ACUTE CHOLECYSTITIS

Pableo, Rachel M.
 General data
• C.D
• 43 y.o.
• Female
• Married
• Roman Catholic
• August 4, 1966
• Solana,Cagayan
• July 29, 2010
 Chief complaint
• Right upper quadrant pain
 History of Present Illness
• 1 year PTA - recurrent RUQ colicky pain
• UTZ – cholecystolithiasis
• 3 months PTA - consulted a PMD and
Omeprazole was prescribed
• Still with RUQ pain - admission
 Past Medical History
• August 2009 – surgery due to a laryngeal cyst
at SPH
 Family History
• unremarkable
 Personal and Social History
• Non-cigarette smoker
• Non-alcoholic beverage drinker
 Review of Systems

• Integumentary: (-) pruritus

• CNS: (-) seizure, (-) h/a, (-) dizziness
• Cardiorespiratory: (-) cough, (-) chest pain
• GIT: (-) vomiting, (-) diarrhea, (-) constipation
• GUT: (-) oliguria, (-) hematuria, (-) dysuria
• Hematologic: (-) gum bleeding, (-) easy
bruisability
• Muskuloskeletal: (-) myalgia, (-) arthralgia
• Endocrine: (-) weight loss, (-) loss of appetite,
(-) fever
 Physical Examination:

• General Survey: Px is conscious, coherent and

not in cardiorespiratory distress
Vital Signs:
• BP: 120/90
• CR: 98 bpm
• RR: 20 bpm
• Temp: 36.8 C
• Skin: (-) pallor, good skin turgor
• HEENT: pink palpebral conjunctiva
• Chest and Lungs: (-) rales, (-) wheezes
• Heart: AP, NRRR, (-) murmur
• Abdomen: flabby, (+) Murphy’s sign
• Extremities: (-) edema, FEP
 Impression
• Acute Cholecystitis
Date Diagnostics IVF/Meds

7/29/10 11:45 am CBC, UA, UTZ, Na, K, •Admit to surgery ward

creatinine, RBS, CXR, 12L •Secure consent for
ECG admission and
Sodium : 149 mmol/L management
(138-145) •NPO
Potassium: 4.06 mmol/L •IVF D5LRS 1L q 8 hrs
(3.5-5.4) •Medicines: Ampi-
Glucose : 5.36 mmol/L Sulbactam 1.5 mg q 12 hrs
(4.10 – 5.90) ANST
Creatinine: 60 umol/L (53 • Ranitidine 50 mg IV q 12
– 115) hrs
Chloride: 104 mmol/L (96 • Ketorolac 30 mg IV q 8
– 110) hrs
ALT: 15 u/L (9 – 72) •For “E” cholecystectomy
ALKP: 82 u/L (38 – 126) •Refer to Medicine for
eval’n prior to
cholecystectomy
Date Diagnostics IVF/ Meds
CBC:
Hgb: 109 g/L (120-160)
Hct: 0.33 (0.38 – 0.47)
Erythrocyte no. conc.: 4.9
(4.5 to 6.0 x 109/L)
Thrombocyte no. conc.:
243 (150-400 x 109/L)
WBC Diff. Ct.:
Neutrophils – 38.4 (35-65)
Lymphocytes – 41.3 (20-
40)
Monocytes – 19.3 (2-8)
Eosinophils – 0 (0-5)
Basophils – 1 (0-1)
U/A:
Yellow, sl. Turbid
pH 6.0
SG 1.030
(-) chemical test
WBC – 12-15/hpf, RBC 6-9
Bacteria - few
 
Date Diagnostics IVF/ Meds
UTZ of of Hepatobiliary
tree and Pancreas
Result: Cholelithiasis
7/29/10 3:45 pm CXR: no cardiomegaly, no Patient seen and
BP: 130/90, HR: 81 bpm, infiltration examined
RR: 18 bpm 12L ECG : sinus rhythm, Patient was referred for
non-specific ST-T wave eval’n due to
changes cholecystectomy
A: stable cardiopulmonary
status at the time of
examination
P: no absolute CI for the
contemplated procedure
Date Diagnostics IVF/ Meds
7/30/10 1:00 am Post –op orders
Status post
cholecystectomy
NPO
Monitor VS q 15 mins.
Until stable
OR @ 5-6 pm via face
mask
IVF: Plain NSS x 30 gtts/
min , D5LRS x 30 gtts/min
Meds: Intrathecal
morphine given
Ketorolac 30 mg IV q g
hrs after negative skin test
Tramadol 50 mg IV PRN -
moderate to severe pain
Ranitidine 50 mg IV q 8 hrs
while on NPO
Date Diagnostics IVF/ Meds
7/30/10 8:50 am Soft diet
IVF: D5LRS 1L q 8 hrs
Continue meds
Probable discharge
tomorrow
D/C Tramadol
7/31/10 (+) BM MGH
Soft, non tender Dulcolax 2 adult
suppository now
Bladder draining prior to
discharge
Home Meds:
Cefuroxime 500 mg TID for
7 days
Ketomed 10 mg 1 tab TID
Omeprazole 20 mg BID
Follow-up - Aug. 5, 2010
Discharge
GALLSTONE DISEASE

