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Infectious Disease - Cholangitis/Cholecystitis
DESCRIPTION: Cholangitis is a clinical diagnosis based on symptoms and indicators of systemic sepsis that originate in the biliary tract, while cholecystitis is an acute or chronic inflammation of the gallbladder.
• Gallbladder inflammation, also known as gaseous cholecystitis, is typified by gas in the gallbladder lumen that may penetrate the gallbladder wall and/or surrounding tissues.
EPIDEMIOLOGY • Three to ten percent of patients with stomach pain have acute cholecystitis. In patients older than 50, the frequency rises to 20%.
• Biliary colic affects 1–4% of cholelithiasis patients each year. Twenty percent of people with symptoms go on to develop acute cholecystitis if they are not treated.
RISK ELEMENTS
• Cholelithiasis is the cause of 90–95% of acute cholecystitis cases.
• The risk of cholelithiasis and cholecystitis is elevated by both obesity and severe dieting.
• Hemolytic disorders, such as sickle cell disease and G6PD deficiency, raise the incidence of pigment stones and the biliary blockage that follows.
• Some ethnic groups, like Pima Indians, are more likely to experience stone formation.
Diabetes mellitus, ischemia, sepsis, and other low-flow states; motility disorders; severe burns or trauma; direct chemical injury; allergic reactions; prolonged use of total parenteral nutrition; vasculitis; collagen disease; sarcoidosis; infections (such as TB, actinomycosis, ascariasis, and HIV/AIDS); and gallbladder torsion are all linked to acalculous cholecystitis.
– In AIDS patients, acalculous cholecystitis usually develops earlier in life and is linked to infections with the cytomegalovirus (CMV) and cryptosporidium.
• Patients with diabetes mellitus and the elderly are more likely to develop emphysematous cholecystitis.
• An infectious consequence of retrograde endoscopic cholangiopancreatography (ERCP).
Considerations for Pregnancy
Although cholelithiasis is common during pregnancy, it is unknown if cholecystitis is also more common during this time.
Genetics • Although cholecystitis tends to be more severe in men, gallstones are more than twice as common in women than in men.
The incidence of acalculous cholecystitis is somewhat higher in men.
OVERALL PREVENTION
Gallstone development can be avoided with a low-fat diet. Acute cholecystitis has also become less common when biliary colic is treated with stone removal or cholecystectomy.
PATHOPHYSIOLOGY Gallstone blockage is the cause of acute calculous cholecystitis.
Gallbladder stasis and stagnated bile cause acalculous cholecystitis.
• Common bile duct blockage causes acute cholangitis, which is accompanied by elevated biliary
pressures. Cholangitis symptoms may arise from the movement of bacteria or endotoxins from the bile ducts into the circulation and lymphatic systems due to obstruction.
ETIOLOGY • Progesterone, fibrate, estrogen, ceftriaxone, and octreotide are among the drugs that have been linked to the development of cholestasis or gallstone formation that results in acute cholecystitis. Additional medications linked to cholecystitis include dapsone, which promotes hemolysis, erythromycin and ampicillin hypersensitivity, and opioids and anticholinergic drugs, which impair gallbladder motility.
• Polymicrobial illnesses predominate. Escherichia coli, Klebsiella species, Enterococcus species, Enterobacter species, and Pseudomonas species are the most frequently cultured organisms. Following surgery or an interventional endoscopy, Staphylococcus and Pseudomonas may be discovered. Patients with diabetes, the elderly, and those recovering from biliary system surgeries are more likely to have anaerobes.
• Choledocholithiasis, malignant biliary strictures, iatrogenic bile duct damage, and stricture of the bile duct are obstructive lesions that increase the risk of pyogenic bacterial cholangitis.
primary sclerosing cholangitis, congenital intrahepatic biliary dilatation (Caroli's disease), biliary anastomosis, and parasite entrance into the bile duct. The trematodes Clonorchis and Opisthorchis, the nematodes Ascaris and, infrequently, Strongyloides, and the cestodes Echinococcus granulosus and Echinococcus multilocularis are among the parasites linked to cholangitis.
History of Diagnosis
• Abdominal pain in the right upper quadrant that may radiate to the infrascapular region is a common symptom of biliary tract disease.
