics and analgesia Usually for patients with high risk if surgery is done such as in septic patients Done in preparation for eventual surgery
- 68. Management on the Patient Started with Cefazolin and shifted to Cephalexin as oral IV Hydration was done Open Cholecystectomy performed Tramadol/Paracetamol for pain control
- 69. Histopathologic Findings: Chronic Cholecystitis with History of Cholelithiasis
- 70. Chronic Cholecystitis Due to repeated obstruction and inflammation Thickened, non-distending, non-functioning GB shrunken, and small Mucosa proliferates into lumen with Rokitansky- Aschoff sinuses Muscular wall replaced by fibrotic tissue Similar presentation to Acute Cholecystitis
- 71. Thank You.
- 72. References Kliegman, R., Geme, J.S. (2019). Nelson: Textbook of Pediatrics (21st Ed., pp. 2048-2055). Canada: Elsevier. Kliegman, R., Lye, P. (2018). Nelson Pediatric Symptom- Based Diagnosis (1st Ed., pp. 161-181). Canada: Elsevier. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA 2003; 289:80. Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg 1993; 165:399.
Editor's Notes
- Nine days prior to consult, the patient had sudden onset of epigastric pain, squeezing in character, with a pain scale of 10/10, with no apparent aggravating factors and was associated with multiple episodes of vomiting of previously ingested food about 1 cup per episode. No medications or consults were done and pain gradually decreased and resolved.
- Seven days prior to consult, there was recurrence of epigastric pain of similar character and intensity, associated with multiple vomiting episodes of an unrecalled number of times, about ¼ - 1 cup in volume per episode of mostly previously ingested food. Pain gradually lessened in intensity through the day and eventually resolved. No interventions or consults were done.
- Five days prior to consult, recurrence of epigastric pain with a pain scale of 4/10 of same character and associated with vomiting episodes of an unrecalled number of times about ¼ cup per episode. Teleconsult was done and she was managed with Domperidone and Gaviscon of an unrecalled dose. Patient then had relief of epigastric pain and cessation of vomiting.
- Three days prior to consult, there was recurrence of epigastric pain still of the same squeezing character as with the previous episodes, now with a 7/10 intensity and with vomiting of an unrecalled amount and frequency. Consult was done at National Children’s Hospital where she was managed as a case of Peptic ulcer disease and was prescribed Omeprazole 40mg once a day for 7 days with eventual relief of pain thereafter. There was no recurrence of pain until…
- One day prior to consult, sudden recurrence of epigastric pain 4/10 of the same character radiating to the right upper quadrant associated with 7 vomiting episodes of previously ingested food ½ cup in amount per episode. No consult or management done at the time and pain persisted. Five hours prior to consult, pain increased to 10/10 of same squeezing character in the epigastric area associated with 5 vomiting episodes of same character. Consult was then done at our institution.
- Mother claims that the patient has complete primary immunizations given at a local health center. Claims to have been given boosters, but was unable to recall any specific one. Has interest with romantic relationships More independece with parents Spends more time with friends Newly graduated student with good performance
- One of the most common complaints in a child Diagnosis is dependent on history and clinical features Majority of abdominal pain is from a benign cause Most common medical cause is gastroenteritis; surgical is appendicitis Differential diagnosis is wide and varies with age group Challenge is to identify the correct diagnosis or disease with possibly life-threatening consequences
- Joon Sung Kim. Acute Abdominal Pain in Children. Pediatr Gastroenterol Hepatol Nutr 2013 December 16(4):219-224
- Pain relief after a bowel movement suggests a colonic condition, and improvement in pain after vomiting may occur with conditions localized to the small bowel. In surgical abdomen, abdominal pain generally precedes vomiting, and vomiting precedes abdominal pain in medical conditions. Bilous vomiting- POSSIBLE BOWEL OBSTRUCTION
- Joon Sung Kim. Acute Abdominal Pain in Children. Pediatr Gastroenterol Hepatol Nutr 2013 December 16(4):219-224
- Pneumonia may cause upper bdominal pain esp when the intercostal muscles are involved or if there is pleuritis
- CBC – infection, anemia d/t bleed, hydration status Urinalysis for UTI which may present as abdominal pain esp in children UTZ is also ideal for children as it is painless and no contrast or sedation is needed nor is a rigid positioning Radiograpgs for perforated viscus or obstruction CT scan for trauma and extent of abdominal masses
- Patient was initially seen at the Emergency Room with a complaint of persisting hypogastric pain of 9 days duration. Upon seeing the patient, she was seen to be in pain, on physical examination, abdominal tenderness was noted mostly on the epigastric area radiating to the right upper quadrant areas, abdomen was soft and no guarding on palpation noted. Patient was initially managed as a possible case of Non-ulcerative Dyspepsia and was given IV Omeprazole and Aluminum hydroxide+Magnesium carbonate with no relief of symptoms. Patient also had 2 vomiting episodes about ½ cup in amount, initially of previously ingested food. Plasil was given IV. Diagnostic tests were done at the ER level revealing a high WBC and neutrophilic predominance in CBC and increased WBC in urinalysis though urine catch may have been poor as many epithelial cells were seen. Amylase, Lipase and Alkaline Phosphatase were taken with normal results and Upper abdomen ultrasound was requested as well revealing Gallbladder hydrops and cholecystolithiasis; because of this Acute Cholecystitis with Cholecystolithiasis was now considered. Patient was promptly referred to surgery for evaluation and management on further physical examination other than the previous, a small, smooth, round and tender mass was palpated on the right upper quadrant; patient was subsequently admitted.
