Aetiopathogenesis and management of calculus cholecystitis

DR BASHIR YUNUS

GENERAL SURGERY UNIT PRESENTATION

3/9/2015 [email protected] 1

• INTRODUCTION

• DEFINITION

• EPIDEMIOLOGY

• RELEVANT ANATOMY

• AETIOLOGY

• PATHOGENESIS

• MANAGEMENT

• HISTORY

• PHYSICAL EXAMINATION

• INVESTIGATIONS

• TREATMENT

• COMPLICATIONS

• CONCLUSION


Cholecystitis is the inflammation of the gall bladder.

Calculus cholecystitis results from obstruction by gall stone and is the

commonest cause of cholecystitis.

• EPIDEMIOLOGY

(Fat, Fair, Female, Fertile, at Fourty)

90% of patient with acute cholecystitis is associated with calculus

obstruction. Cholelithiasis is common in western countries. 10% of

adult white hours gall stones . 60% of patients are women. It afflicts

more than 20million Americans annually. Most are silent. Only 20%

develop acute cholecystitis



Pear shape organ that lie at the underside of the liver between the right and left lobe

7.5-12cm long

Capacity about 25-30ml

Cystic duct is 3cm in length, 1-3mm in diametre

CHD 2.5cm

CBD 7.5cm


Should be identified

during

cholecystectomy to

avoid damage to

extrahepatic biliary

system

• Three factors are important in the formation of gall stones

• Metabolic ; reduction of bile salt cholesterol ratio below 13:1 e.g

avitaminosis A or excessive gallbladder absorption in ifection

• Infection; streptococci, E.coli, salmonella, Cl. welchi

• Bile stasis; stasis enable gall stone to grow

• Types of stone;

• Cholesterol (20%)

• Pigment (5%)

• Mixed (75%)


• Cholesterol stones:• Obesity, age <50

• Estrogens: female, multiparity, OCPs

• Commer in western/ developed countries

• Terminal ileal resection or disease (Crohn’s Disease)

• Impaired gallbladder emptying: starvation, DM type 1

• Rapid weight loss: rapid cholesterol mobilization and biliary stasis

• Inborn error of bile salt metabolism

• hyperlipidemia

• Pigment stones :• Commoner in Asia and Africa

• More in rural than urban area

• Chronic (contains calcium bilirubinate):

• Cirrhosis

• Chronic hemolysis

• Biliary stasis (strictures, dilation, biliary infection)

• Associated with GI disoders eg

• When stone becomes impacted in the cystic duct the gall bladder becomes inflamed(chemical and bacterial inflammation). The mucous membrane is swollen and the wall thickened. The event may now take several turns

the mucous membrane may become lifted away from the sides of the stone wedged in the neck of the gall bladder, so that the muco-purulent content of the bladder drain into the common bile duct. The attack is then temporarily arrested.

Impaction may persist leading to empyema of the gall bladder.

May perforate (rare- due thickening of wall from recurrent cholecytitis, seen diabetic and elderly)

Gangrene of the gall bladder- interference to blood supply

Empyema and inflammatory mass

Mirzzi syndrome


stones

obstruction to bile outflow

inflammation of gall bladder wall due to phospholipases from the mucosa hydrolyzes biliary

lecithin to lysolecithin (toxic to the mucosa)

disrupt normal protective

glycoprotein layer

exposed the mucosal epithelium to the direct

detergent action of bile salts

Superimposed bactrial infection

Distended gall

bladder

Prostaglandin

released

Mucosal and

mural

inflammation

Increase

intraluminal

pressure

Compromise

mucosal blood

flow

• HISTORY

• Pain

• Epigastric

• Right hypochondrial

• Sudden onset

• Associated with fatty meals

• Nausea and vomiting

• Fever

• Jaundice +/-

• Transient

• Usually sets in 2nd or 3rd day of the illness

• Marked or persistent in choledocholithiasis


• PHISICAL SIGNS

• Pyrexia

• Tenderness, rebound tenderness and guarding or rigidity are

found in the right hypochondrium.

• Omental phlegmon- mass gallbladder and omentum, at the

right hypochodrium, as pain subside. It may turn out to be an

empyema or carcinoma especially in the elderly.

