Safra Yolu Hastalıkları ve Kolesistit
Özet
Safra yolu hastalıkları, acil servise başvuran hastalarda abdominal ağrının önemli nedenlerinden biri olup, klinik spektrum biliyer kolikten akut kolesistit ve akut kolanjite kadar uzanmaktadır. Bu hastalıklar benzer semptomlarla prezente olabilmekle birlikte, patofizyolojik mekanizmaları, klinik seyirleri ve tedavi öncelikleri açısından belirgin farklılıklar göstermektedir. Akut kolesistit, çoğunlukla sistik kanal obstrüksiyonuna bağlı gelişen lokal inflamatuvar bir süreç olarak ortaya çıkarken, akut kolanjit biliyer obstrüksiyon zemininde gelişen ve hızla sistemik inflamatuvar yanıt ile çoklu organ yetmezliğine ilerleyebilen bir biliyer sepsis tablosudur. Tanısal süreçte klasik klinik bulgular yardımcı olmakla birlikte duyarlılıkları sınırlıdır. Bu nedenle 2018 Tokyo Kılavuzları doğrultusunda sistematik tanı ve şiddet sınıflaması yapılması önerilmektedir. Akut kolanjitte erken antibiyotik tedavisi yaşamsal öneme sahip olmakla birlikte, klinik iyileşme esas olarak zamanında sağlanan biliyer dekompresyona bağlıdır. Akut kolesistitte ise prognoz, uygun hasta seçimi ve cerrahi girişimin optimal zamanlaması ile yakından ilişkilidir. Her iki hastalıkta da tanısal gecikme ve yanlış yönetim, morbidite ve mortaliteyi anlamlı düzeyde artırmaktadır.
Biliary tract diseases constitute a significant cause of abdominal pain in emergency department admissions, encompassing a wide clinical spectrum ranging from biliary colic to acute cholecystitis and acute cholangitis. Although these conditions may present with overlapping symptoms, they differ substantially in terms of pathophysiology, clinical course, and therapeutic priorities. Acute cholecystitis typically arises as a localized inflammatory process secondary to cystic duct obstruction, whereas acute cholangitis represents a biliary sepsis driven by obstructive pathology and may rapidly progress to systemic inflammatory response and multiorgan failure. While classical clinical signs may aid diagnosis, their limited sensitivity necessitates a structured, guideline-based approach, as outlined in the Tokyo Guidelines 2018, for accurate diagnosis and severity assessment. In acute cholangitis, early initiation of antimicrobial therapy is essential; however, definitive clinical resolution depends primarily on timely biliary decompression. In contrast, the prognosis of acute cholecystitis is closely related to appropriate patient selection and optimal timing of surgical intervention. Delayed diagnosis or inappropriate management in either condition is associated with significantly increased morbidity and mortality.
Referanslar
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Fraquelli M, Casazza G, Conte D, Colli A. Non-steroid anti-inflammatory drugs for biliary colic. Cochrane Database Syst Rev. 2016 Sep 9;9(9):CD006390. doi:10.1002/14651858.CD006390.pub2 PubMed PMID: 27610712; PubMed Central PMCID: PMC6457716.
Al-Waili N, Saloom KY. The analgesic effect of intravenous tenoxicam in symptomatic treatment of biliary colic: a comparison with hyoscine N-butylbromide. Eur J Med Res. 1998 Oct 14;3(10):475–9. PubMed PMID: 9753705.
Akıncı N, Bakan N, Karaören G, Tomruk SG, Sökmen HM, Yanlı Y, et al. Comparison of Clinical Effects of Dexketoprofen and Paracetamol Used for Analgesia in Endoscopic Retrograde Cholangiopancreatography. Turk J Anaesthesiol Reanim. 2016 Feb;44(1):13–20. doi:10.5152/TJAR.2016.09483 PubMed PMID: 27366549; PubMed Central PMCID: PMC4894112.
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de Oliveira GS, Torri GB, Gandolfi FE, Dias AB, Tse JR, Francisco MZ, et al. Computed tomography versus ultrasound for the diagnosis of acute cholecystitis: a systematic review and meta-analysis. Eur Radiol. 2024 Nov;34(11):6967–79. doi:10.1007/s00330-024-10783-8 PubMed PMID: 38758253.
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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. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31–40. doi:10.1002/jhbp.509 PubMed PMID: 28941329.
