Acute Cholecystitis

Radionuclide imaging 

Ultrasonography is the most useful radiologic test for diagnosing acute cholecystitis.

It has a sensitivity and specificity of 95%.

In addition to being a sensitive test for documenting the presence or absence of stones, it will show the thickening of the gallbladder wall and the pericholecystic fluid.

Focal tenderness over the gallbladder when compressed by the sonographic probe (sonographic Murphy’s sign) also is suggestive of acute cholecystitis.

Biliary radionuclide scanning (HIDA scan) may be of help in the atypical case. Lack of filling of the gallbladder after 4 hours indicates an obstructed cystic duct and, in the clinical setting of acute cholecystitis, is highly sensitive and specific for acute cholecystitis. A normal HIDA scan excludes acute cholecystitis.

Ref: Oddsdottir M., Pham T.H., Hunter J.G. (2010). Chapter 32. Gallbladder and the Extrahepatic Biliary System. In F.C. Brunicardi, D.K. Andersen, T.R. Billiar, D.L. Dunn, J.G. Hunter, J.B. Matthews, R.E. Pollock (Eds), Schwartz’s Principles of Surgery, 9e.

Patient in the question is showing features of disseminated intravascular coagulation secondary to sepsis caused by acute cholecystitis. Next best step in the management of patients coagulopathy, is to remove the foci of infection by doing an exploratory laparotomy.

The morbidity and mortality associated with DIC are primarily related to the underlying disease rather than the complications of the DIC. The control or elimination of the underlying cause should be the primary concern. Management of DIC involves, administration of fresh frozen plasma to replace the coagulation factors, cryoprecipitate to replace the low fibrinogen levels.

Ref: Harrison’s Internal Medicine, 18th Edition, Chapter 116

Cholecystectomy is the definite line of treatment for patients with acute cholecystitis.

Early cholecystectomy performed within 2-3 days of presentation is preferred over interval or delayed cholecystectomy.

Effects and complications of gallbladder stones are:

Ref: Bailey & Love 25/e, Page 1120.

A i.e. USG

C i.e. HIDA Scan

HIDA Scan & PIPIDA are best test to rule out acute cholecystitisQ with.–400% negative predictive value. It can be pseudo positive in chronic malnutrition, & Parenteral nutrition & alcoholic liver disease.

Ans. is ‘c’ i.e. Laparoscopy cholecystectomy immediately

Management of Acute cholecystitis

• IV fluids, analgesics and antibiotics are given initially in a pt. presenting with acute cholecystitis.
• Cholecystectomy is the definitive treatment.
• The timing of cholecystectomy was a matter of debate in the past.
• Early cholecystectomy performed within 2 to 3 days of presentation is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial medical therapy. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy is done as it provides a definitive treatment in one hospital admission & quicker recovery time.
• Laparoscopic cholecystectomy is the preferred approach
• Conversion to open cholecystectomy is made if the inflammation prevents adequate visualization of important structures. The conversion rate to open cholecystectomy is higher in the settings of acute cholecystitis than with chronic cholecystitis.
• If a patient presents late, after 3 to 5 days of illness, or in unfit for surgery, he is treated with analgesics, antibiotics and laparoscopic cholecystectomy is scheduled for approximately 2 months later. But if the patient fails to respond to initial medical therapy he would then need a surgical intervention. Laparoscopic cholecystectomy could be attempted, but the conversion rate is high and some prefer to go directly for an open cholecystectomy. For those unfit for surgery, a percutaneous cholecystostomy or an open cholecystostomy under local analgesia can be performed.
• Acute cholecystitis may progress to complications like empyema of the gall bladder, emphysematous cholecystitis, or perforation of the gall bladder despite antibiotic therapy.

Emergency cholecystectomy is the procedure of choice for these complications, if the patient can safely withstand an anesthetic. Laparoscopic cholecystectomy could be attempted, but the conversion rate to open procedure is high and some prefer to go directly for an open cholecystectomy. Occasionally, the inflammatory process obscures the structures in the triangle of Calot, making dissection and ligation of the cystic duct unsafe. In these patients, partial cholecystectomy, cauterization of the remaining gall bladder mucosa, and drainage avoid injury to the CBD. If a patient is too unstable to tolerate a surgery, percutaneous cholecystostomy (or an open cholecystostomy) under local analgesia can be performed to drain the gall bladder. Delayed cholecystectomy can then be done once the inflammation has resolved.

Ans. is ‘c’ i.e. USG 

Ultrasound is the investigation of choice for both acute as well as chronic cholecystitis.

