CHRONICCHRONIC CHOLE-CYSTITIS

Biliary tract Biliary tract diseasesdiseases

Lykhatska G.V

CHRONICCHRONIC CHOLECYSTITIS

is chronic inflammation of gall-bladder. The gallbladder is a small, pear-shaped organ connected to the liver, on the right side of the abdomen, which stores bile and releases it into the small intestine to help in the digestion of fat.

BILIARY ANATOMYBILIARY ANATOMY

There are two types of cholecystitisThere are two types of cholecystitis

Acute cholecystitisAcute cholecystitis is the sudden inflammation of the is the sudden inflammation of the gallbladder that causes marked abdominal pain, often gallbladder that causes marked abdominal pain, often with nausea, vomiting and fever. with nausea, vomiting and fever.

Chronic cholecystitisChronic cholecystitis is a lower intensity inflammation is a lower intensity inflammation of the gallbladder that lasts a long time. It may be of the gallbladder that lasts a long time. It may be caused by repeat attacks of acute cholecystitis. Chronic caused by repeat attacks of acute cholecystitis. Chronic cholecystitis may cause intermittent mild abdominal pain, cholecystitis may cause intermittent mild abdominal pain, or no symptoms at all. Damage to the walls of the or no symptoms at all. Damage to the walls of the gallbladder leads to a thickened, scarred gallbladder. gallbladder leads to a thickened, scarred gallbladder. Ultimately, the gallbladder can shrink and lose its ability Ultimately, the gallbladder can shrink and lose its ability to store and release bileto store and release bile

Types of gallstonesTypes of gallstones

Prevalence of gall stonesPrevalence of gall stones according according to ageto age

Gall stones vary from pure cholesterol (white), Gall stones vary from pure cholesterol (white), through mixed, tothrough mixed, to bile salt predominant (black)bile salt predominant (black)..

Gall stones vary fromGall stones vary from

EtiologyEtiologyand and Risk Factors

Acute or chronic infection-Esherichia coli (35-40%), -Staphylococus (15%),-Enterococus (15 %), -Streptococus (10%)

Mixed microflora – 30%

- hematogenic way- lymphogenic way- contact way

CLASSIFICATIONCLASSIFICATION

- Chronic calculous cholecystitis

- Chronic non-calculous cholecystitis

CLASSIFICATIONCLASSIFICATIONI. Phase of disease:AcuteUncomplete remissionRemission

II. Severity of disease: mild, moderate, severe.

III. Course of disease: recurrent, permanent.

IV. Type of dyskinesia: hypertonic, hypotonic.

CLASSIFICATIONCLASSIFICATIONV. Uncomplicated Complicated:

-Pancreatitis, -Nonspecific ReactiveNonspecific Reactive Hepatitis, -Pericholecystitis,-Cholangitis (Patients present with

biliary pain, jaundice, fever and often rigors. The septicaemia is usually due to Gram-negative organisms, is frequently severe and may be lifethreatening).

Example of diagnosisExample of diagnosis

Chronic non-calculous recurrent cholecystitis,

acute phase,

moderate severity.

Hypotonic biliary dyskinesia.

irradiation of painirradiation of painSyndromes

pain

dyspeptic

cholestatic

intoxication

asthenic

Symptoms and clinical signs

Pain syndrome. (-Pain in right hypochondrium and epigastric area with an irradiation in right supraclavicular area and right shoulder. -If pain syndrome has the strongly expressed character, it is called hepatic colic).

Dyspepsic syndrome. Asthenic syndrome. Intoxication syndrome.

DIAGNOSTIC PROGRAMTotal blood countBiochemical analysis (Glucose, Bilirubin, ALT, AST, GGT, Alkaline phosphatase, Proteins, Amylase, Lipids, Cholesterol, Cholesterol, Liver tests, Sodium, Potassium, Urea, Creatinine)Urinanalysis, Diastase of urineCoagulogramDuodenal tubage and Examination of bile Duodenal tubage and Examination of bile (chemical, (chemical, bacteriological) bacteriological) Examination of feces, CoprogramExamination of feces, CoprogramECGEndoscopyUSDCholecystography

Laboratory tests and diagnostic Laboratory tests and diagnostic studiesstudies

Although laboratory criteria are not reliable in Although laboratory criteria are not reliable in identifying all patients with cholecystitis, the identifying all patients with cholecystitis, the following findings may be useful in arriving at the following findings may be useful in arriving at the diagnosis:diagnosis:              Leukocytosis with a left shift may be Leukocytosis with a left shift may be observed in cholecystitis.observed in cholecystitis.            Alanine aminotransferase (ALT) and Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are aspartate aminotransferase (AST) levels are used to evaluate the presence of hepatitis and used to evaluate the presence of hepatitis and may be elevated in cholecystitis or with common may be elevated in cholecystitis or with common bile duct obstruction.bile duct obstruction.

