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Acute cholecystitis

1. ±âÀü

* inflammatory response´Â ´ÙÀ½ ¼¼°¡Áö ±âÀü¿¡ ÀÇÇØ ÀϾ´Ù.

i) mechanical inflammation : intraluminal pr¡è -> distention -> ischemia

ii) chemical inflammation : phospholipase°¡ lecithin¿¡ ÀÛ¿ëÇÏ¿© lysolecithinÀÌ ºÐºñµÇµµ·Ï

ÇÔ.

iii) bacterial inflammation : ¿ªÇÒºñÀ²ÀÌ 50-85%Á¤µµµÊ.

±Õ> E.coli, Kelbsiella spp. group D streptococcus, Staphylococcus spp. Clostridium spp.

2. Áõ»ó

¨ç pain : 60-70%°¡ spontaneous resolve

¨è jaundice : Ȳ´ÞÀº Ãʱ⿣ µå¹°Áö¸¸ ÁøÇàÇÏ¿© bile duct¿Í ÁÖÀ§ LNÀÇ edematous

inflammatory change°¡ ¹ß»ýÇÏ¸é »ý±æ¼ö ÀÖ´Ù.

¨é low-grade fever : Ư¡ÀûÀ¸·Î low-grade fever°¡ Á¸ÀçÇÏÁö¸¸ shaking chills or rigorµµ

µå¹°Áö ¾Ê´Ù.

3. ÁøÂû¼Ò°ß

¨ç RUQ tenderness, enlarged tense GB(1/4-1/2)

¨è abdominal distension, hypoactive bowel sound from paralytic ileus

±×·¯³ª generalized peritoneal signs & abdominal rigidity´Â µå¹°´Ù.

(perforation½Ã ³ªÅ¸³²)

4. Áø´Ü

Hx + P/EÀÌ °¡Àå Áß¿äÇÏ´Ù.

* triad : RUQ tenderness, fever, leukocytosis(10,000-15,000)

Bil, AST/ALT°¡ »ó½ÂÇÒ¼öµµ ÀÖ´Ù.

Radionuclide scan : GB nonvisualization

USG : stone(+) 90-95%

75%°¡ º¸Á¸Àû Ä¡·á·Î Áõ»óÀÌ ¼Ò½ÇµÈ´Ù.(2-7ÀÏ) -> ÀÌÁß 1/4ÀÌ 1³â³», 60%°¡ 6³â³» Àç¹ß

ÇÏ°Ô µÈ´Ù.

25%´Â ÇÕº´ÁõÀÌ ¹ß»ýÇÏ¿© ÀÀ±Þ¼ö¼úÀÌ ÇÊ¿äÇÏ°Ô µÈ´Ù.

=> µû¶ó¼­ acute cholecystitis´Â Á¶±â¼ö¼úÀû Ä¡·á°¡ ÃÖ¼±ÀÌ´Ù.

Acalculous cholecystitis(5-10%)

1) À§ÇèÀÎÀÚ

i) serious trauma or burns

ii) prolonged laberÈÄ

iii) orthopedic and nonbiliary major surgery ÈÄ

iv) vasculitis

v) GB obstructing adenocarcinoma

vi) DM

vii) GB torsion

viii) 'unusual' bacterial infection

ix) GB parasite infection

2) ´Ù¾çÇÑ systemic disease process¿¡¼­µµ ¹ß°ßµÈ´Ù.

: sarcoidosis, cardiovascular disease, TBc, syphilis, actinomycosis,

prolonged parenteral hyperalimentation

Á¶±âÁø´Ü ¹× ¼ö¼úÀÌ ÇÊ¿äÇÏ´Ù.

Acalculous cholecystopathy

GB motilityÀÌ»óÀ¸·Î biliary painÀ» ¾ß±âÇÏ´Â ÁúȯÀÌ´Ù.

CCK infusionµ¿¾ÈÀÇ cholescintigraphy¸¦ ÅëÇÑ GB ejection fractionÀ» ÃøÁ¤ÇÏ¿© °Ë»çÇÑ´Ù.

* Áø´Ü ±âÁØ

i) typical RUQ painÀÇ Àç¹ß

ii) abnormal CCK cholescintigraphy (GBEF < 40%)

iii) CCK infusion½Ã painÀ¯¹ß

Emphysematous cholecystitis

GB wallÀÇ ischemia or gangreneÀ¸·Î »ý±â¸ç Gas-producing organismÀÇ °¨¿°À¸·Î ¹ß»ý

ÇÑ´Ù.

