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Cholecystitis, Principles and practice of surgery - The liver &…
Cholecystitis
Pathophysiology
In 5% of cases, bile inspissation (due to dehydration) or bile stasis (due to trauma or severe systemic illness) can block the cystic duct, causing an acalculous cholecystitis (usually in critically ill patients or >65years old). Occasionally, extrinsic compression may play a role in the development of bile stasis. Some patients with sepsis may have direct gallbladder wall inflammation and localised or generalised tissue ischaemia without obstruction. Acute cholecystitis usually settles after 4-5 days
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Common pitfalls
Mirizzi syndrome: Uncommon Obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch. The gallstone together with the inflammatory response causes firstly obstruction then eventually erodes into the bile duct evolving into a cholecystocholedochal or cholecystohepatic fistula with different degrees of communication between the gallbladder and bile duct. Presenting symptoms are similar to cholecystitis but may be confused with other obstructing conditions such as common bile duct stones and ascending cholangitis due to the presence of jaundice. Treated with laparoscopic cholecystectomy.
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Investigations
VBG, Lactate and bloods cultures if septic
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MRCP – Suitable for pregnant patients . If CBD dilitation but no stones seen on USS or LFTS abnormal
EUS – consider if MRCP does not allow diagnosis to be made (nice guidelines). More accurate but higher risk as invasive.
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Principles and practice of surgery - The liver & biliary tract chapter
NHS GGC guidelines for intra abdominal sepsis
Handbook of hepato-pancreato-biliary surgery (Zyromski, N. 2015)
BMJ - Cholecystitis
Nice guidelines - Cholecystitis