• Acute cholecystitis frequently starts with a fever and biliary colic attack that gets worse over time.
– A history of previous assaults that ended on their own is reported by 60–70% of patients.
– Cholecystitis (and cholangitis) causes constant pain, in contrast to biliary colic.
• Undefined stomach pain or an inexplicable fever are two symptoms of acalculous cholecystitis. Particularly in critically ill patients who are not responding, a high index of suspicion is necessary.
• The symptoms of acute cholangitis frequently include fever and chills, jaundice, and discomfort in the right upper quadrant (Charcot's triad).
– Charcot's triad is only present in 50–70% of patients. Lethargy, mental disorientation, and shock (Reynolds' pentad) are further presenting symptoms.
– Disseminated intravascular coagulation and renal failure are other indicators of organ failure.
Physical examination: Tenderness in the right upper quadrant of the abdomen is 98% sensitive to biliary tract illness. The palpation of a mass in the right upper quadrant is one of the other less sensitive findings. Abdominal discomfort in the right upper quadrant is one of the findings that point to biliary tract disease.
• Acute cholecystitis can be detected by the presence of a Murphy's sign, which is pain felt when the right subcostal region is palpated during inspiration.
Tests for Diagnosis and Interpretation Lab
• Fever and leukocytosis are common symptoms in patients with acute cholecystitis.
WBC count >12,500 cells/mm3 or temperature >38.5°C indicate the presence of infection.
The severity of the condition is indicated by anomalies in the BUN, Cr, platelet count, and prothrombin time.
• Half of patients had slightly raised serum bilirubin, and 25% have slightly elevated serum aminotransferases.
• There is frequently an increase in C-reactive protein.
• Concomitant gallstone pancreatitis or gangrenous cholecystitis may be indicated by elevated amylase values.
• 90% of patients with choledocholithiasis and jaundice have positive biliary cultures, while 50% of patients with biliary blockage do. Incomplete bile duct obstruction is more likely to result in positive cultures than full obstruction. Although bacterial colonization is typically linked to advanced age (>70 years), prior biliary system operations, and common duct stones, bile in healthy persons is typically sterile.
Imagining
• The diagnosis of cholecystitis is often established by ultrasound.
– Gallbladder wall thickening greater than 2 mm, pericholecystic fluid, intramural gas, ductal dilatation, or direct discomfort when the probe is put over the gallbladder (sonographic Murphy's sign) are all signs of acute cholecystitis.
– A sonographic Murphy's sign and the presence of stones have a 92% positive predictive value (PPV).
– The gallbladder wall thickening and stone presence had a 95% PPV.
– When there are no stones and a normal gallbladder wall or Murphy's sign is missing, the negative predictive value is 95%.
Diagnostic Techniques and Other
• Hepatobiliary scintigraphy uses an intravenous injection of technetium-labeled iminodiacetic acid analogs to monitor the flow of bile. It is 80–90% sensitive for acute cholecystitis and shows occlusion of the cystic duct if there is no gallbladder filling 60 minutes after treatment. Usually utilized when ultrasonography is not diagnostic, the false positive rate ranges from 10% to 20%.
• When used in conjunction with US to diagnose cholangitis, CT with intravenous contrast may show pneumobilia and bile duct dilatation.
TREATMENT MEDICATION
Patients with acute cholecystitis or cholangitis should receive antibiotics that target Enterobacteriaceae.
For mild-to-moderate instances of community-acquired acute cholecystitis, the Infectious Diseases Society of America advises using cefazolin, cefuroxime, or ceftriaxone.
• Vancomycin should be added to healthcare-associated biliary infections of any severity. • Broad-spectrum antibiotic therapy, such as imipenem-cilastatin, meropenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime, is advised for acute cholangitis or acute cholecystitis in the presence of advanced age, immunocompromised patients, or severe physiologic disturbance.
Give antibiotics as a preventative measure for cholecystectomy or to patients who have diabetes, immunodeficiency, or advanced age.
• Start taking antibiotics an hour before and stop taking them
• antibiotics for acute cholecystitis without signs of infection outside the gallbladder within 24 hours of cholecystectomy.
Since the pathogenicity of enterococci in immunocompetent hosts has not been established, anti-enterococcal medication is not necessary for community-acquired biliary infections in these individuals.
