Colelitiasis y colecistitis
ColelitiasisDefinición: Presence of stones in the gallbladder.
Risk factors for developing this disease include:
Age greater than 40, where the incidence is 4 times greater than the younger population (1).
Pregnancy is considered as a predisposing factor that increases the risk by up to 12% for multiparous (2 and 3).
Being a woman increases the risk ratio of 3 to 1 with respect to men primarily in the fourth decade of life (4-5-6).
The intake of oral contraceptives has also been associated with increased likelihood of developing gallstones (7-8).
Family history can be increased to twice the risk of developing this condition (9-10).
Obesity is also a predisposing factor involving their role in impaired cholesterol metabolism (11-12-13-14).
Diabetics, (15) cirrhotic patients, (16) and some medications such as octreotide and ceftriaxone and fibrates could be involved. (17-18-19)
In patients with Crohn's disease has increased the evidence (20-21)
Among the protectors to prevent the development of gallstones factors have been postulated statins (22-23), ascorbic acid, (24) Coffee moderate (25-26), and vegetable proteins (27).
Knowing these risk factors and protective factors the first pillar in the management of this disease is education.
Once diagnosed cholelithiasis patients can be classified into 4 groups:
Group 1: imagenological incidental in asymptomatic cholelithiasis.
Group 2: Patient with symptomatic cholelithiasis image without complications.
Group 3: Patient with Atypical image with cholelithiasis.
Group 4: typical image but symptomatic patient who does not show calculations
Those asymptomatic patients have a 20% risk of becoming symptomatic ever in life (28).
Among the complications that can have they are:
Acute cholecystitis in 10% of symptomatic to 10 years can present choledocholithiasis, cholangitis, of miritzzi syndrome, gallstone ileus, gallbladder cancer; asymptomatic patients generally have lower risk of developing complications versus symptomatic patient (29)
Biliary colic typically described as a deep pain in the right upper quadrant that may radiate to the back (30), associated with nausea and vomiting (31).
The trigger is associated with heavy meals that stimulate gallbladder contraction. Atypical symptoms can range from chest pain, diffuse abdominal pain, bloating, reflux symptoms until retro sternal pain.
As can be found paraclinical leukocytosis and elevated liver function tests.
Ultrasonography is the most sensitive test demonstrating acoustic shadows or biliary sludge (32-33) while the scenery may have a sensitivity up to 80% because calculations can be isodense bile (34-35-36-37).
There is an option diagnosed eco-endoscopy has better sensitivity than trans-abdominal ultrasound primarily in obese patients (38-39-40)
Among the differential diagnoses may be mentioned peptic ulcer disease, gastroesophageal reflux, functional disorders of the gallbladder, liver disease, sphincter of Oddi, pancreatitis, irritable colon, urolithiasis and acute myocardial infarction.
For patients in group 1 or asymptomatic, overall surgical management due to the low probability of becoming symptomatic (1% per year) is considered education as a pillar of handling only those with risk factors for complications, comorbidities is not recommended is considered individually cholecystectomy also taking into account the size of the calculi.
For group 2 patients with typical symptoms is considered hydration, pain management with analgesic, anti-inflammatory (41-42), opioids (43) and anticholinergic agents because they relax smooth muscle (controversial utility) (44).
Cholecystectomy is the definitive management and helps prevent future complications.
The existence of alternative substances such as solvents medical management can be an alternative for patients at high surgical risk. 600 mg ursodeoxycholic acid can reduce the risk of complications and cholecystectomy (45).
As for laparoscopic surgery technique is associated with shorter hospital stay, less disability, less post surgical pain and is more aesthetic front open cholecystectomy in different ways (46-47).
After surgery, over 92% of patients improve symptoms (48).
Surgical complications occur in 2.6% of laparoscopic cholecystectomy and includes biliary fistula, bile duct injury, intestinal perforation, and bleeding abdominal collections.
Group 3 or atypical symptoms in whom laparoscopic cholecystectomy is recommended but caution should be exercised in ruling out other causes that may explain the pain.
Group 4 with typical symptoms but definitely image cholelithiasis a functional assessment of the gallbladder must be performed with a scan demonstrating low ejection fractions vesicular serious for which definitive management laparoscopic cholecystectomy. If the functional test is normal be ruled differential diagnoses.
Special mention is biliary disease during pregnancy where the gallbladder motility decreases and increases the saturation of bile cholesterol (49-50).
The diagnosis is made by ultrasound with sensitivity and specificity close to 100% (51-52-53)
Among the differential diagnosis of pain in pregnant women must be taken into account HELP syndrome after 20 weeks, acute fatty liver, placenta abruption, uterine rupture, infection of the amniotic fluid and preeclampsia.
The management is based on pain management and surgical management. The surgery is not associated with increased risk of preterm birth (51-54-55-56).
The conservative medical management in pregnant women during the first and second quarters have more risk of complications (57), as relapse or exacerbation of the box up to 50% can lead to emergency surgery in 20% of patients treated medically. (58-59-60-61-62-63).
Surgical management for obstetric patient laparoscopic cholecystectomy because it offers recovery earlier, reduced post surgical pain, decreased opioid use, decreased risk of surgical wound infection, less risk of hernias and incisions smaller incisions and less uterine manipulation (64-65-66).
AgudaDefinición cholecystitis: The acute inflammation of the gallbladder.
It is characterized by right upper quadrant pain and inflammatory response. It can be a complication of cholelithiasis (67) or may not be associated with calculi in 10% of cases associating the latter to further complications (68).
Chronic cholecystitis refers to infiltration of chronic inflammatory cells and is given by recurrent exacerbations that ultimately lead to fibrosis and thickening of the gallbladder (69-70-71).
Semiologically often positive Murphy sign with a sensitivity of 97% and a specificity of 48% (72), in case of complications would have signs of sepsis, peritonitis, crackled (in case of emphysematous cholecystitis), intestinal obstruction (ileus -biliar) syndrome miritzzi of bouveret (calculation impacted pylorus or duodenum) and cholangitis syndrome.
The diagnosis is confirmed by ultrasound with greater thickened 4mm wall or double wall image giving a positive sonomurphy edema is the replica of the physical examination ultrasound ultrasound reaches 88% sensitivity and 80% specificity (73-74-75- 76-77).
The Cholescintigraphy (HIDA SCAM) using technetium 99 and inminoacetico acid is injected intravenous, is taken up by hepatocytes and excreted in the bile, this test is useful for the integrity of the bile duct with sensitivity and specificity of 97% and 90 % (76 -78).
The resonance cholangiopancreatography evaluates the integrity of the intra and extra hepatic bile duct and is sensitive to evaluate the bile duct (79).
The abdominal CT is useful for evaluating the complications of acute cholecystitis as drilling, emphysematous cholecystitis and differential diagnoses (80-81-82-83).
The definitive management is laparoscopic cholecystectomy.
Always consider the individualization of each case taking into account the specificities, co-morbidities, beliefs of each patient, offering the best available evidence for management.
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