CHOLECYSTITIS

Acute cholecystitis

inflammation of the gallbladder (acute cholecystitis) is an acute inflammatory reaction of the

gallbladder wall accompanied by complaints of right upper abdominal pain, tenderness, and
fever. until now the pathogenesis of this disease that is quite often encountered is still
unclear. although there are no epidemiological data on the population, the incidence of
cholecystitis and gallstones (cholelithiasis) in our country is relatively lower compared to
western countries.

Etiology and pathogenesis

factors that influence the onset of attacks of acute cholecystitis are bile stasis, bacterial
infections, and gallbladder wall ischemia. the main cause of acute cholecystitis is a
gallbladder stone (90%) located in the cystic duct which causes static bile, while a small
number of cases arise without the presence of gallstones (acute calculus cholecystitis). how
static static cystic duct can cause acute cholecystitis, is still unclear. it is estimated that many
influential factors, such as bile density, cholesterol, lysolesitin and money prostaglandins
damage the mucous lining of the gallbladder wall followed by inflammatory reactions and
suppuration.

Acute calculus acute cholecystitis can occur in patients who are treated long enough and
receive nutrition parenterally, in obstruction due to gallbladder malignancy, stones in the bile
duct or is one of the complications of other diseases such as typhoid fever and diabetes
mellitus.

Clinical Symptoms

a rather typical complaint for attacks of acute cholecystitis is the right upper or epigastric
stomach colic and tenderness and increase in body temperature. sometimes the pain radiates
to the right shoulder or scapula and can last up to 60 minutes without subsiding. the severity
of complaints varies greatly depending on the presence of mild inflammatory abnormalities
up to gangrene or gallbladder perforation.

on physical examination palpable during the gall bladder, tenderness, accompanied by signs
of local peritonitis (Murphy's sign).
jaundice is found in 20% of cases, generally mild (bilirubin <4.0 mg / dl). if the bilirubin
level is high, it is necessary to think about adanta stones in the extra hepatic bile duct.

Laboratory examination shows the presence of leukocytosis and the possibility of elevation of
serum transaminases and alkaline phosphotase. if complaints of pain increase with high
temperature and shivering and leukocytosis, the possibility of empyema and gallbladder
perforation needs to be considered.

Diagnosis

Plain abdominal photographs cannot show a picture of acute cholecystitis. only in 15% of
patients is it possible to see opaque stones (radiopaque) because they contain enough calcium.

oral cholecystography cannot show the gallbladder if there is obstruction so that this
examination is not useful for acute cholecystitis.

ultrasound examination (USG) should be done routinely and is very useful to show the size,
shape, thickening of the gallbladder wall, stones and extra hepatic bile ducts. the value of
sensitivity and accuracy of USG reaches 90% -95%.

Bile duct scintigraphy uses radioactive substances HIDA or 99n Tc6 Iminodiacetic acied has
a value slightly lower than ultrasound but this technique is not easy. the appearance of the
choledococcal duct without the presence of gallbladder in the examination of oral
cholecystography or scintigraphy strongly supports acute cholecystitis.

abdominal CT scan is less sensitive and expensive but is able to show the presence of a small
pericolescopic abscess that may not be seen on an ultrasound examination.

a differential diagnosis for sudden right upper abdominal pain that needs to be considered
such as spinal nerve pain, organ abnormalities under the diaphragm such as the retrosecal
appendix, intestinal obstruction, perforation of the peptic ulcer, acute pancreatitis and
myocardial infarction.

Treatment

Common treatments include complete rest, parenteral nutrition, a mild diet, painkillers such
as pethidine and antispasmodics. Antibiotic administration in the early cloud phase is very
important to prevent complications of perionitis, cholangitis, and septicema. ampicillin,
cephalosporins and metronidazole are sufficient to kill germs that are common in acute
cholecystitis such as E. Coli, Strep. faecalis, and klabsiella.

when when the action of cholecystectomy is carried out it is debatable whether it should be
done as soon as possible (3 days) or waited 6-8 weeks after conservative therapy and the
patient's general condition is better as many as 50% of cases will improve without surgery.
surgeons who are pro-early surgery state that the emergence of gangrene and the
complications of failure of conservative therapy can be avoided, the duration of hospital stay
is shorter and costs can be reduced. while those who disagree stated, early surgery will cause
the spread of infection to the peritoneal cavity and early surgical techniques will cause the
spread of acute inflammation around the duct to obscure anatomy.

Prognosis

Spontaneous healing is found in 85% of cases, even though the gallbladder becomes thick,
fibrotic, full of stones and no longer functioning. not infrequently recurrent cholecystitis.
Sometimes acute cholecystitis develops rapidly into gangrene, empyema, and perforation of
the gallbladder, fisistel, liver abscess or general peritonitis. This can be prevented by
providing adequate antibodies at the beginning of the attack. Acute surgery in patients aged
(> 75 years) has a poor prognosis in addition to the possibility of many postoperative
complications.

Chronic cholecystitis

Chronic cholecystitis is more common in clinical settings, and is very closely related to
litiasis and more often arises slowly.

Clinical Symptoms

the diagnosis of chronic cholecystitis is often difficult to enforce because the symptoms are
very minimal and not prominent such as dyspepsia, full feeling in the epigastrium and nausea
especially after eating high-fat foods, which sometimes disappear after belching. History of
gallstones in the family, recurrent jaundice and colic, local pain in the gallbladder area with
positive Murphy signs, can support the diagnosis.

Differential diagnoses such as fat intolerance, peptic ulcer, spastic colon, right colon
carcinoma, chronic pancreatitis, and koledokus duct abnormalities need to be considered
before deciding to do cholecystectomy.
Diagnosis

Oral cholecystography examination, ultrasonography and colloangiography can show

cholelithiasis and gallbladder function. endoscopie retrograde choledochopancreaticography
(ERCP) is very useful for showing the presence of gallstones in the gallbladder and
koledokus duct.

Prognosis

In most patients with chronic cholecystitis with or without symptomatic gallbladder stones, it
is recommended for cholecystectomy. The decision for cholecystectomy is rather difficult for
patients with minimal complaints or other diseases that increase the risk of surgery.

Referensi :
Sudoyo, Aru W. dkk. Buku Ajar Ilmu Penyakit Dalam. Jilid II Edisi VI.Jakarta: Interna Publi
shing Pusat Penerbitan Ilmu Penyakit Dalam. Hal 479-480