- Na K Cl; SGPT SGOT, Bilirubin, bleed parameters and CXR – normal Non-dilated gallbladder; Non-thickened wall; Multiple subcentimeter stones; No pericholecystic fluid. Cefazolin was started along with venoclysis and additional diagnostic procedures were done: serum electrolytes, SGPT, SGOT, Bilirubin levels, bleeding parameters taken and Chest X-ray with normal findings. Patient then underwent emergency Cholecystectomy; intraoperative findings were as follows: Non-dilated gallbladder; Non-thickened wall; Multiple subcentimeter stones; No pericholecystic fluid. The patient was able to tolerate the procedure without incident. After the procedure, vital signs of the patient remained stable and pain control after surgery was adequate with the patient not having any subjective complaints of pain.
- On the first hospital day, patient had stable vital signs and adequate fluid intake and output with multiple flatus and no bowel movements. Pain control remained adequate without any subjective complaints and the post-operative site was well coapted with no erythema or discharge noted. Diet was shifted to soft diet, patient had good appetite at the time and bowel movements were eventually passed during the end of the day.
- On the second hospital day, patient had stable vital signs and adequate fluid intake and output with multiple flatus and no bowel movements. Patient had good pain control, and post-operative site was well coapted with no noted active bleeding or discharge. No other subjective complaints were noted. Diet was progressed to full low fat diet. Cefazolin IV was then shifted to oral Cephalexin which the patient also tolerated well. IV fluids were discontinued as fluid intake and appetite was adequate.
- On the third hospital day, Patient had good pain control, and post-operative site was well coapted with no noted active bleeding or discharge. No other subjective complaints from the patient. Patient was then discharged well and stable.
- ------- Predominantly occurs when obstruction at the cystic duct is prolonged >6 hours----if lower and spontaneous resolution: biliary colic -------- A syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation.
- Incidence increases with age but the reason for this is unclear. But is said to be associated with hormone balance such as in the elderly androgen<estrogen Uncommon in children and is usually caused by infection Pathogens include streptococci (groups A and B), Gram-negative organisms―particularly Salmonella and Leptospira interrogans―and a number of viral infections (hepatitis A, Epstein-Barr virus, and cytomegalovirus). Parasitic infestation with Ascaris or Giardia lamblia may be found Gallstone formation 2-3 times more in females than males In an ultrasonographic survey of 1570 children (ages 6-19 yr) the overall prevalence of gallstone disease was 0.13% (0.27% in female subjects). Historically, pigment stones were more common in children but as obesity becomes more common, cholesterol stones begin to predominate. Scandinavian descent, Pima Indians, and Hispanic populations; less common among individuals from sub-Saharan Africa and Asia
- Obesity has assumed an increasingly important role as a risk factor for cholesterol cholelithiasis in children, particularly in adolescent girls. --excess of cholesterol in relation to the chlesterol reabsorption of the GB. Supersaturation of bile with cholesterol, leading to crystal and stone formation, Prevalence of gallstones in women are associated with hormonal changes as well as the changes in pregnancy. Although gallstones and cholecystitis are more common in women, men with gallstones are more likely to develop cholecystitis (and more severe cholecystitis) than women with gallstones. Pregnancy increases the risk for cholesterol gallstones because during pregnancy, bile contains more cholesterol, and the gallbladder does not contract normally. LESS ESTROGEN; MORE CHOLESTEROL; PREGNANT LESS ESTROGEN(increased estrogen associated with increased HDL decreaset LDL and TAGs)
- Hemolytic disease increases bilirubin excretion and formation of pigment stones Ileal resection: bile salts are reabsorbed in the ileum; bile salts allosws solubility of cholesterol in bile hence prevent crystal formation Chron’s disease commonly involves the last segment of the small bowel, called the terminal ileum, which is where much of the metabolism of bilirubin occurs Pregnancy: less estrogen, anatomic changes imparing excretion of bile Prolonged use of high-dose ceftriaxone, a 3rd-generation cephalosporin, has been associated with the formation of calcium-ceftriaxone salt precipitates (biliary pseudolithiasis) in the gallbladder. Biliary
- Obstructions by gall stones or abnormal strictures Inflammation from infection or mucosal abrasion by stones Majority of cases of calculous cholecystitis are due to organism such as E. coli, Streptococci, Salmonella, Klebsiella, etc 75% of bile cultures mostly e.coli e.Coli 35-50% Staph 15% Enterococc 15% Strep10% Mixed 30%
- Most common biliary pathology Mostly asymptomatic (>80%) Approximately 1-2% of asymptomatic patients will develop symptoms requiring cholecystectomy per year Although gallstones can form anywhere in the biliary tree, the most common point of origin is within the gallbladder
- Usually due to increased levels of bilirubin due to factors such as in hemolytic disease
- Right upper quadrant or epigastric pain that may radiate to the back or right scapula Colicky or dull, constant pain that may be associated with nausea, vomiting, or anorexia Usually severe lasting a few minutes but is typically prolonged Fever, nausea, vomiting, and anorexia. History of fatty food ingestion one hour or more before the initial onset of pain. Jaundice if a stone migrates from the gallbladder and obstructs the common bile duct.
