Saturday, April 30, 2011

Cholecystitis acute

INCIDENCE RATE APPROXIMATELY SAME IN WORLDWIDE
5 TO !0 % MORTALITY OCCURS IN PATIENTS OLDER THAN 60 YEARS.

ACUTE CHOLECYSTITIS : is an inflammation of the gall bladder ,and is usually associated with stones. Occasionally it occurs without stones,i.e. acalculous cholecystitis.The later may be due to infection with E coli .Clostridia,or rarely Salmonella typhi. Acalculous cholecystitis may occur after prolonged starvation or total parenteral nutrition. Stasis is probably a contributing factor in the latter conditions .

The gall bladder becomes oedematous ,with mucosal ulceration ,and a fibrinopurulent exudate .Acute inflammatory cells infiltrate the wall . Even in the presence of thrombosis of the cystic artery ,gangrene is rare ,as the gall bladder gains a blood supply directly from the liver via the gall bladder bed .However ,gangrene does occasionally occur with perforation of the gall bladder ,resulting in generalised bile peritonitis or a localised abscess depending on whether the gall bladder has been walled off by adhesions or not .An empyema of the gall bladder may also result, suppuration occuring within the gall bladder and the gall bladder becoming distended with pus. Occasionally the gall bladder may fistulate into the duodenum.

Factors that haw initiate the inflammatory process include the manufacture of inflammatory mediators (eg, lysolecithin and prostaglandins); an increase in intraluminal pressure in association with compromise of the murder supply; and chemical botheration by bile acids. 
90 % calculous and 10 % acalculous, Acalculous cholecystitis associated with higher complication rate and associated with acute illness ( i.e. burns ,trauma, major surgery ) ,fasting ,hyperalimentation leading to gall bladder stasis ,vasculitis ,carcinoma of gall bladder or common bile duct ,some gall bladder infections ( Leptospira ,Streptococcus,Parasitic ,etc.) but in >50% of cases an underlying explanation is not found.

In patients who hit emphysematous cholecystitis, ischemia of the gall bladder surround is followed by infection with gas-forming organisms that display pedal in the bladder lumen, in the gall bladder wall, or both. In 30-50% of patients, preexisting diabetes mellitus is present; the male-to-female ratio is 5:1.1 Gas haw be confined to the gall bladder; however, in 20% of cases, pedal is also seen in the rest of biliary tree. Gallstones are not inform in 30-50% of cases, and the mortality rate is 15%.1  There is a predisposition for gangrene formation and perforation, but clinical symptoms are mild; much symptoms can be deceptive. Emphysematous cholecystitis haw occur after chemoembolization performed as palliation for hepatocellular carcinoma; after fat embolism during aortography; and after gall bladder hypoperfusion during viscus resuscitation.



CLINICAL FINDINGS
Acute cholecystitis usually occurs with correct upper quadrant discompose and tenderness. The abdominal discompose increases with time. The place of discompose is usually the correct subcostal region, though the discompose haw begin in the epigastrium or the mitt upper quadrant and then shift to the correct subcostal region to the area of the gallbladder  inflammation. Referred discompose to the correct shoulder or the interscapular region haw be experienced. Approximately greater than half of patients hit had preceding attacks of similar discompose that spontaneously resolved. Anorexia, nausea, and vomiting haw occur, but vomiting is seldom severe. Most patients are symptom and hit no leukocytosis.

When feverishness occurs, the patient's temperature is seldom higher than 38°C. Chills are unusual; their proximity suggests a case of complicated cholecystitis (abscess or associated cholangitis).

In some patients with acute cholecystitis  hit mild jaundice, which haw be related to ordinary hepatic edema, bile duct edema, or both, or to the proximity of calculi within the common bile duct.1 In most patients, improvement occurs within 24 hours after hospitalization, and signs and symptoms gradually subside. Persistent pain, feverishness and leukocytosis, chills, and more nonindulgent localized or generalized compassionateness haw indicate complicated disease, much as abscess manufacture or GB perforation. The utilization of empyema of the GB haw display systemic toxicity, and it haw be predictive of GB perforation.

Acute acalculous cholecystitis  is difficult to diagnose clinically. It often occurs in children  and in patients who are critically ill or who hit fresh undergone pronounce from nonindulgent trauma, burns, or surgery. Predisposing factors allow prolonged fasting, immobility, and hemodynamic instability. Often, these patients cannot impart pain; however, fever, jaundice, vomiting, abdominal tenderness, leukocytosis, and hyperbilirubinemia are highly suggestive findings.

In approximately 1/3rd of patients, a distended, tender gall bladder haw be palpable as a distinct mass. This is an important clinical finding and haw confirm the diagnosis.

LABORATORY TEST Shows mild leukocytosis ,serum bilirubin alkaline phosphatase and AST may be mildly elevated.
DIAGNOSTIC INVESTIGATIONS


CHEST AND PLAIN ABDOMINAL X-RAYS it can help to exclude other causes ,and show radio-opaque stones .
ORAL CHOLECYSTOGRAPHY it is unreliable during acute attack , and is postponed until patients has recovered.
ULTRASONOGRAPHY confirm the diagnosis.
RADIOISOTOPE SCANNING confirm the diagnosis .






TREATMENT
CONSERVATIVE TREATMENR FOLLOWED BY CHOLECYSTECTOMY 
No oral intake ,nasogastric suction .IV fluids and electrolytes ,analgesia ( mepridine or NSAIDS ). and antibiotics ( ureidopenicillins ,ampicillin sulbactam ,third generation cephalosporins ,anaerobic coverage should be added if gangerous or emphysematous cholecystitis is suspected , consider combination with aminoglycosides in diabetic patient or others with signs of gram-negative sepsis.Acute symptoms will resolve in 70% of patients.

SURGERY  Optimal timing of surgery depends on patients stabilization and should be performed as soon as feasible. Urgent cholecystectomy is appropriate in most patients with a suspected or confirmed complication. Delayed surgery is reserved for patients with high risk of emergent surgery and where the diagnosis is in doubt.


Recurrent symptoms are common in patients with acute cholecystitis who are treated expectantly; most patients need elective cholecystectomy.

Percutaneous cholecystostomy is a minimally invasive procedure that can goodness patients with serious comorbidity who are at broad venture from major surgery. Percutaneous cholecystostomy can be performed at the bedside low local drug and is suitable for patients in qualifier care units and those with burns. It is the expressed treatment in patients with acalculous cholecystitis , or it may be used as a temporising measure—to pipage pussy bile and retard the requirement for expressed treatment.



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