Discussion
 Prevalence and Incidence
• one of the most common problems affecting
the digestive tract
• Factors :
-age
- gender
- ethnic background
 Predisposing conditions:
- Obesity - gastric surgery
- pregnancy - hereditary spherocytosis
- dietary factors - sickle cell disease
- Crohn's disease - thalassemia
- terminal ileal resection
 Prevalence and Incidence
• 3x more in women than men
• first-degree relatives - twofold greater
prevalence
 NATURAL HISTORY
• asymptomatic throughout life
• Some progress to a symptomatic stage, with
biliary colic caused by a stone obstructing the
cystic duct - may progress to complications
related to the gallstones.
• Approximately 3% of asymptomatic individuals
become symptomatic per year.

• Complicated gallstone disease develops in 3 to 5% of

symptomatic patients per year.
 Gallstone Formation
• result of solids settling out of solution
• major organic solutes in bile are:
*bilirubin
*bile salts
* phospholipids
*cholesterol
• classified by their cholesterol content as
either:
* cholesterol stones
* pigment stones – black or brown
 CHOLESTEROL STONES
• single large stones with
smooth surfaces
• contain variable
amounts of bile
pigments and calcium,
but are always >70%
cholesterol by weight
• Most cholesterol stones
are radiolucent
• Whether pure or of mixed
nature: common primary
event in the formation of
cholesterol stones is
supersaturation of bile
with cholesterol.
 PIGMENT STONES
• contain <20% cholesterol
• dark because of the presence of calcium
bilirubinate
• Black pigment
stones are usually
small, brittle, black,
and sometimes
spiculated
• formed by supersaturation of calcium
bilirubinate, carbonate, and phosphate
• Brown stones are
usually <1 cm in
diameter, brownish-
yellow, soft, and often
mushy
• usually secondary to
bacterial infection
caused by bile stasis
• major part of the stone:
*Precipitated calcium
bilirubinate
*bacterial cell bodies
 ACUTE CHOLECYSTITIS
• secondary to gallstones in 90 to 95% of cases
• Obstruction of the cystic duct by a gallstone
is the initiating event that leads to gallbladder
distention, inflammation, and edema of the
gallbladder wall
• It is an inflammatory process, probably
mediated by:
* lysolecithin
*bile salts
* PAF
 CLINICAL MANIFESTATIONS
• Attack of biliary colic - unremitting and may
persist for several days
• Usually right upper quadrant or epigastrium
• Radiate to the right upper part of the back or
the interscapular area - more severe
 CLINICAL MANIFESTATIONS
• Febrile
• Complains of anorexia, nausea, and vomiting
• Reluctant to move
• Focal tenderness (RUQ)
• A Murphy's sign, an
inspiratory arrest with
deep palpation in the
right subcostal area, is
characteristic of acute
cholecystitis
 Laboratory Findings
• mild to moderate leukocytosis (12,000 to
15,000 cells/mm3
• high WBC (above 20,000) - gangrenous
cholecystitis, perforation, or associated
cholangitis
• mild elevation of serum bilirubin, < 4 mg/mL,
with mild elevation of ALP, transaminases,
and amylase
• Severe jaundice is suggestive of common bile
duct stones or obstruction of the bile ducts
• by severe pericholecystic inflammation
secondary to impaction of a stone in the
infundibulum of the gallbladder that
mechanically obstructs the bile duct (Mirizzi's
syndrome)
 DIAGNOSIS
• Ultrasonography is the most useful radiologic
test for diagnosing acute cholecystitis
 TREATMENT
• IV fluids, antibiotics, and analgesia
• Gram (-) aerobes, anaerobes
• Typical regimens:
* 3rd generation cephalosporin with good
anaerobic coverage
* 2nd generation cephalosporin combined with
metronidazole
 TREATMENT
• aminoglycoside with metronidazole – if the
patient is with allergies
• Cholecystectomy – definitive treatment for
acute cholecystitis
Laparoscopic cholecystectomy -
procedure of choice for acute
cholecystitis
• When patients:
* present late (after 3 to 4 days of illness)
*unfit for surgery
- they can be treated with antibiotics with
laparoscopic cholecystectomy scheduled for
approximately 2 months later
THANK YOU 