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Acute Cholecystitis
Overview
Acute Cholecystitis is an inflammation of the gallbladder, characterized by a sudden violation of the movement of bile as a result of blockade of its outflow. Perhaps the development of pathological destruction of the walls of the gallbladder. In the vast majority of cases (85-95%), the development of acute cholecystitis is combined with calculi (stones), more than half (60%) of patients have bacterial infection of bile (E.Coli, cocci, salmonella, etc.). In acute cholecystitis, symptoms occur once, develop and, with adequate treatment, subside without leaving pronounced consequences. They refer to chronic cholecystitis when there are recurrent acute bouts of gallbladder inflammation.
Acute cholecystitis is more common in women and the risk increases with age. There are suggestions about the influence of hormonal levels on the development of cholecystitis.
Classification:
According to morphological changes in the wall of the gallbladder, four forms of acute cholecystitis are distinguished:
• Catarrhal;
• Phlegmonous;
• Gangrenous;
• Gangrenous-perforative.
Different severity of inflammation implies a different clinical picture.
In the catarrhal form, the inflammatory process affects the mucous membrane of the gallbladder. Clinically, this is manifested by pains of moderate intensity, intoxication syndrome is not expressed, nausea occurs.
In the phlegmonous form, inflammation affects all layers of the gallbladder wall. There is a more intense pain syndrome, fever to febrile numbers, vomiting and flatulence. An enlarged painful gallbladder may be palpated. Symptoms appear:
• With. Murphy - interruption of inspiration when probing the gallbladder;
• With. Mussi - georgievsky, otherwise called phrenicus symptom - more painful palpation on the right between the legs of the sternocleidomastoid muscle (exit point of the phrenic nerve);
• With. Ortner - pain when tapping on the right costal arch.
In the gangrenous form, the intoxication syndrome comes to the fore: tachycardia, high temperature, dehydration (dehydration), symptoms of peritoneal irritation appear.
With perforation of the gallbladder (gangrenous-perforative form), the clinical picture of peritonitis prevails: muscle tension of the anterior abdominal wall, positive symptoms of peritoneal irritation, bloating and pronounced intoxication syndrome.
Forms of cholecystitis without appropriate treatment can flow from one to another (from catarrhal to gangrenous), and the initial development of destructive changes in the bladder wall is also possible.
Symptoms
The main symptom is biliary colic - acute severe pain in the right hypochondrium, upper abdomen, possibly radiating to the back (under the right shoulder blade). Irradiation happens less often in the left part of the body. Alcohol use, the consumption of fatty, spicy meals, and extreme stress can all precede the development of biliary colic.
Acute cholecystitis may also be accompanied by the following in addition to the pain syndrome:
• Temperature increase;
• White dense coating on the surface of the tongue;
• Fever;
• Yellowing of the skin and whites of the eyes;
• Nausea;
• Vomit.
In mild cases (without the presence of gallstones), acute cholecystitis proceeds quickly (5-10 days) and ends with recovery. When an infection is attached, purulent cholecystitis develops, in people with weakened body defences, it can turn into gangrene and perforation (breakthrough) of the gallbladder wall. These conditions are fatal and require immediate surgical treatment.
Causes
Usually, the disease is provoked by errors in the diet - the intake of fatty and spicy foods, which leads to intense bile formation, spasm of the sphincters in the biliary tract and biliary hypertension.
• Contributing factors are diseases of the stomach , and in particular gastritis with low acidity. They lead to a weakening of the protective mechanisms and the penetration of microflora into the biliary tract.
• With thrombosis of the cystic artery against the background of the pathology of the blood coagulation system and atherosclerosis, the development of a primary gangrenous form of acute cholecystitis is possible.
• Provoking factors in the presence of cholelithiasis can also be physical activity, "shaking" ride, which leads to displacement of the stone, blockage of the cystic duct and subsequent activation of the microflora in the lumen of the bladder.
• Infection of bile with bacterial flora, the development of infection (bacterial cholecystitis);
• Reflux of pancreatic enzymes into the gallbladder (enzymatic cholecystitis).
Pathogenesis:
Previously, it was believed that the main factor leading to the development of acute cholecystitis is bacterial. In accordance with this, treatment was prescribed aimed at eliminating the inflammatory process. At present, ideas about the pathogenesis of the disease have changed and, accordingly, treatment tactics have changed.
