Acute Cholecystitis

Acute cholecystitis is inflammation of the gallbladder that develops within hours, mostly as a result of Zystikusverschlusses. The symptoms are pain and tenderness in the right upper abdomen. This is sometimes accompanied by fever, chills, nausea and vomiting. The ultrasound examination of the abdomen shows gallstones and sometimes an accompanying inflammation. Standard treatment is antibiotics and cholecystectomy.

(See also Overview biliary function.)

Acute cholecystitis is inflammation of the gallbladder that develops within hours, mostly as a result of Zystikusverschlusses. The symptoms are pain and tenderness in the right upper abdomen. This is sometimes accompanied by fever, chills, nausea and vomiting. The ultrasound examination of the abdomen shows gallstones and sometimes an accompanying inflammation. Standard treatment is antibiotics and cholecystectomy. (See also Overview biliary function.) The acute cholecystitis is the most common serious complication of cholelithiasis. Conversely, ? 95% of patients with acute cholecystitis cholelithiasis. If a stone gets stuck in the cystic duct and closes it permanently, is an acute inflammation developed. The bile congestion promotes the release of inflammation-associated enzymes (z. B. Phospholipase A, converts the lecithin to lysolecithin, which can then trigger an inflammation). The damaged mucosa secrete more fluid into the gallbladder than it absorbs. The resulting strain leads to further release of inflammatory mediators (for. Example, prostaglandins) and to the increase of mucosal damage and ischemia receiving the inflammation upright. A bacterial superinfection may be added. The vicious cycle of secretion and inflammation leads to necrosis and perforation if left unchecked. When the acute inflammation recedes and then heals, creates a fibrotic and contracted gallbladder with impaired ability to concentrate bile and to empty sign of chronic cholecystitis. Acute cholecystitis akalkulöse The akalkulöse cholecystitis is cholecystitis without stones. It is responsible for 5-10% of cholecystectomy in acute cholecystitis. Risk factors include: Critical illness (. Eg major surgery, burns, sepsis or trauma) Prolonged fasting or TPN (both predispose to biliary stasis) Shock immunodeficiency vasculitis (such as SLE, rheumatoid arthritis nodosa.) The mechanism is likely due to inflammatory mediators, which are released during ischemia, infection or stasis of bile. Sometimes a pathogen can be identified (eg. As Salmonella sp. Or cytomegalovirus in immunodeficient patients). In young children, the akalkulöse cholecystitis often occurs as a result of a febrile illness without identifiable pathogens. Symptoms and signs Most patients have had previous episodes of biliary colic or acute cholecystitis. The pain of acute cholecystitis is about the quality and location like a biliary colic, but takes longer (i. E.> 6 h) and is violent. Often vomiting and tenderness are right subcostally. Within hours, the so-called developed. Murphy’s sign (a deep inspiration exacerbates the pain during palpation in the right upper quadrant and stops the inspiration) with involuntary posture of the right upper abdominal muscles. Moderately elevated temperatures are common. In elderly patients the first and only symptoms may be systemic and not specific (eg. As loss of appetite, vomiting, nausea, fatigue, fever). Sometimes no fever developed. Acute cholecystitis is improving usually within 2-3 days, and 85% of patients recover within 1 week without treatment. Complications Without treatment, 10% of patients develop a covered perforation and 1% a free perforation with peritonitis. Increasing abdominal pain, high fever, and a tensioned touch sensitive abdominal wall or an ileus are suggestive of the presence of a empyema (facilities) in the gallbladder, gangrene or a perforation. If the acute cholecystitis of jaundice and cholestasis is accompanied, one has to a partial closure of the ductus choledochus, z. For example, by a stone or an inflammation, think. Complications include the following: Mirizzi syndrome: Rare remains a gallstone in the cystic duct insert and compresses and closes from there the bile duct, triggering a Chloestase. Gallstone Pancreatitis: gallstones pass from the gallbladder into the bile ducts and block the pancreatic duct. Cholezystoenterische fistula: Rarely has a large stone eroded the wall of the gallbladder, thereby creating a fistula (or elsewhere in the abdominal cavity) to the small intestine; the stone can this happen free or the small intestine (gallstone ileus) close. Acute cholecystitis akalkulöse The symptoms are similar to communicate to those of acute cholecystitis with gallstones, but the disease can be difficult to diagnose because the patients are possibly seriously ill (eg. As ICU) and possibly are not able to clear , A überblähtes abdomen or unexplained fever may be the only clue. If left untreated, can develop a Gallenblasengangrän or perforation, leading to sepsis, shock and Pertonitis quickly; Mortality reached 65%. Tips and risks patients at risk for akalkulöse cholecystitis (z. B. critically ill patients, fasting or