REFERENCES

STRAS BERG SM. ACUTE CALCULOUS CHOLECYSTITIS N ENGL J MED 2008; 358:2804-11 HUFFMAN JL, SCHENKER S. ACUTE ACALCULOUS CHOLECYSTITIS: A REVIEW. CLIN GASTROENTEROL HEPATOL 2010; 8:15-22.

 A complication of Cholelithiasis

20 millions in USA/year
Most Gallstones Asymptomatic Biliary colic develops 1% to 4% Acute cholecystitis in 20% of these symptomatic patients

60% women
Older With/without previous attacks More frequent in men relative to its incidence and more severe DM 90% of acute cholecystitis is associated with gallstones

Figure 1. Ultrasonographic images of three Gallbladders. A normal, sonolucent gallbladder (panel A) is characterized by a thin wall and an absence of acoustic shadows. In a patient with symptomatic gallstones (panel B), the

gallblader contains small echogenic objects with posterior

acoustic ghadows that are typical of gallstones (arrow), with a normal wall thickness. In a patient with acute calculous cholecystitis (panel c), thickening is visible in the gallbladder wall (arrow), along with a lare gallstone (arrowhead)

Figure 2. Hepatobiliary Scintigraphy. Figure 2. Hepatobiliary Scintigraphy. 10 minutes after the intravenous injection of a technetium-labeled analogue of iminodiacetic acid. InPanel A, a normal liver is visible
In InPanel A, a normal liver is visible 10 minutesfilling of the bile duct (arrow) and gallbladder (arrowhead) can be seen. In Panel C, acid. Panel B, at 55 minutes after tracer injection, after the intravenous injection of a technetium-labeled analogue of iminodiacetic at 1 hour afterB, at 55injection in a patient with acute cholecystitis and obstructionandthe cystic duct, there is filling of the bile duct C, at In Panel tracer minutes after tracer injection, filling of the bile duct (arrow) of gallbladder (arrowhead) can be seen. In Panel (arrow) but no filling of the gallbladder. 1 hour after tracer injection in a patient with acute cholecystitis and obstruction of the cystic duct, there is filling of the bile duct (arrow) but no filling of the gallbladder.

 Local symptoms and signs

Murphy's sign Pain or tenderness in RUQ Mass in RUQ

Systemic signs
Fever Leucocytosis Elevated CRP

Imaging findings
A confirmatory finding on US or HB scintography Presence of one local signs or symptoms One systemic sign, and A confirmatory finding on an imaging test

acute cholecystitis not meeting criteria for a more severe grade Mild gallbladder inflammation, no organ dysfunction

VA

presence of one or more of following: WBC>18000

Palpable, tender mass in RUQ Duration > 72h

VB

Marked local in tlammarion: biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis presence of one or more of following:

CVS dysfunction ( BP requiring dopamine at 5 microgr/kg/min or any dose of Dobutamine) CNS dysfunction (level of consciousness) Respiratory dysfunction (ratio of pO2 of arterial blood to the fraction of inspired oxygen<300) Renal dysfunction (oliguria, Cr> 2mg/dL) Hepatic dysfunction (PT INR >1.5) Hematologic dysfunction (platelet<100.000)

VC

Laparascopic VS open Early VS delayed From 24h to 7 days after initial attack 2-3 months after afte initial attack

Percutaneous Operative

Fasting, obstruction, post surgical ileus, TPN Inspissated bile toxic to epithelium

Clinical findings Setting (inpatient, out patient) Fever, abdominal pain Leucocytosis, abnormal LFT

Radiology US CT HIDA SCAN

Surgery Aspiration of GB/ drainage Laparatomy

Figure 1. (A and B) Longitudinal and horizontal sonogram of a 64-year-old man with positive Murphy sign, showing hydrops. (C) CT scan 6 hours later showing thickened GB wall (white arrow), hydrops, and pericholecystic inflammation (asterisk). Figure courtesy of Dr Shaile Choudhary, MD (Department of Radiology, University of Texas Health Science at San Antonio, San Antonio, TX).