CHOLECYSTITISINTRODUCTION:Prevalence 11-36%.Risk factors:ObesityPregnancyCrohns disease.Terminal ileum resection.Gastric surgery.Hereditary spherocytosis, sickle cell disease, thalassemia.Female.1st degree relative.

Natural History:Most pt remain asymptomatic3% become symptomatic per year (biliary colic) 3-5% develop complications per year; acute cholecystitis, choledocholithiasis, cholangitis, pancreatitis, cholecystocholedochal fistula, and cholecystoenteric fistula.Prophylactic cholecystectomy may indicated for elderly pts with DM, individual who will be isolated from medical care for extended period of time, and in population with increased risk of cancer.Porcelain G.B. is an absolute indication for cholecystectomy.

CHRONIC CHOLECYSTITIS

Cholecystitis is the inflammation of the gallbladder, usually resulting from a gallbladder stone blocking the cystic duct.It lasts for a long time and characterized by repeated attacks of pain (biliary colic).

It may become thick walled, scarred and small. The gallbladder usually contains sludge (a microscopic particles or materials similar to gallstones)It block its opening into the cystic duct or reside in cystic duct itself.

What is Cholecystitis

Notice thickness of galldladder wall, abundant polyhedric stones and small papillary tumor in the cystic duct.

morphology

Enlarged mucosal folds of the gallbladder can be seen, and in many there will be an infiltrate of foamy histiocytes. There is very little inflammation of the acute or chronic type here, and if there is any at all, it will be found in the muscular wall and serosal fat. This is a very common and benign process, and very likely is the starting point for some types of gall stones.

The physical examination may reveal fever, tachycardia, and tenderness in the RUQ(right upper quadrant) or epigastric region, often with guarding or rebound.

The Murphy sign, which is specific but not sensitive for cholecystitis, is described as tenderness and an inspiratory pause elicited during palpation of the RUQ. A palpable gallbladder or fullness of the RUQ is present in 30-40% of cases. Jaundice may be noted in approximately 15% of patients.

Clinical manifested

Many patients present with diffuse epigastric pain without localization to the RUQ. Patients with chronic cholecystitis frequently do not have a palpable RUQ mass secondary to fibrosis involving the gallbladder.

The main symptoms is pain in the upper right side or upper middle of the abdomen. The pain may :

Be sharp, cramping, steadySpread to the back or below the right shoulder blade

Other symptoms : clay-colored stools, fever, nausea or vomitting, yellowing of skin(jaundice)Symptoms

Cholecystitis is diagnosed by doctors mainly based on symptoms and results of imaging tests.Ultrasonography is the best way to detect gallstones in the gallbladder or the thickening of its wall. Diagnostic

Ultrasound of the Abdomen.Ultrasound is a simple, rapid, and noninvasive imaging technique. It is the diagnostic method most frequently used to detect gallstones and is the method of choice for detecting cholecystitis.

If possible, the patient should not eat for 6 or more hours before the test, which takes only about 15 minutes. During the procedure, the doctor can check the liver, bile ducts, and pancreas, and quickly scan the gallbladder wall for thickening (characteristic of cholecystitis.

Liver blood test are often normal unless the person has an obstructed bile duct. Other blood test can detect some complications such as high level of a pancreatic enzyme (lipase or amylase) in pancreatitis.

A high count of WBC suggest inflammation, an abscess, gangrene or a perforated gallbladder.continue

This surgery uses a smaller surgical cuts, which results in a faster recovery. Patients are often sent home from the hospital on the same day as surgery or the next morning. Open cholecystectomy requires larger cut in the upper-right part of the abdomen.

Gall stones may also be dissolved with medication taken by mouth. But may take 2 years or longer to work.Laparoscopic Cholecystectomy

The condition is not always preventable.Eating less fatty food may relieve symptoms who have not had their gallbladder removed.Management

ACUTE CHOLECYSTITIS

Acute Inflammation of gall bladder is called ACUTE CHOLECYSTITIs

Etiology Obstruction Bacterial invasion Trauma and chemical irritation Pancreatic reflux

EtiologyCALCULOUS

etiologyACALCULOUSCholesterosis(strawberry gall bladder)Cholesterol polyposis of gall bladderCholecystitis glandularis proliferansDiverticulosis of gall bladderTyphoid of gall bladder

etiology BACTERIAL INFECTION E-coliKlebsiellaS.faecalisSalmonellaClostridia Anaerobes

classificationOn etiology: calculous,acalculous,emphysamatous On inflammation:simple,destructive

Emphysamatous

classificationOn morphology: catarhal,phlegmonous,gangrenous,gangrenous perforation

