Akut Taşlı Kolesistit Tanı ve Tedavi Yaklaşımı
Özet
Akut taşlı kolesistit, genellikle sistik kanalın bir safra taşı tarafından tıkanması sonucu gelişen safra kesesinin akut inflamasyonudur. Safra taşı varlığı hastaların büyük çoğunluğunda ultrasonografi ile saptanır. Hastalık tipik olarak sağ üst kadranda 4-6 saatten uzun süren şiddetli ağrı, ateş, bulantı ve pozitif Murphy işareti ile kendini gösterir. Tanı sürecinde klinik muayene, laboratuvar testleri ve ilk tercih olarak transabdominal ultrasonografiyi içeren sistematik bir yaklaşım uygulanır. Tedavide hastaların hastaneye yatırılarak intravenöz sıvı, analjezik ve en sık izole edilen gram-negatif aeroblar ile anaeroblara yönelik ampirik antibiyotik tedavisiyle desteklenmesi esastır. Akut taşlı kolesistitin cerrahi standardı erken dönemde uygulanan laparoskopik kolesistektomidir; bu yöntem açık cerrahiye kıyasla daha kısa hastanede kalış süresi ve daha düşük morbidite avantajı sunar. Cerrahi açıdan yüksek riskli olan veya ileri evre organ disfonksiyonu bulunan hastalarda ise perkütan kolesistostomi veya endoskopik safra kesesi drenajı gibi alternatif tedavi yöntemleri başarıyla tercih edilmektedir.
Acute calculous cholecystitis is an acute inflammation of the gallbladder, typically triggered by the obstruction of the cystic duct by a gallstone. The presence of gallstones is detected via ultrasonography in more than ninety percent of cases. Patients characteristically present with severe right upper quadrant pain lasting more than four to six hours, fever, nausea, and a positive Murphy's sign. Diagnosis requires a systematic, multifactorial approach integrating clinical examination, serological tests, and transabdominal ultrasonography as the primary imaging modality. Initial management focuses on hospitalization, intravenous fluid resuscitation, analgesia, and empirical antibiotic therapy targeting the most common gram-negative aerobes and anaerobes. Laparoscopic cholecystectomy represents the gold standard for surgical treatment and should ideally be performed early, offering shorter hospital stays and lower complication rates compared to open surgery. For critically ill individuals or high-risk surgical patients, alternative minimally invasive gallbladder drainage techniques, such as percutaneous cholecystostomy or endoscopic drainage, are effectively utilized to resolve the acute infection.
Referanslar
Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172-87.
Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin North Am. 2010;39(2):157-69, vii.
Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci. 2007;52(5):1313-25.
Ambe PC, Papadakis M, Zirngibl H. A proposal for a preoperative clinical scoring system for acute cholecystitis. Journal of Surgical Research. 2016;200(2):473-9.
Jones MW, Genova R, O'Rourke MC. Acute cholecystitis. 2017.
Yusoff IF, Barkun JS, Barkun AN. Diagnosis and management of cholecystitis and cholangitis. Gastroenterology Clinics. 2003;32(4):1145-68.
Hirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K, et al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. Journal of hepato-biliary-pancreatic surgery. 2007;14(1):78-82.
Zakko SF, Afdhal N. Acute calculous cholecystitis: Clinical features and diagnosis. Official reprint from Up To Date. 2019.
Singer AJ, McCracken G, Henry MC, Thode Jr HC, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Annals of emergency medicine. 1996;28(3):267-72.
Adedeji O, McAdam W. Murphy's sign, acute cholecystitis and elderly people. Journal of the Royal College of Surgeons of Edinburgh. 1996;41(2):88-9.
Wertz JR, Lopez JM, Olson D, Thompson WM. Comparing the diagnostic accuracy of ultrasound and CT in evaluating acute cholecystitis. AJR American journal of roentgenology. 2018;211(2):W92.
Kiewiet JJ, Leeuwenburgh MM, Bipat S, Bossuyt PM, Stoker J, Boermeester MA. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012;264(3):708-20.
Liu C-L, Lo C-M, Chan JK, Poon RT, Fan S-T. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis. Gastrointestinal endoscopy. 2000;51(1):28-32.
Miura F, Okamoto K, Takada T, Strasberg SM, Asbun HJ, Pitt HA, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. Journal of Hepato‐biliary‐pancreatic Sciences. 2018;25(1):31-40.
Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, et al. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). Journal of hepato-biliary-pancreatic sciences. 2013;20(1):35-46.
Miura F, Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gouma DJ, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. Journal of hepato-biliary-pancreatic sciences. 2013;20(1):47-54.
Ansaloni L, Pisano M, Coccolini F, Peitzmann A, Fingerhut A, Catena F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World journal of emergency surgery. 2016;11(1):1-23.
Dyrhovden R, Øvrebø KK, Nordahl MV, Nygaard RM, Ulvestad E, Kommedal Ø. Bacteria and fungi in acute cholecystitis. A prospective study comparing next generation sequencing to culture. Journal of Infection. 2020;80(1):16-23.
Bogacki P, Krzak J, Gotfryd-Bugajska K, Szura M. Evaluation of the usefulness of the SAGES Safe Cholecystectomy Program from the viewpoint of the European surgeon. Videosurgery and Other Miniinvasive Techniques. 2020;15(1):80.
Mou D, Tesfasilassie T, Hirji S, Ashley SW. Advances in the management of acute cholecystitis. Annals of gastroenterological surgery. 2019;3(3):247-53.
Vollmer CM, Zakko SF, Nezam HA. Treatment of acute calculous cholecystitis. Up To Date (http://www uptodate com/contents/treatment-of-acute-calculous-cholecystitis. 2016.
Pisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World journal of emergency surgery. 2020;15(1):1-26.
Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. Journal of gastrointestinal surgery. 2006;10(7):1081-91.
Giger U, Michel J, Vonlanthen R, Becker K, Kocher T, Krähenbühl L. Laparoscopic cholecystectomy in acute cholecystitis: indication, technique, risk and outcome. Langenbeck's archives of surgery. 2005;390(5):373-80.
Peker Y, Ünalp HR, Durak E, Karabuga T, Yilmaz Y, Genç H, et al. Laparoscopic cholecystectomy in patients aged 80 years and older: an analysis of 111 patients. Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 2014;24(2):173-6.
Catani M, De Milito R, Romagnoli F, Silvestri V, Usai V, Modini C, editors. Laparoscopic approach to the acute cholecystitis in pregnancy. Geneve: Act of the Congress: 18th International Congress of the EAES; 2010.
de Goede B, Klitsie P, Hagen S, Van Kempen B, Spronk S, Metselaar H, et al. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Journal of British Surgery. 2013;100(2):209-16.
Sabour AF, Matsushima K, Love BE, Alicuben ET, Schellenberg MA, Inaba K, et al. Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis. Surgery. 2020;167(3):569-74.
Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database of Systematic Reviews. 2013(6).
Krishnamoorthi R, Jayaraj M, Chandrasekar VT, Singh D, Law J, Larsen M, et al. EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Surgical endoscopy. 2020;34(5):1904-13.