The development of acute cholecystitis is associated with a block of the gallbladder, which triggers all subsequent pathological reactions. The block is most often formed as a result of a stone wedging into the cystic duct. This is aggravated by reflex spasm of the sphincters in the bile ducts, as well as increasing edema
As a result of biliary hypertension, the microflora in the biliary tract is activated, and acute inflammation develops. Moreover, the severity of biliary hypertension directly depends on the degree of destructive changes in the wall of the gallbladder.
An increase in pressure in the biliary tract is a trigger for the development of many acute diseases of the hepatoduodenal zone (cholecystitis, cholangitis, pancreatitis). Activation of the intravesical microflora leads to even greater edema and impaired microcirculation, which, in turn, significantly increases the pressure in the biliary tract - a vicious circle closes.
Prevention
Prevention consists in the timely rehabilitation of stone carriers, that is, in performing cholecystectomy in a planned manner for patients with chronic calculous cholecystitis. Even the founder of biliary surgery, Hans Kehr, said that "wearing a stone in the gallbladder is not the same as an earring in the ear." In the presence of cholecystolithiasis, factors leading to the development of acute cholecystitis should be avoided - do not break the diet.
Treatment
Maintenance therapy (hydration, analgesics, antibiotics).
• Cholecystectomy.
Management includes hospitalization, IV fluids, and analgesics such as NSAIDs (ketorolac) or opioids. In case of vomiting or development of intestinal obstruction, a nasogastric tube is installed, nothing is prescribed orally to the patient. Patients are treated with parenteral antibiotics to treat probable infectious complications, but their effectiveness has not been clearly proven. Intravenous use of medications like piperacillin/tazobactam 4 g every 6 hours, ticarcillin/clavulanate 4 g every 6 hours, or ceftriaxone - 2 g every 24 hours in conjunction with metranidazole - 500 mg every 8 hours are all examples of empiric antibiotic treatment directed targeting gram-negative intestinal flora.
Cholecystectomy leads to resolution of acute cholecystitis and biliary pain. Usually, early cholecystectomy is preferred within the first 24 to 48 hours in the following situations:
• The diagnosis is clear, the patient is at low surgical risk;
• The patient is elderly or diabetic and has a high risk of infectious complications;
• The patient has empyema, gangrene, perforation, or acalculous cholecystitis.
Surgery may be delayed in patients with severe chronic comorbidities (eg, cardiopulmonary disease) that increase surgical risk. Such patients should seek to delay cholecystectomy until comorbidities stabilize or cholecystitis resolves. If acute cholecystitis has resolved, then cholecystectomy may be performed ≥6 weeks later. Delayed surgical care suggests the possibility of recurrence of biliary complications.
Percutaneous cholecystostomy serves as an alternative to cholecystectomy for patients with high surgical risk: elderly patients with acalculous cholecystitis, patients in intensive care units with burns, trauma, or respiratory failure.
Prognosis:
For those who receive prompt and effective care, the prognosis is often good. Following a radical procedure, you must follow diet No. 5 for a predetermined amount of time (at least three months), with the exclusion of fatty, fried, and spicy meals. Small meals should be had five to six times each day in fractional amounts. Pancreatic enzymes and herbal choleretic medicines are required (they should not be taken before to surgery).
Tests Required for Diagnosis
For diagnosis, it is important to identify violations in the diet or stress conditions during the survey, the presence of symptoms of biliary colic, palpation of the abdominal wall. If acute inflammation of the gallbladder is suspected, an ultrasound scan of the abdominal organs is mandatory. It shows an increase in the organ, the presence or absence of stones in the gallbladder and bile duct.
Ultrasound examination of the inflamed gallbladder has thickened (more than 4 mm) walls with a double contour, there may be an expansion of the bile ducts, a positive murphy's symptom (bladder tension under the ultrasound probe).
Computed tomography gives a detailed picture of the abdominal organs. For a detailed study of the bile ducts, the ercp technique (endoscopic retrograde cholangiopancreatography) is used.
A blood test shows signs of inflammation (leukocytosis, high ESR), dysproteinemia and bilirubinemia, increased activity of enzymes (amylases, aminotransferases) in a biochemical study of blood and urine.
Differential Diagnosis
In case of suspicion of acute cholecystitis, differential diagnosis is carried out with acute inflammatory diseases of the abdominal organs: acute appendicitis, pancreatitis, liver abscess, perforated stomach ulcer. And also with an attack of urolithiasis, pyelonephritis, right-sided pleurisy.
An important criterion in the differential diagnosis of acute cholecystitis is functional diagnosis.