• In the event that post-operative difficulties develop, intra-operative gallbladder bile cultures may be utilized to inform antibiotic selection.
• Systemic antibiotics and, in cases of more severe illness, biliary drainage are used to treat acute cholangitis.
ADDITIONAL MEDICATION
Overall Actions
• Correct fluid status and electrolyte imbalances with intravenous fluids; • Stop oral intake and start nasogastric suction.
• The most common analgesics are meperidine or pentazocine.
OTHER PROCEDURES AND SURGERY
• Because to the lower rate of complications, fewer expenses, and shorter recovery times, early cholecystectomy is preferable over delayed (post-"cooling off") cholecystectomy.
• Biliary decompression can be achieved via endoscopic gallbladder draining and stenting or percutaneous transhepatic gallbladder aspiration, in addition to open or laparoscopic cholecystectomy.
• When a gallbladder perforation or emphysematous cholecystitis, two complications of acute cholecystitis, are suspected or confirmed, an urgent cholecystectomy is necessary.
• In cases of acute cholangitis, biliary drainage can be carried out percutaneously or via endoscopy (ERCP). It might be necessary to use emergency surgical drainage.
PROGNOSIS FOR ONGOING CARE • Of the 75% of patients with acute cholecystitis whose symptoms resolve, around a quarter will relapse within a year, and 60% will have at least one recurrent episode within six years.
• Acute cholangitis has a mortality rate of 10–30%.
DIFFICULTIES
• Chronic cholecystitis can be brought on by recurrent episodes of mild acute cholecystitis or by long-term irritation from big gallstones.
• Acalculous cholecystitis has a higher rate of complications than calculous cholecystitis.
• Gallbladder empyema carries a substantial risk of perforation and/or Gram-negative sepsis.
• Inflammation and adhesion development may cause fistulization into a nearby organ that is adherent to the gallbladder wall.
• Elderly people are far more likely than younger patients to experience severe acute cholangitis (along by shock or mental impairment).
• Sepsis and hepatic abscess are possible outcomes of acute cholangitis.
• Cholangitis may be obscured by an enlarged and painful liver caused by the abscess.
DESCRIPTION: Cholangitis is a clinical diagnosis based on symptoms and indicators of systemic sepsis that originate in the biliary tract, while cholecystitis is an acute or chronic inflammation of the gallbladder.
• Gallbladder inflammation, also known as gaseous cholecystitis, is typified by gas in the gallbladder lumen that may penetrate the gallbladder wall and/or surrounding tissues.
EPIDEMIOLOGY • Three to ten percent of patients with stomach pain have acute cholecystitis. In patients older than 50, the frequency rises to 20%.
• Biliary colic affects 1–4% of cholelithiasis patients each year. Twenty percent of people with symptoms go on to develop acute cholecystitis if they are not treated.
RISK ELEMENTS
• Cholelithiasis is the cause of 90–95% of acute cholecystitis cases.
• The risk of cholelithiasis and cholecystitis is elevated by both obesity and severe dieting.
• Hemolytic disorders, such as sickle cell disease and G6PD deficiency, raise the incidence of pigment stones and the biliary blockage that follows.
• Some ethnic groups, like Pima Indians, are more likely to experience stone formation.
Diabetes mellitus, ischemia, sepsis, and other low-flow states; motility disorders; severe burns or trauma; direct chemical injury; allergic reactions; prolonged use of total parenteral nutrition; vasculitis; collagen disease; sarcoidosis; infections (such as TB, actinomycosis, ascariasis, and HIV/AIDS); and gallbladder torsion are all linked to acalculous cholecystitis.
– In AIDS patients, acalculous cholecystitis usually develops earlier in life and is linked to infections with the cytomegalovirus (CMV) and cryptosporidium.
• Patients with diabetes mellitus and the elderly are more likely to develop emphysematous cholecystitis.
• An infectious consequence of retrograde endoscopic cholangiopancreatography (ERCP).
Considerations for Pregnancy
Although cholelithiasis is common during pregnancy, it is unknown if cholecystitis is also more common during this time.
Genetics • Although cholecystitis tends to be more severe in men, gallstones are more than twice as common in women than in men.
The incidence of acalculous cholecystitis is somewhat higher in men.
