ACUTE CHOLECYSTITIS Acute cholecystitis is initiated by gall stone, which obstructs the gallbladder outlet.

Each year 1 2 % of asymptomatic gallbladder stone develop serious symptom or complication. Acute cholecystitis occurs in approximately 10 % to 20 % of patients with symptomatic gallbladder stone (1). In acute cholecystitis the pain and right upper quadrant abdominal symptoms may persist more than 6 hours and is accompanied by local peritonitis and systemic evidence of inflammation. The ultrasonography findings include a distended gallbladder stone or sludge containing gallbladder, thickened wall, mucosal separation (double larger), peri cholecystics, fluid collection or intramural air (table 1) (fig. 1) (2). Tab. 1 Diagnostic criteria for acute cholecystitis A B C Local signs of inflammation (1) Murphys signs, (2) RUQ, mass / pain / tenderness Systemic signs of inflammation (1) Fever, (2) elevated CRP, (3) elevated WBC count > 3 mg / dl Imaging findings of acute cholecystitis

One item in A and one in B definite diagnosis C confirms the diagnosis Imaging findings of acute cholecystitis Ultrasonography findings (level 4) (fig. 1) Sonography Murphys sign Thickened (gallbladder wall (> 4 mm) Enlarged gallbladder ( > 8 cm x 4 cm) Incarcerated gallbladder, debris echo, peri cholecystic fluid collection Sonolucent layer in the gallbladder wall (double larger) Striated intramural lucencies, and Doppler Signal. MRI CT scan (level 3 b) (fig. 2) Tc HIDA scans (level 4) Tab. 2 : Categories of Acute Cholecystitis Mild (grade I) Moderate (grade II) No findings of organ dysfunction. No criteria for moderate or severe acute cholecystitis 1) elevated WBC (>18.000/mm3) (2) palpable tenderness in the right upper abdominal quadrant (3) duration > 72 hours (4) marked local inflammation

Severe

Acute cholecystitis is accompanied by one or more organ dysfunction : (1) Cardiovascular (hypotension) (2) Neurological (decrease consciousness) (3) Respiratory (Pa O2) Fi O2 ratio < 300) (4) Renal oliguria, creatinine > 2.0 mg/dl) (5) Hepatic (PT INR > 1.5) (6) Hematological (platelet count < 100.000 / mm3)

Flowchart for the management of acute cholecystitis (fig 3) (3) Mild (grade I) Acute cholecystitis Moderate (grade II) Acute Cholecystitis Early laparoscopic cholecystectomy is the preferred treatment or elective cholecystectomy Early laparoscopic or open cholecystectomy. In difficult case, percutaneous gallbladder drainage is recommended, then elective cholecystectomy can be performed after improvement

Severity of acute Appropriate organ support in addition to medical cholagitisSevere treatment. Management of severe local inflammation by (grade III) percutaneous gallbladder drainage and / or Acute Cholecystitis cholecystectomy if needed. Mild Moderate (grade II)Severity Onset of organ dysfunctionNoNoYesResponse to initial medical treatmentYesNoNo Treatment of acute Cholangitis The treatment of acute cholangitis should be guided by the grade of severity of the disease. Initial management of acute cholangitis comprise appropriate empiric antibiotic (Chepalosporin III + Metronidazol) with bowel rest and rehydration. (fig 5) (3, 5)

Fig. 5 : Flowchart for the management of acute cholangitis (5) Emergent drainage is essential for severe cases whereas patients with moderate and mild disease should also receive drainage as soon as possible if they do not respond to conservative treatment (12). Biliary drainage is the treatment of choice for moderate or severe acute cholangitis in elderly patients (recommendation C)(12) How do we select the mode of biliary drainage (12) : Endoscopic biliary drainage, either nasobiliary drainage or biliary stent placement (recommendation A) Percutaneous transhepatic biliary drainage (recommendation B) Acute cholangitis resulting from CBD stone traditionally was managed by supportive measures and parenteral antibiotics followed by early surgery if improvement was slow or absent (5, 17) Cholecystectomy is indicated after the resolution of acute cholangitis (recommendation B) (12). Choledocholithiasis is most common as primary cause of cholangitis (1, 5, 6, 8, 9, 11) In our series of 151 consecutive patients with gallbladder stone in Surabaya from January 2005 until August 2006 we analyzed 14 patients (9.27%) with common bile duct stone. Our data suggested that acute cholangitis and dilated CBD were the most significant risk for choledocholithiasis