Ultrasound showing Ultrasound showing normalnormal gallbladder gallbladder UltrasonographyUltrasonography is is the the important important procedure for the procedure for the diagnosis of chronic diagnosis of chronic gallbladder disease.gallbladder disease. In 90%In 90% to 95% of to 95% of cases of cases of cholelithiasis, cholelithiasis, ultrasonography ultrasonography demonstratesdemonstrates the the echo of the calculus echo of the calculus and the acoustic and the acoustic shadow behind theshadow behind the calculus.calculus.

Ultrasound of the liver and gall Ultrasound of the liver and gall bladderbladder

Ultrasound of the Ultrasound of the liver and gall liver and gall bladderbladder

Ultrasound showing Ultrasound showing cchronic hronic cholecystitischolecystitis

Chronic cholecystitis. USEChronic cholecystitis. USE

SStonetone in in the gallbladder the gallbladder

UltrasoundUltrasound of the of the gallbladder showing, gallbladder showing, in the center of thein the center of the image, a stone within image, a stone within the gallbladder with a the gallbladder with a triangular area of triangular area of acousticacoustic attenuation attenuation (“shadowing”) behind (“shadowing”) behind the gallstone the gallstone

Ultrasound image of Ultrasound image of gall bladder withgall bladder with dark dark area (a) representing area (a) representing gall bladder and gall bladder and multiplemultiple white echoes white echoes (b) representing (b) representing stones. stones.

Bottom: The gallBottom: The gall bladder after bladder after cholecystectomy with cholecystectomy with multiple small stonesmultiple small stones

Cholecysto-Cholecysto-graphy.graphy.

CholelithiasisCholelithiasis

    This cholangiogram, obtained during endoscopic retrograde This cholangiogram, obtained during endoscopic retrograde cholangiopancreatography, shows a normal gallbladder (black arrow) cholangiopancreatography, shows a normal gallbladder (black arrow)

and a narrowed biliary tree with many areas ofsegmental stenosis and a narrowed biliary tree with many areas ofsegmental stenosis

(white arrows), diagnostic of primary sclerosing cholangitis(white arrows), diagnostic of primary sclerosing cholangitis..

ChCholanolanggioioggrama. Cholecystitis.rama. Cholecystitis.

This magnetic This magnetic resonance resonance cholangiopancreatocholangiopancreato--gramgram shows multiple shows multiple gallstones (arrows) gallstones (arrows) in the common bile in the common bile ductduct (choledocholithiasis) (choledocholithiasis)

This magnetic This magnetic resonanceresonance tomography of the tomography of the gallbladdergallbladder

Cholelithiasis (computed tomography) 1 - chronic cholecystitis Cholelithiasis (computed tomography) 1 - chronic cholecystitis (thickening of the walls of the gall bladder), 2 - calcium-containing (thickening of the walls of the gall bladder), 2 - calcium-containing

stones in the area stones in the area neck of the gallbladderneck of the gallbladder

CT- scan. GallstonesCT- scan. Gallstones  

Differential diagnosisDifferential diagnosis

Peptic ulcer diseasePeptic ulcer disease

Chronic pancreatitisChronic pancreatitis

Chronic hepatitisChronic hepatitis

Tumors (liver, gall bladder)Tumors (liver, gall bladder)

Pleurisy (right-sided)Pleurisy (right-sided)

Subdiaphragmatic abscessSubdiaphragmatic abscess

TREATMENTAcute cholecystitis requires analgesia, intravenous Acute cholecystitis requires analgesia, intravenous support and antibiotics, and usually settles with these support and antibiotics, and usually settles with these measures. measures. Subsequent cholecystectomy may then be performed Subsequent cholecystectomy may then be performed when the acute episode has resolved. when the acute episode has resolved. Careful selection of patients with chronic cholecystitis Careful selection of patients with chronic cholecystitis is important as not all patients are pain-free when the is important as not all patients are pain-free when the gallbladder is removed; symptoms may abate gallbladder is removed; symptoms may abate spontaneously and not recur; and there is an spontaneously and not recur; and there is an increasing, associated, operative mortality with increasing, associated, operative mortality with advancing age. advancing age. Laparoscopic cholecystectomy has increased the Laparoscopic cholecystectomy has increased the acceptability of the procedure for patients and has acceptability of the procedure for patients and has consequently become widely available. consequently become widely available.

