 So yesterday we spoke about the complications of gallstones. Now, one of the most common complications that we would see in the QK Surgery Unit at Critiscute Hospital is of course acute colisostitis. That is where the stone usually gets lodged where the gallbladder goes over into the cystic duct. It is unlike biliary colic in that that stone really stays there and inflammation starts sitting in. That stone is stuck there. You start getting a demer of the wall of the gallbladder itself and with that engorgement you get a little bit of venous congestion as well. You get infiltration of your immune cells and you get patchy necrosis even as the blood struggles to flow properly through that area. So that's acute inflammation. About 50 to 75% of cases will actually have bacterial overgrowth, remember that. And then most of the time we will see negative bacilli although we do see some streptococcus regalis at times in certain circumstances. So that's the definition really. It's that gallstone getting stuck there is the most common cause of it. Of course we call it properly in Humus 2-2, calculus colisostitis. Acute calculus colisostitis because of course you get the ray A-calculus and that's not what we're talking about. And so it's a gallstone colisostitis acute biliary colisostitis. Acute gallstone colisostitis. Now who are the people that you should look out for? So imagine you are confronted with this question and exam. You might be given a clinical scenario or you might just be asked do you talk about acute colisostitis? Depending on what system your medical education is all about. So if you were just to talk freely about acute colisostitis first of all what patients should you look out for? Well there's definitely with us at least a preponderance to the female population. They're usually in the middle ages, slightly younger although we see all age ranges I must say of acute colisostitis from early 20s right until our elderly population. So we really see it in a whole spectrum of ages. Some of the patients are slightly overweight. I'm not going to put this down as a disease of obesity really. We see patients with absolutely normal weight and see patients with slight overweight. So it's not very clear why some people will then develop gallstones and then colisostitis. Remember the vast majority of people with gallstones as we discussed yesterday they get an ultrasound and we pick up these gallstones but those are totally asymptomatic or we pick up many asymptomatic gallstones these days for ultrasounds for other reasons. So why some of them would go on to develop biliary colic and then acute colisostitis we don't know. So from biliary colic obviously you do get the colisostitis and the incidence is about I would say 2% more per year so if you have a slightly younger patient with gallstones the chances of getting acute colisostitis are much higher because still probably a long time to live in an older population with that sort of incidence per year perhaps not. So that's the patient population that we're really looking out for. So what do these patients present with? Well they've got pain in the right upper quadrant. Some in the epigastrium, some towards the back, some towards the shoulder should just watch out. It's not always specific and remember the elderly, the diabetics, immunocompromised patients they might not have a lot of symptoms at all but let's stick to the normal. You're going to have a right upper quadrant pain, epigastric pain and that pain persists for a couple of, not just a couple of hours like the biliary colic and then disappears, it really lasts for hours and then into days even before they really come to us. So they've got this pain, they're nauseous with it or nauseated with it and they feel like vomiting as well. So really feel ill when you take their temperature of course their temperature is elevated. The majority of the time they have a bit of a tachycardia. They're a bit dehydrated because they really don't feel like eating. And the first thing we would do for them is a symptomatic relief and putting up an intravenous line. You've got to check their electrolytes and then tailor your intravenous fluids and you've got to let them take fluids already but an intravenous line and some analgesia. They really need some good proper analgesia. The blood test that we do, we would do a full blood count and you are going to see a raised white cell count and the majority of that's going to be neutrophils and you might see a bit of raised urea on your urea and electrolytes as the patients are slightly dehydrated and then on the liver function tests, you might see nothing. We see a lot of patients with normal liver functions but some of them will have their cellular enzymes raised some of them will have their alkaline phosphatase raised and the bilirubin must be normal. Once the bilirubin goes up, we're talking extroperic biliri obstruction. So that should really be normal. And we confirm the diagnosis now, on the right hand's at least, just with an ultrasound. Now when you examine these patients, you can elicit a Murphy's sign remember they'll be tender and they write up a quadrant so you put your hand underneath their upcage on the right hand side and ask them to slowly breathe in and as you breathe in, your diaphragm's moved down the liver moves down, pushes the gallbladder down and pushes that gallbladder, the tender gallbladder into your hand and that causes pain and they stop. Now on the ultrasound, you get an ultrasonic Murphy's sign because the probe can see where the gallbladder is and press exactly on that, so that's a very good one. So on the ultrasound, we're going to see stones the acoustic shadow of those stones we're going to see thickening of the wall of the gallbladder we might even see some pericolor cystic fluid. So that's how we make our diagnosis. Now in some areas, they also do a Hyda scan that's from Nuclear Medicine. Remember that a normal cystic duct will then show up the cystic duct is not obstructed by the stone but by the acute color cystitis, the whole gallbladder will fill up nicely on the Hyda scan. If not, then you know there's an obstruction and you can also diagnose acute color cystitis. Remember, patients who haven't eaten for a while we might get some false results and the patients who haven't eaten for a while so an intensive care unit that doesn't really work. So how do we treat these patients then? Once confirmed, remember they've got the IV line they've got the analgesia, we add antibiotics for them. Now the main step of therapy is the surgery. We have to go for color cystectomy. The vast majority of them, if all else is fine no recent heart attack or anything else wrong if at all possible we do a color cystectomy and we try to do a color cystectomy as soon as possible. Now within about three days to a week that's a very bad surgical period. Remember the inflammation is at its worst and your complication rate is definitely going to be slightly higher although there are people who are reporting that the incidence of complications are not higher. In our circumstances these patients come in late and our theaters are over booked so it's very difficult to do a color cystectomy a laparoscopic color cystectomy in the acute stage so we usually treat them with antibiotics and until they get better send them home and bring them back for an elective procedure six weeks later. But the ideal would be a patient comes in early and they have their color cystectomy immediately. Now for those patients who are too late we treat them in antibiotics and they don't get better. For them we put in a percutaneous color cystectomy tube. It's sort of a new thing. We don't exactly know what the place of it is how long to keep it in what to do with it afterwards and so we are busy with a research project in my research unit just looking at what happens to these patients with the percutaneous drains. We also put the percutaneous drains in the gallbladder of course for the patients who are so ill and they have other comorbidities and they cannot go to theater. So in a nutshell that is a cute calculus color cystitis.