| Cholecystitis Classification and external resources |
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| ICD-10 | K81. |
|---|---|
| ICD-9 | 575.0, 575.1 |
| DiseasesDB | 2520 |
| eMedicine | med/346 |
Cholecystitis is inflammation of the gall bladder. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings K00-K93 - Diseases of the digestive system (K00-K14 Diseases of oral cavity salivary glands and jaws ( Disorders of Tooth development and Eruption The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens The gallbladder (or cholecyst sometimes gall bladder is a small organ whose function in the body is to store Bile and aid in the digestive process
Contents |
Causes and pathology
Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. In Medicine, gallstones (choleliths are Crystalline bodies formed within the body by accretion or concretion of normal or abnormal Bile component This leads to inspissation of bile, bile stasis, and secondary infection by gut organisms, predominantly E coli and Bacteroides species. Inspissation is the process of thickening by Dehydration. More specifically it is the process used when heating high- Protein containing media for example to enable Bile or gall is a bitter yellow or green Alkaline fluid secreted by Hepatocytes from the Liver of most Vertebrates In many species In Medicine, stasis means the state in which the normal flow of a body liquid stops for example the flow of Blood through vessels or of intestinal contents
The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.
Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis.
Stones in the gallbladder may not cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.
Symptoms
Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first. In Anatomy, the scapula, omo, or shoulder blade, is the Bone that connects the Humerus (arm bone with the Clavicle (collar
This is usually accompanied by a low grade fever, vomiting and nausea.
More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Jaundice, also known as icterus (attributive adjective "icteric" is yellowish discoloration of the Skin, sclerae (whites of the eyes Ascending cholangitis or acute cholangitis (or sometimes cholangitis without a modifier - from Greek chol - bile + ang - vessel + itis Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction. Ileus is a disruption of the normal propulsive gastrointestinal motor activity from non-mechanical mechanisms In medicine a fistula (pl fistulas or fistulae is an abnormal connection or passageway between two Epithelium -lined organs or vessels that normally do not connect Bowel obstruction (or intestinal obstruction) is a mechanical or functional obstruction of the intestines preventing the normal transit of the products of digestion
Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, diarrhea
Diagnosis
Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:
- fever (usually low grade in uncomplicated cases)
- tender right upper quadrant +/- Murphy's sign
Subsequent laboratory and imaging tests are used to confirm the diagnosis and exclude other possible causes. In Medicine, Murphy's sign refers to a maneuver during a Physical examination as part of the Abdominal examination and a finding elicited in ultrasonography
Differential diagnosis
Acute cholecystitis
- This should be suspected whenever there is acute right upper quadrant or epigastric pain.
- Other possible causes include:
- Perforated peptic ulcer
- Acute peptic ulcer exacerbation
- Amoebic liver abscess
- Acute amoebic liver colitis
- Acute pancreatitis
- Acute intestinal obstruction
- Renal colic
- Acute retrocolic appendicitis
- Other possible causes include:
Chronic cholecystitis
- The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders:
- Peptic ulcer
- Hiatus hernia
- Colitis
- Functional bowel syndrome
quick differential
- biliary colic - cystic duct blocked. sharp and constant pain without fever. no murphy's. LFT wnl. u/s
- cholecystitis - cystic duct blocked with infection. colicky brief pain at first, then constant pain in RUQ with fever caused by e coli, klebsiella, pseudomonas, b fragilis, enterococcus. murphy's sign. increased AST, ALT, AP, WBC. u/s
- choledocholithiasis - common bile duct blocked. colicky pain. jaundice. increased bilirubin. cholangiogram.
- cholangitis - infection of entire biliary tract. charcot triad. jaundice and fever. increased AST, ALT, AP, bilirubin. cholangiogram.
Investigations
Blood
Laboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin (although this may indicate choledocholithiasis), and possibly an elevation of the WBC count. Alkaline phosphatase ( ALP) ( is a Hydrolase Enzyme responsible for removing Phosphate groups from many types of molecules including Bilirubin (formerly referred to as hematoidin) is the yellow breakdown product of normal Heme Catabolism. Choledocholithiasis is the presence of Gallstones in the Common bile duct. CRP (C-reactive protein) is often elevated. The degree of elevation of these laboratory values may depend 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. Not to be confused with Supersonic. Ultrasound is cyclic Sound pressure with a Frequency greater than the upper The 2 major diagnostic criteria are cholelithiasis and sonographic Murphy's sign. In Medicine, gallstones (choleliths are Crystalline bodies formed within the body by accretion or concretion of normal or abnormal Bile component In Medicine, Murphy's sign refers to a maneuver during a Physical examination as part of the Abdominal examination and a finding elicited in ultrasonography 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%. Computed tomography (CT is a Medical imaging method employing Tomography. 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. A calculus is a stone (a Concretion of material usually mineral salts that forms in an organ or duct of the body CT cannot see noncalcified gallbladder calculi, and cannot assess for a Murphy's sign.
Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis. Nuclear medicine is a branch of Medicine and Medical imaging that uses the nuclear properties of matter in diagnosis and therapy Technetium (tɛkˈniːʃɪəm is the lightest Chemical element with no Stable isotope. Bilirubin (formerly referred to as hematoidin) is the yellow breakdown product of normal Heme Catabolism. 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.
