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CHOLECYSTITISINTRODUCTION:Prevalence 11-36%.Risk
factors:ObesityPregnancyCrohns disease.Terminal ileum
resection.Gastric surgery.Hereditary spherocytosis, sickle cell
disease, thalassemia.Female.1st degree relative.
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Natural History:Most pt remain asymptomatic3% become symptomatic
per year (biliary colic) 3-5% develop complications per year; acute
cholecystitis, choledocholithiasis, cholangitis, pancreatitis,
cholecystocholedochal fistula, and cholecystoenteric
fistula.Prophylactic cholecystectomy may indicated for elderly pts
with DM, individual who will be isolated from medical care for
extended period of time, and in population with increased risk of
cancer.Porcelain G.B. is an absolute indication for
cholecystectomy.
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CHRONIC CHOLECYSTITIS
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Cholecystitis is the inflammation of the gallbladder, usually
resulting from a gallbladder stone blocking the cystic duct.It
lasts for a long time and characterized by repeated attacks of pain
(biliary colic).
It may become thick walled, scarred and small. The gallbladder
usually contains sludge (a microscopic particles or materials
similar to gallstones)It block its opening into the cystic duct or
reside in cystic duct itself.
What is Cholecystitis
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Notice thickness of galldladder wall, abundant polyhedric stones
and small papillary tumor in the cystic duct.
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morphology
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Enlarged mucosal folds of the gallbladder can be seen, and in
many there will be an infiltrate of foamy histiocytes. There is
very little inflammation of the acute or chronic type here, and if
there is any at all, it will be found in the muscular wall and
serosal fat. This is a very common and benign process, and very
likely is the starting point for some types of gall stones.
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The physical examination may reveal fever, tachycardia, and
tenderness in the RUQ(right upper quadrant) or epigastric region,
often with guarding or rebound.
The Murphy sign, which is specific but not sensitive for
cholecystitis, is described as tenderness and an inspiratory pause
elicited during palpation of the RUQ. A palpable gallbladder or
fullness of the RUQ is present in 30-40% of cases. Jaundice may be
noted in approximately 15% of patients.
Clinical manifested
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Many patients present with diffuse epigastric pain without
localization to the RUQ. Patients with chronic cholecystitis
frequently do not have a palpable RUQ mass secondary to fibrosis
involving the gallbladder.
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The main symptoms is pain in the upper right side or upper
middle of the abdomen. The pain may :
Be sharp, cramping, steadySpread to the back or below the right
shoulder blade
Other symptoms : clay-colored stools, fever, nausea or
vomitting, yellowing of skin(jaundice)Symptoms
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Cholecystitis is diagnosed by doctors mainly based on symptoms
and results of imaging tests.Ultrasonography is the best way to
detect gallstones in the gallbladder or the thickening of its wall.
Diagnostic
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Ultrasound of the Abdomen.Ultrasound is a simple, rapid, and
noninvasive imaging technique. It is the diagnostic method most
frequently used to detect gallstones and is the method of choice
for detecting cholecystitis.
If possible, the patient should not eat for 6 or more hours
before the test, which takes only about 15 minutes. During the
procedure, the doctor can check the liver, bile ducts, and
pancreas, and quickly scan the gallbladder wall for thickening
(characteristic of cholecystitis.
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Liver blood test are often normal unless the person has an
obstructed bile duct. Other blood test can detect some
complications such as high level of a pancreatic enzyme (lipase or
amylase) in pancreatitis.
A high count of WBC suggest inflammation, an abscess, gangrene
or a perforated gallbladder.continue
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This surgery uses a smaller surgical cuts, which results in a
faster recovery. Patients are often sent home from the hospital on
the same day as surgery or the next morning. Open cholecystectomy
requires larger cut in the upper-right part of the abdomen.
