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5.Right lower lobe pneumonia
6.Appendicitis
7.Hepatitis
8.Herpes zoster d. Diagnosis
1.Gallbladder ultrasound is the diagnostic study of choice. If acute cholecystitis needs to be documented further, a HIDA may be performed.
2.Other mandatory studies include a complete blood count; measurement of serum amylase, serum bilirubin, and liver enzymes; an electrocardiogram; and chest radiograph.
3.Levels of the following may be elevated in patients with acute cholecystitis:
a.Serum alkaline phosphatase in 23%
b.Bilirubin in 45%
c.Aspartate transaminase in 40%
d.Amylase in 13%
4.Ultrasonography may show stones and a thick-walled edematous gallbladder wall.
5.Cholescintigraphy will show any existing failure of the gallbladder.
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e.Treatment
1.Cholecystitis should be treated with cholecystectomy. As the bile is usually infected, perioperative antibiotics are needed. There are two approaches to the timing of surgery.
a.Immediate surgery; that is, within 72 hours of the onset of symptoms
b.Delayed surgery; that is, after recovery from the acute attack with intravenous fluids and antibiotics. Surgery should be performed approximately 6 weeks after the acute inflammation has resolved.
2.Most surgeons now advocate early surgical intervention in the treatment of acute cholecystitis. This is due to the improved safety of current techniques, the effectiveness of perioperative antibiotics, and the high risk (at least 50%) of recurrent acute cholecystitis if surgery is delayed. Our approach is as follows.
a.If symptoms began within 72 hours of the time of presentation, laparoscopic cholecystectomy is performed.
b.If symptoms began more than 72 hours before the time of presentation and the patient is responding to medical management (i.e., a nasogastric tube, intravenous fluids, nothing by mouth, and antibiotics), then surgery is delayed for 4–6 weeks.
c.Deterioration or failure to improve on medical management is an indication for surgery.
3.Acalculous cholecystitis is acute or chronic cholecystitis in the absence of stones. The acute form occurs as a complication of burns, sepsis, trauma, or collagen vascular disease. The chronic condition may also be referred to as biliary dyskinesia.
a.Etiology. Possible causes include:
1.Kinking or fibrosis of the gallbladder
2.Thrombosis of the cystic artery
3.Sphincter spasm with obstruction of the biliary and pancreatic ducts
4.Prolonged fasting
5.Dehydration
6.Systemic disease, such as the multiorgan failure associated with trauma
7.Generalized sepsis
b.Diagnosis. Diagnostic tests used and their results are similar to those for calculous cholecystitis, except that no stones are seen. The cholescintigram is especially accurate for cholecystitis when it fails to visualize the gallbladder.
c.Treatment is cholecystectomy or cholecystostomy if the patient is too ill to tolerate cholecystectomy.
4.Complications of cholecystitis (and cholelithiasis) require urgent surgery.
a.Emphysematous cholecystitis is an acute, usually gangrenous cholecystitis complicated by secondary invasion of the gallbladder wall by gas-forming organisms.
1.Unlike acute cholecystitis, emphysematous cholecystitis is three times more prevalent in men than women and may occur without cholelithiasis.
2.Radiologically, the gallbladder is filled with gas in the absence of any communication between the gallbladder and the gastrointestinal tract.
3.Treatment is urgent cholecystectomy. Antibiotics effective against Clostridia and coliform organisms are given.
b.Gangrenous cholecystitis results when extensive inflammation causes thrombosis of the cystic artery and resultant necrosis of the gallbladder. Bile cultures and appropriate antibiotics are essential.
c.Perforated cholecystitis results from necrosis of the gallbladder wall and leakage of bile into the peritoneal cavity. Peritonitis or, more commonly, subhepatic abscess may result.
d.Biliary-enteric fistula and gallstone ileus are complications of cholelithiasis, cystic duct obstruction, recurrent cholecystitis, adhesions to the surrounding viscera, perforation, fistula formation, and passage of the stone into the bowel.
1.The site of fistula with the gallbladder is most commonly the duodenum, but the colon or any other intraabdominal viscera may be involved.
2.Site of bowel obstruction
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a.As the stone travels in the gastrointestinal lumen, the terminal ileum is the most common site of obstruction because this is the narrowest portion of the small bowel. Stones smaller than 2–3 cm are usually passed per rectum.
b.If a stone is passed free into the peritoneal cavity, extraluminal obstruction secondary to inflammation and adhesions can occur anywhere.
3.Clinical presentation
a.Bowel obstruction is a disease of the elderly, and concomitant multisystem disease is common.
b.The patient presents with symptoms of small bowel obstruction (i.e., nausea, vomiting, obstipation, pain, and distention).
c.About 25% of patients have symptoms of acute cholecystitis immediately preceding the episode of obstruction. About 70% of the patients have a history of cholelithiasis.
4.Diagnosis
a.The correct diagnosis is made preoperatively in fewer than 25% of cases.
b.The diagnosis is suggested by the history and by plain films of the abdomen. These may show small bowel obstruction accompanied by air in the biliary tree or a radiopaque stone in the right lower quadrant (seen in only 15% of cases).