TREATMENT

1. Bed rest.

2. Hunger (1–3 days), then diet № 5.

3. Desintoxication therapy.

4. Spasmolytics, Analgetics (Spasmalgon 5 ml, No-shpa 2% 2 ml, Papaverin 2% 2 ml, Platyphyllin 0,1% 1 ml, Baralgin 5 ml, Analgin 50% 2 ml).

5. Antibacterial therapy (Ampiox, Ofloxacin, Cephalosporines, Furasolidon)

Acute purulent Acute purulent cholangitis cholangitis is characterized by is characterized by “Charcot’s triad” or “intermittent hepatic fever”: “Charcot’s triad” or “intermittent hepatic fever”:

high  body temperature, chillshigh  body temperature, chills,, sweating, as well as  sweating, as well as jaundicejaundice

Clinical pictureClinical picture

Dyskinesia of the gall bladder Dyskinesia of the gall bladder and biliary tract.and biliary tract.

Dyskinesia of biliary tract - functional Dyskinesia of biliary tract - functional disorder of motor function of the disorder of motor function of the gallbladder and extrahepatic bile gallbladder and extrahepatic bile ductsducts..

-         Hypertonic, hyperkinetic type-         Hypertonic, hyperkinetic type

-         Hypotonic, hypokinetic type-         Hypotonic, hypokinetic type

-         Mixed type.-         Mixed type.

          The symptoms are of intermittent, dull RUQ pain – The symptoms are of intermittent, dull RUQ pain – constantconstant (hypotonic, hypokinetic type)   (hypotonic, hypokinetic type)  or or colickycolicky (hypertonic, hyperkinetic type). (hypertonic, hyperkinetic type).

Treatment.Hypertonic-hyperkinetic Treatment.Hypertonic-hyperkinetic typetype

Diet Diet №5№5Sedatives(valerian tincture-20-30 drops 3 times Sedatives(valerian tincture-20-30 drops 3 times a daya day,,korvaloli 20drops 3 times a daykorvaloli 20drops 3 times a daySpasmolitic drugs(gastrotsepin 2ml intramusc.2 Spasmolitic drugs(gastrotsepin 2ml intramusc.2 times a day or 25 mg 2 times a day 40 min times a day or 25 mg 2 times a day 40 min before mealsbefore meals,, no-shpa 2.0ml 2 times a no-shpa 2.0ml 2 times a dayday,,duspatalini 200mg 2 timesa dayduspatalini 200mg 2 timesa dayDrugs decreasing the gallbladdes Drugs decreasing the gallbladdes tonus(hepabene 1 caps 3 times a day after tonus(hepabene 1 caps 3 times a day after mealsmeals,,galstena 20drops 3 times a day befope galstena 20drops 3 times a day befope meals)meals)physiotherapyphysiotherapy

Hypotonic-hypokinetic typeHypotonic-hypokinetic type

Medicamental therapy:Medicamental therapy:Drugs contributing to gallbladder Drugs contributing to gallbladder contractilitycontractility,,atonia of Oddi and Lutkens atonia of Oddi and Lutkens sphincters (hofitol 2 tabl.3 times a daysphincters (hofitol 2 tabl.3 times a day;;sorbit-sorbit-10%solution during 3 weeks)10%solution during 3 weeks)Drugs stimulating the gallbladder tonus and Drugs stimulating the gallbladder tonus and contractility(domperydon during 3 weekscontractility(domperydon during 3 weeks,,primer primer 1 tabl.3 times a day)1 tabl.3 times a day)Duodenal tubage(33% magnesium sulfate or Duodenal tubage(33% magnesium sulfate or olive oil or sorbite 1-2 times per week)olive oil or sorbite 1-2 times per week)