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Cholecystitis

Biliary Tract
Made up of:
Intra hepatic ducts
Exta hepatic ducts
Gallbladder
Common Bile Duct
The Gallbladder
The gallbladder concentrates and
stores bile.
Bile:
Secreted by the liver
Contains cholesterol, bile pigments
and phospholipids
Flows from the liver, through the
hepatic ducts, into the gallbladder
Exits the gallbladder via the cystic
duct
Flows from the cystic duct into the
common bile duct, into the small
intestine
In the small intestine, aids digestion
by breaking down fatty foods and
fat-soluble vitamins
Cholecystitis
Cholecystitis is an
inflammation of the
gallbladder wall and
nearby abdominal
lining.

Abdominal wall

Gallbladder
Those who are most at risk.
These are all adjectives to describe the person most at
risk of developing symptomatic gallstones.

FAIR FAT FORTY FEMALE


Signs and Symptoms.
Complaints of indigestion after
eating high fat foods.
Localized pain in the right-upper
quadrant epigastric region.
Anorexia, nausea, vomiting and
flatulence.

Increased heart and respiratory rate


causing patient to become diaphoretic
which in turn makes them think they
are having a heart attack.
Signs and Symptoms.
Low grade fever.
Elevated leukocyte count.
Mild jaundice.
Stools that contain fat steatorrhea.
Clay colored stools caused by a lack of bile in the
intestinal tract.
Urine may be dark amber- to tea-colored.
Acute Acalculous Cholecystitis
Presence of an inflamed gallbladder in the absence of an
obstructed cystic or common bile duct
Typically occurs in the setting of a critically ill patient (eg,
severe burns, multiple traumas, lengthy postoperative care,
prolonged intensive care)
Accounts for 5% of cholecystectomies
Aetiology is thought to have ischemic basis, and gangrenous
gallbladder may result
Increased rate of complications and mortality
An uncommon subtype known as acute emphysematous
cholecystitis generally is caused by infection with clostridial
organisms and occlusion of the cystic artery associated with
atherosclerotic vascular disease and, often, diabetes.
Acute Calculous Cholecystitis
Inflammation of the gallbladder that develops in the
setting of an obstructed cystic or bile duct
Most patients have complete remission within 1-4 days.
25-30% of patients either require surgery or develop
some complication
Perforation occurs in 10-15% of cases.
Acute Calculous Cholecystitis
90% of cases
Obstruction in the neck of the gall bladder or in
the cystic duct by a gall stone distention- acute
inflammation- secondary bacterial infection
Symptoms
Right upper quadrant pain continuous, longer
duration
Signs
Fever, Local peritonism.
Murphys sign
2 fingers on RUQ, ask patient to breathe in.
Positive if pain and arrest of inspiration
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP
Ultrasound of abdomen
Thickened gallbladder wall, pericholecystic
fluid and stones
OGD (Oesophagogastroduodenoscopy)
Treatment
Nil by mouth
Analgesia
Intravenous antibiotics
Cholecystectomy
Stages of Acute Cholecystitis.

- Gallbladder has a grayish


appearance & is edematous.
- As acute cholecystitis - Gallbladder undergoes
-There is an obstruction of the progresses, the gangrenous change and
cystic duct and the gallbladder begins to the wall becomes very
gallbladder begins to swell. become necrotic and gets dark green or black.
a speckled appearance as
- It no longer has the "robin - This is the stage when
the wall begins to die.
egg blue" appearance of a perforation occurs.
normal gallbladder.
CHRONIC CHOLECYSTITIS
associated with the presence of gallstones
result from repeated bouts of subacute or acute
cholecystitis or from persistent mechanical irritation of the
gallbladder wall by gallstones.
The presence of bacteria >25% of patients
may be asymptomatic for years,
may progress to symptomatic gallbladder disease or to
acute cholecystitis, or may present with complications
Empyema / Mucocoele
Empyema refers to a gallbladder filled
with pus due to acute cholecystitis