Bacteria culture : anaerobe(C. welchi or C. perfringens), aerobe(E. coli)

³ëÀÎÀ̳ª ´ç´¢º´ ȯÀÚ¿¡¼­ ÈçÈ÷ ¹ß»ýÇϸç Áø´ÜÀº simple abdomenÀ¸·Î ÇÒ¼ö ÀÖ´Ù.

morbidity, mortality°¡ ³ô¾Æ ÀÀ±Þ ¼ö¼ú ¹× Ç×»ýÁ¦ Ä¡·á°¡ ÇÊ¿äÇÏ´Ù.

Chronic cholecystitis

1/4À̻󿡼­ bile³» bacteria°¡ Á¸ÀçÇÑ´Ù.

Clostridium spp.¸¦ µ¿Á¤Çϱâ À§ÇØ bileÀÇ Gram stain & culture°¡ ÃßõµÈ´Ù.

¼ö¼úÀüÈÄ antibiotics¸¦ »ç¿ëÇÏ¿© ¼ö¼úÈÄ¿¡ ¹ß»ýÇÒ¼ö ÀÖ´Â septic complicationÀ» ¿¹¹æ

Çϵµ·Ï ÇÑ´Ù.

Complications

1) Empyema

cholangitis¿Í À¯»çÇÑ Áõ»óÀ» º¸ÀδÙ.

- high fever, severe RUQ pain, marked leukocytosis, prostration

GB sepsis and/or perforationÀÇ high risk

2) Hydrops or mucocele

cystic ductÀÇ prolonged obstruction

ÀÌ·¯ÇÑ Æó¼â´Â ÈçÈ÷ Å« ´ÜÀϰἮ¿¡ ÀÇÇØ ¹ß»ýÇÏ¿© ´ã³¶³»°­ÀÌ ÆØÃ¢Çϸ鼭

mucosal epithelial cellÀÌ mucus(mucocele) or clear transudate(hydrops)¸¦ ºÐºñÇÏ¿©

»ý±ä´Ù.

ÁøÂû¼Ò°ßÀº ÈçÈ÷ visible, easily palpable nontender mass°¡ RUQ -> Rt iliac fossaÂÊÀ¸·Î

¸¸Á®Áö¸ç ÈçÈ÷ ¹«Áõ»óÀÌ´Ù.

±×·¯³ª cholecystectomy°¡ ÇÊ¿äÇѵ¥ empyema, perforation or gangreneÀÇ À§ÇèÀÌ ³ô±â

¶§¹®ÀÌ´Ù.

3) Gangrene or perforation

gangeneÀ̶õ wall ischemia, patchy or complete tissue necrosis°¡ »ý±â´Â °ÍÀ» ¸»Çϸç

perforationÀÌ ÀϾ±â ½±´Ù.

i) localized perforation : omentumÀÌ °¨½ÎÁö¸¸ ¹Ýº¹µÈ ¿°ÁõÀ¸·Î adhesionÀÌ ¹ß»ýÇÑ´Ù.

bacterial superinfectionÀ¸·Î abscess°¡ Çü¼ºµÈ´Ù.

ii) free perforation : ´ú ÈçÇÏÁö¸¸ mortality rate°¡ 30%³ª µÈ´Ù. ¾î¶² ȯÀÚµéÀº RUQ painÀÇ

°©ÀÛ½º·± ¼Ò½ÇÈÄ generalized peritonitis signÀÌ »ý±ä´Ù.

4) Fistula formation or gallstone ileus

½ÊÀÌÁöÀåÀ¸·ÎÀÇ fistula Çü¼ºÀÌ °¡Àå ÈçÇÏ¸ç ±× ´ÙÀ½ÀÌ colonÀÇ hepatic flexure, stomach,

jejunum, abd wall, renal pelvisµîÀÇ ¼øÀÌ´Ù.

cholecystectomy½ÃÇàȯÀÚÀÇ 5%¿¡¼­ " silent " biliary-enteric fistula°¡ °üÂûµÈ´Ù.

Asymptomatic cholecysto-enteric fistula´Â simple abdomen¿¡¼­ ¿ì¿¬È÷ Áø´ÜµÇ±âµµ

ÇÑ´Ù.

