Acalculous Cholecystitis

Acalculous Cholecystitis - Acalculous Cholecystitis...

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Unformatted text preview: Acalculous Cholecystitis Cholecystitis Katie Reeder Hayes AM Report July 10, 2006 Definition Definition Acute necroinflammatory disease of the Acute gallbladder Absence of stones (bet you figured that Absence out) out) 10% of cholecystitis cases Males>females Who’s at Risk? Who’s Immunosuppressed Critically ill (trauma, burns, sepsis, vent) CAD Diabetes Cholesterol emboli TPN Obstetric patients Recent surgery Pathophysiology Pathophysiology Gallbladder stasis and/or ischemia Inflammatory response in GB wall Bile salts concentrate in GB tissue Progresses to tissue necrosis Inflammation of cystic duct can progress Inflammation to CBD, leading to biliary obstruction to Pathogens Pathogens Usual: Klebsiella, ecoli, enterococcus, Klebsiella, pseudomonas, bacteroides pseudomonas, Unusual: typhoid, campylobacter, typhoid, leptospirosis, clostriudium, vibrio, Q fever, dengue fever fever, Immunosuppressed: CMV, CMV, microsporidium, cryptosporidium, salmonella, candida salmonella, Presentation Presentation May be subtle – vague RUQ pain (25%), May leukocytosis, fever leukocytosis, May rapidly progress to septic shock May also be similar to classic May cholecystitis w/ positive Murphy’s sign cholecystitis May become jaundiced Mortality 10-50% To the lab… To LFT abnormalities: +/- elevated TBili, LFT ↑AlkPhos and aminotransferases Blood cultures prior to antibiotics To the basement… To Ultrasound (1st test of choice) Absence of stones Thickened GB wall >5mm US Murphy’s sign “champagne bubble” sign Perforation +/- abcess formation (oops) 30-92% sensitive, >90% specific HIDA scan: failure to opacify the gallbladder = failure positive positive 79% sensitive, 87% specific Normal HIDA scan Normal Differential Differential Classic cholecystitis Peptic ulcer disease/perforation Bowel ischemia/perforation Acute pancreatitis Hepatic/subphrenic abcess Pyelonephritis Treatment Treatment Blood cultures Blood Antibiotics If untreated: Zosyn, Unasyn or Imipenam If already on broad spectrum: If 3rd generation ceph PLUS Metronidazole OR Imipenam PLUS/MINUS Fluconazole If known MRSA hx consider Vanc And the Pager is… And Surgical Consult at time of diagnosis Remember: A GI consult means fun and GI education for the whole team, but it will not take out your patient’s funky rotting gallbladder take If too high risk, cholecystostomy or ERCP with If nasobiliary catheter Our patient Our Surgery delayed 2/2 anticoagulation Pathology at surgery showed transmural Pathology necrosis necrosis Operative report described gangrenous, Operative inflamed and necrotic tissue, purulent “oozing” from gallbladder, and old blood in GB and fossa in Prolonged 2 wk post-op hospital course Phuong’s Takehome Point Phuong’s Consider ACC in ICU and Consider immunosuppressed patients immunosuppressed If US non-conclusive, proceed with HIDA Wake up that surgeon NOW References References Laurila JJ et all. “Histopathology of acute acalculous cholecystitis in Laurila critically ill patients”. Histopathology, 2005 47(5):485-92 critically ”. 2005 Owen, Charles and Rajeev Jain. “Acute Acalculous Cholecystitis”. Owen, Current Treatment Options in Gastroenterology, 2005 8:99-104. Current Afdhal, Nezam. “Acalculous Cholecystitis”. UpToDate, revised Afdhal, UpToDate revised November 2004. November ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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