Acute Cholecystitis Cp2 Surgery by Helmy

8/6/2019 Acute Cholecystitis Cp2 Surgery by Helmy

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Anatomy of gall bladder



Ch olecystitisRelated to inflammation wit

hin t

he gallbladder

Acute:- Acute bacterial inflammation of t h e gall

bladder wit h or wit h out stones.- Types :-

1. C alculous (obstructive, commonest)- complication of c h olelit h iasis

2. Acalculous (non-obstructive)



Acute c h olecystitis

C ommon organisms responsible:1. E. C oli

2. Streptococci3. Salmonella4. Klebsiella5. Ot h ers: C lostridium

~~bile stasis precipitates infection



Path ogenesis ( C alculous)

STONE / BILIAY SLUDGEObstruction of bile flow mucosal erosion

Stasis destruction of cellsby toxic bile salts

Bacterial proliferation release inflammatorymediators (Pg I2 n E2)

Necrosis and perforation





Acalculous c h olecystitis

± Usually associated wit h major illness likepolytrauma, burns, major surgery

± Distension of gall bladder

± Features are like t h rombosis, necrosisand edema



SymptomsOften h ave h istory of biliary colic4 F : fat, forty, fertile, femalesevere constant epigastric or RUQ pain

anorexia, nausea and vomiting arecommonLow grade fever (except in clostridialinfection)If th e stone moves to C BD, obstructive

jaundice and c h olangitis may occur.



Signssystemic signs ± low grade fever (<38.5 º C ),tac h ycardiaMurph y¶s sign +ve (sudden cessation of inspiration wit h deep RUQ palpation)

Boas¶ sign (area of h yperast h esia bw 9 th and11 th ribs posteriorly on t h e rig h t sideGuarding and rigidity @ upper abdomenVague mass (consisting inflammed GB,omentum, inflammatory exudates)





Differential Diagnosis

1. perforated peptic ulcer 2. acute pancreatitis3. h iatus h ernia

4. rig h t lower lobe pneumonia5. myocardial infarction6. appendicitis



Investigations

Full blood count ± WB C h igh

Liver Function test ± mildly elevated bilirubin, ALP ± sometimes slig h t elevation AST, ALT

X-Ray Abd ± view any gall stones (radio opaque) ± TRO perforated ulcer (air under diap h ragm)





U/S abdomen (Diagnostic test)

Th icken gallbladder wall (>3mm)Peric h olecystic fluidDistended gallbladder Present of gallstone / cystic duct stone

Sonograp h ic Murp h y¶s sign (pain on inspiration after placement of USG probe over gallbladder)



Principle of Treatment

C onservative followed by c h olecystectomy->90% subside

-4 principles:

a)NBM and intravenous fluids ( h ydrate t h e patient)b)Analgesicsc)Antibiotics - Use broad spectrum as C eferoximed)Antiemetics , if severe vomiting, NG suctioning

may be required



Inflammation subsiding, NG tube removed,fluids followed by a fat free diet

lack of improvement wit h conservative

treatment ±±> operate with

in 24-48h

ours(ch olecystectomy)

Subsequent management- monitoring of

vital signs and USG done to look for localcomplications.



C omplication

1. Empyema2. Perforation3. Mucocele4. Gallstone ileus

5. Gangrenous c h olecystitis6. Ch olecystoenteric fistulas



Th ank You

Acute Cholecystitis Cp2 Surgery by Helmy

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