Gallstone ileus´Â stone size°¡ Å« °æ¿ì(>2.5cm)¿¡ cholecystoenteric fistula°¡ Çü¼ºµÇ°í

IC valve

¿¡ ºüÁ®³ª¿Â ´ã¼®ÀÌ impactµÊÀ¸·Î¼­ intestinal obstructionÀÌ ¾ß±âµÈ´Ù.

simple abdomenÀ¸·Î Áø´ÜÇÒ¼ö ÀÖÀ¸¸ç laparotomy with stone extractionÀÌ ÇÊ¿äÇÏ´Ù.

5) Limey(milk of Ca) bile and porcelain GB

Calcium salt°¡ GB lumen³»·Î ºÐºñµÇ¾î ´ã³¶³» Ä®½·ÀÌ Ä§ÂøµÈ´Ù.

-> Diffuse hazzy opacification of bile or simple abdomen»ó layering effect

ÀÓ»óÀûÀ¸·Î´Â ¹«ÇØÇϳª hydropic GB¿¡¼­ °¡Àå ÈçÈ÷ ¹ß»ýÇϹǷΠcholecystectomy°¡

ÇÊ¿äÇÏ´Ù.

Ä¡·á

1) Medical Tx

pain control :morphineº¸´Ù sphincter of Oddi spasmÀ» ´ú ¾ß±âÇÏ´Â meperidineÀ̳ª

NSAID¸¦ »ç¿ëÇϵµ·Ï ÇÑ´Ù.

antibiotics combination(+AG)ÇÏ´Â °æ¿ì : DM, debilitated pt, gram-negative sepsis sign(+)

2) Surgical Tx

Postcholecystectomy complication

¼ö¼úÁ÷ÈÄ atelectasis, other pul disorder, abscess, hemorrhage, biliary-enteric fistula,

bile leaksÀÌ »ý±æ¼ö ÀÖ´Ù. ¼ö¼úÈÄ ´ë·« 75-90%¿¡¼­ Áõ»óÀÌ ÁÁ¾ÆÁöÁö¸¸ Áõ»óÀÌ °è¼ÓµÇ´Â

ȯÀÚµéÀÌ ÀÖ´Ù.

* mc causes of persistent cholecystectomy sx

= overlooked extrabiliary disorders

(reflux esophagitis, peptic ulcer, pancreatitis, or more common IBS)

¼Ò¼ö¿¡¼­ extrahepatic bile duct disorders°¡ Áö¼ÓÀû Áõ»óÀ» ¾ß±âÇÒ¼ö ÀÖ´Ù.

= "Postcholecystectomy syndromes"

: biliary stricture, retained biliary calculi, cystic duct sump syndrome,

stenosis or dyskinesia of th sphincter of Oddi, bile salt-induced diarrhea or gastritis

Cystic duct stump syndrome

cholecystectomy½ÃÇàÈÄ long cystic duct remnant(>1cm) ȯÀÚ¿¡¼­ ÀÜ·ù´ã°ü °á¼®ÀÌ ¾ø´Â

»óÅ¿¡¼­ biliary colic or cholecystitis Áõ»óÀÌ ¹ß»ýÇÒ¼ö Àִµ¥ À̶§ cystic duct stump

syndromeÀ̶ó ÇÑ´Ù.

Papillary stenosis

Ampulla of VaterÀÇ ¹Ýº¹Àû ¿°ÁõÀ̳ª papillary segmentÀÇ glandular hyperplasia¿¡ ÀÇÇØ

¹ß»ýÇÑ´Ù.

* 5 criterias

i) RUQ or epigastric pain

ii) abnormal LFT

iii) ERCP»ó CBD dilatation

iv) Á¶¿µÁ¦ÀÇ delayed drainage(>45 ºÐ)

v) sphincter of Oddi basal pressure¡è

* Ä¡·á : endoscopic or surgical sphincteroplasty

* Sphincterotomy Ix

Áõ»óÀÌ Áö¼ÓµÇ°Å³ª, ´ëÁõÄ¡·á¿¡ ¹ÝÀÀÀÌ ¾øÀ» ¶§, severe disability, ȯÀÚ°¡ ¼±ÅÃÇÑ °æ¿ì

Sphincter of Oddi dyskinesia

2-3°³¿ù medical tx(nitrite, anticholingergics)ÈÄ È£Àü ¾øÀ» ¶§ endoscopic sphincterotomy

or surgical sphincteroplastyÀÇ ÀûÀÀÀÌ µÈ´Ù(ƯÈ÷ basal sphinter pre¡èÀÇ °æ¿ì¿¡