Dec
30
2010

BILIARY INFECTIONS: ACUTE ACALCULOUS CHOLECYSTITIS

BILIARY INFECTIONS: ACUTE ACALCULOUS CHOLECYSTITIS
Infection of the gallbladder may occur in the absence of gallstones in approximately 10% of patients with acute cholecystitis, and this is termed acalculous cholecystitis. Although it is less common than acute calculous cholecystitis, it is much more serious, accounting for an overall mortality rate of approximately 40%. Failure to diagnose and treat к acute acalculous cholecystitis early enough can lead to gangrene or perforation of the gallbladder wall. Cases of this disease are typically found in elderly patients with multiple comorbid conditions or in the critically ill who have undergone major surgery, suffered serious trauma or burns, or are receiving parenteral nutrition.
Pathogenesis
The pathogenesis of acute acalculous cholecystitis is poorly understood but is likely associated with bile stasis and gallbladder dysfunction.
Impaired gallbladder contractile function may occur in the elderly or critically ill, leading to biliary stasis, gallbladder wall inflammation, and ischemia. Necrosis and bacterial invasion of the gallbladder mucosa can subsequently occur.
Clinical Manifestations
The clinical findings of acute acalculous cholecystitis are usually indistinguishable from those of acute calculous cholecystitis. Fever, RUQ abdominal pain, nausea, and anorexia are common. In some situations, however, fever, leukocytosis, and vague abdominal pain may be the only clues. A RUQ mass may be palpable, and jaundice is seen in up to 20% of patients due to partial biliary obstruction induced by inflammation extending into the common bile duct.
Diagnosis
The clinical diagnosis of acalculous cholecystitis can be extremely difficult and requires a high index of suspicion. Leukocytosis, conjugated hyperbilirubinemia, and mild elevations in transaminases are common.
As with acute calculous cholecystitis, abdominal ultrasonography is considered the first-line study and usually demonstrates a large, tense gallbladder without stones. Other findings include a thickened (>5 mm) and edematous gallbladder wall, pericholecystic fluid, biliary sludge, and a sonographic Murphy sign. Abdominal CT scan can also be used to confirm the diagnosis.
Treatment
Prompt institution of therapy is essential. After blood cultures have been drawn, intravenous antibiotics that cover the biliary flora should be started. The definitive treatment is either open or laparoscopic cholecystectomy. With unstable patients in whom surgery is contraindicated, ultrasound-guided cholecystostomy should be considered.
*104/348/5*
Infection of the gallbladder may occur in the absence of gallstones in approximately 10% of patients with acute cholecystitis, and this is termed acalculous cholecystitis. Although it is less common than acute calculous cholecystitis, it is much more serious, accounting for an overall mortality rate of approximately 40%. Failure to diagnose and treat к acute acalculous cholecystitis early enough can lead to gangrene or perforation of the gallbladder wall. Cases of this disease are typically found in elderly patients with multiple comorbid conditions or in the critically ill who have undergone major surgery, suffered serious trauma or burns, or are receiving parenteral nutrition.
Pathogenesis
The pathogenesis of acute acalculous cholecystitis is poorly understood but is likely associated with bile stasis and gallbladder dysfunction.
Impaired gallbladder contractile function may occur in the elderly or critically ill, leading to biliary stasis, gallbladder wall inflammation, and ischemia. Necrosis and bacterial invasion of the gallbladder mucosa can subsequently occur.
Clinical Manifestations
The clinical findings of acute acalculous cholecystitis are usually indistinguishable from those of acute calculous cholecystitis. Fever, RUQ abdominal pain, nausea, and anorexia are common. In some situations, however, fever, leukocytosis, and vague abdominal pain may be the only clues. A RUQ mass may be palpable, and jaundice is seen in up to 20% of patients due to partial biliary obstruction induced by inflammation extending into the common bile duct.
Diagnosis
The clinical diagnosis of acalculous cholecystitis can be extremely difficult and requires a high index of suspicion. Leukocytosis, conjugated hyperbilirubinemia, and mild elevations in transaminases are common.
As with acute calculous cholecystitis, abdominal ultrasonography is considered the first-line study and usually demonstrates a large, tense gallbladder without stones. Other findings include a thickened (>5 mm) and edematous gallbladder wall, pericholecystic fluid, biliary sludge, and a sonographic Murphy sign. Abdominal CT scan can also be used to confirm the diagnosis.
Treatment
Prompt institution of therapy is essential. After blood cultures have been drawn, intravenous antibiotics that cover the biliary flora should be started. The definitive treatment is either open or laparoscopic cholecystectomy. With unstable patients in whom surgery is contraindicated, ultrasound-guided cholecystostomy should be considered.
*104/348/5*
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Written by admin in: Anti-Infectives |

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