Abdominal pain

SITE - RIGHT HYPOCHONDRIUMTYPE - COLICKYONSET SUDDENDURATION MORE THAN 12 hrs RADIATION BACKSHOULDERRIGHT HYPOCHONDRIUMLEFT HYPOCHONDRIUM

Symptoms: 2 gastrointestinal Nausea, bilious vomiting Abdominal distension Belching or flatulence 3. Fever

signsGENERALTACHYCARDIAPYREXIA

From MMWR Aug 2004

From MMWR Aug 2004Local TENDERNESS - RT HYPOCHONDRIUMRIGIDITY - RT HYPOCHONDRIUMMURPHYS SIGNBOAS SIGNMASS

murphys sign

Boas signAn area of hyperasthesia between 9th and 11th rib posteriorly right side is a feature

Ortner sign-tenderness when handtaps the edge of rightcostal arch

Laboratory findings Elevated leukocyte count Elevated serum bilirubin Elevated amylase level

Instrumental investigationPLAIN X-RAY ABDOMEN

Radioopaque gall stone

ULTRASONOGRAPHYDilatation of billiary treeStonesFluid

Common bile duct dialation

Intra hepatic duct dialation

Gall stone

GALL BLADDER RADIONUCLIDE SCAN

ORAL CHOLECYSTOGRAM

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP

HIDA ScanFor this test, a radioactive substance (radionuclide) is injected intravenously. A gamma camera detects the radioactivity given off and a computer is used to produced an image. Thus the movement of the radionuclide from the liver through the biliary tract can be followed.

Images of the liver, bile ducts, gallbladder and upper part of small intestines are taken. If the radionuclide does not fill the gallbladder, the cystic duct is probably blocked by a gallstones.

Cholescintigraphy, another imaging test, is useful when acute cholecystitis is difficult to diagnose.

HIDA SCAN SHOWING NONVISUALIZATION OF GALL BLADDER

ERCP showing mirizzi syndrome

DIFFERENTIAL DIAGNOSIS

RARE

ACUTE PYELONEPHRITIS

HEPATITIS

MYOCARDIAL INFARCTION

PNEUMONITIS

complicationEMPYEMAPERFORATIONPERITONITISABSCESSFISTULAMUCOCELEACUTE PANCREATITISGALL STONE ILEUSOBSTRUCTIVE JAUNDICE

TreatmentNonsurgical or preoperative management Intravenous fluids Nasogastric tube Broad spectrum antibiotics

Naspgastric tube: ryles tube admistration immediately continued 3 to 5 days.aspirating HCL decreases the secretion of bile.spasm of bladder may come down intravenous fluid: in the beginning 5 % dexrose saline may be started but subsquently fluid may be changed according to electrolyte balance of paitentAnalgesic +anticholinergic given to reduce spasm

Antibiotic

broad spectrum to control inflammation.combination of Cephalosporin with metronidazole is good.

Conservative treatment stopped and early cholecystectomy advised1)pain and tenderness spread across the abdomen2)gall bladder increases in size3)Pulse rate continuse to rise4)In very elderly patient

Surgical Treatment1.Attack within 48-72 h of diagnosis2.Deterioration in patients general condition3.Complications are present Perforation Peritonitis Acute obstructive suppurative cholangitis Acute pancreatitis

Surgical methodsOpen cholecystectomyLaparoscopic cholecystectomy

Two method in cholecystectomy: duct first method: the cystic duct and artery are first dissected and divided fundus first method: in which dissection is started from fundus and gradually proceed toward cystic duct

Operative problems1)CBD and right hepatic artery injury during the operation of fundus first method

2)Slipped of clip or ligature may lead to profuse bleeding

3)Biliary leakage from some unknown duct which may lead to syndrome known as Waltman-Walter syndrome- this syndrome is manifested by chest pain or upper abdominal pain,low BP,tachycardia.it mimics coronory thrombosis,pulmonary embolism.this condition is fatal so immediately reexplored the abdomen

Postoperative treatment1)Drainage is removed after 48 hours or it may be kept for longer period2)Gastric aspiration and IV fluid is continued until the peristalsis of intestine is come back

Acute acalculous cholecystitisFew patients with acute cholecystitis have acalculous inflammationMajor surgerySepticaemiatraumapancreatitiscomplication of parenteral nutritionBest diagnosedd using a nuclear imaging hepatobiliary iminodiacetic acid scanthe inflammatory reaction in the gallbladder wall may be intense and severe, leding to gangrene and perforationin ill patients, percutaneous drainage (cholecystostomy) under ultrasound guidance may be considered, but urgent cholecystectomy is often advisable.

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