mechanism
- inflammation of gallbladder resulting from sustained obstruction of cystic duct by gallstone (80%)
- no cholelithiasis in 20% (acalculous – see below)
signs and symptoms
- often have history of biliary colic
- severe constant epigastric or RUQ pain
- anorexia, nausea and vomiting are common
- systemic signs – low grade fever (<38.5 ºC), tachycardia
- focal peritoneal findings – Murphy’s sign (sudden cessation of inspiration with deep RUQ palpation)
- palpable gallbladder in one third of patients
differential diagnosis
- perforated or penetrating peptic ulcer
- MI
- Pancreatitis
- hiatus hernia
- right lower lobe pneumonia
- appendicitis
- hepatitis
- herpes zoster
diagnostic investigation
- elevated WBC, left shift
- mildly elevated bilirubin, ALP
- sometimes slight elevation AST, ALT
- U/S shows distended, edematous gallbladder, pericholecystic fluid, large stone stuck in gallbladder neck, sonographic Murphy’s sign (maximum tenderness elicited by probe over site of gallbladder)
complications
- hydrops: mucus accumulation in gallbladder; may lead to necrosis
- gangrene and perforation: may cause localized abscess or generalized peritonitis (can occur 3 days after onset)
- empyema of gallbladder (suppurative cholangitis) – gallbladder contains frank pus
- cholecystoenteric fistula from repeated attacks of cholecystitis
- gallstone ileus
- choledocholithiasis – 15% of patients with gallstones
- emphasematous gallbladder
treatment
- admit, hydrate, NPO, NG tube, analgesics once diagnosis is made, antibiotics if high risk (elderly, immunosuppressed)
- E.coli, Klebsiella, Enterococcus and, Enterobacter account for > 80% of infections, 1st and 2nd generation cephalosporins are first choice antobiotic coverage
- lack of improvement with conservative treatment ––> operate within 24-48 hours (cholecystectomy)
- earlier O.R. if high risk (DM, steroids) or severe disease
post cholecystectomy advice
- Gradual Reintroduction of Fat: Initially, stick to a low-fat diet. Gradually reintroduce fats to allow the digestive system to adapt. High-fat meals can cause diarrhea or indigestion.
- Small, Frequent Meals: Eating smaller, more frequent meals can help in managing symptoms and aid digestion.
- Avoid Certain Foods: Initially, avoid spicy foods, fatty meats, fried foods, full-fat dairy products, and gas-producing foods like beans, cabbage, and carbonated drinks.
- Increase Fiber Intake: Gradually increase fiber intake to help manage diarrhea but be cautious as too much fiber too soon can cause gas and cramping.
- Bile acid binders like cholestyramine can be effective in treating post-cholecystectomy diarrhea
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