• Positive Murphy’s sign

• Positive Boas sign; tenderness over the 9th- 11th right ribs

posteriorly


• Abdominal Uss; • Calculi cast acostic shadow (80-90%)

• Thickening wall mucosa

• Distended gall bladder with serosal oedema (halo sign)

• Pericystic collection of fluid

• Plain X-ray • Opacity (10-20%)

• Gas seen in gall bladder or biliary passage ; suggests infection by anaerobes or passage of stone into the duodenum

• Full blood count ; leucocytosis

• LFT; slight elevation of serum transaminase, elevataedalkaline phosphatase, bilirubin

• Elevated serum amylase


• The general accepted practice is non-operative management in the acute phase followed by cholecystectomy. (interval or delayed cholecystectomy 6 weeks after inflammation has subsided)

• Argument ;• Majority of patients settle on conservative measures

• Dissection of inflammed area could lead to spread of infection

• With inflammation there is anatomical anomalies with risks of error

• Patient with high risk of perforation are frequently identifiable(diabetic and aged)

However, in recent years, early operation is increasingly offered. Following conservative measures, patient is operated as elective in the next available operation list in few days.3/9/2015 [email protected] 15

• REST THE INFLAMMED GALLBLADDER

• NPO, N-G tube aspiration

• IV fluids

• Anticholinergic drugs; propantheline 15mg i.m 8hourly or atropine

0.6mg i.m 8hourly for more rapid action

• SEDATION + analgesia

• Pethidine 100mg i.m

• NSAID suppresses pain from tension within the biliary system

• ANTIBIOTICS

• Broad spectrum and bactericidal. Third generation

cephalosporines are agent of choice


1. Signs of incipient perforation; temperature and pulse

not improving in 24-36hours. Pain and tenderness

persist across the abdomen.

2. Spreading gangrene of the gallbladder with redness and

oedema of the overlying skin

3. Presence of inflammatory mass in the right

hypochondrium

4. Mucocele

5. Detection of gas in the extrabiliary system

6. Detection of intestinal obstruction


• Cholecystectomy

The gall bladder and cystic duct are removed by

transection and dissection of the cystic duct close to the

common bile duct

Types; Open or laparoscopic

Principles;

• Adequate exposure

• Exclude concomitant pathology of neighboring structures-

preliminary laparotomy

• Defining anatomy

• Adequate hemostasis


Newer, fewer post op complication, shorter hospital stay

Absolute contraindications

• I. Sepsis including cholangitis

• 2. Diffuse peritonitis

• 3. Bleeding diathesis.

Relative contraindications

• I. Previous upper abdominal surgery

• 2. Acute cholecystitis

• 3. Choledocholithiasis

• 4. Gallstone pancreatitis

• 5. Co-existent carcinoma, diverticular and

• inflammatory bowel disease

• 6. Cirrhosis

• 7. Significant anaesthetic risks

• 8. Minor bleeding disorder (eg. aspirin intake)

• 9. Pregnancy

• 10. Obesity.


• Unclear anatomy

• No tissue plane

• Uncontrollable bleeding

• Accidental damage

• Equipment failure

• Lack of progress


• Cholecystostomy

The fundus of the gall bladder is opened and stone

removed with a forceps self retaining catheter place and

exteriorised via a separate wound. Elective

cholecystectomy the performed in 3-6 weeks

• Unfit – severely ill

• Elderly

• Empyema

• Persistent and progressive symptoms

. Better option as chances of injury to adjacent structures is higher

in emergency cholecystectomy


• Iatrogenic bile duct injury

• Post op bile leak

• Haemorrhage

• Retained stone

• Post cholecystectomy syndrome

• Inadvertent bowel injury

• Subcutaneous emphysema

• Anaesthetic complication

• Acute appenditis

• Perforated peptic ulcer

• Acute pancreatitis

• Acute pyelonephritis

• Myocardial infarction

• Right lobar pneumonia


• Overall reported mortality of acute cholecystitis is 2-3%

with much higher figures (10%) in patient over 70. This is

largely due to incidental cardiorespiratory disease and

complication.


• Steven M. strasberg, MD; acute calculus cholecystitis. The new England jornal of Medicine 2008; 358:2804-11

• E.A Badoe et al, “Principles and Practice of surgery including pathology in the tropics” 4th edition, Assembly of God Literature Center ltd, 2009

• Bailey and Love’s “Short Practice of Surgery” 26th edition CRC press Taylor and Francis group. 2013

• www.slideshare .net

• www.wikepedia .org


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Aetiopathogenesis and management of calculus cholecystitis

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