~Teachingcenter的醫學筆記~

急性膽囊炎的診斷(Tokyo guidelines, 2018)
Diagnostic Criteria for Acute Cholecystitis (Tokyo guidelines)

● 臨床表現Clinical manifestation：
 A.局部發炎症狀(symptoms and signs of local inflammation)
    (1) Murphy’s sign
    (2) RUQ mass/pain/tenderness
 B.全身性發炎症狀(signs of systemic inflammation)
    (1) Fever
    (2) Leukocytosis
    (3) Elevated CRP
 C. 影像學發現(imaging findings)
    在US、CT、Tc-HIDA scan、MRI影像上發現
    -膽囊周圍積液(pericholecystic fluid)
    -膽囊結石/膽囊內壞死組織(gallstones/debris)
    -膽囊壁增厚等發炎情形

● 確診Definite diagnosis：
 (1) 有一個A加一個B就要安排影像學檢查
 (2) 影像學確診
(C confirms the diagnosis when acute cholecystitis is suspected clinically)

補充：
=若當下無法確診，可於每6~12小時再檢查一次
=發炎3~7天內，且風險低的病人，建議盡早腹腔鏡切除膽囊
=高風險的病人，則建議PTGBD (percutaneous transhepatic gallbladder drainage)或內視鏡引流(endoscopic drainage (either via EUS or ERCP))
=抗生素的選擇應基於疾病的嚴重程度給予

常見造成膽囊炎的細菌(Typical bacteria causing cholecystitis)：
 1. E. coli
 2. Klebsiella
 3. Enterococcus
 4. Pseudomonas
 5. Enterobacter

急性膽囊炎的嚴重度分級

Severity Grading of Acute Cholecystitis, Tokyo guidelines (2018)

● Mild (Grade I)：
- Symptoms do not meet the criteria for a more severe grade
- Mild gallbladder inflammation, no organ dysfunction
→ Early laparoscopic cholecystectomy is recommended.
→For high risk patients (CCI ≥6, ASA ≥3), conservative treatment can be considered initially (antibiotics, supportive care), with operation once clinical response achieved.
● Moderate (Grade II)：
- Presence of one or more of the following：
…(1) Leukocytosis (WBC >18000/ul)
…(2) Palpable tender mass in the RUQ(Courvoisier's sign)
…(3) Duration of complaints > 72h
…(4) Marked local inflammation (biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis)
→ Recommendation：
…(1) Early or delayed cholecystectomy (Laparoscopic surgery should be performed by a highly experienced surgeon within 96 h of the onset of acute cholecystitis)
…(2) Urgent/early GB drainage (PTGBD), then delayed cholecystectomy or early operation for patients in whom PTGBD treatment fails.
→ In high risk patients (CCI ≥6, ASA ≥3), gallbladder drainage should be considered early with delayed/elective operation.
● Sever (Grade III)：
- Presence of one or more of the following：
…(1) Cardiovascular dysfunction (hypotension requiring treatment with dopamine >= 5ug/kg/min, or any dose of dobutamine)
…(2) Neurological dysfunction (decreased level of consciousness)
…(3) Respiratory dysfunction (PaO2/FiO2 ratio < 300)
…(4) Renal dysfunction (oliguria, creatinine > 2.0 mg/dL)
…(5) Hepatic dysfunction (PT-INR > 1.5)
…(6) Hematological dysfunction (PLT count < 100000/uL)
→ Urgent /early GB drainage (PTGBD)
→ Surgery is reserved for patients in whom PTGBD treatment fails.
→ Resuscitative measures should be initiated at first with antibiotics, fluid resuscitation and vasopressor/respiratory support as needed.

PTGBD的適應症：
●無法接受全身麻醉的病人
(Contraindications to general anesthesia)
●嚴重的膽囊炎(合併器官衰竭)
(Severe cholecystitis (with organ failure))
●嚴重發炎超過72小時
(Late presentation (>72 hours after onset of symptoms))
●內科治療(抗生素)失敗
(Failure of medical (antibiotic) therapy)

PTGBD約可以緩解90%急性膽囊炎病人的病情，膽囊的引流減壓可以舒緩局部和全身性的發炎反應，而在引流後決定膽囊切除的時機，通常會安排在六周以後，但如果病情惡化，則會安排在六周內緊急切除膽囊