BILIARY COLIC (or CHRONIC CHOLECYSTITIS) many patients with acute cholecystitis have a history of episodic biliary colic ...
BILIARY COLIC (or CHRONIC CHOLECYSTITIS)
- many patients with acute cholecystitis have a history of episodic biliary colic
- mechanism: gallstone temporarily impacted in cystic duct, no infection
Signs and symptoms
- steady pain (not colic) in epigastrium or RUQ for minutes to hours
- frequently occurs at night or after fatty meal
- can radiate to right shoulder or scapula
- associated nausea/vomiting
- no peritoneal findings
- no systemic signs
Differential diagnosis
- Pancreatitis
- PUD
- hiatus hernia with reflux
- gastritis
Diagnostic investigation
- normal blood work
- U/S shows gallstones
Treatment : elective cholecystectomy (95% success)
ACUTE CHOLECYSTITIS
Mechanism
- inflammation of gallbladder resulting from obstruction of cystic duct by gallstone (80%)
- no cholelithiasis in 20% (acalculous - see below)
Signs and symptoms
- severe constant epigastric or RUQ pain
- systemic signs - fever, tachycardia
- focal peritoneal findings - Murphy's sign (sudden cessation of inspiration with deep RUQ palpation)
- palpable gallbladder in one third of patients
Differential diagnosis
- perforated or penetrating peptic ulcer
- myocardial infarction
- pancreatitis
- hiatus hernia
- right lower lobe pneumonia
- appendicitis
- hepatitis
- herpes zoster
Diagnostic investigation
- Elevated WBC, left shift
- mildly elevated bilirubin, ALP
- sometimes slight elevation AST, ALT
- U/S shows distended, edematous gallbladder, pericholecystic fluid, large stone stuck in gallbladder neck, sonographic Murphy's sign
Complications
- Hydrops: mucus accumulation in gallbladder due to cystic duct obstruction; may lead to necrosis
- gangrene and perforation: may cause localized abscess or generalized peritonitis (can occur 3 days after onset)
- empyema of gallbladder (suppurative cholangitis)
- cholecystoenteric fistula from repeated attacks of cholecystitis gallstone ileus
- choledocholithiasis - 15% of patients with gallstones
Mortality 5%
Treatment
- admit, hydrate, NG tube, antibiotics if high risk (elderly, mmunosuppressed)
- lack of improvement with conservative treatment ---->operate within 24-48 hours (cholecystectomy)
- earlier O.R. if high risk (DM, steroids) or severe disease
- Laparoscopic tube cholecystostomy if general anesthetic contraindicated
