Level of competence 2

CHOLECYSTITIS
 INTRODUCTION

The gallbladder (GB) is a pear shape distensible

organ :
• Size 4x8cm, normal capacity of 30-50ml
• Lies in fosse of the visceral surface of the liver, on
a line separating right and left lobe
• GB store and concentrate bile, where 90% of
water & electrolyte reabsorbs
 ACUTE CHOLECYSTITIS
is an acute inflammation of the GB wall usually
follows obstruction of the cystic duct/ neck of GB.

90-95% by stone (calculous acute

cholecystitis) and 5-10% without stone
(a calculous acute cholecystitis) found
in surgery
 In acute inflammation, GB is
distended

The fundus come in close contact with :

• the abdominal wall
• the 1st and 2nd portion
of duodenum
• the flexure hepatic of
the colon
 PATHOGENESIS
CYSTIC DUCT OBSTRUCTION

INFLAMMATION RESPONS OF GB
1. Mechanical inflammation
(intraluminal pressure  & distention → ischemia of mucosa/ wall GB)
2. Chemical inflammation (release of lysolecithin, PG & other local tissue factors)
3. Bacterial inflammation (50-85% of patients)
aerob enterobacter (E.coli, klebsiella spp). ne(-) gram coccus & anaerob (Cl.welchii, Cl.
perferigens)

COMPLICATIONS
hydrops, necrosis, ganggren, emphyema & perforation
 II. CLINICAL MANIFESTATIONS &
DIAGNOSIS

• Clinical manifestation of calculous and

acalculous acute cholecystitis are
indistinguishable
• The presentation may range from mild -
quite severe with systemic toxicity
• Acalculous acute cholecystitis usually more
severe because associated with severe diseases
such as severe trauma/ burns, major non-
hepatobiliary surgery, infections, etc.
 The TRIAD of suspected
Acute Cholecystitis diagnosis

• Sudden onset of RUQ tenderness/ pain

(Murphy’s sign)
• Fever
• Leucocytosis (10.000-15.000 cell/mm3)
 CONFIRMATION EXAMINATION

• Radiological studies : USG, CT-Scan or

radionuclide hepatobiliary scanning (e.g.
HIDA)

Radionuclide scanning bile duct imaging is

seen without visualization of GB because of
cystic duct obstruction
 III. CLINICAL MANAGEMENT
Measures in the first few hours after admission
of patients with suspected acute cholecystitis

• WBC count
• US, CT-Scan or HIDA scan
• Surgical consultation
Although surgical intervention remains
the mainstay of therapy for acute
cholecystitis or it’s complications but
medical management should be done
as the initial therapy
• INTRAVENOUS BROAD SPECTRUM
ANTIBIOTIC ADMINISTRATION
- ampicilllin-sulbactam (3gr q 6h)
- piperacillin-tazobactam (4.5 gr q 8h)
with or without an aminoglycoside
or metronidazole
- cephalosporin 3rd generation
(cefoperazone “STABIXIN”)
2gr q 12h for 5-7 days
• Mild ANALGESIC for pain e.g. mepheridine
or NSAIDs
• Keep patients NIL BY MOUNTH,
occasionally a nasogastric tube maybe
required for severe vomiting
• INTRAVENOUS FLUID started immediately
• Correct electrolyte (K,Mg,Ca,P) abnormality or
acid/base imbalance
• Medical treatment of associated other medical
condition should be prompt for anticipation of
surgery
Most patients improve over 24-72 hours (2 –7
days) without surgical intervention, but some
patients don’t improve or worsen and in
these such cases URGENT SURGERY be
strongly considered