immunocompromised patients) should be monitored closely for subtle signs of the disease (eg. As abdominal rigidity, unexplained fever). Diagnostic sonography Choleszintigraphie: If the results of ultrasonography are inconclusive or the suspicion of a akalkulöse cholecystitis is. The suspected acute cholecystitis is based on symptoms and findings. Transabdominal sonography is the best study to detect gallstones. The investigation also a local abdominal tenderness over the gallbladder reveals (sonographic Murphy’s sign). Fluid around the gallbladder or thickening of the gallbladder wall are signs of acute inflammation. Choleszintigraphie is useful if the findings are not unique. suspected if the radionuclides are not shown, with which the gall-bladder is filled, is closed to a bile duct (i. e. the impact of a stone). False positives can result from the following: Severe underlying disease (because the gall bladder stasis prevents the filling) Severe liver disease (because the liver does not separate the radionuclides) Previous sphincterotomy (which facilitates complete parenteral nourishment will and no oral feeding the output into the duodenum, instead of the gallbladder) provocation with morphine increases the tone of the sphincter of Oddi, thus supporting the filling so that a false positive result can be easily excluded. A CT scan of the abdomen helps to detect complications such as Gallenblasenperforation or pancreatitis. Laboratory tests are carried out, but not alone lead to a diagnosis. Leukocytosis with a left shift is frequent. In uncomplicated acute cholecystitis liver function tests are normal or only slightly elevated. Slight cholestasis-typical changes (bilirubin up to 4 mg / dl and slightly elevated alkaline phosphatase) are often, but reflect more likely the effect of inflammatory mediators directly on the liver than the mechanical obstruction. Significant gains, especially if lipase (amylase is less specific) is> 2-fold increases, indicate a closure of the bile duct. The passage of a stone through the biliary tract increases the Tansaminasen (ALT, AST). Acute cholecystitis Acute akalkulöse akalkulöse cholecystitis is suspected when a patient has no gallstones, but a ultrasonographisches Murphy’s sign or a thickened wall of the gallbladder and pericholezystische liquid. A swollen gallbladder, Sludge and a thickened wall of the gallbladder without pericholezystische liquid (due to low albumin or ascites) may simply result from a severe underlying disease. Using computed tomography detected extrabiliäre anomalies. Biliary scintigraphy is useful; the lack of filling with radionuclides indicates an edematous cystic duct obstruction. The administration of morphine helps a false-positive result due to a gall bladder stasis to eliminate. Therapy Support Measures (hydration, analgesics, antibiotics) cholecystectomy The patient care comprises hospitalization, infusions and analgesics, such as a NSAID (ketorolac) or opioid. The patient must stay sober and if vomiting is a problem or a small bowel obstruction is present, an extraction is carried out via a nasogastric tube. Usually antibiotics are given, even if the benefits are not proven. Empirically, especially gram-negative enterobacteria should be covered. Options are i.v. Ceftriaxone 2 g every 24 h, and 500 mg metronidazole every 8 h, piperacillin / tazobactam 4 g every 6 h or ticarcillin / clavulanate 4 g every 6 h. With the cholecystectomy cure the disease and eliminate the biliary pain. The early cholecystectomy is generally preferred, best during the first 24 to 48 hours in the following situations: The diagnosis is clear and the patients have a low risk of surgery. The patients are elderly or have diabetes and therefore at greater risk of infectious complications. Patients have empyema, gangrene, perforation or akalkulöse cholecystitis. The operation can be delayed when patients have a severe chronic disease (eg. As heart-lung disease), which increases the surgical risk. In such patients, the cholecystectomy is deferred until the comorbidities have been stabilized stabilized or until the cholecystitis has subsided. Is cholecystitis subsided, a cholecystectomy should be performed ? 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications. Percutaneous cholecystostomy is an alternative to cholecystectomy for patients with very high surgical risk, such as the elderly, persons with akalkulöser cholecystitis and patients who are in intensive care for burns, trauma or respiratory disorders. Important Points Most (? 95%) of patients with acute cholecystitis have cholelithiasis. In elderly patients, the symptoms of cholecystitis may be non-specific (eg. As loss of appetite, vomiting, nausea, fatigue), and fever may be absent. Although acute cholecystitis subsides spontaneously in 85% of patients, a covered perforation or other complications in 10% developed. Ultrasonography and, if findings are inconclusive, Choleszintigraphie should be performed. The treatment is effected by means of infusion, antibiotics and analgesics; in unstable patients cholecystectomy is performed.

Health Life Media Team

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