Acute Cholecystitis & Cholangitis

Acute Cholecystitis &
Cholangitis
Acute Cholecystitis
Definition
• Inflamasi pada dinding kantung empedu akibat obstruksi persisten.
Etiology
• gallstone (95%)
• bileduct stricture
• neoplasma (primer ataupun sekunder)
Pathophysiology
• Etiology  obstruksi kantung empedu scr persisten  ↑ tekanan di kantung empedu 
distensi  ↓ aliran darah  ischemia  invasi bakteri  inflamasi  bisa perforasi
• Bakteri yang biasa invasi: Escherichia coli, Enterococcus, Klebsiella, dan Enterobacter.
CM
HT LE
• steady & severe abdominal pain on RUQ, radiating to
back, right scapula, or right clavicular area • leukocytosis with shift to the left
• fever, chills, nausea, anorexia, vomiting • mildly elevated bilirubin and
PE alkaline phosphatase levels
• tenderness over gallbladder area (right hypochondrium) • normal or only mildly elevated
with or without a palpable mass
• Murphy sign  As the gallbladder area is palpated, the
serum amylase and lipase levels
patient is asked to take a deep breath that brings the (unless there is concomitant
gallbladder down to the palpating hand. At the height acute pancreatitis)
of inspiration, as the gallbladder touches the palpating
hand, the breath is arrested with a gasp (Murphy sign).
Sign is not found in chronic cholecystitis. Sensitivity to
Murphy sign may be diminished in elderly patients.
Diagnosis
• Abdominal ultrasound findings  gallstones, sludge, lumen distention, mural thickening
with a hypoechoic or anechoic zone within the thickened wall, increased flow on color
Doppler sonography, and pericholecystic fluid; none of these, however, is pathognomonic of
acute cholecystitis.
• Sonographic Murphy sign  presence of maximal tenderness elicited by direct pressure of
the transducer over the gallbladder.
• Abdominal CT  needed only when the diagnosis is vague or when abscess formation or
gangrene is suspected. Gallstones, sludge, gallbladder distention, mural thickening,
pericholecystic fluid, and subserosal edema are major findings.
• Magnetic resonance cholangiopancreatography (MRCP)  a noninvasive technique for
evaluating the intrahepatic and extrahepatic bile ducts, is superior to ultrasound for
detecting stones in the cystic duct.
• MRI  helps in diagnosing complications of acute cholecystitis
Management
• bowel rest, parenteral fluids and nutrition
• intravenous antibiotics
• A combination of ampicillin (2 g intravenously every 4 hours) and gentamicin
(dosed according to weight and renal function)
• β-Lactam–based therapy and fluoroquinolones are other options.
• Definitive therapy  cholecystectomy.
• laparoscopy
• open surgical approaches
• percutaneous cholecystostomy
Complication
• emphyema of gallbladder  severe acute cholecystitis caused by a gas-forming
organism such as Clostridium perfringens, noted often in elderly persons and diabetic
patients
• gangrene  severe gallbladder inflammation with mural necrosis associated with an
increased risk for perforation.
• intraabdominal abscess
• diffuse peritonitis
• Chronic cholecystitis  may be secondary to repeated attacks of uncomplicated
acute cholecystitis or without prior attacks. The symptoms are vague and may be
only nonspecific epigastric or right upper quadrant pain. Histologically, patients have
chronic inflammatory cell infiltration of the gallbladder associated with gallstones
and thickening of the gallbladder wall.
DDx
• acute pancreatitis
• appendicitis
• acute hepatitis
• peptic ulcer disease
• disease of the right kidney
• right-sided pneumonia
• Fitz-Hugh-Curtis syndrome (gonococcal
perihepatitis)
• liver abscess
• perforated viscus
• cardiac ischemia.
Cholangitis
Definition
• Infeksi pada common bile duct (CBD) yang diawali obstruksi.
Etiology
• Penyebab infeksi: bakteri Gram (-)
• Obstruksinya disebabkan oleh:
• Choledocholithiasis (80%)
• Malignancy of CBD
• Iatrogenic (akibat instrumentasi, postoperative biliary stricture, atau papillary stenosis)
Pathophysiology
• Obstruksi  tekanan intraduktus ↑  pertumbuhan bakteri ↑  infeksi &
inflamasi  bisa menyebar secara lokal ke hepar atau ke sirkulasi sistemik
Clinical Manifestation
• Abdominal ultrasonography helps in
• RUQ abdominal pain, intermittent fever and
jaundice (Charcot triad) evaluating the size of the CBD and the
• shaking chills (suggesting bacteremia)
presence of stones.
• in elderly patient should be suspected when there • Abdominal CT may show the same findings
is sudden onset, mental confusion, lethargy, and although less precisely, and MRCP better
delirium delineates the ductal morphology.
• right upper quadrant tenderness • Blood culture should be performed early in
Diagnosis the evaluation. Blood culture is usually
• leukocytosis, mildly elevated bilirubin levels, and positive for enteric organisms. Organisms
elevated alkaline phosphatase levels. that frequently cause cholangitis are
• Rarely, liver function abnormalities mimic acute Escherichia coli, Klebsiella, Enterococcus,
hepatitis, with greatly elevated serum levels of Enterobacter, Streptococcus, and Pseudom
aspartate transaminase and alanine Pseudomonas aeruginosa; anaerobic bacteria
transaminase.
are found in less than 10% of patients.
• However, normal liver enzyme levels do not
exclude cholangitis. Hyperamylasemia, when • Leukopenia, thrombocytopenia,
noted, is mild and less than three times the upper coagulopathy, and renal failure suggest
limit of normal. severe disease.
Management
Prognosis
• antibiotics and aggressive fluid
Untreated bacterial cholangitis has
resuscitation.
a poor prognosis, and even with
• In patients with impacted stones treatment, mortality rates range
and evidence of cholangitis, ERCP from 5% to 30%.
with sphincterotomy and stone
extraction is warranted after vital
signs are stabilized.
• nasobiliary drainage catheter
Summary

Acute Cholecystitis & Cholangitis

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