Therapy
For most patients, in most centres, the definitive treatment is surgical removal of the gallbladder. Supportive measures are instituted in the meantime and to prepare the patient for surgery. These measures include fluid resuscitation and antibiotics. In modern usage an antibiotic is a Chemotherapeutic agent with activity against Microorganisms such as Bacteria, fungi or Protozoa Antibiotic regimens usually consist of a broad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate (Timentin), or a cephalosporin (e. g. ceftriaxone) and an antibacterial with good coverage against anaerobic bacteria, such as metronidazole. Ceftriaxone ( INN) (ˌsɛftraɪˈæksoʊn/ /ˌkɛf- is a third-generation Cephalosporin Antibiotic. An anaerobic organism is any Organism that does not require Oxygen for growth and may even die in its presence Metronidazole ( INN) (mɛtrəˈnaɪdəzoʊl is a Nitroimidazole anti-infective medication used mainly in the treatment of infections caused by susceptible For penicillin allergic patients aztreonam and clindamycin may be used.
Gallbladder removal, cholecystectomy, can be accomplished via open surgery or a laparoscopic procedure. Cholecystectomy (/ˌkɔləsɪsˈtɛktəmi/ plural cholecystectomies is the surgical removal of the Gallbladder. Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery Laparoscopic procedures can have less morbidity and a shorter recovery stay. In Medicine, Epidemiology and Actuarial science, the term morbidity can refer to the state of poor health (from Latin Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. A laparoscopic procedure may also be 'converted' to an open procedure during the operation if the surgeon feels that further attempts at laparoscopic removal might harm the patient. Open procedure may also be done if the surgeon does not know how to perform a laparoscopic cholesystectomy.
In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy), the managing physician may elect to have an interventional radiologist insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves. Cholecystectomy (/ˌkɔləsɪsˈtɛktəmi/ plural cholecystectomies is the surgical removal of the Gallbladder. Interventional radiology (abbreviated IR or sometimes VIR for vascular and interventional radiology) is a subspecialty of Radiology in which In Surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin rather than by using an "open" The patient may later warrant cholecystectomy if their condition improves. Cholecystectomy (/ˌkɔləsɪsˈtɛktəmi/ plural cholecystectomies is the surgical removal of the Gallbladder.
Complications of cholecystitis
- Perforation or rupture
- Ascending cholangitis
Complications of cholecystectomy
- bile leak ("biloma")
- bile duct injury (about 5-7 out of 1000 operations. Ascending cholangitis or acute cholangitis (or sometimes cholangitis without a modifier - from Greek chol - bile + ang - vessel + itis Open and laparoscopic surgeries have essentially equal injuries, but the recent trend is towards fewer injuries with laparoscopy, probably because the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
- abscess
- wound infection
- bleeding (liver surface and cystic artery most common sites)
- hernia
- organ injury (intestine and liver at highest risk, especially if gallbladder through inflammation has become adherent/scarred to other organs (e. g. transverse colon)
- deep vein thrombosis/pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)
Gall bladder perforation
Gall bladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis. The transverse colon the longest and most movable part of the colon, passes with a downward convexity from the right Hypochondrium region across the abdomen opposite In Medicine, deep vein thrombosis (also known as deep-vein thrombosis or deep venous thrombosis and usually abbreviated as DVT) is the formation Pulmonary embolism (PE is a blockage of the Pulmonary artery or one of its branches usually occurring when a venous Thrombus (blood clot from a vein The early diagnosis and treatment of GBP are crucial to patient morbidity and mortality.
Approaches to this complication will vary based on the condition of an individual patient, the evaluation of the treating surgeon or physician, and the facilities' capability. It can happen at the neck from pressure necrosis of an impacted calculus, or at the fundus. Calculus ( Latin, calculus, a small stone used for counting is a branch of Mathematics that includes the study of limits, Derivatives It can result in a local abscess, or perforation into the general peritoneal cavity; if the bile, is infected diffuse peritonitis supervenes readily and rapidly. An abscess (abscessus is a collection of Pus (dead Neutrophils) that has accumulated in a cavity formed by the tissue on the basis of an infectious process Peritonitis is defined as Inflammation of the Peritoneum (the Serous membrane which lines part of the abdominal cavity and some of the Viscera Death can result.
A retrospective study looked at 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis. Patients were treated with analgesics and antibiotics within the first 36 hours after admission (with a mean of 9 hours), and proceeded to surgery for a cholecystectomy. Cholecystectomy (/ˌkɔləsɪsˈtɛktəmi/ plural cholecystectomies is the surgical removal of the Gallbladder. Two patients died and 6 patients had further complications. The morbidity and mortality rates were 37. 5% and 12. 5%, respectively in the present study. The authors of this study suggests that early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance. [1]
See also
References
- ^ Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E (2006). Boas' or Boas's sign is Hyperaesthesia (increased or altered sensitivity below the right scapula can be a symptom in acute Cholecystitis (inflammation "Diagnosis and treatment of gallbladder perforation". World J. Gastroenterol. 12 (48): 7832-6. PMID 17203529.
- Shea, JA, Berlin, JA, Escarce, JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154:2573.
- Fink-Bennett, D, Freitas, JE, Ripley, SD, Bree, RL. The sensitivity of hepatobiliary imaging and real time ultrasonography in the detection of acute cholecystitis. Arch Surg 1985; 120:904.
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