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Referanslar
Nagral S. Anatomy relevant to cholecystectomy. J Minim Access Surg. 2005 Jun;1(2):53–8. doi:10.4103/0972-9941.16527 PubMed PMID: 21206646; PubMed Central PMCID: PMC3004105.
Wang X, Yu W, Jiang G, Li H, Li S, Xie L, et al. Global Epidemiology of Gallstones in the 21st Century: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol. 2024 Aug;22(8):1586–95. doi:10.1016/j.cgh.2024.01.051 PubMed PMID: 38382725.
European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016 Jul;65(1):146–81. doi:10.1016/j.jhep.2016.03.005 PubMed PMID: 27085810.
Elizabeth J. Haines, Holly Thompson. Biliary Tract Disorders. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10 th ed. Elsevier; 2023. p. 1058–83.
Justin Coomes, Melissa Platt. Abdominal Pain. In: Current Diagnosis & Treatment: Emergency Medicine. 7 th ed. McGraw- Hill; 2022. p. 227–49.
Zakko SF. UpToDate [Internet]. Clinical manifestations and evaluation of gallstone disease in adults. Available from: https://www.uptodate.com/contents/clinical-manifestations-and-evaluation-of-gallstone-disease-in-adults?search=kolelitiyazis&topicRef=673&source=see_link#H1
Fraquelli M, Casazza G, Conte D, Colli A. Non-steroid anti-inflammatory drugs for biliary colic. Cochrane Database Syst Rev. 2016 Sep 9;9(9):CD006390. doi:10.1002/14651858.CD006390.pub2 PubMed PMID: 27610712; PubMed Central PMCID: PMC6457716.
Al-Waili N, Saloom KY. The analgesic effect of intravenous tenoxicam in symptomatic treatment of biliary colic: a comparison with hyoscine N-butylbromide. Eur J Med Res. 1998 Oct 14;3(10):475–9. PubMed PMID: 9753705.
Akıncı N, Bakan N, Karaören G, Tomruk SG, Sökmen HM, Yanlı Y, et al. Comparison of Clinical Effects of Dexketoprofen and Paracetamol Used for Analgesia in Endoscopic Retrograde Cholangiopancreatography. Turk J Anaesthesiol Reanim. 2016 Feb;44(1):13–20. doi:10.5152/TJAR.2016.09483 PubMed PMID: 27366549; PubMed Central PMCID: PMC4894112.
Basurto Oña X, Robles Perea L. [Anti-inflammatory drugs for biliary colics: systematic review and meta-analysis of randomized controlled trials]. Gastroenterol Hepatol. 2008 Jan;31(1):1–7. doi:10.1157/13114562 PubMed PMID: 18218271.
Wu S dong, Zhang Z hai, Jin J zhe, Kong J, Wang W, Li D yan, et al. [Effects of different drugs on the sphincter of Oddi motility: study with choledochoscope manometry]. Zhonghua Yi Xue Za Zhi. 2005 Jul 20;85(27):1911–5. PubMed PMID: 16255987.
MacKenzie M, Zed PJ, Ensom MHH. Opioid Pharmacokinetics-Pharmacodynamics: Clinical Implications in Acute Pain Management in Trauma. Ann Pharmacother. 2016 Mar 1;50(3):209–18. doi:10.1177/1060028015625659
National Institute for Health and Care Excellence (NICE). Gallstone disease: diagnosis and management. [Internet]. London: NICE; 2014 [cited 2026 Feb 12]. Available from: https://www.nice.org.uk/guidance/cg188
Gomi H, Solomkin JS, Schlossberg D, Okamoto K, Takada T, Strasberg SM, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3–16. doi:10.1002/jhbp.518 PubMed PMID: 29090866.
QM Anstee, DEJ Jones. Hepatology. In: Davidson’s Principles and Practice of Medicine. 23. Baskı. Elsevier; 2018. p. 845–910.
Cho JY, Han HS, Yoon YS, Ahn KS. Risk factors for acute cholecystitis and a complicated clinical course in patients with symptomatic cholelithiasis. Arch Surg. 2010 Apr;145(4):329–33; discussion 333. doi:10.1001/archsurg.2010.35 PubMed PMID: 20404281.
Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003 Jan 1;289(1):80–6. doi:10.1001/jama.289.1.80 PubMed PMID: 12503981.
