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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_907_Библиотеки_им_академика_М_И_Перельмана
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Case Conclusion
Once diagnosed with symptomatic cholelithiasis, the
patient is admitted to the Obstetrics Antepartum unit for
preoperative pain control and fetal monitoring. That
afternoon she undergoes a laparoscopic
cholecystectomy and is admitted postoperatively for 24
hours of fetal monitoring. After an uneventful stay, she is
discharged on postoperative day 1. Her follow-up visit
reveals no further pain, and her pregnancy progressed
uneventfully to term.
TAKE HOME POINTS
The presenting signs and symptoms of symptomatic
cholelithiasis may be nonspecific and difficult to
distinguish from those associated with pregnancy.
The changing position of intra-abdominal contents
during pregnancy complicates the examination of the
gravid abdomen.
Asymptomatic cholelithiasis, even found during
pregnancy, is not an indication for cholecystectomy.
For symptomatic cholelithiasis, a cholecystectomy
can be safely performed in all trimesters of
pregnancy.
Nonoperative management of symptomatic
cholelithiasis exposes the patient to a high rate of
recurrence and associated complications.
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recurrence and associated complications.
Laparoscopic cholecystectomy is preferred to an
open procedure and carries the same benefits as in
the nonpregnant patient.
An obstetric consultation should be obtained for all
cases involving a viable fetus (>24 weeks gestation)
and will typically include preoperative and
postoperative fetal monitoring.
SUGGESTED READINGS
Basso L, McCollum PT, Darling MR, et al. A study of cholelithiasis during
pregnancy and its relationship with age, parity, menarche, breastfeeding, dysmenorrhea, oral contraception and a maternal history of
cholelithiasis. Surg Gynecol Obstet. 1992;175:41–46.
Date RS, Kaushal M, Ramesh A. A review of the management of gallstone
disease and its complications in pregnancy. Am J Surg. 2008;196:599–
608.
Ko CW. Risk factors for gallstone-related hospitalization during pregnancy
and the postpartum. Am J Gastroenterol. 2006;101:2263–2268.
Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging in the triage of pregnant
patients with acute abdominal and pelvic pain. Abdom Imaging.
2009;34:243–250.
Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test
sensitivity and specificity in suspected biliary tract disease. Arch Intern
Med. 1994;154:2573–2581.
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23
Acute Cholecystitis
DANIELLE FRITZE and JUSTIN B. DIMICK
Presentation
A 70-year-old woman with multiple chronic medical
conditions presents to the emergency room with 36
hours of right upper-quadrant (RUQ) pain and
subjective fever. She describes numerous prior
episodes of postprandial RUQ abdominal pain that
resolves after several hours. While her pain is
occasionally accompanied by nausea and vomiting,
she denies jaundice, alcoholic stools, or dark urine. On
exam, she is febrile to 38.5°C with otherwise normal
vital signs. Her abdomen is soft with a well-healed
vertical midline incision. She has marked tenderness to
palpation in the right subcostal region and a positive
Murphy’s sign.
Differential Diagnosis
While this patient’s symptoms of fever, RUQ pain, and
vomiting represent the classic manifestations of acute
cholecystitis, the clinical presentation is not always
straightforward. Frequently, acute cholecystitis must be
distinguished from other complications of cholelithiasis.
Biliary colic results from temporary impaction of a gallstone
in the gallbladder neck. It is characterized by postprandial
abdominal pain, nausea, and vomiting that resolve over
several hours. Signs of systemic inflammation, such as
fever and elevated white blood cell count, are usually
absent. Gallstones in the common bile duct (CBD), that is,
choledocholithiasis, may cause RUQ pain with
spontaneous passage of a stone or could progress to
ascending cholangitis or biliary pancreatitis. Acalculous
biliary disease is also a diagnostic consideration.
