Acute cholecystitis

1. Acute cholecystitis
R. Lunevicius
Teaching programme 2019
Department of General Surgery
15 November 2019
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2. 2
RHV
MHV LHV
CHA
LHA
PHA
CBD
IVC
PV
P6
P7
P5
P4
P3
P2
GB
Illustrated by Kenzo YASUI MD, PhD
Nagoya, Aichi Cancer Centre, Japan
1. The primary function of the GB is to concentrate and store bile
2. The GB has storage capacity of 30 – 50 mL
3. As part of gustatory response, the stored bile is then released from the
GB in response to cholecystokinin

3. 3
A scheme developed by
R. Lunevicius, 2018
GB is divided into 3 portions: fundus (Gf), body (Gb) and neck (Gn)
NB! Hartmann’s pouch is a part of the Gn, a common location for gallstones to become lodged,
causing cholestasis and acute calculous cholecystitis

4. Definition, pathophysiology
AC is acute inflammation of the gallbladder wall, usually as
a response to cystic duct obstruction by a gallstone
 AC is accompanied by cholelithiasis in 95% of patients
The pathophysiology of AC is incompletely understood
1.Concentration of bile may be altered, inducing mucosal
inflammation
2.Arterial occlusion and ischemia may be later changes
3.AC is rarely caused by bacterial infection initially
Example: Intraoperative gallbladder bile cultures during the first
few days of illness are positive in < 33% of cases
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5. Symptoms, Sings, Management
AC begins with recurrent colicky pain in 75% of patients
Pain becomes severe, localizing to the RUQ + nausea, vomiting are usual
Primary physical finding: involuntary guarding of right-sided abdominal
muscles within few hours
The GB becomes palpable in < 50% of cases
Murphy’s sign is painful splinting of respiration during deep inspiration and
RUQ palpation: frequent
Fever is low grade at first, and Neutrophilia is modest
A typical episode of AC improves in 2 to 3 days and resolves within 1 week
Management includes rehydration with with IV fluids
Antibiotics: commonly administered prophylactically against sepsis
Cholecystectomy cures AC in nearly all patients
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6. Complications
As AC is primarily an inflammatory process, all
consequences of it – i.e. secondary and tertiary processes
- should be regarded as a complications:
Infection and empyema
Gangrene (necrosis)
Perforation and infection of surrounding spaces and
tissues (subhepatic abscess, liver abscess, etc.)
Jaundice and cholangitis
Pancreatitis
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Cystic duct
Cystic artery
Medial branch of CA

7. Important
 To differentiate biliary pain / colic from AC
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8. Biliary colic: symptomatic gallstones
 Rome criteria defines this as :
 ‘steady pain located in the epigastrium
and/or right upper quadrant (RUQ).
 Lasting at least 30 minutes
 Dutch gall stones guidelines : Dutch
Association of Surgery (DAS)
 Two other symptoms, in addition to biliary
colic
 Pain radiating to the back
 Positive response to a simple analgesic

9.  S3 Guidelines for Diagnosis and
Treatment of Gallstones: German Society for
Digestive and Metabolic Disease
 Agrees with above DAS definition; however
 Added on that symptomatic GS is often
associated with nausea & vomiting
 American Academy of Family
Physicians (AAFP1)
 Defined biliary pain as ‘steady pain which
rapidly increased in intensity and reaches a
plateau, can last 4-6 hours and sometimes
radiated to the right upper back’

10. Tokyo Guidelines (TG13)
TG13 diagnostic criteria for acute cholecystitis
A. Local signs of inflammation etc.
(1) Murphy's sign, (2) RUQ mass/pain/tenderness
B. Systemic signs of inflammation etc.
(1) Fever, (2) elevated CRP, (3) elevated WBC count
C. Imaging findings
Imaging findings characteristic of acute cholecystitis
Suspected diagnosis: One item in A + one item in B
Definite diagnosis: One item in A + one item in B + C

11. Imaging findings: US-scan
Ultrasonography should be
performed at the initial consultation
for all cases for which AC is
suspected (recommendation 1, level A)
Findings are mainly enlarged
gallbladder, thickening of the
gallbladder wall, gallbladder stones,
and debris

12. Grade 1 (mild) AC:
by Tokyo guidelines
 Grade I (mild) acute cholecystitis
Does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis.
Grade I can also be defined as acute cholecystitis in a healthy patient with
no organ dysfunction and mild inflammatory changes in the gallbladder,
making cholecystectomy a safe and low‐risk operative procedure
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13. Grade II (moderate) acute cholecystitis
 Associated with any one of the following
conditions:
 Elevated white blood cell count (>18,000/mm
3
)
 Palpable tender mass in the right upper
abdominal quadrant
 Duration of complaints >72 h
 Marked local inflammation (gangrenous
cholecystitis, pericholecystic abscess, hepatic
abscess, biliary peritonitis, emphysematous
cholecystitis)
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14. Grade III (severe) acute cholecystitis
 Associated with dysfunction of any one of the following
organs/systems:
1. Cardiovascular dysfunction: Hypotension requiring
treatment with dopamine ≥5 μg/kg per min, or any dose of
norepinephrine
2. Neurological dysfunction: Decreased level of
consciousness
3. Respiratory dysfunction: PaO2/FiO2 ratio <300
4. Renal dysfunction: Oliguria, creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT‐INR >1.5
6. Haematological
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15. Always think what is better for a patient
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