Gall stones may also be dissolved with medication taken by
mouth. But may take 2 years or longer to work.Laparoscopic
Cholecystectomy
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The condition is not always preventable.Eating less fatty food
may relieve symptoms who have not had their gallbladder
removed.Management
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ACUTE CHOLECYSTITIS
Acute Inflammation of gall bladder is called ACUTE
CHOLECYSTITIs
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Etiology Obstruction Bacterial invasion Trauma and chemical
irritation Pancreatic reflux
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EtiologyCALCULOUS
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etiologyACALCULOUSCholesterosis(strawberry gall
bladder)Cholesterol polyposis of gall bladderCholecystitis
glandularis proliferansDiverticulosis of gall bladderTyphoid of
gall bladder
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etiology BACTERIAL INFECTION
E-coliKlebsiellaS.faecalisSalmonellaClostridia Anaerobes
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classificationOn etiology: calculous,acalculous,emphysamatous On
inflammation:simple,destructive
Emphysamatous
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classificationOn morphology:
catarhal,phlegmonous,gangrenous,gangrenous perforation
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Abdominal pain
SITE - RIGHT HYPOCHONDRIUMTYPE - COLICKYONSET SUDDENDURATION
MORE THAN 12 hrs RADIATION BACKSHOULDERRIGHT HYPOCHONDRIUMLEFT
HYPOCHONDRIUM
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Symptoms: 2 gastrointestinal Nausea, bilious vomiting Abdominal
distension Belching or flatulence 3. Fever
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signsGENERALTACHYCARDIAPYREXIA
From MMWR Aug 2004
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From MMWR Aug 2004Local TENDERNESS - RT HYPOCHONDRIUMRIGIDITY -
RT HYPOCHONDRIUMMURPHYS SIGNBOAS SIGNMASS
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murphys sign
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Boas signAn area of hyperasthesia between 9th and 11th rib
posteriorly right side is a feature
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Ortner sign-tenderness when handtaps the edge of rightcostal
arch
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Laboratory findings Elevated leukocyte count Elevated serum
bilirubin Elevated amylase level
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Instrumental investigationPLAIN X-RAY ABDOMEN
Radioopaque gall stone
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ULTRASONOGRAPHYDilatation of billiary treeStonesFluid
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Common bile duct dialation
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Intra hepatic duct dialation
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Gall stone
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GALL BLADDER RADIONUCLIDE SCAN
ORAL CHOLECYSTOGRAM
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP
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HIDA ScanFor this test, a radioactive substance (radionuclide)
is injected intravenously. A gamma camera detects the radioactivity
given off and a computer is used to produced an image. Thus the
movement of the radionuclide from the liver through the biliary
tract can be followed.
Images of the liver, bile ducts, gallbladder and upper part of
small intestines are taken. If the radionuclide does not fill the
gallbladder, the cystic duct is probably blocked by a
gallstones.
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Cholescintigraphy, another imaging test, is useful when acute
cholecystitis is difficult to diagnose.
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HIDA SCAN SHOWING NONVISUALIZATION OF GALL BLADDER
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ERCP showing mirizzi syndrome
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DIFFERENTIAL DIAGNOSIS
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RARE
ACUTE PYELONEPHRITIS
HEPATITIS
MYOCARDIAL INFARCTION
PNEUMONITIS
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complicationEMPYEMAPERFORATIONPERITONITISABSCESSFISTULAMUCOCELEACUTE
PANCREATITISGALL STONE ILEUSOBSTRUCTIVE JAUNDICE
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TreatmentNonsurgical or preoperative management Intravenous
fluids Nasogastric tube Broad spectrum antibiotics
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Naspgastric tube: ryles tube admistration immediately continued
3 to 5 days.aspirating HCL decreases the secretion of bile.spasm of
bladder may come down intravenous fluid: in the beginning 5 %
dexrose saline may be started but subsquently fluid may be changed
according to electrolyte balance of paitentAnalgesic
+anticholinergic given to reduce spasm
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Antibiotic
broad spectrum to control inflammation.combination of
Cephalosporin with metronidazole is good.
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Conservative treatment stopped and early cholecystectomy
advised1)pain and tenderness spread across the abdomen2)gall
bladder increases in size3)Pulse rate continuse to rise4)In very
elderly patient
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Surgical Treatment1.Attack within 48-72 h of
diagnosis2.Deterioration in patients general
condition3.Complications are present Perforation Peritonitis Acute
obstructive suppurative cholangitis Acute pancreatitis
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Surgical methodsOpen cholecystectomyLaparoscopic
cholecystectomy
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Two method in cholecystectomy: duct first method: the cystic
duct and artery are first dissected and divided fundus first
method: in which dissection is started from fundus and gradually
proceed toward cystic duct
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Operative problems1)CBD and right hepatic artery injury during
the operation of fundus first method
2)Slipped of clip or ligature may lead to profuse bleeding
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3)Biliary leakage from some unknown duct which may lead to
syndrome known as Waltman-Walter syndrome- this syndrome is
manifested by chest pain or upper abdominal pain,low
BP,tachycardia.it mimics coronory thrombosis,pulmonary
embolism.this condition is fatal so immediately reexplored the
abdomen
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Postoperative treatment1)Drainage is removed after 48 hours or
it may be kept for longer period2)Gastric aspiration and IV fluid
is continued until the peristalsis of intestine is come back
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Acute acalculous cholecystitisFew patients with acute
cholecystitis have acalculous inflammationMajor
surgerySepticaemiatraumapancreatitiscomplication of parenteral
nutritionBest diagnosedd using a nuclear imaging hepatobiliary
iminodiacetic acid scanthe inflammatory reaction in the gallbladder
wall may be intense and severe, leding to gangrene and
perforationin ill patients, percutaneous drainage (cholecystostomy)
under ultrasound guidance may be considered, but urgent
cholecystectomy is often advisable.
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