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Kharkov National Medical University

Department of Surgery No.

Course: 4th, general medicine


Group: 11
Date: 20/11/2015
Topic: Acute Cholecystitis

ACUTE CHOLECYSTITIS
1

Acute cholecysitis is inflammation of the gallbladder that causes severe abdominal


pain. It is usually a complication of cholelithiasis that involves the gallbladder with
various degrees of severity.
Physiology of the gallbladder:
The gallbladder stores and concentrates bile. Bile flow is controlled by hepatic
secretory pressure, the tone of Sphincter of Oddi, gallbladder contraction and the
rate of gallbladder fluid absorption.
The gallbladder also releases bile in to the common hepatic duct.
Anatomy of gallbladder:
Fundus or tip
Corpus
Infundibulum called Hartmanns pouch
Neck
Cystic duct (2-4 cm long)
Biliary tract
The Biliary tract includes the intra-hepatic bile duct, the extra-hepatic biel dut, the
gallbladder and the sphincter of Oddi.
Intra-hepatic bile duct:
Bile canaliculi
Segmental bile duct
Lobal bile duct
Right or left hepatic duct
Extra-hepatic bile duct:
Left and right hepatic bile duct
Common hepatic duct, ductus hepaticus communis
Common bile duct, ductus choleduchus
Cystic duct of gallbladder,
Sphincter of Oddi
Classification of acute cholecystitis
Types of acute cholecystitis:
acute calculous cholecystitis 90-95%
acute acalculous cholecystitis
Forms of acute cholecystitis:
Simple or catarrhal
Phelgmonous
Gangrenous
Perforated

Acute calculous cholecystitis


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-involves a gallstone; is a complication of cholelithiasis.


-the gallstone blocks the pathway from the gallbladder to the cystic duct leading
ultimately to inflammation of the gallbladder.
-obstruction of cystic duct increase intraluminal pressure in the gallbladder.
-is associated with arterial dilation and entesive venous filling
Acute acalculous cholecystitis, AAC
-is inflammation of the gallbladder without stone formation
-is associated with arterial occlusion and minimal or no vneous filling . The critical
factor in acute acalculous cholecystis is gallbladder ischemia or reperfusion injury.
-bile stasis due to volume depletion is also a factor in AAC (lysophospholipid choline
I bile can cause local injury of the gallbladder wall/mucosa; other bile components
like -glucuronidase can induce AAC
Clinical picture of acute cholecystitis
Sudden pain in the rugiht upper quadrant (RUQ)
NB: sudden pain is also in biliary colic but the onset of the pain in biliary colic
is food-related.
Pain in acute cholecystitis is not connected with meals and begins as a dull,
poorly localized pai in the mid-epigastrium.
Tenderness and n rigidity of RUQ
Nausea, vomiting
Signs of acute cholecystitis in acute calculous and acalculous cholecystitis
Murphys sign press the right upper quadrant region while the patient is
inspiring deeply. Murphys sign is positive when patient stops breathing
during inspiration because your pressing caused pain.
Kers sign- kers point is where the right lateral edge of the rectus abdominis
muscle meets the right costal arch. Kers point is the projection of the
gallbladder. Kers sign is positive if pain is felt by the patient when you
percuss Kers point.
Ortners sign - is positive when pain is felt if you strikKers point with edge of
the palm.
De Mussy-Georgievskys sign or the phrenic sign- pressing the clavicular
edge of the sternocleidomastoid muscle causes pain in the right upper
quadrant.
Boas sign- area of hyperesthesia between 9 th and 11th rib posteriorly on the
right side
Laboratory investigations
CBC = leukocytois 12,000-15,000 cells
Check liver function, serum bilirubin, serum alkaline phosphatase and serum
amylase
Instrumental methods
3

-US to demonstrate gallstones


-CT to show thickening of the gallbladder wall.
Management
Conservative treatment:
Admit the ptient to the hospital
Diet
Iv hydration
Systemic antibiotics
Monitor the patient
Other drugs ie spasmolytics, anithistamines, but do not give pain killers. If you do
give pain killers you wont be able to tell when the inflammation spreads 9pain
intensifies) and you wont know when to use surgical treatment.
Surgical treatment
-Open or laparoscopic cholecystectomy
Open cholecystectomy: usually a midline incision is used; is of 2 types antegrade
and retrograde
-Surgery s contraindicated in carcinoma, choledocholithiasis, biliary stenosis, sever
abdominal infection, pregnancy
Differential diagnosis
Appendicitis
Cholangitis
Cholelithiasis
Diverticulitis
Gastroenteriritis
hepatitis

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