cholecystitis - TheTimingofSurgery VincentC.Schooler,MD...

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Acute Cholecystitis and  Acute Cholecystitis and  The Timing of Surgery: The Timing of Surgery:       When is it time to heal with steel? When is it time to heal with steel? Vincent C. Schooler, MD Vincent C. Schooler, MD Resident Grand Rounds Resident Grand Rounds June 6, 2003 June 6, 2003
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Clinical Cases Clinical Cases Case 1 80 yo female 3 days of N/V/RUQ pain  PMH: Cholelithiasis, DM, CHF, HTN WBC 17 (6% bands); Tbili 9, ALP 197, AST  699, ALT 650, Amylase 103, Lipase 19 Abd CT    Cholelithiasis with pericholecystic fluid  and gallbladder distention HIDA Scan   Cystic duct obstruction
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Clinical Cases Clinical Cases Case 2 48 yo male progressive RUQ pain for 2 weeks PMH: DM, HTN, Obesity WBC 6.8, Tbili 0.8, ALP 88, AST 34, ALT 66 Abd U/S: Cholelithiasis in neck of gallbladder,  negative Murphy’s sign, No CBD dilatation
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Clinical Questions Clinical Questions What is the optimal time for surgery in these  patients? What is the evidence that supports a  laparoscopic approach to patients with acute  cholecystitis? What evidence-based clinical factors exist to  predict a successful laparoscopic surgical  outcome? 
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Statistics Statistics About 3 million adults in the U.S. have  gallstones Elderly, diabetics, obese patients, debilitated  patients   increased incidence of gallstones 90% of acute cholecystitis cases due to  gallstones 
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Background Background Aging is the most significant factor    higher  incidence of acute cholecystitis 1 Acute Cholecystitis is the initial presentation  of symptomatic gallstones in 15% - 20% of  patients
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Acute Cholecystitis Acute Cholecystitis RUQ Pain Fever  Leukocytosis Severe persistent pain +/- Jaundice Positive Murphy’s Sign
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Acute Cholecystitis Acute Cholecystitis 3 3 Persistent cystic duct obstruction Pain lasts > 4 hours Usually fatty food ingestion   1 hr before pain 2200  Biliary Colic 3= Cleveland Clinic Journal of Med 3= Cleveland Clinic Journal of Med
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Acute Cholecystitis  Acute Cholecystitis  Distention and inflammation of the gallbladder  Obstruction of cystic duct   Chemical irritants  in the bile Lysolecithin Prostaglandins
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UptoDate 2003 UptoDate 2003
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Acute Cholecystitis Acute Cholecystitis     Thickened gallbladder wall or edema Pericholecystic Fluid Sonographic Murphy’s Sign
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Acute Cholecystitis Acute Cholecystitis
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Acute Cholecystitis  Acute Cholecystitis  Early stages   Edema and hyperemia Later stages   Adhesions, fibrosis, and necrosis Triangle of Calot visible in early stages Courtesy of Netter
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Management of Acute Cholecystitis
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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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cholecystitis - TheTimingofSurgery VincentC.Schooler,MD...

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