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Acute Abdominal Pain

Acute Cholecystitis/Biliary Colic - Diagnostic Features/Management Choices

Differential Diagnosis: -

  • Acute appendicitis
  • Acute pancreatitis - Serum amylase increased 20-30% patients.
  • Alcoholic hepatitis - 10% patients with acute cholecystitis have SGOT/SGPT > 300.
  • Gonococcal perihepatitis
  • Pneumonitis
  • Hepatic tumors.
  • Perforated peptic ulcer - usually produces more striking findings.

    Management (Stepped Care) :


    - Start appropriate antibiotics* and I.V. fluids.
    - At 24 hours assess response to Rx: -
    - presence or absence of fever, tachycardia, leucocytosis, peritoneal signs, and liver tests.
    - The presence of all of the above features should also raise the question of choledocholithiasis and ascending cholangitis.
    - If patient not improved, early surgery must be considered.

  • Recall that the gallbladder can be palpable in up to one third cases of acute cholecystitis.

    Follow-up in Recurring/Chronic Cholecystitis:-

    Asymptomatic Patients:-
    - 1% will become symptomatic per year
    - most will develop symptoms before complications
    - indicators for surgery in an asymptomatic patient (rare):
    - access to medical care

  • porcelain gallbladder (high incidence of carcinoma)
    - Native American women and from Chile : increased incidence of GB cancer (up to 5% of cases).
    - diabetics - controversial - diabetics have a 3 - 5 times increased mortality if they do develop cholecystitis.

    Symptomatic Patients:-

  • Surgery is still the treatment of choice.
  • most cholecystectomies ( > 95%) are performed laparoscopically
  • quicker recovery compared to cholecystectomy
  • success rate is proportional to the experience of the laparoscopic surgeon.

    Complications of Surgery:

  • bile duct injury
  • fistula
  • stricture
  • transection
  • papillary dysfunction
  • post cholecystectomy diarrhoea.

    Lithotripsy:

  • not usually done, expensive
  • high chance of recurrence
  • occasionally needed for particularly large stones

    Solvents:

  • ursodiol
  • lowers cholesterol secretion - increases solubility
  • only effective for small (1cm) stones in functioning GB
  • 60% effective at 6 months
  • 50% will recur by 5 years
  • may be effective in prevention for high risk patients (diabetes, pregnant women, post-delivery); indicated in bile duct stricture after cholecystectomy.

  • Solvent side effects:-
  • diarrhea
  • increased aminotransferases

    * Antibiotic choices : vary with local preferences - see also:

  • IDSA Practice Guidelines (http://www.idsociety.org/)
  • (on Palm PDA) - ePocrates RX Pro (http://www.epocrates.com)

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