OVERALL PREVENTION
Gallstone development can be avoided with a low-fat diet. Acute cholecystitis has also become less common when biliary colic is treated with stone removal or cholecystectomy.
PATHOPHYSIOLOGY Gallstone blockage is the cause of acute calculous cholecystitis.
Gallbladder stasis and stagnated bile cause acalculous cholecystitis.
• Common bile duct blockage causes acute cholangitis, which is accompanied by elevated biliary
pressures. Cholangitis symptoms may arise from the movement of bacteria or endotoxins from the bile ducts into the circulation and lymphatic systems due to obstruction.
ETIOLOGY • Progesterone, fibrate, estrogen, ceftriaxone, and octreotide are among the drugs that have been linked to the development of cholestasis or gallstone formation that results in acute cholecystitis. Additional medications linked to cholecystitis include dapsone, which promotes hemolysis, erythromycin and ampicillin hypersensitivity, and opioids and anticholinergic drugs, which impair gallbladder motility.
• Polymicrobial illnesses predominate. Escherichia coli, Klebsiella species, Enterococcus species, Enterobacter species, and Pseudomonas species are the most frequently cultured organisms. Following surgery or an interventional endoscopy, Staphylococcus and Pseudomonas may be discovered. Patients with diabetes, the elderly, and those recovering from biliary system surgeries are more likely to have anaerobes.
• Choledocholithiasis, malignant biliary strictures, iatrogenic bile duct damage, and stricture of the bile duct are obstructive lesions that increase the risk of pyogenic bacterial cholangitis.
primary sclerosing cholangitis, congenital intrahepatic biliary dilatation (Caroli's disease), biliary anastomosis, and parasite entrance into the bile duct. The trematodes Clonorchis and Opisthorchis, the nematodes Ascaris and, infrequently, Strongyloides, and the cestodes Echinococcus granulosus and Echinococcus multilocularis are among the parasites linked to cholangitis.
History of Diagnosis
• Abdominal pain in the right upper quadrant that may radiate to the infrascapular region is a common symptom of biliary tract disease.
• Acute cholecystitis frequently starts with a fever and biliary colic attack that gets worse over time.
– A history of previous assaults that ended on their own is reported by 60–70% of patients.
– Cholecystitis (and cholangitis) causes constant pain, in contrast to biliary colic.
• Undefined stomach pain or an inexplicable fever are two symptoms of acalculous cholecystitis. Particularly in critically ill patients who are not responding, a high index of suspicion is necessary.
• The symptoms of acute cholangitis frequently include fever and chills, jaundice, and discomfort in the right upper quadrant (Charcot's triad).
– Charcot's triad is only present in 50–70% of patients. Lethargy, mental disorientation, and shock (Reynolds' pentad) are further presenting symptoms.
– Disseminated intravascular coagulation and renal failure are other indicators of organ failure.
Physical examination: Tenderness in the right upper quadrant of the abdomen is 98% sensitive to biliary tract illness. The palpation of a mass in the right upper quadrant is one of the other less sensitive findings. Abdominal discomfort in the right upper quadrant is one of the findings that point to biliary tract disease.
• Acute cholecystitis can be detected by the presence of a Murphy's sign, which is pain felt when the right subcostal region is palpated during inspiration.
Tests for Diagnosis and Interpretation Lab
• Fever and leukocytosis are common symptoms in patients with acute cholecystitis.
WBC count >12,500 cells/mm3 or temperature >38.5°C indicate the presence of infection.
The severity of the condition is indicated by anomalies in the BUN, Cr, platelet count, and prothrombin time.
• Half of patients had slightly raised serum bilirubin, and 25% have slightly elevated serum aminotransferases.
• There is frequently an increase in C-reactive protein.
• Concomitant gallstone pancreatitis or gangrenous cholecystitis may be indicated by elevated amylase values.
• 90% of patients with choledocholithiasis and jaundice have positive biliary cultures, while 50% of patients with biliary blockage do. Incomplete bile duct obstruction is more likely to result in positive cultures than full obstruction. Although bacterial colonization is typically linked to advanced age (>70 years), prior biliary system operations, and common duct stones, bile in healthy persons is typically sterile.
Imagining
• The diagnosis of cholecystitis is often established by ultrasound.
