Acute Cholecystitis in a Large Calculous Gall Bladder with Multiple

CASE REPORT / OLGU SUNUMU
2014
Acute Cholecystitis in a Large Calculous Gall Bladder with Multiple
Polipozis
Çoklu Polipli, Taşlı Büyük Safra Kesesinde Akut Kolesistit
AUTHORS /
YAZARLAR
Muhteşem Erol
Yayla
Family Medicine
Specialist, 5th Family
Medicine Center,
Afyon,Turkey
ABSTRACT
Acute cholecystitis is an acute inflammatory disease of the gallbladder. More than 90% of
cases of acute cholecystitis are associated with cholelithiasis. As in our case, a palpable mass is
present in one quarter of patients after 24 hours of symptoms. Ultrasonography detects
cholelithiasis in about 98% of patients. Gallbladder polyps are often detected incidentally.
About 5% of the healthy population is expected to have gall bladder polyps. The risk of
malignancy is increased in polyps with diameters of 10 mm or greater, patients aged over 50
years, coexisting gallstones and rapid growth of polyps. We would like to represent a case of
acute calculous cholecystitis with multiple polyps and large gall bladder in an elderly patient.
Keywords: cholecystitis, polyps, cholelithiasis
ÖZET
Akut kolesistit safra kesesinin akut inflamatuar hastalığıdır. Akut kolesistitli vakaların
%90’ı taşlı kolesistittir.Vakamızda olduğu gibi, 24 saat süren semptomlar sonrası dörtte bir
hastada palpe edilebilen bir kitle oluşur. Ultrason %98 hastada kolelityazisi saptar. Safra kesesi
polipleri ise sıklıkla rastlantısal olarak saptanır. Sağlıklı populasyonun %5’inde safra kesesi
polibi olması beklenir. 10 mm ve üstü, 50 yaş üstü ve eşlik eden safra kesesi taşları ve hızlı
büyüyen poliplerde malignensi riski artmıştır. Bu vakada, yaşlı bir hastada multipl polipli, taşlı
ve büyük safra keseli kolesistit olan bir hastayı sunmayı amaçladık.
Anahtar kelimeler: kolesistit, polipler, kolelityazis
Introduction
Acute cholecystitis is an acute inflammatory disease of the gallbladder (1). More
than 90% of cases of acute cholecystitis are associated with cholelithiasis. The
gallbladder becomes enlarged, tense, and reddened with inflammation and wall
thickening and an exudate of pericholecystic fluid may develop. The inflammation is
sterile at first in most cases, but secondary infection of Enterobacteriaceae or
enterococci family or anaerobes occurs in the majority of patients (2,3).
The main symptom of uncomplicated cholelithiasis is biliary colic, caused by the
obstruction of the gallbladder neck by a stone. Mild impaction may cause pain only, but
if impaction is lasting for many hours, an inflammation can occur. The pain is
characteristically episodic, severe, and located in the epigastrium or right upper
quadrant. Patients commonly have pain that radiates into the back, accompanied by
nausea and vomiting. Acute cholecystitis usually begins with an attack of biliary colic,
often in a patient who has had previous attacks, but the pain persists and is localized in
the right upper quadrant (4).
Corresponding Author / İletişim için
Dr. Muhteşem Erol Yayla
Family Medicine Specialist, 5th Family Medicine Center, Afyon,Turkey
E-mail:[email protected]
Date of submission: 13.11.2013 / Date of acceptance: 08.04.2014
116 Euras J Fam Med 2014; 3(2):116-118
Case
Patient was 83 years old female. She was having
abdominal pain for 3 days, and began vomiting at the
day of attending to Sultandağı State Hospital. There
was no blood, but bile with a yellowish brown colour
in vomiting material. She had no diarrhea and she
was constipated for 2 days. She had mild jaundice in
appreance. She had intense tenderness with deep and
superficial palpation, escipecially on the right upper
quadrant of abdomen. A mass with indistinct borders
was palpated in the abdomen.
An abdominal ultrasonographic image shows a
gall bladder with dimentions of 10.5x5.6x7.7 mm. On
the image multipl polyps were detected and the gall
bladder wall thickness was over 5 mm. Neither gall
bladder neck nor pancreas could be imaged. She is
thought to have acute cholecystitis. She was referred
to the hospital afterwards where the cholecystectomy
was performed. No complication has occured after
cholecystectomy and she was discharged after 2 days
of hospitalization.
Image 1. Ultrasonographic image of the case
Discussion
Most patients with gallstones are asymptomatic.
Biliary colic develops in 1 to 4% annually in those
patients, and acute cholecystitis eventually develops
in about 20% of these symptomatic patients if they
are left untreated. Such patients tend to be older than
those with uncomplicated symptomatic cholelithiasis
(5-8). Our patient’s age was consistent with this
literature information.
Tenderness and guarding in the right upper
quadrant are frequent signs. As in our case, a palpable
mass is present in one quarter of patients after 24
hours of symptoms but is rarely present early in the
clinical course. Murphy’s sign may be useful,
particularly when direct tenderness is absent
(Murph’s sign: the arrest of inspiration while
palpating the gallbladder during a deep breath).
Occasionally, acute cholecystitis may cause systemic
sepsis and organ failure, usually in the setting of
gangrenous or emphysematous cholecystitis. Fever
and an elevation in the white cell count are classically
described in patients with acute cholecystitis, but
either or both may be absent (9). In elderly patients,
delays in diagnosis are common and physical
examination and laboratory findings may be normal
(10). Even if our patient was old, white cell count
was high, symptoms was mild for a cholecystitis with
a gall bladder of this dimention.
Ultrasonography detects cholelithiasis in about
98% of patients. Acute calculous cholecystitis is
diagnosed radiologically by the concomitant presence
of thickening of the gallbladder wall (5 mm or
greater), pericholecystic fluid, or direct tenderness
when the probe is pushed against the gallbladder
(ultrasonographic Murphy’s sign) (4).
Gallbladder polyps are often detected incidentally
and they are more frequently encountered with the
increased use of ultrasonography. About 5% of the
healthy population is expected to have gall bladder
polyps (11). The risk of malignancy is increased in
polyps with diameters of 10 mm or greater, age over
50 years, coexisting gallstones and rapid growth of
polyps (12). Polyp size greater than 10 mm is the
most established predictor of malignancy; and in
polyps less than 10 mm in diameter, the risk of cancer
is minimal (13-16). Multiple polyps in our case
exposed in a pathology specimen. None of them was
over 10 mm in diameter. Yet pathologic microscobic
examination was performed due to coexisting gall
stones and old age of patient and no malign cell was
encountered.
117
Yayla ME. Acute Cholecystitis in a Large Calculous Gall Bladder with Multiple Polipozis
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