CHOLECYSTITIS AND CHOLELITHIASIS

History:
     RISK FACTORS = Fair, fat, female, fertile > 40
     Biliary Colic = constant, RUQ pain, after meals, radiates to scapula, abrupt onset
     Low grade fever 99 -101F
     Nausea, vomiting, anorexia
     Fatty food intolerance, dark urine, clay colored stools
     Bloating, Jaundice, Flatulence, Obesity 
     Hx of Gallstones
     Hx of alcohol ingestion
     High Fat diet, estrogen therapy, diabetes
     Charchot's Triad = RUQ pain, jaundice, fever & chills = ascending cholangitis

Physical Exam
     General = Obese, restless
     Vitals = mild tachycara, Low Grade fever, Shallow respirations, Hypotension
     HEENT: Sclera icterus, jaundice
     Abdomen = Epigastric or RUQ tenderness, guarding, ridgidity, rebound
      **MURPHY'S SIGN = increased tenderness & insp. Arrest during deep RUQ palpation

Labs:
     Moderate Leukocytosis
     Mild Bilirubin elevation
     Increased Alk Phos, AST and Amylase

Imaging:
     GB Ultrasound = GB dialted with stones, Bile duct wall thickening, Liver abcess
                    Gas in biliary tree
     HIDA Scan = + if GB doesn't visualize in 4 hrs with radionucleotide in common duct
          ** Useful if Bilirubin < 9
          ** False + if patient hasn't eaten in 48 hrs
     Plain Abd. X-Ray = Enlarged GB shadow, Calcifications in GB
          ** Mercedes Benz Sign = gallstones appear as radiolucent clefts
          ** Air in GB wall = emphysematous cholecystitis
          ** Biliary Tree Air = cholcystenteric fistula

Differential Diagnosis:  
     Cholecystits, cholangitis, peptic ulcer, pancreatitis, appendicitis, GERD, hepatitis,
     nephrolitiasis, pyelonephritis, hepatic mets, gonococcalperihepatitis, pneumonia, angina

Complications:
     Perforated GB, cholangitis, cholecystenteric fistula, gallstone ileus, choledocolithiasis

TREATMENT OPTIONS:
1. Remove GB during acute stage (open or laparoscopic cholecyctectomy with IOC)
2. Conservative Therapy followed by elective cholecystectomy
     Antibiotics:
          1. Gentamicin 1.5 - 2 mg/kg then 2-5mg/kg/d IV 
                    and 
              Metronidazole 1.0 g over 1h, then 500 mg IV q6h
          2. Unasyn 1.5 - 3 g IV q6h
     3. Timentin 3.1g IV q4-6h
     4. Zosyn 4-5g IV q6h
     