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. 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