Case Nine - Acute cholecystitis Flashcards
what is acute cholecystitis caused by
a blockage in the cystic duct or neck of the gallbladder (95% of the cases are gallstones or sludge)
what can the obstruction cause
increase in mucus secretions from the gallbladder which causes gallbladder distension, and may affect the blood supply to the gallbladder
what is often the initial event in cholecystitis
often an obstruction to gallbladder emptying
in 95% of the cases, a gallstone is the cause. it is different to biliary colic because it is not a problem in the bile duct, but a problem in the gallbladder or in the cystic duct
what are the two effects of distension of the bile ducts
obstruction of blood flow to the gallbladder, as well as initiating an inflammatory response to the bile retained in the gallbladder
this can lead to mucosal damage, which in turn leads to the release of phospholipase,
what does phospholipase do
converts lecithin into lysolecithin which is a very potent toxin
what are the symptoms of acute cholecystitis and what are the y similar to
similar to biliary colic, and often differentiation is difficult
cholecystitis often results in a more prolonged pain with a fever and leukocytosis
what is Murphys sign
there will be RUQ pain
this is usually worse on inspiration. Murphy’s sign is where you would put your hand under the patient’s ribs and ask them to breathe in. As they do so, their gallbladder will be forced down against your hand, and it will cause them a lot of pain
when is Murphy’s sign only a positive result
only a positive result if the sign is negative in the LUQ
why does the pain radiate in acute cholecystitis and how does this differentiate
the pain is more likely to radiate to the shoulder tip in this than in other biliary conditions because the radiation is caused by irritation of the diaphragm and this is more likely in cholecystitis
what are the investigations carried out for acute cholecytsisis
FBC
serum amylase
serum bilirubin
USS
what would an FBC in acute cholecystitis show
raised ESR, CRP, WCC
what would a serum amylase show
increase as acute pancreatitis may be present as a compliation of gallstones
what would the USS detect
gallstones
gallbladder wall thickening
dilated common bile duct >6mm
what are the antibiotics given in acute cholecystitis
cefuroxime
metronidazole
what are the pain reliefs given in acute cholecysistis
usually diclofenac (NSAID) with pethidine (fast acting opioid) in more severe cases
what are the complications of acute cholecystitis
gangrene
bacterial infection and subsequent empyema
perforation
what is empyema
this is a collection of pus in the body cavity . it is different from an abcess, which is a colleciton of pus in a newly formed body cavity
what may be seen in patients with chronic cholecystisis
vague abdominal symptoms
sometimes associated with GI malignancy
what investigations are used to look for chronic cholecystitis
USS - evidence of gallstones and check common bile duct diameter
MRCP - may also be used to check for stones. In this procedure, MRI scanning is used to visualise the biliary tree. It is much less invasive than ERCP - which requires the insertion of dye into the biliary tree via OGD. ERCP has obvious therapeutic advantages that MRCP does not.
M,RCP is used to supplement USS
what is the treatment of chronic cholecystitis
ERCP - usually performed to remove any stones from the common bile duct and perform sphincterotomy before cholecystectomy
cholecystectomy - performed in troubling cases
what does the inflammatory response in acute cholecystitis cause
wall ischaemia and infection to ensue to cause localised peritonitis
what are the several modalities used to image a stone in the common bile duct
transabdominal ultrasound first line
MRCP
EUS
what is the gold standard for visualising stones in the CBD
endoscopic ultrasound (EUS)
why must any CBD stones causing obstructive jaundice be removed first prior to a laparoscopic cholecystectomy
a high biliary pressure from any obstruction can cause a bile leak from the cystic duct stump where the gallbladder is amputated during the cholecystectomy
what does a thickened wall gallbladder indicate
either acute or chronic inflammation of the gallbladder
what kind of finding is pericholecystic fluid
an acute finding
what is the intial treatment in AandE of acute cholecystitis
Initial treatment would include:
- Analgesia
- Antiemetics
- Antibiotics (according to hospital guidelines)
- Fluid balance (intravenous fluids)
- Venous thromboembolism prophylaxis
- Nil by mouth, in anticipation for surgery
what definitive management would you offer
laparoscopic cholecystectomy
surgery should be considered to remove the gallbladder on the same hospital admission (laparoscopic cholecystectomy)
what are the risks of laparoscopic cholecystectomy surgery
The general risks of surgery include bleeding, infection, pain, chest and urinary infections, deep vein thrombosis/pulmonary embolism and risks associated with general anaesthesia. Specifically for a laparoscopic cholecystectomy:
- Damage to the common bile duct
- Bile leak
- Damage to surrounding structures (such as the duodenum or stomach)
- Conversion from a laparoscopic procedure to an open procedure
what are the components of Charcot’s triad for diagnosing acute cholangitis
right upper quadrant pain
jaundice
pyrexia
what does Reynolds pentad include
it has the three components of Charcot’s - RUQ pain, jaundice and temp
but it also includes mental status alterations and sepsis
what does an obstructive pattern of jaundice to the LFT’s suggest
common bile duct obstruction
what is the definition of acute cholangitis
infection of the biliary tree caused by a downstream obstruction of the common bile duct
what are the causes of acute cholangitis
cholelithiasis (most common)
benign biliary structure
sclerosing cholangitis
malignant strictures
what are the risk factors for acute cholangitis
age
history of gallstones
previous biliary surgery that may lead to a narrowing of the bile duct
what investigations should be performed to investigate a suspected diagnosis of acute cholangitis
an urgent US of the abdomen should be performed to investigate the cause of the biliary obstruction
relieving the biliary obstruction will treat the cute cholangitis
what are the principles of treating a common bile duct obstruction
to either remove the cause or relieve the obstruction using a stent (in the case of a stricture)
this can be achieved endoscopically by an ERCP
what is an ERCP
endoscopic retrograde cholangiopancreatohraphy
it is an endoscopic procedure where a side viewing endoscope is used to identify and cannulate the ampulla of Vater which opens into the second part of the duodenum
a radio-opaque dye is then injected retrograde and passes up Into the CBD and the pancreatic duct
fluoroscopy are used to visualise the dye to detect any ‘filling defects’ that could indicate either a stone or a stricture
what is the advantage of an ERCP
that it can also be used to perform certain therapeutic procedures in the same procedure, such as extracting the stone using a wire basket, a sphincterterotomy of the sphincter of Oddi (to better allow the passage of bile) to to insert a stent across the obstruction to relieve the jaundice
what is ERCP NOT used for
a diagnostic procedure
first line is USS and MRCP to diagnose the cause of the biliary obstruction before an ERCP os performed
what are the risks of ERCP
acute pancreatitis (5%)
gastric/duodenal perforation
bleeding
risks associated with sedation
what is the initial treatment for acute cholangitis
Initial treatment would include:
● Analgesia
● Antiemetics
● Antibiotics (according to hospital guidelines)
● Fluid balance (intravenous fluids and urinary catheter)
● Venous thromboembolism prophylaxis
● Nil by mouth, in anticipation for an ERC
how would you treat acute pancreatitis after ERCP for acute cholangitis
analgesia
antiemetics
no antibiotics (still on these for cholangitis)
fluid balance
VTP
what is not a risk factor for developing gallstone disease
younger age
what condition is not associated with gallstone disease
peptic ulcer disease
what is Mirizzi’s syndrome
this is compression of the CBD from a gallstone in Hartmann’s pouch
A 35-year-old woman presents with intermittent right upper quadrant pain which lasts for a few hours each time she eats fatty foods. Bloods show a normal WCC and CRP, as well as normal LFTs and lipase. What is the most likely diagnosis?
biliary colic