Cholecystitis . Inflammation of the gallbladder wall .
Summary
[ hide ]
- 1 Anatomy
- 2 Epidemiology
- 3 Etiology
- 1 Physical examination
- 4 Clinical picture
- 5 Diagnosis
- 6 Complications
- 7 Treatment
- 8 Sources
Anatomy
The gallbladder is a reservoir or pocket that is located infra lobular (right side of the liver region).
It is made up of 4 regions known as body, bottom, head and neck . It has an approximate size of 10 × 5 × 4 cm. It leads to the cystic duct (which, when joined with the hepatic duct, gives rise to the common bile duct), which measures between 2-5 cm, with an approximate diameter of 5 mm.
epidemiology
There is a higher incidence in women than in men, reaching in some countries 10: 1 women: men. Currently, the most prevalent ages are those in productive stages, from 20 to 40 years.
Being a woman is considered predisposing factors due to estrogenic hormones, since these increase Low Density Proteins (LDL) as well as Very Low Density Proteins (VLDL) and cholesterol in the bile juice and decrease the concentration of bile acids and salts within it, which makes it easier for the formation of stones within the gallbladder . Due to the levels of estrogenic hormones that occur in pregnancy, the fact that women are multiparous (or multigesta) is considered as a risk factor as well as being overweight since the lipid profile in these patients is usually higher.
Etiology
Acute cholecystitis can be lithiasic, when it is generated by the impaction of a stone somewhere in the bile drainage system (cystic duct, and hepato-choledochial duct); and allyasic when the anatomopathology is not accompanied by calculation. This is more complex to explain, understand and diagnose, since its causes are mainly due to viruses such as the Epstein-Bar virus, the Herpesviridae family, or bacteria such as the Salmonella genus , among others.
The majority of chronic cholecystitis is due to the presence of a stone unable due to its size to impact the duct. It opens the way to the constant perforation of the mucosa, with the always classic consequence, of what happens when a tissue is subjected to chronic damage: namely neoplastic pathology.
Physical exploration
A diaphoretic patient with painful facies is found, being in most cases with abdominal distension, painful on palpation of the right upper quadrant. Upon palpation, a classic sign is obtained, the sign of Murphy: pain of abrupt appearance when pressing with the finger on the point of Murphy, a point located on the rib margin and passing through the right hemiclavicular line.
Clinical picture
It is characterized by pain in the region of the right upper quadrant, which can be moderate to intense, colic or stabbing. The pain increases with the consumption of highly seasoned, irritating, fatty and cholecystokinetic foods (coffee, chocolate); and decreases with ambulation and fasting (on some occasions).
This pain can last a minimum of 5 to 10 minutes or last several hours. In many cases this pain can radiate to the back or to the right shoulder. The intensity of pain and its duration is not proportional to the degree of injury or involvement. On some occasions it is usually accompanied by vagal or adrenergic discharges, which are manifested by excessive cold sweating, nausea, and vomiting of gastric content.
Diagnosis
Acute cholecystitis usually produces persistent right upper quadrant pain, typical on physical examination by the physician. It can be accompanied by nausea , vomiting and restlessness. In case of infection, fever (not always), general malaise and jaundice usually appear (not always present, the typical yellow discoloration of the skin and membranes in jaundice is accompanied by darker urine and light colored soft stools) . Along with the medical history and physical examination, the diagnosis is usually confirmed by abdominal ultrasound. Currently, due to the clear suspicion of biliary lithiasis, ultrasound is performed by intraoperative laparoscopy , which allows the removal of thegallbladder if diagnosis is confirmed in the same operation. ERCP. Endoscopic Retrograde Cholangiopancreatography A type of endoscopy in which the oddi sphincter is passed through to view the gallbladder and pancreas.
Pain referred to the right shoulder in acute hepatobiliary processes and laparoscopic post-surgery is explained by irritation of the peritoneum in the affected region. This is innervated by the Phrenic Nerve (which supplies the diaphragm muscle) originated in the cervical plexus (III to IV), which also originates sensory and motor nerves for the shoulder region. This symptom is also usually seen in ectopic pregnancy due to irritation of the blood in the subphrenic space. Something similar can be found in acute pancreatitis with referred pain in the left shoulder (Von Eisemberg sign) Schumperlik V. et al., The Surgical Clinics of NA, 80: 213,2000.
In cases in which the diagnosis cannot be confirmed by ultrasound, it may be necessary to carry out other complementary tests such as a contrast study of the bile ducts (cholangiography).
Complications
Among the most frequent complications we have: External and internal fistulas
Biliary ileus
Acute pancreatitis
Perforated gallbladder
Piocolecisto
Hydrocolecisto
Localized peritonitis (subphrenic abscess)
Generalized peritonitis
Treatment
The definitive treatment for cholecystitis is surgical, through cholecystectomy , which should preferably be laparoscopically.
