java barcode reader library open source ACUTE CHOLECYSTITIS in Objective-C

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ESSENTIALS OF DIAGNOSIS
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Steady, severe pain and tenderness in the right hypochondrium or epigastrium
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Liver, Biliary Tract, & Pancreas
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Nausea and vomiting Fever and leukocytosis
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presence of gallstones but is not sensitive for acute cholecystitis (67% sensitivity, 82% specificity); findings suggestive of acute cholecystitis are gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy s sign
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Cholecystitis is associated with gallstones in over 90% of cases It occurs when a stone becomes impacted in the cystic duct and inflammation develops behind the obstruction Acalculous cholecystitis should be considered when unexplained fever or right upper quadrant pain occurs within 2 4 weeks of major surgery or in a critically ill patient who has had no oral intake for a prolonged period; multiorgan failure is often present Primarily as a result of ischemic changes secondary to splanchnic vasoconstriction or intravascular coagulation, gangrene may develop, resulting in perforation Although generalized peritonitis is possible, the leak usually remains localized and forms a chronic, wellcircumscribed abscess cavity Acute cholecystitis caused by infectious agents (eg, cytomegalovirus, cryptosporidiosis, or microsporidiosis) may occur in patients with AIDS
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Differential Diagnosis
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The disorders most likely to be confused with acute cholecystitis are perforated peptic ulcer, acute pancreatitis, appendicitis in a high-lying appendix, perforated colonic carcinoma or diverticulum of the hepatic flexure, liver abscess, hepatitis, pneumonia with pleurisy on the right side, and even myocardial ischemia Definite localization of pain and tenderness in the right hypochondrium, with radiation around to the infrascapular area, strongly favors the diagnosis of acute cholecystitis True cholecystitis without stones suggests the rare possibility of polyarteritis nodosa affecting the cystic artery
Complications
A Gangrene of the Gallbladder
Continuation or progression of right upper quadrant abdominal pain, tenderness, muscle guarding, fever, and leukocytosis after 24 48 hours suggests severe inflammation and possible gangrene of the gallbladder Necrosis may occasionally develop without definite signs in the obese, diabetic, elderly, or immunosuppressed patient Other serious acute complications include gallbladder perforation (usually with formation of a pericholecystic abscess), emphysematous cholecystitis (secondary infection with a gas-forming organism), and empyema
Clinical Findings
A Symptoms and Signs
The acute attack is often precipitated by a large or fatty meal and is characterized by the sudden appearance of steady pain localized to the epigastrium or right hypochondrium, which may gradually subside over a period of 12 18 hours Vomiting occurs in about 75% of patients and in half of instances affords variable relief Right upper quadrant abdominal tenderness (often with Murphy s sign, or inhibition of inspiration by pain on palpation of the right upper quadrant) is almost always present and is usually associated with muscle guarding and rebound pain A palpable gallbladder is present in about 15% of cases Jaundice is present in about 25% of cases and, when persistent or severe, suggests the possibility of choledocholithiasis Fever is typical
B Chronic Cholecystitis and Other Complications
Chronic cholecystitis results from repeated episodes of acute cholecystitis or chronic irritation of the gallbladder wall by stones and is characterized pathologically by varying degrees of chronic inflammation of the gallbladder Calculi are usually present In about 4 5% of cases, the villi of the gallbladder undergo polypoid enlargement due to deposition of cholesterol that may be visible to the naked eye ( strawberry gallbladder, cholesterolosis) In other instances, adenomatous hyperplasia of all or part of the gallbladder wall may be so marked as to give the appearance of a myoma (pseudotumor) Hydrops of the gallbladder results when acute cholecystitis subsides but cystic duct obstruction persists, producing distention of the gallbladder with a clear mucoid fluid Occasionally, a stone in the neck of the gallbladder may compress the bile duct and cause jaundice (Mirizzi s syndrome) Xanthogranulomatous cholecystitis is a rare variant of chronic cholecystitis characterized by grayish-yellow nodules or streaks, representing lipid-laden macrophages, in the wall of the gallbladder Cholelithiasis with chronic cholecystitis may be associated with acute exacerbations of gallbladder inflammation, common duct stone, fistulization to the bowel, pancreatitis, and, rarely, carcinoma of the gallbladder Calcified (porcelain) gallbladder has generally been thought to have a high association with gallbladder carcinoma and to be an indication for cholecystectomy, although the risk of gall-
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