Sphincter of Oddi dysfunction or biliary dyskinesia with low
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gallbladder ejection fraction often mimics the symptoms of
biliary colic. Acute acalculous cholecystitis may be the end
result of gallbladder hypoperfusion but usually is limited to
critically ill patients. Nonbiliary abdominal pain due to
gastroenteritis, acute hepatitis, ulcer disease, or bowel
obstruction must also be excluded.
Workup
The diagnosis of acute cholecystitis is strongly suggested
by this patient’s history and is supported by characteristic
findings on her physical exam. Constant, burning, RUQ pain
is the most common presenting symptom in patients with
cholecystitis. The pain occurs following ingestion of a highfat meal and may awaken the patient from sleep. Many
patients have known gallstones and nearly half report prior
episodes of biliary colic. Approximately 5% to 10% of
patients with biliary colic will go on to develop acute
cholecystitis or another complication of gallstones each
year. Physical exam reveals fever and right subcostal or
epigastric tenderness, possibly with localized guarding.
Occasionally, a tender mass is palpable just inferior to the
right costal margin. Inspiratory arrest with deep palpation in
the RUQ, known as Murphy’s sign, is a classic finding in
acute cholecystitis.
Further evaluation of RUQ pain includes laboratory tests
and imaging. This patient had an elevated white blood
count of 13,000, bilirubin of 1 mg/dL, and normal liver and
pancreatic enzymes. Leukocytosis with a predominance of
neutrophils is common and helps to distinguish acute
cholecystitis from biliary colic. Serum transaminases,
bilirubin, and pancreatic enzymes are within the normal
range or mildly elevated. Elevated liver enzymes or bilirubin
should raise suspicion for choledocholithiasis but may also
result from extrinsic compression of the common hepatic
duct by a stone impacted in the neck of the gallbladder
(Mirizzi syndrome). Elevated amylase and lipase indicate
pancreatitis, potentially related to choledocholithiasis.
While acute cholecystitis may be diagnosed by several
imaging modalities, abdominal ultrasound (US) is
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considered first line in the evaluation of RUQ pain. This
patient’s US was consistent with acute cholecystitis,
demonstrating gallstones with gallbladder wall thickening,
pericholecystic fluid, and a normal caliber CBD (Figure 1).
Some patients experience a sonographic Murphy’s sign,
that is, pain caused by the US probe pressing directly on
an inflamed gallbladder. Although CBD stones are not
consistently identified by US, dilation of the CBD (>8 mm)
suggests biliary obstruction. However, bile duct dilation on
US is a speci fic but not very sensitive indicator of
obstruction. Often, patients with elevated bilirubin or
alkaline phosphatase levels will have normal size bile ducts
on US.
FIGURE 1 • US with classic findings of cholecystitis: cholelithiasis,
thickened gallbladder wall and pericholecystic fluid.
While characteristic US findings are sufficient to
diagnose acute cholecystitis in a patient with a concordant
history and exam, other imaging modalities may be helpful
in cases of diagnostic uncertainty. hepatobiliary
iminodiacetic acid (HIDA) scan is considered the gold
standard for diagnosis of acute cholecystitis in this setting,
with sensitivity and specificity >95%. It is particularly useful
in distinguishing cholecystitis from biliary colic and other
nonbiliary processes but may have false-positive results in
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the setting of chronic cholecystitis. Nonvisualization of the
gallbladder at 60 minutes is diagnostic for cholecystitis
(Figure 2). Gallbladder contraction may be stimulated by
morphine or cholecystokinin to further increase HIDA’s
accuracy in diagnosing cholecystitis. Measurement of the
gallbladder ejection fraction by HIDA also allows for
identification of biliary dyskinesia.
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FIGURE 2 • HIDA scan consistent with acute cholecystitis. At 45 minutes
after injection of contrast, there is opacification of he intra- and extrahepatic
biliary tree and duodenum. The gallbladder is not visualized.
