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¢Çϸé¼
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¿¡