Ans is ‘c’ i.e. Boas’ sign 

Boas’ sign: In cases of acute cholecystitis pain radiates to the tip of the right shoulder and an area of skin below the scapula is found to be hypersensitive. This is k/a Boas’ sign. Sensitivity is quite less.

Also Know:

Murphy’s sign: Seen in acute cholecystitis. Murphy’s sign is elicited by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s _.fingers) and winces with a ‘catch’ in breath, the test is considered positive. In order for the test to be considered positive, the same maneuver must not elicit pain when performed on the left side.

Grey Turner & Cullen’s sign: positive in severe necrotizing pancreatitis. Grey Turners sign is bluish discolouration seen at the flanks. Bluish discolouration around the umbilicus is known as Cullen’s sign.

Ans. is ‘b’ i.e., Tube cholecystostomy 

Ans. B: USG

– Abdominal radiographs are usually not indicated, as most gallstones are not radio-opaque.

– Chest radiographs may be performed to exclude a thoracic cause of pain and bowel perforation.

Ultrasound:

– Initial investigation of choice for suspected acute cholecystitis.

Ultrasonographic signs of acute gallbladder inflammation include gallbladder wall thickening/oedema, pericholecystic fluid, gallstones, and positive ultrasonic Murphy’s sign.

– >90% diagnostic accuracy and varies with the morphologic criteria used.

– Colour/power Doppler increases accuracy over Gray-scale sonography.

–  Advantages: allows evaluation of other abdominal structures (can identify an alternative diagnosis), provides preoperative information such as gallbladder size, stone size, gallbladder wall status, and the presence of biliary dilatation.

Tc-IDA Radionuclide Scan:

– Superior diagnostic accuracy and specificity compared to ultrasound.

Used to clarify a negative, equivocal or technically difficult ultrasound in the presence of continued clinical suspicion of acute cholecystitis.

– The hallmark of acute cholecystitis (acalculus as well as calculus) is persistent gall bladder non-visualisation 30 minutes post morphine or on the 3-4 hour delayed image.

– False positives can occur in alcoholics, intensive care unit patients, patients on prolonged fasting, cystic fibrosis and chronic cholecystitis.

– Morphine augmentation reduces false positives and is superior to delayed imaging.

– In critically ill patients in whom acalculous cholecystitis is suggested on US, Tc-IDA scan with pretreatment cholecystokinin to empty gallbladder prior to Tc-IDA scan, or percutaneous cholecystostomy may be indicated. Post treatment Cholecystokinin can be used to evaluate gallbladder function in chronic cholecystitis. Limitations: longer examination time, unreliable in severe hepatocellular disease or at serum bilirubin levels >340-500 mmol/L, and inability to diagnose extra-biliary causes of acute right upper quadrant abdominal pain and to provide anatomical information.

Other Imaging:

Endoscopy or Barium studies may be indicated in certain patients to identify alternative diagnoses which may clinically simulate acute cholecystitis.

– Computed Tomography

• CT is useful when the clinical picture is non-specific as it can detect other intra-abdominal inflammatory processes, and when complications of acute cholecystitis are suspected.
• Sensitivities for CT diagnosis of acute cholecystitis have not been established
• CT features of acute cholecystitis include

1. Pericholecystic inflammatory changes, including contrast enhancement of the liver adjacent to the gallbladder, inflammatory stranding of pericholecystic tissues, and pericholecystic fluid.
2. Loss of distinction between walls of the gallbladder and adjacent liver.
3. Gallbladder wall thickening, contrast enhancement.
4. Gallbladder distension.
5. Presence of gallstones.

• Advantages: allows other diagnoses, able to identify complications of acute cholecystitis.
• Limitations: exposure to ionising radiation, less sensitive (57%-88%) for detection of gallstones compared to ultrasound.

Ans. HIDA scan

Ans.On HIDA scan. gall bladder is not visualized

Ans:C.)Strawberry Gall bladder.

Strawberry gallbladder

• It refers to the surface appearance (not shape) of the mucosa of the gallbladder due to multiple small collections of triglycerides and cholesterol esters within the lamina propria of the gallbladder wall (gallbladder wall cholesterolosis).
• Strawberry gallbladder represents diffuse cholesterolosis and is a common, idiopathic, non-neoplastic condition.

Pathology

• There is deposition of cholesterol esters within the lamina propria of the gallbladder wall.

Radiographic features

Ultrasound

• brightly hyperechoic foci within the gallbladder wall
• no posterior acoustic shadowing
• when cholesterosis is focal, it forms multiple small cholesterol polyps .