- Patient may lie still due to pain; exacerbated by movement Voluntary or involuntary guarding RUQ tenderness that is exacerbated during inspiration by the palpation of the right subcostal area (Murphy’s sign) A palpable mass may be noted as the omentum “walls off” the inflammed gallbladder
- Imaging of choice in the diagnosis of AC presence of thickening of the gallbladder wall( >5 mm), peri-cholecystic fluid, or direct tenderness when the probe is pushed against the gallbladder (ultrasonographicMurphy's sign).
- HIDA agent is given intravenously HIDA agent is excreted in the biliary tree within 1 hour of administration A normal unobstructed gallbladder will take up the dye excreted in the biliary tree as in its normal function No visualization in the scan is diagnostic as dye is unable to enter the gallbladder due to obstruction Sensitivity of 80-90%
- Here is another image of a HIDA scan between a normal and an obstructed gallbladder
- Gangrene – wall lumen or gas, focal irregularity defect in wall, intraluminal membranes, no mural enhancement pericholecystic abcess emphysematous cholecystitis: gas in the walls Peritonitis – smooth thickening of peritoneum
- Leukocytosis with a left shift may be observed in cholecystitis. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to evaluate for the presence of hepatitis and may be elevated in cholecystitis or with common bile duct obstruction. Bilirubin and alkaline phosphatase assays are used to evaluate for the presence of common bile duct obstruction. Amylase/lipase assays are used to evaluate for the presence of pancreatitis. Amylase may also be elevated mildly in cholecystitis. An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis. Urinalysis is used to rule out pyelonephritis and renal calculi. retrospective study by Singer et al: no combination of laboratory or clinical values was useful in identifying patients at a high risk for a positive finding of cholecystitis
- Singer et al: retrospective study showed that of 40 patients 36(90%) did not present with fever and 16 (40%) did not have leukocytosis
- Nelson’s antimicrobial therapy: Cefazolin 30mg/kg or cefoxitin 40mg/kg The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h). In severe life-threatening cases, the Sanford Guide recommends imipenem/cilastatin (Primaxin, 500 mg IV q6h). Alternative regimens include a third-generation cephalosporin plus metronidazole (Flagyl, 1 g IV loading dose followed by 500 mg IV q6h). Escherichia coli and Bacteroides fragilis, as well as Klebsiella, Enterococcus, and Pseudomonas Analgesics, such as oral oxycodone/acetaminophen (Percocet) or hydrocodone/acetaminophen (Vicodin) Antiemetics, such as oral/rectal promethazine (Phenergan) or prochlorperazine (Compazine), to control nausea and to prevent fluid and electrolyte disorders *****morphine is not the agent of choice because of the possibility of increasing tone at the sphincter of Oddi. Meperidine instead
- Histologic sections from the gallbladder specimen demonstrate hyperplastic mucosa with acute and chronic inflammation traversing the mucosa, submucosa, muscularis propria and the serosa. Rokitansky-Aschoff sinuses are seen as several invaginated mucosal epithelium within the muscularis layer. Interstitial edema and vascular congestion are seen. No evidence of malignancy seen.
- Rokitansky-Aschoff sinuses are diverticula of the gallbladder wall which may be microscopic or macroscopic. Histologically, they are outpouchings of gallbladder mucosa that sit within the gallbladder muscle layer.