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Acute Cholecystitis

Definition:
  • Acute inflammation of the gallbladder, typically due to obstruction of the cystic duct.
Etiology:
  • Gallstones: Responsible for 90% of cases.
  • Acute acalculous cholecystitis: In 10% of cases, no cause of obstruction is found. Notably seen at extremes of age and associated with trauma, burns, and surgery.
Pathophysiology:
  • Obstruction causes chemical irritation due to bile stasis.
  • Subsequent onset of bacterial infection.
Clinical Presentation:
  • Right upper quadrant pain: Can radiate to the back and shoulder tip.
  • Associated with vomiting.
  • Systemic symptoms: Such as fever and raised inflammatory markers.
  • Murphy’s sign: Pain during palpation below the right costal margin on inspiration, although present in only 40% of cases.
Investigations
  • CT abdomen: if acute undifferentiated abdominal pain
  • Ultrasound: Gold standard, shows gallbladder wall thickening, pericholecystic fluid, and stones if present.
  • Blood tests: Elevated white blood cell count, CRP, and potentially liver function tests.
Management:
  • Conservative measures:
    • IV fluids
    • IV antibiotics (commonly broad-spectrum like co-amoxiclav)
    • Analgesia
  • If symptoms persist or complications develop:
    • Urgent intervention, e.g., drainage for gallbladder empyema.
    • Cholecystectomy: Usually performed electively ~6 weeks after symptom resolution, but may be emergent if conservative measures fail.
Complications:
  • Gallbladder empyema (pus-filled).
  • Gallbladder gangrene or perforation.
  • Biliary peritonitis.
  • Cholangitis.

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