Acute cholecystitis

The patient's symptoms are those of biliary colic (13.2), but they last more than 24 hours. To begin with they are due to a chemical inflammation caused by concentrated bile under pressure, but bacterial infection may follow. He has a 95% chance of recovering in 10 days, even without treatment. There is a 5% chance that the infection will spread to his smaller bile-ducts (cholangitis), or that he will develop peritonitis from a perforation of his gall-bladder.

Operate if: (1) he has cholangitis which is threatening his life, or (2) his gall-bladder forms a gradually enlarging acute inflammatory mass. It will be acutely inflamed, oedematous, and perhaps gangrenous, so don't try to remove it. Instead, drain it (cholecystostomy). This may save his life and is simple and safe, but it will seldom cure him permanently, so you will probably have to refer him for cholecystectomy later.

Acute on chronic cholecystitis (relapsing cholecystitis, recurrent biliary colic) is usually less severe than a typical acute attack, and is one of the more common kinds of gall-bladder disease. His symptoms may subside without infection and leave his gall-bladder distended with mucus (mucocoele of the gall-bladder), or it may distend with pus and perhaps burst (empyema of the gall-bladder).

FORCEPS, gallstone, Desjardin's, one only. Use these long slender forceps for removing stones from the biliary system.

Fig 13-1 CHOLECYSTOSTOMY. A, the incision. B, the purse string suture inserted. C, aspirating the gall-bladder. D, removing stones. E, inserting a Foley catheter. Kindly contributed by Gerald Hankins.

ACUTE CHOLECYSTITIS SIGNS. The patient is febrile, looks sick, and lies still. Tenderness is well localized in his right upper quadrant. He may be exquisitely tender (unlike biliary colic), and show guarding and rigidity. Murphy's sign is usually positive (13.2). A well-localized mass usually forms a few days after the start of his attack, just below his right costal margin. Mild jaundice does not always mean that his common duct is obstructed by a stone.

If he has jaundice, swinging fever, chills and rigors, suspect that his cholecystitis is complicated by cholangitis.

SPECIAL TESTS. His serum bilirubin and alkaline phosphatase will probably be slightly raised, and his total white count markedly so.

X-RAYS are less useful than ultrasound. Vomiting will make it impossible for him to take contrast medium by mouth.

THE DIFFERENTIAL DIAGNOSIS includes amoebic liver abscess (31.12), perforated peptic ulcer (11.2), acute pancreatitis (13.9), acute pyelonephritis, and volvulus of his small gut with strangulation (10.9).

NON-OPERATIVE TREATMENT [s7]FOR ACUTE CHOLECYSTITIS This is only safe if you are sure of the diagnosis.

Analgesics are needed, because his pain is severe. So give him enough pethidine (avoid morphine because it may increase the pain of biliary colic), if necessary 4-hourly for 24 hours.

Nasogastric suction is not essential, but it will keep his stomach empty and so relieve his nausea and vomiting.

Rehydration may be necessary. Correct his initial fluid loss with saline, and then give him his daily fluid requirements (A 15.3).

Antibiotics are less necessary than you might expect, because the inflammation in his gall-bladder is predominantly chemical. Give him chloramphenicol, ampicillin, or tetracycline.

Continue this treatment for 3 or 4 days, and then start to feed him. His symptoms should start to improve in 24 hours, and he should be symptom free in 3 weeks. Advise him to take a low- fat diet, and refer him for an interval cholecystectomy after about two months.

CHOLECYSTOSTOMY [s7]FOR ACUTE CHOLECYSTITIS INDICATIONS. Drain his gall-bladder if: (1) intense pain persists, (2) swinging fever continues with tachycardia, (3) his abdominal tenderness gets worse, the area of guarding extends, or the mass increases in size, or (4) he has rigors and deepening jaundice, indicating cholangitis.

EQUIPMENT. If you don't have Desjardin's stone forceps, a Fogarty balloon catheter, pushed past the stone, inflated, and withdrawn is often effective. You may possibly be able to use a tiny Foley catheter. Sponge forceps are much less satisfactory. Find two assistants in addition to the trolley nurse.

ANAESTHETIC. (1) General anaesthesia, intubation, and relaxants. If he is very sick or very old you can operate under local anaesthesia.

INCISION. Feel for the area of maximum tenderness, an ill-defined mass, or both (A, in Fig. 13-1). Centre the incision over this area, and cut through all layers of his abdominal wall. Or, do an upper median or paramedian incision. You will probably find his gall-bladder easily. If you don't find it, carefully separate the adherent omentum and transverse colon by pushing them away with your finger. Pack large swabs (''lap pads') round his gall-bladder carefully; it easily ruptures and spills infected bile into his peritoneal cavity.

If the structures below the right lobe of his liver are matted together in an oedematous haemorrhagic mass, so that his gall bladder is difficult to find, insert your hand over the upper surface of his liver, and draw your fingers down until you reach its edge. Then move your hand medially over the convex surface of his liver until you reach his falciform ligament, joining his liver to his diaphragm. At its lower edge is his ligamentum teres. About 5 cm to the right of this, you should be able to feel the tense, turgid, elongated mass of his fiery- red, acutely inflamed, oedematous, and perhaps partly necrotic gall-bladder.

Try to expose enough of the fundus of his gall-bladder to allow you to drain it. Use your finger, or a ''swab on a stick' (4-8), to carefully ''peel' away his omentum, the hepatic flexure of his colon, and his transverse mesocolon. Avoid sharp dissection. If he bleeds, control it with packs.

If you don't find a tense inflamed gall-bladder when you operate, look for acute pancreatitis (13.9), a liver abscess (31.12) or a localised perforation of a peptic ulcer (11.2) etc.

Surround the exposed area of his gall-bladder to minimize spillage. Insert a purse string suture of 2/0 chromic catgut (B). Plunge a trocar and cannula, attached (if you have the kind with a side tube) to a sucker, through the purse string (C). Withdraw the trocar far enough to allow you to aspirate his gall- bladder, milking any remaining exudate up towards the suction. When you have sucked his gall-bladder empty, take a swab from the wall for culture. Feel for gallstones. Expect to find them in Hartmann's pouch (13-3), near the point where his gall- bladder joins his cystic duct. Gently try to get your hand into a position where it can palpate this area comfortably, taking care not to tear his gall-bladder.

Use scissors to enlarge the opening to 1.5 cm. Feel for stones with a pair of Desjardin's stone forceps or sponge- holding forceps. Guide the stones into the jaws of the forceps (D) with your fingers outside his gall-bladder.

CAUTION ! Don't try to remove stones which are too tightly wedged lower down. You may do much damage. Leave them. They may free themselves later: if they don't they can be removed later at an interval cholecystectomy.

Insert a 20 to 26 Ch Malecot, de Pezzer, or Foley catheter, into his gall-bladder. Tie the purse string snugly around it (E), and apply a second one 5 mm away from the first. Bring the tube out through a separate stab incision. Irrigate the wound with saline, close it in a single layer (9.8), and leave his skin unsutured for delayed primary closure.

Pass a piece of silk around the catheter at least twice, and suture it to his skin. Attach it to a bottle for drainage.

POSTOPERATIVELY, expect bile to start draining in a day or two. Remove the tube in 10 to 15 days. If it is still discharging, he can go home for a few weeks with it in place. The fistula will slowly close unless a stone has been left in Hartmann's pouch (when a small mucous fistula will result). Warn him that his underlying disease has been relieved, not cured. Refer him to an expert for cholecystectomy about 2 months later.