Mucocele refers to an overdistended


gallbladder filled with mucoid or clear
and watery content.
Empyema / Mucocoele
Symptoms
Right upper quadrant pain continuous, longer duration
Signs
Fever, Local peritonism.
Murphys sign
2 fingers on RUQ, ask patient to breathe in. Positive if pain and arrest of inspiration
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP
Ultrasound of abdomen
Thickened gallbladder wall, distended gallbladder, pericholecystic fluid, stones
Treatment
Nil by mouth
Analgesia
Intravenous antibiotics
Cholecystectomy
Ascending Cholangitis
Obstruction of biliary tree with bile duct infection

Symptoms
Unwell, pain, jaundice, dark urine, pale stools
Charcot triad (ie, fever, right upper quadrant pain, jaundice) occurs in
only 20-70% of cases

Signs
Sepsis (Fever, tachycardia, low BP), Jaundice.
Investigations
Bloods U&E, FBC, LFT, Amylase, CRP, Coagulation screen
Ultrasound of abdomen
Treatment
Intravenous antibiotics
Endoscopic Retrograde CholangioPancreatogram
Diagnostics.
Fecal studies.

Serum bilirubin tests.

Ultrasound of the
gallbladder.
Diagnostics.
Oral cholecystogram
- the patient takes iodine-containing tablets by
mouth
- iodine is absorbed from the intestine into the
bloodstream
- removed from the blood by the liver and
excreted by the liver into the bile (it is
concentrated in the gallbladder )outlines the
gallstones that are radiolucent (x-rays pass
through them).
HIDA scan
imaging test used to examine the gallbladder and the
ducts leading into and out of the gallbladder
also referred to as cholescintigraphy.
Operative cholangiography
common bile duct is directly injected with radiopaque
dye.
Medical Management.
Lithotripsy If the attack of
for patients with only a cholelithiasis is mild
FEW stones. bed rest is prescribed.
patient is placed on
NPO to allow GI tract
and gallbladder to rest.
an NG tube is placed
on low suction.
fluids are given IV in
order to replace lost
fluids from NG tube
suction.
Medical Management.
If stones are present in the
common bile duct, an
endoscopic sphincterotomy
must be performed to remove
them BEFORE a
cholecystectomy is done.

A number of various instruments


are inserted through the
endoscope in order to "cut" or
stretch the sphincter.
Once this is done, additional
instruments are passed that
enable the removal of stones and
the stretching of narrowed regions
of the ducts.
Drains (stents) can also be used
to prevent a narrowed area from
rapidly returning to its previously
narrowed state.
Surgical Management.
Cholecystectomy
or
Laparoscopic Cholecystectomy
removal of the gallbladder.

This is the treatment of choice.


The gallbladder along with the cystic
duct, vein and artery are ligated.
Cholecystectomy
Laparoscopic
cholecystectomy standard of
care
Timing
Early vs interval operation
Patient consent
Conversion to open procedure
10%
Bleeding
Bile duct injury
Damage to other organs
Cholecystectomy
Asymptomatic gallstones do not require operation

Indications
A single complication of gallstones is an indication for
cholecystectomy (this includes biliary colic)
After a single complication risk of recurrent complications is high
(and some of these can be life threatening e.g. cholangitis,
pancreatitis)

Whilst awaiting laparoscopic cholecystectomy


Low fat diet
Dissolution therapy (ursodeoxycholic acid) generally useless
Cholecystectomy
All performed laparoscopically

Advantages:
Less post-op pain
Shorter hospital stay
Quicker return to normal activities

Disadvantages:
Learning curve
Inexperience at performing open cholecystectomies
Cholecystectomy when to perform?
After acute cholecystitis, cholecystectomy traditionally performed
after 6 weeks

Arguments for 6 weeks later


Laparoscopic dissection more difficult when acutely inflammed
Surgery not optimal when patient septic/dehydrated
Logistical difficulties (theatre space, lack of surgeons)

Arguments for same admission


Research suggests same admission lap chole as safe as elective chole
(conversion to open maybe higher)
Waiting increases risk of further attacks/complications which can be life
threatening
Risk of failure of conservative management and development of dangerous
complication such as empyema, gangrene and perforation can be avoided

National guidelines state any patient with attack of gallstone


pancreatitis should have lap chole within 3 weeks of the attack
THE END
Questions?

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