Cases of Bile Duct Blockage and Subsequent Acute Cholecystitis - Case Study Example

Acute cholecystitis is an inflammation of the gallbladder that is characterized by a sharp pain in the upper right quadrant. It is usually caused by the presence of gallstones which block the bile duct, leading to a build up of bile and subsequent inflammation (Sherlock et al, 2002). There may also be bacterial species present, including Escherichia coli or Salmonella spp (Eldar et al, 1997). The syndrome is usually mild and has a good prognosis, although complications can lead to gangrene and tissue necrosis, which are more dangerous and lethal (South-Paul et al, 2010). The disease is fairly common, with over 500,000 operations being performed each year in the United States on individuals presenting with more severe cases of bile duct blockage and subsequent acute cholecystitis. Acute cholecystitis is the case of this inflammation that occurs sporadically, with the similar chronic cholecystitis being characterised by a more constant inflammation (South-Paul et al, 2010). Acute cholecystitis is far more common in women than in men, and occurs in the population more frequently with age (Sherlock et al, 2002). Pregnancy can also increase the liklihood of getting acute cholecystitis due to the presence of hormones that increase the liklihood of developing gallstones and the subsequent blocking and inflammation (Lai et al, 1998). There are many associated symptoms which are usually vague, and include nausea and fever (Eldar et al, 1997). Acute cholecystitis can be diagnosed in a number of ways that will be discussed within the course of this essay, but imaging techniques are the most conclusive, with metabolic panels being used as the primary detection method in suspected cases (Sherlock et al, 2002). Imaging techniques are the only way to get a conclusive diagnosis of the affliction. Treatment is usually antibiotics, although more severe and aggressive treatments are necessary in cases where gangrene and tissue necrosis are present. Operations may be needed to remove the causative gallstones (Kiviluoto et al, 1998). This essay will discuss all of these features of acute cholecystitis in more detail. (Image from http://www.uninet.edu/cin2001-old/conf/moreno/Image18.jpg) Aetiology Colecystitis is often caused by gallstones forming in the gallbladder, and especially refers to those that obstruct the custic duct (Sherlock et al, 2002). This obstruction can lead to issues with the bile system, which involve a thickening of the bile and associated stasis. This may very often lead to secondary infections by pathogens including but not limited to Escherichia coli (South-Paul et al, 2010). Both the initial problem with gallstones and the secondary infection can lead to to the inflammation that is characteristic of cholecystitis, and especially cases of acute cholecystitis. It is interesting to note that the incidence is higher in females, and this has been linked to higher levels of progesterone during the pregnancy period (Eldar et al, 1997). Epidemiology Around 10-20% of Americans have gallstones (Sherlock et al, 2002) and this is mirrored in countries with a similar breakdown of age, ethnicity and wealth (Eldar et al, 1997). From these individuals, around 30% will develop acute cholecystitis (South-Paul et al, 2010) and it is more likely to affect female than males. In the United States, around 500,000 operations are carried out each year to remove the cholecysts (Ralls et al, 2005). The chances of getting acute cholecystitis increases with age, although the reason for this is not clear. This increasing of incidence with age is more pronounced in elderly men (Lo et al, 1998). Cholelithiasis (gallstones) is more pronounced in white people of Hispanic or Scandinavian descent, and less common in those from Asia or sub-Saharan Africa (Sherlock et al, 2002). A brief case history A 40-year old woman with a weight in the clinically obese category is complaining of pain in the right upper quadrant. She has a history of gallstones, and is running a mild fever of 38C. She is also complaining of nausea. On further investigation, it is evident that there is a mild case of associated jaundice (serum bilirubin levels of 62micromol/L). Due to the sex, age and history of this patient, a metabolic panel with bicarbonate is carried out, as recommended by Sherlock et al, (2002). All counts of aspirate aminotransferase, alanine aminotransferase, bilirubin and alkaline phosphate are normal, although this cannot be used to rule out acute cholecystitis. White blood cell count is 11,000 cells/ul, a common feature of a milder case of inflammation of the gallbladder. Due to these symptoms, the examining physician had a reason to suspect acute colecystitis. An ultrasound was carried out and there appeared to be gallstones and a mild inflammation of the gallbladder, although this was not conclusive from this test. Due to this, an abdominal CT scan was done on the patient, which confirmed the gallstones and the inflammation, leading to a diagnosis of acute colecystitis (Singer et al, 2008) A blood test was also carried out to check for symptoms of gangrene and sceptacemia, both of which were not present in the individual, although there was evidence of E. coli in the patient (Singer et al, 2008) The patient was presumed to have a mild case of acute cholecystitis from the diagnostic measures above. She was treated with a broad-spectrum antibiotic intravenously, as well as being administered intravenous hydration. The patient made a full recovery, and was sent home with instructions for bowel rest and a diet plan to help prevent a recurring case cholecystitis (Singer et al, 2008). Clinical diagnosis There is no conclusive diagnostic tests for acute cholecystitis. However, testing levels of white blood cells, aspirate aminotransferase, alanine aminotransferase, bilirubin and alkaline phosphate may show to be elevated in some cases (South-Paul et al, 2010). However, it must be noted that this does not give a conclusive diagnosis of acute cholecystitis. Singer et al (2008) have shown that there may also be elevated levels of hepatic 2,6-dimethyliminodiacetic acid in some cases, although again this cannot be used as a conclusive diagnostic test. Levels of amylase during testing may be up to three times higher in patients presenting with acute cholecystitis (Sherlock et al, 2002). All these levels can be examined using a metabolic panel with bicarbinate. From all these