cholecistitis acute and tratement

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Uncomplicated cholecystitis has an excellent prognosis; the development of complications such as perforation or gangrene renders the prognosis less favorable.

Signs and symptoms

The most common presenting symptom of acute cholecystitis is upper abdominal pain. The following characteristics may be reported:

• Signs of peritoneal irritation may be present, and the pain may radiate to the right shoulder or scapula
• Pain frequently begins in the epigastric region and then localizes to the right upper quadrant (RUQ)
• Pain may initially be colicky but almost always becomes constant
• Nausea and vomiting are generally present, and fever may be noted

Patients with acalculous cholecystitis may present with fever and sepsis alone, without history or physical examination findings consistent with acute cholecystitis.

Cholecystitis may present differently in special populations, as follows:

• Elderly (especially diabetics) – May present with vague symptoms and without many key historical and physical findings (eg, pain and fever), with localized tenderness the only presenting sign; may progress to complicated cholecystitis rapidly and without warning
• Children – May present without many of the classic findings; those at higher risk for cholecystitis include those who have sickle cell disease, serious illness, a requirement for prolonged total parenteral nutrition (TPN), hemolytic conditions, or congenital and biliary anomalies

The physical examination may reveal the following:

• Fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound
• Palpable gallbladder or fullness of the RUQ (30-40% of patients)
• Jaundice (~15% of patients)

The absence of physical findings does not rule out the diagnosis of cholecystitis.

See Presentation for more detail.

Diagnosis

Laboratory tests are not always reliable, but the following findings may be diagnostically useful:

• Leukocytosis with a left shift may be observed
• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct (CBD) obstruction
• Bilirubin and alkaline phosphatase assays may reveal evidence of CBD obstruction
• Amylase/lipase assays are used to assess for pancreatitis; amylase may also be mildly elevated in cholecystitis
• Alkaline phosphatase level may be elevated (25% of patients with cholecystitis)
• Urinalysis is used to rule out pyelonephritis and renal calculi
• All females of childbearing age should undergo pregnancy testing

Diagnostic imaging modalities that may be considered include the following:

• Radiography
• Ultrasonography
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Hepatobiliary scintigraphy (see the image below)Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.
• Endoscopic retrograde cholangiopancreatography (ERCP)

The American College of Radiology (ACR) makes the following imaging recommendations:

• Ultrasonography is the preferred initial imaging test for the diagnosis of acute cholecystitis; scintigraphy is the preferred alternative
• CT is a secondary imaging test that can identify extrabiliary disorders and complications of acute cholecystitis
• CT with intravenous (IV) contrast is useful in diagnosing acute cholecystitis in patients with nonspecific abdominal pain
• MRI, often with IV gadolinium-based contrast medium, is also a possible secondary choice for confirming a diagnosis of acute cholecystitis
• MRI without contrast is useful for eliminating radiation exposure in pregnant women when ultrasonography has not yielded a clear diagnosis
• Contrast agents should not be used in patients on dialysis unless absolutely necessary

See Workup for more detail.

Management

Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications.

For acute cholecystitis, initial treatment includes bowel rest, IV hydration, correction of electrolyte abnormalities, analgesia, and IV antibiotics. Options include the following:

• Sanford guide – Piperacillin-tazobactam, ampicillin-sulbactam, or meropenem; in severe life-threatening cases, imipenem-cilastatin
• Alternative regimens – Third-generation cephalosporin plus metronidazole
• Emesis can be treated with antiemetics and nasogastric suction
• Because of the rapid progression of acute acalculous cholecystitis to gangrene and perforation, early recognition and intervention are required.
• Supportive medical care should include restoration of hemodynamic stability and antibiotic coverage for gram-negative enteric flora and anaerobes if biliary tract infection is suspected.
• Daily stimulation of gallbladder contraction with IV cholecystokinin (CCK) may help prevent formation of gallbladder sludge in patients receiving TPN

For cases of uncomplicated cholecystitis, outpatient treatment may be appropriate. The following medications may be useful in this setting:

• Levofloxacin and metronidazole for prophylactic antibiotic coverage against the most common organisms
• Antiemetics (eg, promethazine or prochlorperazine) to control nausea and prevent fluid and electrolyte disorders
• Analgesics (eg, oxycodone/acetaminophen)

Surgical and interventional procedures used to treat cholecystitis include the following:

• Laparoscopic cholecystectomy (standard of care for surgical treatment of cholecystitis)
• Percutaneous drainage
• ERCP
• Endoscopic ultrasound-guided transmural cholecystostomy Endoscopic gallbladder drainage                                                                                                                                                                      Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. Uncomplicated cases can often be treated on an outpatient basis; complicated cases may necessitate a surgical approach. In patients who are unstable, percutaneous transhepatic cholecystostomy drainage may be appropriate. Antibiotics may be given to manage infection. Definitive therapy involves cholecystectomy or placement of a drainage device; therefore, consultation with a surgeon is warranted. Consultation with a gastroenterologist for consideration of ERCP may also be appropriate if concern exists ofcholedocholithiasis.
• Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery.
  For more information, see the Medscape Reference article Imaging in Cholecystitis and Biliary Colic.