In patients for whom there is a suspicion of
choledocholithiasis, visualization of the biliary tree with
Magnetic resonance cholangiopancreatography (MRCP)
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may help with the diagnosis (F ig ur e 3). Therapeutic
sphincterotomy and stone extraction may be accomplished
by ERCP in those patients with signs or symptoms of
persistent biliary obstruction. While CT scan should not
routinely be used to evaluate suspected cholecystitis given
its low sensitivity and specifici ty, abdominal CT may
suggest the diagnosis by revealing cholelithiasis, an
enhancing and thickened gallbladder wall, pericholecystic
fluid, and surrounding inflammatory fat stranding (Figure 4).
FIGURE 3 • MRCP demonstrating a thickened gallbladder wall and
gallstones within the cystic duct, but no biliary dilation or
choledocholithiasis. The filling defects within the gallbladder likely
represent small polyps. Reformatted images delineate the patient’s biliary
anatomy.
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FIGURE 4 • CT scan consistent with acute cholecystitis demonstrating a
dilated, thick-walled gallbladder with surrounding inflammatory stranding.
A large gallstone is lodged in the gallbladder neck.
Diagnosis and Treatment
The initial management of acute cholecystitis includes NPO
status with systemic broad-spectrum antibiotics and
resuscitation as dictated by the patient’s condition. Ideally,
cholecystectomy is performed upon diagnosis, within 48
hours of the onset of symptoms. Surgery is performed
during the same hospitalization if possible, despite how
long the patient has had symptoms. Although some
advocate delaying operation if the patient has had
symptoms >72 hours, we do not follow this practice.
Despite the myth that cholecystectomy is easier after a
“cooling off” period, evidence indicates that interval
cholecystectomy, performed more than 6 weeks after
recovery from acute cholecystitis, does not result in fewer
operative complications and is associated with a longer
length of hospital stay. During this time, the acute process
progresses to chronic fibrotic scarring, which can make
dissection even more difficult. Thus, we believe early urgent
cholecystectomy is the treatment of choice if at all feasible.
Cholecystectomy may be accomplished via either a
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laparoscopic or an open approach. Laparoscopic
cholecystectomy is associated with decreased length of
hospital stay, less patient discomfort, and shorter recovery
time. Patients with a hostile abdomen, known aberrant
anatomy, significant inflammation, or who are unlikely to
tolerate pneumoperitoneum are best served with open
cholecystectomy.
In patients whose comorbidities or clinical condition
pose a prohibitive operative risk, drainage of the
gallbladder may be accomplished via percutaneous or
laparoscopic cholecystostomy. Decompensated cardiac
failure, unstable angina, and severe or poorly controlled
chronic lung disease are among the conditions that may
render surgery unnecessarily high risk. Critically ill patients
who develop acute cholecystitis in the setting of multiorgan
failure or septic shock are particularly well served with
cholecystostomy tube. A cholecystostomy tube may remain
in place indefinitely, especially for patients with a limited life
expectancy, or serve as a bridge to cholecystectomy when
and if the patient’s condition improves. Any trial of tube
removal must be preceded by contrast injection to confirm
a patent cystic duct. Up to 50% of patients will develop
recurrent cholecystitis following tube removal; thus, most
patients benefit from cholecystectomy if they are a fit
operative candidate. Performing cholecystectomy after a
tube placement poses a unique technical challenge given
the chronic nature of the inflammation and fibrosis around
the triangle of Calot. In this setting, the risk of conversion to
an open procedure, or the necessity to perform a partial
cholecystectomy, is quite high and should be considered
prior to taking the patient to the operating room.
Although this particular patient has multiple
comorbidities, these do not constitute a prohibitive
operative risk, so the choice is made to proceed with
cholecystectomy. An attempt at laparoscopy is planned
with anticipated conversion to an open operation should
adhesions from her prior colectomy inhibit reasonable
progress or obscure relevant anatomy. In order to avoid
disrupting the mesh from her ventral hernia repair, alternate
port placement will be used.
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