5.Treatment
FIGURE 14-14 Cholecystostomy. A: Placement of purse-string suture in fundus of gallbladder and incision through serosa; (B) trochar decompression; (C) removal of calculus from ampulla; (D) sagittal section demonstrating two concentric purse-string sutures, intraluminal catheter, and suturing of serosa of gallbladder to peritoneum. (Reprinted with permission from Schwartz S, Shires
G. Tom, Spencer Frank C. Principles of Surgery, 5th ed. New York: McGraw-
Hill; 1989:1405.)
c.Cholecystostomy is an alternative procedure when extensive inflammation makes cholecystectomy too dangerous or a patient is too ill to undergo cholecystectomy. In this procedure, the gallbladder fundus is opened, bile and stones are removed, and a tube is placed in the gallbladder for external drainage. This procedure can be done operatively or percutaneously (Fig. 14-14).
E
Postcholecystectomy syndrome is the term given to symptoms that develop after or persist despite cholecystectomy.
1.In patients who have undergone cholecystectomy for chronic cholecystitis and cholelithiasis, postcholecystectomy symptoms are usually extrabiliary in origin and caused by:
a.Hiatal hernia
b.Peptic ulcer
c.Pancreatitis
d.Irritable bowel
e.Food intolerance
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2.Symptoms may be biliary in origin and caused by:
a.A stone in the common bile duct
b.A stone in the stump of the cystic duct
c.Stenosis of the sphincter of Oddi
d.Biliary stricture
3.Evaluation should be directed toward identifying these extrabiliary and biliary etiologies and may include ERCP, esophagogastroduodenoscopy, UGI radiograph, ultrasound, and CT scan.
F Bile duct disorders
1.Choledocholithiasis (stones in the common bile duct) can be single or multiple and are found in 10%–20% of patients who undergo cholecystectomy. Most stones are formed in the gallbladder and pass into the duct. However, primary common duct stones can form in the absence of a gallbladder.
a.Clinical presentation. Some patients are asymptomatic. Most patients present with right upper quadrant pain that radiates to the back and right shoulder, intermittent obstructive jaundice, acholic stools, or bilirubinuria.
b.Diagnosis
1.In contrast to neoplastic obstruction of the common bile duct, the gallbladder is not palpable.
2.Diagnostic studies include ultrasonography, ERCP, and, less commonly, transhepatic cholangiography or a radionuclide scan.
3.Liver function test results are consistent with obstructive jaundice and include elevations in bilirubin and alkaline phosphatase.
c.Surgical treatment involves cholecystectomy, choledochotomy (opening the common duct), common bile duct exploration, stone removal, T tube placement, and T tube operative cholangiography (Fig. 14-15).
1.Operative cholangiography has decreased the need for common bile duct exploration but has increased the proportion of positive explorations, that is, explorations in which stones are found.
2.The only absolute indication for common bile duct exploration is a palpable stone in the common bile duct.
3.When any of the following are present, operative cholangiography is performed, although these were at one time considered to be indications for duct exploration:
a.Increased size of the common bile duct
b.History of jaundice
c.Small stones in the gallbladder with a large cystic duct
d.A history of cholangitis or pancreatitis
4.Common bile duct exploration is not necessary if the operative cholangiogram is of good quality and demonstrates both:
a.No filling defects
b.Free flow of contrast medium into the duodenum
5.Common bile duct exploration is indicated if the operative cholangiogram shows either:
a.Filling defects within the intrahepatic or extrahepatic biliary tree
b.Obstruction of the flow of bile into the duodenum
d.Complications. Stones that remain after surgery complicate up to 5%–10% of common bile duct explorations.
1.No treatment is necessary for small stones, as they usually pass spontaneously.
2.Treatment options for large stones are:
a.Chemical dissolution by intraductal administration of methyl-tert-butyl ether or mono-octanoin
b.Mechanical extraction under fluoroscopic guidance
3.Primary or recurrent common bile duct stones can be treated surgically with a biliary-enteric connection to allow stones to pass out of the biliary tree. The two most common methods are choledochoduodenostomy or choledochojejunostomy; transduodenal sphincteroplasty or endoscopic sphincterotomy are also acceptable options.
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FIGURE 14-15 Algorithm for treatment of common bile duct stones. SXS, symptoms;
LFTs, liver function tests; UTZ, ultrasound; ERCP, endoscopic retrograde cholangiopancreatography; CBD, common bile duct; CBDE, common bile duct exploration.
2.Cholangitis, or infection of the bile ducts, is a potentially life-threatening disease that results from concurrent biliary infection and obstruction. E. coli is the most common offending organism.
a.Etiology. Benign postoperative strictures and common bile duct stones account for 60% of the cases. Neoplasms, sclerosing cholangitis, plugged biliary drainage tubes, and biliary contrast studies are other causes.
b.Clinical presentation. Charcot's triad of fever, jaundice, and right upper quadrant pain is present in 70% of cases. In severe cases, hypotension may be present.
c.Treatment includes antibiotics, resuscitation with fluids and electrolytes, and relief of the obstruction.
d.Prognosis depends on the cause of the obstruction; from best prognosis to worst, the order is stones, benign stricture, sclerosing cholangitis, and neoplasm.
3.Primary sclerosing cholangitis is a disease of unknown etiology that affects the biliary tract, resulting in stenosis or obstruction of the ductal system. Progressive obstruction, if not relieved, results in biliary cirrhosis and liver failure.