Hladik AJ, Barden M. Acute Cholecystitis in the Elderly Patient: How Is It Different? In: Graham A, Carlberg DJ, editors. Gastrointestinal Emergencies: Evidence-Based Answers to Key Clinical Questions [Internet]. Cham: Springer; 2019 [cited 2026 Feb 12]. p. 211–2. Available from: https://doi.org/10.1007/978-3-319-98343-1_63 doi:10.1007/978-3-319-98343-1_63
Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41–54. doi:10.1002/jhbp.515 PubMed PMID: 29032636.
Childs DD, Lalwani N, Craven T, Arif H, Morgan M, Anderson M, et al. A meta-analysis of the performance of ultrasound, hepatobiliary scintigraphy, CT and MRI in the diagnosis of acute cholecystitis. Abdom Radiol (NY). 2024 Feb;49(2):384–98. doi:10.1007/s00261-023-04059-w PubMed PMID: 37982832.
Zakko SF, Afdhal NH. UpToDate [Internet]. [cited 2026 Feb 12]. Acute calculous cholecystitis: clinical features and diagnosis. Available from: https://www.uptodate.cn/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis
Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, et al. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci. 2012 Sep;19(5):578–85. doi:10.1007/s00534-012-0548-0 PubMed PMID: 22872303; PubMed Central PMCID: PMC3429769.
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 J Emerg Surg. 2020 Nov 5;15(1):61. doi:10.1186/s13017-020-00336-x PubMed PMID: 33153472; PubMed Central PMCID: PMC7643471.
de Oliveira GS, Torri GB, Gandolfi FE, Dias AB, Tse JR, Francisco MZ, et al. Computed tomography versus ultrasound for the diagnosis of acute cholecystitis: a systematic review and meta-analysis. Eur Radiol. 2024 Nov;34(11):6967–79. doi:10.1007/s00330-024-10783-8 PubMed PMID: 38758253.
Radiopaedia.org [İnternet]. [cited 2026 Feb 18]. Case 29606. Available from: https://radiopaedia.org/cases/29606/studies/30112?new_full_screen_viewer=true
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. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31–40. doi:10.1002/jhbp.509 PubMed PMID: 28941329.
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine. 2021 Nov;49(11):e1063. doi:10.1097/CCM.0000000000005337
Vollmer CM Jr, Zakko SF, Afdhal NH. UpToDate [Internet]. Treatment of acute calculous cholecystitis. Available from: https://www.uptodate.com/contents/treatment-of-acute-calculous-cholecystitis
Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):55–72. doi:10.1002/jhbp.516 PubMed PMID: 29045062.
Shirah BH, Shirah HA, Saleem MA, Chughtai MA, Elraghi MA, Shams ME. Predictive factors for gangrene complication in acute calculous cholecystitis. Ann Hepatobiliary Pancreat Surg. 2019 Aug;23(3):228–33. doi:10.14701/ahbps.2019.23.3.228 PubMed PMID: 31501810; PubMed Central PMCID: PMC6728255.
Kowalski A, Kashyap S, Pfeifer C. Emphysematous Cholecystitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2026 Feb 15]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK448099/ PubMed PMID: 28846291.
Inukai K. Gallstone ileus: a review. BMJ Open Gastroenterol. 2019;6(1):e000344. doi:10.1136/bmjgast-2019-000344 PubMed PMID: 31875141; PubMed Central PMCID: PMC6904169.
Kiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, Gabata T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). Journal of Hepato-Biliary-Pancreatic Sciences. 2018;25(1):17–30. doi:10.1002/jhbp.512
Gutt C, Schläfer S, Lammert F. The Treatment of Gallstone Disease. Deutsches Ärzteblatt international. 2020 Feb 28. doi:10.3238/arztebl.2020.0148
Ahmed M. Acute cholangitis - an update. World J Gastrointest Pathophysiol. 2018 Feb 15;9(1):1–7. doi:10.4291/wjgp.v9.i1.1 PubMed PMID: 29487761; PubMed Central PMCID: PMC5823698.
Mayumi T, Okamoto K, Takada T, Strasberg SM, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences. 2018;25(1):96–100. doi:10.1002/jhbp.519
Li W, Chang N, Li L. Heterogeneity and Function of Kupffer Cells in Liver Injury. Front Immunol. 2022;13:940867. doi:10.3389/fimmu.2022.940867 PubMed PMID: 35833135; PubMed Central PMCID: PMC9271789.
Zimmer V, Glanemann M, Lammert F. Acute and Chronic Inflammation of the Biliary System. Visc Med. 2015;31(3):153–4. doi:10.1159/000434668
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