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Aetiopathogenesis and management of calculus cholecystitis

  3. 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 3/9/2015 3
  4. 3/9/2015 4 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
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  6. 3/9/2015 6 Should be identified during cholecystectomy to avoid damage to extrahepatic biliary system
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  8. • 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%) 3/9/2015 8
  9. • 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)
  10. • 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 3/9/2015 10
  11. 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
  12. • 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 3/9/2015 12
  13. • 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 3/9/2015 13
  14. • 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, elevataed alkaline phosphatase, bilirubin • Elevated serum amylase 3/9/2015 14
  15. • 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 15
  16. • 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 3/9/2015 16
  17. 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 3/9/2015 17
  18. • 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 3/9/2015 18
  19. 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. 3/9/2015 19
  20. • Unclear anatomy • No tissue plane • Uncontrollable bleeding • Accidental damage • Equipment failure • Lack of progress 3/9/2015 20
  21. • 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 3/9/2015 21
  22. • Iatrogenic bile duct injury • Post op bile leak • Haemorrhage • Retained stone • Post cholecystectomy syndrome • Inadvertent bowel injury • Subcutaneous emphysema • Anaesthetic complication
  23. • Acute appenditis • Perforated peptic ulcer • Acute pancreatitis • Acute pyelonephritis • Myocardial infarction • Right lobar pneumonia 3/9/2015 23
  24. • 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. 3/9/2015 24
  25. • 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 3/9/2015 25

Hinweis der Redaktion

  1. Bilesalt and lecithine keeps cholestherol in soluble state Moynihan aphorism “a gallstone is a tombstone erected to the organism within it” PIGMENT STONE: Hemolytic anemias and infections of the biliary tract → increased unconjugated bilirubin in the biliary tree → form precipitates : insoluble calcium bilirubinate salts. CHOLESTEROL STONE: when bile is supersaturated with cholesterol, with GB hyopomotility, it precipitates. Mucus hypersecretion trap crystals aggregating into stone.
  2. The major complications are bile duct injury (1%), bile leak with biliary peritonitis (4 %), bleeding (3%), perforation Of a viscus (0.3%) and retained stones. About 90% of patients having successful laparoscopic cholecystectomy leave hospital within 24h andover 91 % return to full normal activity in one week