tests, it appears that the white blood cell count elevation is the most conclusive, with 61% of patients with acute cholecystitis having a count of 11,000 cells/ul. A count of 15,000 cells/ul could indicate gangrene or extreme inflammation (Eldar et al, 1997). The main symptom of acute cholecystitis is an intense pain in the abdomen that can radiate towards the shoulder blade. Other symptoms include fever, nausea, vomiting, loss of appetite and jaundice (South-Paul et al, 2010). The pain in the abdomen is usually enough for a physician to suspect acute cholecystitis, especially if it has lasted for more than 5 hours (which rules out biliary colic) (Yamashita et al, 2007). In patients presenting with this pain, several conditions should be ruled out to ensure that the diagnosis is correct. These include, but are not limited to, abdominal aneurism, pregnancy, eclampsia, hepatitis, gastroenteritis, myocardial infarction, appendicitis, cholangitis, an obstruction of the small bowel, urinary tract infections and pancreatitis (Sherlock et al, 2002). A conclusive diagnosis can also be helped by imaging, with ultrasonography and nuclear medicine being the two best imaging styles (Yamashita et al, 2007). These will usually show both the gallstones and the related inflammation of acute cholecystitis (Sherlock et al, 2002). CT scanning and abdominal radiography can also be used in patients that are suspected of the condition but do not show any signs using the aforementioned imaging techniques (Ralls et al, 2005). Anatomy of billiary system The biliary system includes the bile duct, the pancreas and the liver (Yamashita et al, 2007) and forms part of the digestive system. It is responsible for the absorption of nutrients and the disposal of waste (Eldar et al, 1997). There are also a number of ducts involved in the biliary system. Together, these work to produce and store bile for release into the duodenum (Ralls et al, 2005). The pathway of the system is as follows. The hepatocytes of the liver produce the bile from waste products. This then flows through the hepatic duct and through the cystic duct which leads from the gallbladder (Eldar et al, 1997). These join to form the common bile duct, which in turn joins the pancreatic duct to empty the bile into the duodenum, where it is used for the emulsification of fats in the small intestine (Sherlock et al, 2002). (Image from http://www.diabetesmonitor.com/images/biliary_system.gif) Pathology In acute cholecystitis the gallbladder wall is edematous and is infiltrated by neutrophils (Lo et al, 1998). This can be caused by a number of things, such as a blocking of the bile duct leading to build up of bile causing infection and inflammation (Eldar et al, 1997). The serosa is usually beige in colour and granulated due to the presence of transmural inflammation (Lo et al, 1998). Under the microscope, the mucosa can appear to be partially eroded (Borzellino & Cordiano, 2008). The gallbladder itself may be filled with blood, bile and gallstones, which lead to the inflammation and pain commonly associated with acute cholecystitis (Lo et al, 1998). Role of imaging modalities in the diagnosis of Acute cholecystitis As previously mentioned, imaging modalities are very useful in the diagnosis of acute cholecystitis. The primary method of detection is ultrasound (Bortoff et al, 2000), although numerous other technologies can be used. Ultrasound usually finds a highly reflective echo from the anterior surface of the gallstone, mobility of the gallstone on moving the patient, and marked posterior acoustic shadowing (Bortoff et al, 2000). Additionally, the older but still effective technique of oral cholecystography can be used in many cases (Sherlock et al, 2002). Imaging modalities are extremely useful in many cases because symptoms can be non-existant or vague, as mentioned above, and the only conclusive proof of acute cholecystitis is an image showing the inflammation (Yamashita et al, 2007). In detection of choledocholithiasis, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography are superior to ultrasound (Bortoff et al, 2000) which leads to detection of the inflammation rather than just the gallstones which alone may not cause any symptoms. The image below shows an ultrasound image of acute cholecystitis. (Image from http://www.med-ed.virginia.edu/courses/rad/edus/text%20jpegs1/5b-AcuteChole-.jpg) Treatment and prognosis The treatment for mild cases of acute cholecystitis are generally a broad-spectrum antibiotic, usually administered intravenously. Bowel rest may also be recommended (Yamashita et al, 2007). Additionally, intravenous hydration and electrolyte treatment can be recommended. Operations to remove the offending gallstones is sometimes necessary in more severe cases of the illness, although this is rare (Sherlock et al, 2002). Analgesia is used to reduce the pain in the upper right quadrant that is caused by the affliction (South-Paul et al, 2010). Prognosis is generally very good for patients with acute cholecystitis. Full recovery is expected in the majority of patients with uncomplicated cases (Borzellino & Cordiano, 2008). It has a very low mortality rate (Yamashita et al, 2007). Most cases involve a complete remission within a few days (Sherlock et al, 2002). However, when there are complications, the prognosis is worse and mortality rates sharply rise, especially in cases involving gangrene or tissue necrosis (Borzellino & Cordiano, 2008). Complications may occur in up to 30% of cases, and of these the majority will require hospitalization and possible surgery (Eldar et al, 1997). Summary and Conclusion To summarize, acute cholecystitis is a fairly simple disease with a good prognosis. It is generally caused by a build up of bile due to a blocked bile duct from the presence of gallstones (Sherlock et al, 2002). It occurs more frequently in females than males, and becomes more common with increasing age (Eldar et al, 1997). It can usually be treated simply with antibiotics, although complications may require surgery and hospitalization (Eldar et al, 1997). Imaging techniques remain the only conclusive diagnosis method, although there are other ways to help rule out other diseases presenting with the same main symptoms. These symptoms are primarily pain in the upper right quadrant, although nausea, jaundice, vomiting and fever may also be present (Sherlock et al, 2002). References Bortoff, Gregory A., Michael Y. M. 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