Cholecystitis - Gallbladder and Bile Ducts

Cholecystitis

Biliary Colic

·        Symptoms: 

o   Gives a colicky pain – waves of intense pain every 10 – 20 minutes with little pain in between. Patient is restless – can‟t get comfortable in any position (as opposed to cholecystitis below)

o  May be mild tenderness on examination

·        Pathogenesis:

o  Impaction of stone in the cystic duct

o  No inflammation of the gall bladder (yet)

·        Investigations:

o  Plain xray (mainly to exclude other causes of an acute abdomen – eg obstruction, perforation, etc)

o  Diagnosis by US – looking for a thickened wall on the gall bladder and filling defects in the ducts

o   CT the best modality for looking for stones

·        Management:

o   IV fluids (may not have been drinking, may need to be nil-by-mouth if they go to surgery)

o   Bloods: FBC, U&Es, LFTs, Amylase, Clotting factors, Group & Hold, ESR/CRP

o   Urine: UTI/pregnancy

o   Pain relief + antiemetics

o   Antibiotics

o   Antispasmodics (eg Buscopan) for colic

 Acute Cholecystitis

·        Most dangerous common complication of cholelithiasis

·        Clinical presentation: acute abdomen.  Symptoms may be obscured by the predisposing condition 

·        90% caused by impaction of stone in the neck: calculus acute cholecystitis. If no stones then acalculous cholecystitis (usually vasculitis)

·        ­Inflammation due to ­pressure, chemical irritation, and secondary infection 

·        Macroscopic appearance: enlarged (bigger than chronic), tense, covered by fibrin, contains turbid bile or puss. Wall is thick and oedematous and the mucosa is red or green-black (gangrenous cholecystitis, due to ¯blood flow secondary to ­pressure) 

·        Microscopic appearance: Acute inflammation, congestion, abscess, necrosis

·        Symptoms: 

o   70% stones are asymptomatic. If symptomatic there is a 30% 5 year risk of complications requiring surgery 

o   Uncomplicated: severe constant epigastric/RUQ pain, lasting several hours, radiating to back, maybe nausea/vomiting. It hurts to move or breath so patient lies still. Local peritonitis (very tender). If impacted then inflammatory component (fever, ­WBCs) 

o   Complicated:

§  Fever, abdominal pain, nausea, vomiting: indicating acute cholecystitis

§  Fever, pain, jaundice: acute cholangitis

§  Abdominal and back pain, collapse, vomiting, hypotension: acute pancreatitis

·        Investigations 

o   Murphy‟s sign: Lay 2 fingers on RUQ.  Patient inspiration ® pain.  No pain on LUQ

o   Gallstones often incidental finding on ultrasound or x-ray (if calcified – only 10% radio-opaque) 

o   Ultrasound picks up 98% of gallbladder stones but only 50% of common bile duct stones. More can be inferred from a dilated duct (> 6 mm) 

o   Serum Amylase: if > 1000 IU/L Þ acute pancreatitis

o   ALP & bilirubin 

o   WBC count ® cholecystitis

o   Antimitochondrial antibody tests ® exclude primary bilary cirrhosis

·        Differential

o   Obstructive Jaundice: pancreatic neoplasm, cholestatic hepatitis

o   Bilary colic: pancreatitis, oesophagitis, peptic ulcer, IBS

o   Ascending Cholangitis

·        Treatment

o   If acute, nil by mouth, pain relief, IV antibiotics (e.g. cefuroxime) 

o   Usually settle with conservative treatment (wait 2 days and see). Then schedule for elective cholesectomy 6 week later (once inflammation settled down)

o   Surgical Options:

§  Lithotripsy

§  Laproscopic cholecystectomy

§  Percutaneous, transhepatic gallbladder canuulation (PTC)

o   Long term:

§  No relationship with high-cholesterol diet.  Avoid obesity

§  Drugs: bile acid treatment – dissolve small cholesterol stones

Chronic Cholecystitis

·        ?Aetiology: no infective or inflammatory agents

·        Macroscopic appearance: normal to enlarged gallbladder with stones and a fibrous thickened wall

·        Microscopic appearance: chronic inflammation, fibrosis and muscular hypertrophy.  Rokitansky- 

·        Aschoff sinuses: herniations through submucosa. Lipid laden macrophages extend into the lamina propria 

·        Symptoms: heartburn, belching, intolerance of fatty foods, discomfort. Can be found in people without gallstones Þ symptoms not specific

Ascending Cholangitis

·        Signs of Acute Cholecystitis plus sweats and rigours

·        Infection of the biliary tract

·        Often accompanies obstruction due to gall stones

·        Also following ERCP (probe introduces gut bacteria into the ducts which are normally sterile)

·        Can be rapidly fatal – have low threshold for treatment 

·        Rare differential Mirrizi Syndrome: no stone in the common duct but its compressed by adjacent inflamed gallbladder

Mucocoele of the Gallbladder

·        Cystic duct becomes obstructed. Trapped bile is absorbed and gallbladder fills with mucus