CHOLECYSTITIS DUE TO ACUTE

CHOLELITHIASIS
DR MUHAMMAD ABUBAKAR RIZWAN
 HISTORY

• MY PATIENT RASHEEDA BB 55 YEAR MARRIED FEMALE

RESIDENT OF GORALA HOUSEWIFE PRESENTED
THROGH ER AT 1/11/2019 WITH COMPLAINTS OF PAIN
IN RHC FOR 7 DAYS AND FEVER FOR 2 DAYS
• SHE WAS IN USOH ABOUT 7 DAYS AGO .THEN THE
PAIN DEVELOPED AT RHQ,SUDDEN IN
ONSET,RADIATING TO BACK AND CLOSE TO THE TIP OF
RIGHT SCAPULA,CONTINUOUS IN
NATURE,AGGREVATED BY MOVING,FATTY FOOD AND
BREATHING .RELIEVED BY PAIN KILLERS.
• FEVER IS CONTINUOUS ,LOW GRADE ,ACUTE IN
ONSET
• NO HISTORY OF CHEST PAIN,JAUNDICE,DARK
COLOUR URINE,PALE
STOOLS,MALENA,CONSTIPATION,SMOKING,STRES
S,PAIN KILLERS.
• PAST MEDICAL HISTORY
• TYPE 2 DM FOR 10 YEARS .USED METFORMIN
500MG TWICE A DAY FOR 7 YEARS
• PAST SURGICAL HISTOTY;
• 1 C-SEC 25 YEARS AGO
• DRUG AND ALLERGY HISTORY;
• PATIENT HAS NO DRUG ALLERGY AND ALSO NO FOOD
ALLERGY
• FAMILY HISTORY;
• NO FAMILY HISTORY OF HTN AND DM.NO KNOWN
HISTORY OF MALIGNANCY.PATIENT FATHER PASSED AWAY
WHEN SHE WAS CHILD,HENCE SHE COULD NOT ESTABLISHED
THE CAUSE OF DEATH.PATIENT’S MOTHER IS CURRENTLY
ALIVE AND WELL.
• MENSTRAL HISTORY;
• MENOPAUSE AT THE AGE OF 52
YEAR.THERE IS NO POST MENOPAUSAL
BLEEDING AND DISCHARGE
• SOCIAL HISTORY;
• NON SMOKER,NON ALCOHLIC,MIDDLE
CLASS FAMILY
 SYSTEMIC REVIEW
• CARDIOVASCULAR SYSTEM;
• SHE HAS NO CHEST PAIN,PALPITATION AND
CLAUDICATION
• RESPIRATORY SYSTEM
• SHE HAS NO CHEST PAIN,SHORTNESS OF BREATH
AND DYSPNEA
• GENITOURINARY SYSTEM;
• SHE HAS NO FREQUENCY,DYSURIA,NOCTURIA AND
INCONTINENCE
• NEUROLOGICAL SYSTEM;
• THERE IS NO HEADACHE,VISUAL DISTURBANCE
AND SPEECH DISTURBANCE
PHYSICAL EXAMINATION FINDINGS
• PATIENT DISTRESSED BY PAIN AND
BREATHING SHALLOWLY.
• B.P=110/70
• PULSE=102/MIN
• TEMP=101
• RR=16/MIN
 EXAMINATION OF ABDOMEN
• UPON SPECIFIC EXAMINATION OF THE
ABDOMEN TENDERNESS AT RHC AND
MRPHY’S SIGN POSITIVE
• LIVER MEASURED 7CM
• SPLEEN AND KIDNEY NOT PALPABLE
• NO FLUID THRILL AND SHIFTING DULLNESS
• BOWEL SOUND POSITIVE
• RECTAL EXAMINATION WAS NORMAL
 DIFFERENTIAL DIAGNOSIS

