X-Ray during laparascopic cholecystectomy
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Cholecystitis

Cholecystitis is inflammation of the gallbladder. It is commonly due to impaction (sticking) of a gallstone within the neck of the gall bladder, leading to inspissation of bile, bile stasis, and infection by gut organisms. Cholecystitis may be a cause of right upper quadrant pain. The pain may actually manifest in the right flank or scapular region at first. In severe cases, the gall bladder can rupture and form an abscess. In severe cases, it may lead to a life-threatening infection of the liver called cholangitis. In other cases, it may lead to a stable inflammatory state termed chronic cholecystitis. more...

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Diagnosis

The classic patient with acute cholecystitis presents with acute right upper quadrant pain, nausea/vomiting, and fever. On physical examination, he or she has a Murphy's sign, which is a diaphragm spasm (due to the intense pain) when the region of the gall bladder is palpated by the examiner.

Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this could indicate choledocholithiasis), and possibly an elevation of the white blood cell count. The degree of elevation of these laboratory values can be dependent on the degree of inflammation of the gallbladder. Patients with acute cholecystitis are much more likely to manifest abnormal laboratory values, while in chronic cholecystitis the laboratory values are frequently normal.

Radiology

Sonography is a sensitive and specific modality for diagnosis of acute cholecystitis; adjusted sensitivity and specificity for diagnosis of acute cholecystitis are 88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign. Minor criteria include gallbladder wall thickening greater than 3mm, pericholecystic fluid, and gallbladder dilatation.

The reported sensitivity and specificity of CT scan findings are in the range of 90-95%. CT is more sensitive than ultrasonography in the depiction of pericholecystic inflammatory response and in localizing pericholecystic abscesses, pericholecystic gas, and calculi outside the lumen of the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.

Hepatobiliary scintigraphy with technetium-99m bilirubin analogs is also sensitive and accurate for diagnosis of acute cholecystitis, and can differentiate between acute and chronic forms of the disease. It can also assess the ability of the gall bladder to expel bile (gall bladder ejection fraction), and low gall bladder ejection fraction has been linked to chronic cholecystitis. However, since most patients with right upper quadrant pain do not have cholecystitis, primary evaluation is usually accomplished with a modality that can diagnose other causes, as well.

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Diagnosing Biliary Colic and Acute Cholecystitis - Brief Article
From American Family Physician, 9/15/00 by Anne D. Walling

Approximately 500,000 cholecystectomies are performed annually in the United States. Symptomatic gallstones are the most common indication for cholecystectomy. A review by Ahmad and colleagues stressed the importance of differentiating biliary colic and acute cholecystitis. Overlapping symptoms may result in misinterpretation.

Approximately 90 percent of gallstones are composed of cholesterol. Gallstones are most likely to develop in patients with supersaturation of bile products, bile stasis or nucleation factors (i.e., mucin, glycoproteins and calcium around which a stone may form). Risk factors for cholesterol gallstone formation include age, obesity, rapid weight loss, pregnancy, female sex, use of exogenous estrogens, diabetes, certain gastrointestinal conditions and certain medications.

About one third of patients with gallstones develop biliary colic or other complications. Colic pain is precipitated by spasm of a dilated cystic duct that is obstructed by gallstones. Attacks of biliary colic are more common at night, possibly because the gallbladder shifts to a horizontal position, facilitating the entry of stones into the cystic duct. Biliary colic is characterized by the sudden onset of intense right upper abdominal pain that may radiate to the shoulder. Sweating and vomiting are common. The pain tends to be steady and lasts up to three hours. Residual abdominal tenderness may occur.

Pain in the area of the gall bladder lasting more than three hours is characteristic of acute cholecystitis. The most common cause is cystic duct obstruction by gallstone(s), and the initial symptom may be epigastric pain. A pain-free interval may occur before symptoms shift to the right upper quadrant. Older patients may have only localized tenderness. As local inflammation becomes more intense, signs and symptoms of tenderness and a local mass can be complicated by systemic toxicity manifested by fever and leukocytosis. The classic Murphy's sign (abrupt interruption of deep inspiration) is elicited by palpation of the gallbladder area. A palpable mass caused by inflammation and adherent omentum is present in 30 to 40 percent of patients with cholecystitis. Abdominal guarding in response to deep palpation is common. Up to 15 percent of patients with acute cholecystitis are jaundiced.

Acalculous cholecystitis is more common in older male patients with serious conditions. Bile statis is the proposed underlying mechanism. Complications develop more rapidly than in patients with calculous cholecystitis. Pathogens can colonize the gallbladder mucosa, creating a carrier state and increasing the risk of future episodes of acute cholecystitis.

Laboratory results are usually normal in patients with biliary colic. Leukocytosis with bandemia is a frequent finding in patients with acute cholecystitis (see the accompanying table), and mild elevations of serum aminotransferase levels may occur within a few hours of onset. Amylase levels may also be elevated as a result of transient obstruction of the pancreatic duct. Obstruction of the common hepatic duct or common bile duct can result in hyperbilirubinemia.

Ultrasonography has high sensitivity and specificity for gallstones but a lower yield for stones in the ductal system. Up to one half of stones in the common bile duct are not detected on ultrasonography. In the gallbladder, stones less than 2 mm in diameter may be missed or misdiagnosed as sludge. Endoscopic retrograde cholangiopancreatography is the test of choice to detect stones in the common bile duct.

Unless the gall bladder is calcified or the patient has other risk factors, asymptomatic gallstones may be managed expectantly. Because 70 percent of patients with biliary colic will have a second episode, surgery may be advised. In patients with acute cholecystitis, prompt surgery is recommended.

COPYRIGHT 2000 American Academy of Family Physicians
COPYRIGHT 2000 Gale Group

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