Acute cholecystitis

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Transcript of Acute cholecystitis

  • 1. Acute cholecystitis
    • Sergey UsovM.D.

2. Gallbladder anatomy 3. Gallbladder anatomy 4. Acute cholecystitis

  • Definition:
  • Acute cholecystitis is an inflammation of a gall-bladder.

5. Etiology and pathogenesis.

  • In etiology of cholecystitis major factors are the following: cholelithiasis, infection. Problems with bile passage through the cystic duct from gallbladder to the common bile duct due to stenosis or obstruction of cystic duct with inflammation process around a cervix of the gallbladder there are.

6. Causes of cholecystitis

  • All reasons of acute cholecystitis causes are divided in two groups:
  • cholecystitis with formation of calculi(gall stones)- 80%.
  • Non calculi cholecystitis 20%.

7. What is that? It might bepineapple ? 8. What is that? It might be precious stone? 9. What is that? It might be jewel? 10. No!Thisis a gall-stone. 11. No! Thisis a gall-stone 12. No! Thisis a gall-stone again No! Thisis a gall-stone again No! Thisis a gall-stone again 13. Causes of cholecystitis

  • Non calculi cholecystitis is conditioned:
  • by gram-positive and gram-negative infections- 10%.
  • or blood supply disturbance of the wall gallbladder 5%.

14. Other causes of cholecystitis

  • microbes: C olibacillus, Proteus, Staphylococcus, Enterococcus and mixed form bacteria.
  • It is particular form of acute cholecystitis (5%) due to:
  • acute pancreatitis (pancreatogenic)
  • or parasitogenic diseases.

15. Pathomorphology of acute cholecystitis

  • The wall of gall-bladder is thickened, edematous, and hyperemic with stratification of fibrin and the gall bladder fills with pus

16. Pathomorphology of cholecystitis

  • The catarrhal acute cholecystitis develops to phlegmonous and suppuration inflammation.
  • Progress of inflammation process can lead to gangrene of the gall bladder.

17. Gangrenous cholecystitis 18. Necrosis of the gall bladder. 19. Classification:

  • A. acute calculi cholecystitis (with presence gall stones)
  • B. acute non - calculi cholecystitis (without gall stones)
  • 1. Catarrhal
  • 2. Phlegmonous
  • 3. Gangrenous
  • 4. Perforated

20. Complication:

  • peritonitis (local, widespread, general)
  • cholangitis (inflammation process into the bile duct)
  • empyema of gall bladder
  • abscess around the gall bladder
  • hydrops of gall bladder
  • mechanical jaundice
  • hepatitis or hepato-renal insufficiency

21. Clinical management:

  • Acute cholecystitis usually begins after violation of a diet:intake of spice or fried food, plenty fatty eating.

22. Pain syndrome .

  • Main symptom of acute cholecystitis is severe pain in right hypochondrium and epigastric area with radiation to right half of the chest and right shoulder. When a hypertension in a gall bladder and bile ducts progresses the pain syndrome is strongly expressed and becomes attack-like in character, but this clinical phenomenon is named as biliary colic.

23. Dyspepsia syndrome :

  • Frequent symptoms which disturb a patient are nausea and repeated vomiting with bile. Later feeling of fullness of abdomen, delay of emptying bowel and gases are often followed.

24. Objective examination

  • A doctor can observe slight icterus skin or sclera during examination in many patients. Tongue is whites-grey in colour. Patients complain of a dryness of mouth. In difficult cases the tongue is usually dry, assessed white stratification with yellow spot.

25. Objective examination

  • Increase of bodys temperature (to 37,5 C) in brief period is insignificant in catarrhal cholecystitis and with destructive forms the temperature could be higher (38C). The fever in the range of 37,7-38,8 is marked inflammation and toxemia. Tachycardia testifies the degree of intoxication.

26. Objective examination

  • The upper part of abdomen isstrongly tense and often palpable mass develops in the hypochondrium region or projection of the gall bladder. By superficial and deep palpation right hypochondrium area a tenderness of the abdominal wall, increased size of gall bladder are exposed. An inflamed gall bladder wrapped in inflammatory adhesions with adjacent organs, especially the omentum.

27. The following symptoms are diagnosed in acute cholecystitis:

  • Murphys sign is a delay of breathing during palpation of gall bladder on inspiration.
  • Kehrs sign is increase of pain withpressure on the area of gall bladder, especially on deep palpation.
  • Ortners sign is tenderness on light percussion at right costal margin by edge of the hand.

28. Diagnostic program:

  • Laboratory analysis . Leukocytes from 10.0/L and more, shift of leukocyte formula to the left, lymphopenia and increased ESR.
  • Sonographicexamination of gall bladder can reveal the increase in its sizes, bulge of walls, development of perivesical abscesses, presence or absence of bile sludge and stones.
  • X-rayexamination with observe of abdominal cavity organs can identify free gas in abdominal cavity and X-ray photography-positive of the gall stones.

29. Cholecystography 30. Cholecystography with contrast agent 31. CT investigation 32. Ultrasonography 33. Ultrasonography 34. Ultrasonography 35. Ultrasonography 36. Cholangiography 37. Differential diagnosis

  • T heseshould be suspected whenever the acute painatright upper quadrantof abdomen is appeared .
    • Perforated peptic ulcer
    • -Acute amoebic liverabscess
    • Acute pancreatitis
    • Acute intestinal obstruction
    • Renal colic
    • Acute retrocolic appendicitis
    • Myocardial infarction
    • Basal pneumonia

38. Treatment

  • For most patients the definitive treatment is surgical removal of the gallbladder. Supportive measures arebas ed in the meantime to prepare the patient for surgery. The in fusion offluid andantibioticsshould be given . Antibiotic regimens usually consist of a broad spectrum antibiotic such asa cephalosporin (e.g. ceftriaxone ) and an antibacterial with good coverage againstanaerobic bacteria , such asmetronidazole .

39. The surgery

  • Gallbladder removal,cholecystectomy , can be accomplished via open surgery or alaparoscopicprocedure. Laparoscopic procedures ha slessmorbidityand a shorter recoveryperiod . Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. Open procedure may also be done if the surgeoncould meet withadifficult clinical cases .

40. Consequently, L aparoscopiccholecystectomy is theGold standardfor thegall bladderplanedsurgery.

  • Film 5 min.

41. Urgentoperations need the open surgical approachand handmade a gall bladder surgery.

  • Film 10 min.

42. C holecystostomy

  • In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required forcholecystectomy ), the managing physicianshouldt akeapercutaneousdrainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves.

43. C holecystostomy 44. The surgery

  • Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult
  • Film 5 min.

45. Complicationsa f tercholecystectomy

  • bile leak ("biloma")
  • bile duct injuryOpen and laparoscopic surgeries have essentially equal rate of injuries, but the recent trend is towards fewer injuries with laparoscopy. It may be that the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
  • Intraabdominalabscess
  • wound infection
  • bleeding (liver surface and cystic artery are most common sites)
  • hernia
  • deep vein thrombosis / pulmonary embolism(unusual- risk can be decreased through use of sequential compression devices on legs during surgery)

46. Thank you!

  • Sergey Usov M.D.