Acute and chronic cholicystitis

Acute & Chronic Lithiatic And Non Lithiatic

Cholecystitis

By:Moh.Mujib MunirzaiAmiri Medical Complex

Date:19/11/2016

ACUTE CHOLECYSTITIS

• Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct.

• Most patients have had prior attacks of biliary colic or acute cholecystitis.

• Pain lasts longer (i.e. >6hr) than in biliary colic and more severe.

• Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients.

Pathogenesis• Obstruction of the cystic duct• Brief impaction may cause pain only• Inflammation the gallbladder

– Enlarged – Tense – Reddened – Wall thickening – Exudate of peri-cholecystic fluid

• BACTERIA– E.coli

– Enterococci – Anerobes(bacteriods)– klebsilla

• The wall of the gallbladder may undergo necrosis and gangrene (gangrenous cholecystitis).

• Bacterial super-infection with gas-forming

organisms may lead to gas in the wall or lumen of the gallbladder (emphysematous cholecystitis).

Diagnosis• Clinical findings• The main symptom of uncomplicated

– biliary colic– caused by the obstruction of the gallbladder neck by a stone.

• The pain is characteristically • Episodic• Severe• Located in the epigastrium or RUQ.• Radiates into the back

– It frequently follows after • food intake or comes on at night.

• Accompanied by nausea and vomiting.

Diagnosis

• Physical Exam:• Murphy's sign

– The arrest of inspiration while palpating the gallbladder during a deep breath.

• Palpable gallbladder because of fibroses, empyema and hydrops GB

Diagnosis

• B. Laboratory finding• Leukocytosis or normal WBC• Serum bilirubin mildly high• Alkalinphosphatas mildly high• Amylase high

• C. Imaging studies– Plain X-ray in 15% calcium stones– Ultrasound studies is very sensitive and shows: stones, sludge,

wall thickness, perigalbladder collection, subhepatic collections– Ultrasound Murphy sign will be positive

USG

• Sensitive• Inexpensive• Reliable

» Sensitivity 85% and Specificity 95%

What will you look in USG?1.GallStone2.Pericholecystic fluid3.GB wall thickening4.Sonographic murphy’s sign

Ultrasound Pictures

Differential diagnosis

• Acute peptic ulcer with or without perforation, by radiography abdomen with pneumopritoneum

• Acute appendicitis specially in subhepatic location by scan, ultrasound

• Acute pancreatitis by lipase, CT Scan

Complications

1. empyema( supporative cholecystitis)Thick wall GB, fever, toxication, chills, WBC Treatment: urgent cholecystectomy or cholecystostomy

2. perforationa. Pericholecystic abscess: is common, palpable mass,

toxication, fever, WBC . Treats by cholecystectomy in poor condition subcutaneous cholecystostomy.

b. Free perforation: occurs in1-2% in early gangrene before adhesion formation and in rupture of localized abscess with sudden pain.

3. Cholecystoenteric fistula: with stomach, duodenum, colon adherent and necrosis and then fistula formation, gallstone ileus, malabsorption and steatorhea. In most cases fistula has no significant symptoms and clinic.

Gangrene and perforation

3 main things to take therapeutic decision:

I. Diagnosis is establishedII. Susceptible general condition by coexistent

diseases III. Sigs of local complications of acute cholecystitis

Emergency cholecystectomy perform in: Empyema gallbladder: high fever, leukocytosis, chills Nonlithiatic cholecystitis Signs of local complications of acute cholecystitis:

subhepatic local collection, perigalbladder collection, sludge bile

Free perforation: sudden abdominal pain on the period of acute cholecystitis

All patients needs urgent cholecystectomy, but in poor condition patients percutaneous cholecystostomy advised

Management of Acute Cholecystitis

1. NPO

2. RYLES TUBE ASPIRATE

3. IV Fluids

4.BROAD SPECTRUM ANTIBIOTICS

5.IV ANALGESICS

6. OBSERVATION

Surgery in a/c CholecystitisWhen presents within 2 to 3 days LAP CHOLECYSTECTOMY

When presents more than 3 days INTERVAL CHOLECYSTECTOMY after 6 weeks

Empyema, Persisting and Progressing Symptoms EMERGENCY CHOLECYSTECTOMY

Acute acalculous cholecystitis

• 5-10% of cases of acute cholecystitis

• Seen in critically ill pts or prolonged TPN

• More likely to progress to gangrene, empyema & perforation due

to ischemia

• Caused by gallbladder stasis from lack of enteral stimulation by

cholecystokinin

• Emergent operation is needed

Chronic Cholecystitis• Long-standing gallbladder inflammation almost

always due to gallstones.• Chronically Inflammed Thickened Gallbladder

which is NONFunctioning NONdistending• Extensive calcification due to fibrosis is called

porcelain gallbladder.

Complications• CBD Stones• Cholangitis• Pancreatitis• Mirizzi’s Syndrome

Treatment of Chronic Cholecystitis isCHOLECYSTECTOMY

summaryCholecystectomy is preferable method for

treatment of acute cholecystitisIn poor condition patients percutaneous

cholecystostomy advisedJust evacuation of bile is enough not

stonesPost improving of general condition

cholecystectomy should be done

THANKS FROM YOUR PATIANCE