– Gallbladder wall thickening greater than 2 mm, pericholecystic fluid, intramural gas, ductal dilatation, or direct discomfort when the probe is put over the gallbladder (sonographic Murphy's sign) are all signs of acute cholecystitis.
– A sonographic Murphy's sign and the presence of stones have a 92% positive predictive value (PPV).
– The gallbladder wall thickening and stone presence had a 95% PPV.
– When there are no stones and a normal gallbladder wall or Murphy's sign is missing, the negative predictive value is 95%.
Diagnostic Techniques and Other
• Hepatobiliary scintigraphy uses an intravenous injection of technetium-labeled iminodiacetic acid analogs to monitor the flow of bile. It is 80–90% sensitive for acute cholecystitis and shows occlusion of the cystic duct if there is no gallbladder filling 60 minutes after treatment. Usually utilized when ultrasonography is not diagnostic, the false positive rate ranges from 10% to 20%.
• When used in conjunction with US to diagnose cholangitis, CT with intravenous contrast may show pneumobilia and bile duct dilatation.
TREATMENT MEDICATION
Patients with acute cholecystitis or cholangitis should receive antibiotics that target Enterobacteriaceae.
For mild-to-moderate instances of community-acquired acute cholecystitis, the Infectious Diseases Society of America advises using cefazolin, cefuroxime, or ceftriaxone.
• Vancomycin should be added to healthcare-associated biliary infections of any severity. • Broad-spectrum antibiotic therapy, such as imipenem-cilastatin, meropenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime, is advised for acute cholangitis or acute cholecystitis in the presence of advanced age, immunocompromised patients, or severe physiologic disturbance.
Give antibiotics as a preventative measure for cholecystectomy or to patients who have diabetes, immunodeficiency, or advanced age.
• Start taking antibiotics an hour before and stop taking them
• antibiotics for acute cholecystitis without signs of infection outside the gallbladder within 24 hours of cholecystectomy.
Since the pathogenicity of enterococci in immunocompetent hosts has not been established, anti-enterococcal medication is not necessary for community-acquired biliary infections in these individuals.
• In the event that post-operative difficulties develop, intra-operative gallbladder bile cultures may be utilized to inform antibiotic selection.
• Systemic antibiotics and, in cases of more severe illness, biliary drainage are used to treat acute cholangitis.
ADDITIONAL MEDICATION
Overall Actions
• Correct fluid status and electrolyte imbalances with intravenous fluids; • Stop oral intake and start nasogastric suction.
• The most common analgesics are meperidine or pentazocine.
OTHER PROCEDURES AND SURGERY
• Because to the lower rate of complications, fewer expenses, and shorter recovery times, early cholecystectomy is preferable over delayed (post-"cooling off") cholecystectomy.
• Biliary decompression can be achieved via endoscopic gallbladder draining and stenting or percutaneous transhepatic gallbladder aspiration, in addition to open or laparoscopic cholecystectomy.
• When a gallbladder perforation or emphysematous cholecystitis, two complications of acute cholecystitis, are suspected or confirmed, an urgent cholecystectomy is necessary.
• In cases of acute cholangitis, biliary drainage can be carried out percutaneously or via endoscopy (ERCP). It might be necessary to use emergency surgical drainage.
PROGNOSIS FOR ONGOING CARE • Of the 75% of patients with acute cholecystitis whose symptoms resolve, around a quarter will relapse within a year, and 60% will have at least one recurrent episode within six years.
• Acute cholangitis has a mortality rate of 10–30%.
DIFFICULTIES
• Chronic cholecystitis can be brought on by recurrent episodes of mild acute cholecystitis or by long-term irritation from big gallstones.
• Acalculous cholecystitis has a higher rate of complications than calculous cholecystitis.
• Gallbladder empyema carries a substantial risk of perforation and/or Gram-negative sepsis.
• Inflammation and adhesion development may cause fistulization into a nearby organ that is adherent to the gallbladder wall.
• Elderly people are far more likely than younger patients to experience severe acute cholangitis (along by shock or mental impairment).
• Sepsis and hepatic abscess are possible outcomes of acute cholangitis.
• Cholangitis may be obscured by an enlarged and painful liver caused by the abscess.
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