The current study demonstrated three level of risk for CBD stones in patients with choledocholithiasis Clinical Presentation
Clinical diagnosis Choledocholithiasis Cholecystitis Pancreatitis Resolving choledocholithiasis CBD 5 mm (10 mm) At least 2 of : T Bili 1.5 (2) Alk. Phos 150 (250 AST 100 ALT 100 Cholecystitis Pancreatitis Resolving Choledocholitiais CBD < 5 mm (10 mm) At least 2 of : T Bili 1.5 (2) Alk. Phos 150 (250 AST 100 ALT 100 Biliary colic

Ultrasound Serum biochemistries

CBD 5 mm (10 mm) At least 2 of : T Bili 1.5 (2) Alk. Phos 150 (250 AST 100 ALT 100

CBD < 5 mm (10 mm) T Bili < 1.5 (2) Alk. Phos < 150 (250 AST < 100 ALT < 100

Therapeutic ERCP

MRC CBD stones No CBD stones

Therapeutic ERCP

LC with IOC

(grade III) (grade I)

LC with IOC

LC with IOC

LC

Timing of Surgery The optimal interval of time between the diagnosis of acute cholangitis and definitive treatment with cholecystectomy has been the subject of prospective randomized trials. Early laparoscopic cholecystectomy (tipically defined as < 3 days) seems to be the preferred surgical technique for patients with acute cholecystitis ( 5, 11, 14, 15). Patients experienced no increased perioperative morbidity or mortality and had a shorter length of hospital stay ( 14, 15, 16). When the gallbladder is difficult : Go fundus first (dome down) and stay near the gallbladder wall. In problematic situations such as fibrotic triangle of Calot consider to do a partial or subtotal cholecystectomy. It is better to remove 95% of the gallbladder (i.e. subtotal cholecystectomy) than 101% (i.e. together with a piece of the bile duct).

Complications od Acute Cholecystitis Several complications of acute cholecystitis are recognized in clinical practice. These include empyema of the gallbladder, emphysematous cholecystitis, perforation and cholecyst enteric fistula. All of these complications need prompt surgical intervention. Unusual Cases Acute acalculous cholecystitis account for 2% - 15% of cases is caused by disturbed micro circulation in critically ill patients and is therefore life threatening condition. The treatment is the same as that for calculous cholecystitis. Abdominal echo and CT scan are useful in the diagnosis of acute acalculous cholecystitis. Percutaneous Transhepatic gallbladder drainage is the treatment of choice for the elderly with acute cholecystitis who are diagnosed as inoperable due to a high surgical risk (recommendation C) Emergency surgery for acute cholecystitis in elderly patients (recommendation C).

ACUTE CHOLANGITIS The pathogenesis of acute cholangitis is biliary infection associated with partial or complete obstruction of the biliary system. Obstruction raises the intra ductal pressure in the bile duct to levels high enough (> 200 mmH2O)

to cause cholangio venous or cholangio lymphatic reflux (normal pressure : 100 mmH2O 150 mmH2O) (fig. 4) (1)

Fig. 4 : Pathophysiology of acute cholangitis (1) Basic concepts of the diagnostic criteria of acute cholangitis are as follows : (4)

(1) Charcots triad is a definite diagnostic criteria for acute cholangitis. Inspite of the fact the presentation of Charcots triad variable in 50% to 70% of patients (6,7). (2) If a patient does not have all the components of Charcots triad, the definite diagnosis can be achieved if both an inflammatory respons and biliary obstruction are demonstrated by the laboratory data (blood test) and imaging findings. (3) (4) Tab 3 : Diagnostic criteria for acute cholangitis (4) (5) (6) A. Clinical data 1. History of biliary disease (7) 2. Fever and chills (8) 3. Jaundice (9) 4. Upper abdominal pain (10) B. Laboratory data 5. Evidence of inflammatory respons (11) 6. Abnormal liver function test (12) C. Imaging 7. Biliary dilatation or evidence of an etiology (13) (stricture, stone, stent etc.) (14) (15) (16) SEVERITY ASSESSMENT

(17) (18) Organ dysfunction is the most common predictor of poor outcome and as classified as severe cholangitis (grade III). (19) Patient with acute cholangitis that is not complicated by organ dysfunction, who did not respond to medical treatment and who continue to have SIRS are classified as moderate cholangitis (grade II). Patients who respond to medical treatment are classified as having mild cholangitis (grade I) (tab. 4)(4). (20) (21) Tab 4 : Criteria for severity assessment of acute cholangitis (4) (22) (23) Criteria