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REFERENCES
STRAS BERG SM. ACUTE CALCULOUS CHOLECYSTITIS
N ENGL J MED 2008; 358:2804-11
HUFFMAN JL, SCHENKER S. ACUTE ACALCULOUS CHOLECYSTITIS:
A REVIEW. CLIN GASTROENTEROL HEPATOL 2010; 8:15-22.
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A complication of Cholelithiasis
20 millions in USA/year
Most Gallstones Asymptomatic
Biliary colic develops 1% to 4%
Acute cholecystitis in 20% of these symptomatic patients
60% women
Older
With/without previous attacks More frequent in men relative to its incidence and more severe
DM
90% of acute cholecystitis is associated with gallstones
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Figure 1. Ultrasonographic images of three Gallbladders.
A normal, sonolucent gallbladder (panel A) is characterized
by a thin wall and an absence of acoustic shadows. In a
patient with symptomatic gallstones (panel B), the
gallblader contains small echogenic objects with posterioracoustic ghadows that are typical of gallstones (arrow),
with a normal wall thickness. In a patient with acute
calculous cholecystitis (panel c), thickening is visible in the
gallbladder wall (arrow), along with a lare gallstone
(arrowhead)
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Figure 2. Hepatobiliary Scintigraphy.
InPanel A, a normal liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid.
In Panel B, at 55 minutes after tracer injection, filling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, at
1 hour after tracer injection in a patient with acute cholecystitis and obstruction of the cystic duct, there is filling of the bile duct
(arrow) but no filling of the gallbladder.
Figure 2. Hepatobiliary Scintigraphy.
InPanel A, a normal liver is visible 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid.
In Panel B, at 55 minutes after tracer injection, filling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, at
1 hour after tracer injection in a patient with acute cholecystitis and obstruction of the cystic duct, there is filling of the bile duct(arrow) but no filling of the gallbladder.
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Local symptoms and signsMurphy's sign
Pain or tenderness in RUQ
Mass in RUQ
Systemic signsFever
Leucocytosis
Elevated CRP
Imaging findingsA confirmatory finding on US or HB scintography
Presence of one local signs or symptoms
One systemic sign, and
A confirmatory finding on an imaging test
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acute cholecystitis not meeting criteria for a more severe grade
Mild gallbladder inflammation, no organ dysfunction
presence of one or more of following:
WBC>18000
Palpable, tender mass in RUQ
Duration > 72h
Marked local in tlammarion: biliary peritonitis, pericholecystic abscess, hepatic
abscess, gangrenous cholecystitis, emphysematous cholecystitis
presence of one or more of following: CVS dysfunction ( BP requiring dopamine at 5 microgr/kg/min or any dose of Dobutamine)
CNS dysfunction ( level of consciousness)
Respiratory dysfunction (ratio of pO2 of arterial blood to the fraction of inspired oxygen 2mg/dL) Hepatic dysfunction (PT INR >1.5)
Hematologic dysfunction (platelet
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Laparascopic VS open
Early VS delayed
From 24h to 7 days after initial attack
2-3 months after afte initial attack
Percutaneous
Operative
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Fasting, obstruction, post surgical ileus, TPN
Inspissated bile toxic to epithelium
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SurgeryRadiologyClinical findings
Aspiration of GB/ drainageUSSetting (inpatient, out patient)
LaparatomyCTFever, abdominal painHIDA SCANLeucocytosis, abnormal LFT
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Figure 1. (A and B) Longitudinal and horizontal sonogram of a 64-year-old man with positive
Murphy sign, showing hydrops. (C) CT scan 6 hours later showing thickened GB wall
(white arrow), hydrops, and pericholecystic inflammation (asterisk). Figure courtesy
of Dr Shaile Choudhary, MD (Department of Radiology, University of Texas HealthScience at San Antonio, San Antonio, TX).