• CHOLECYSTITIS DUE TO ACUTE

CHOLELITHIASIS
• PANCREATITIS
• HEPATITIS
• PERFORATED PEPTIC ULCER
• IHD
• PYELONEPHRITIS AND RENAL CALCULI
 INVESTIGATIONS
• CBC
• TLC=16800
• HB=12.9
• PLATELETS=245
LEUKOCYTOSIS SUGGESTED THERE IS AN ACUTE
INFECTION
• ALKALINE PHOSPHATASE AND BILIRUBIN ARE IN
NORMAL RANGE TO EVALUATE FOR THE PRESENCE
OF CBD OBSTRUCTION
AST/ALT
TO EVALUATE THE HEPATITIS
SERUM AMYLASE
FOR PANCREATITIS
URINE ANALYSIS
RULE OUT PYELONEPHRITIS AND RENAL
CALCULI
• ECG
• IHD
• X-RAY (ABDOMEN AND CHEST)
• LOBAR PNEUMONIA AND PDU
• USG ABDOMEN
• THICKNESS OF GALL BLADDER WALL >3mm
• PERICHOLECYSTIC FLUID
• CBD NORMAL
• SUBSEROSAL EDEMA
• SLOUGHED MUCOSA
• SONOGRAPHIC MURPH’S SIGN POSITIVE
• SENSTIVITY AND SPECIFICITY OF CT AND MRI >95 IN DIAGNOSIS OF ACUTE CHOLECYSTITIS
• HIDA scan.
•  hepatobiliary iminodiacetic acid (HIDA) scan tracks the production and flow of bile from
your liver to your small intestine and shows blockage. A HIDA scan involves injecting a
radioactive dye into your body, which attaches to bile-producing cells so that it can be seen
as it travels with the bile through the bile ducts.
 TREATMENT
• CONSERVATIVE MEASURE
• KEEP NPO
• ANTIBIOTICS
• Empiric coverage, directed at gram-negative enteric organisms, involves IV regimens
such as ceftriaxone 2 g every 24 hours plus metronidazole 500 mg every 8
hours, piperacillin/tazobactam 4 g every 6 hours, or ticarcillin/clavulanate 4 g every 6
.
hours

• ANALGESIC
• Administration of NSAIDs to patients with an attack of biliary colic is recommended e.g 75
mg diclofenac; intramuscular injection,ketorolac or opioid.

• IV FLUIDS
• MONITOR BP,PULSE,TEMP,RR
 WHEN CONSERVATIVE TREATMENT
ABANDONED?
• WORSENING OF SYMPTOMS
• GNERALIZED PERITONITIS
• DEVELOPMENT OF INTESTINAL OBSTRUCTION
• GANGRE OR PERFORATION OF GB
• EMPHEMA OF GB
• IN THESE CONDITIONS EMERGENCY
CHOLECYSTECTOMY SHOULD BE DONE.
 TREATMENT
• EARLY CHOLECYSTECTOMY(2-3 DAYS)
• DIFFICULT TO PERFORM BECAUSE OF
INFLAMMATORY ADHESIONS.
• INTERVAL CHOLECYSTECTOMY(6-10 WEEKS)
• Percutaneous cholecystostomy is an alternative
to cholecystectomy for patients at very high
surgical risk, such as those who are older, those
with acalculous cholecystitis, and those in an
intensive care unit because of burns, trauma, or
respiratory failure.
SEQUELAE/FATE OF ACUTE CHOLECYSTITIS

• RESOLUTION
• EMPYEMA
• MUCOCELE
• GANGRENA
• PERFORATION
• OBSTRUCTIVE JAUNDICE
• CHOLANGITIS
• PANCREATITIS
• GALL STONE ILEUS
Illustration of the most commonly found and, clinically important variations
of the cystic artery. a Indicates the cystic artery originating from right hepatic
artery or aberrant right hepatic artery. b shows the cystic artery originating
from left hepatic artery and c from the gastroduodenal artery. d illustrates the
cystic artery traveling anterior to common hepatic duct while in e it travels
anterior to common bile duct and inferior to cystic duct. A short cystic artery
is seen in f and multiple cystic arteries in g
• THANK YOU!!!!!!!!!!!!!!!!!!