CHOLECYSTITIS SODIENYE HALLIDAY M.D.. OUTLINE WHAT IS CHOLECYSTITIS. BRIEF DESCRIPTION OF THE GALLBLADDER, ITS FUNCTION AND ANATOMY. CAUSES OF CHOLECYSTITIS.

CHOLECYSTITIS

SODIENYE HALLIDAY M.D.

OUTLINE• WHAT IS CHOLECYSTITIS.• BRIEF DESCRIPTION OF THE GALLBLADDER, ITS FUNCTION AND

ANATOMY.• CAUSES OF CHOLECYSTITIS (CHOLELITHIASIS) AND RISK FACTORS.• WHAT IS CHOLELITHIASIS.• TYPES OF CHOLELITHIASIS.• TYPES OF CHOLECYSTITIS.• RISK FACTORS.• CLINICAL PRESENTATION.• TREATMENT.• DIAGNOSIS.

WHAT IS CHOLECYSTITIS?

• CHOLECYSTITIS IS SIMPLY THE INFLAMMATION OF THE GALL BLADDER.

• IT COULD BE ACUTE, CHRONIC, OR ACUTE SUPERIMPOSED ON CHRONIC.

• THE MOST COMMON CAUSE IS CHOLELITHIASIS (GALLSTONES MOST COMMONLY BLOCKING THE CYSTIC DUCT).

• IN THE UNITED STATES CHOLECYSTITIS IS ONE OF THE MOST COMMON INDICATIONS FOR ABDOMINAL SURGERY.

GALLBLADDER.

• THE GALLBLADDER IS A PEAR-SHAPED HOLLOW ORGAN LOCATED JUST BELOW THE LIVER IN THE RIGHT ABDOMEN.

• BILE FUNCTIONS TO STORE AND CONCENTRATE THE BILE PRODUCED BY THE LIVER. THE GALLBLADDERS ABSORPTIVE EPITHELIAL LINNING HELPS TO DO THIS.

• BILE FUNCTIONS TO EMULSIFY FAT AND HELPS NEUTRALIZE ACIDS IN PARTIALLY DIGESTED FOOD.

ANATOMY OF THE GALLBLADDER

THE GALLBLADDERS POSITION IN RELATION TO THE LIVER AND PANCREASE

BILIARY TRACT

HISTOLOGY OF THE GALLBLADDER

• NO MUSCULARIS MUCOSA

• NO SUBMUCOSA

NORMAL G.I EPITHELIUM LAYERS

GALLBLADDER HISTOLOGY

CHOLECYSTITIS

• WHY AND HOW DOES THE GALLBLADDER GET INFLAMED WHETHER ACUTE, CHRONIC OR ACUTE SUPERIMPOSED WITH CHRONIC.

• MAIN CAUSE: CHOLELITHIASIS

CHOLELITHIASIS

• THIS IS THE FORMATION OF GALLSTONES MAINLY IN THE CYSTIC DUCT OF THE GALLBLADDER.

CAUSES: 1. SUPERSATURATION OF BILE WITH CHOLESTEROL OR

BILIRUBIN.2. DECREASED PHOSPHOLIPID (LECITHIN) OR BILE

ACIDS.3. STASIS (HYPOMOBILITY OF THE GALLBLADDER):

PROMOTES NUCLEATION.4. MUCUS HYPERSECRETION THAT TRAP THE STONES: TRAPS

PRECIPITATED CRYSTALS.

PHARMACOLOGY TIE-IN• CHOLESTYRAMINE:

THIS IS AN ORAL DRUG THAT SERVES TO REDUCE THE AMOUNT OF CHOLESTEROL IN THE BLOOD AND STOP THE PRURITIS ASSOCIATED WITH LIVER DISEASE.

CHOLESTEROL IS CONVERTED TO BILE IN THE LIVER AND IS EXCRETED INTO THE DUODENUM(ILEUM) AS BILE. MOST OF THIS BILE THAT ENTERS THE INTESTINE IS REABSORBED AGAIN INTO THE BLOOD. MOST OF THIS BILE ACIDS ARE REMOVED FROM THE BLOOD BY THE LIVER AND AGAIN EXCRETED INTO BILE.

NOW IN ORDER TO REDUCE ITCHING THAT STEMS FROM THE ACCUMULATION OF BILE SALTS, CHOLESTYRAMINE BINDS TO BILE ACIDS PROHIBITING THE RECYCLING OF BILE BY THE ILEUM. THIS BINDING TO BILE INHIBITS ITS RECIRCULATION AND LEADS TO THE ACCUMULATION OF UNSOLUBULIZED CHOLESTEROL INCREASING CHANCES OF BILE STONE FORMATION.

TYPES OF GALLSTONES

• CHOLESTEROL STONES (ACCUMULATION OF CHOLESTEROL): MOST COMMON TYPE OF STONES.

• PIGMENT STONES (ACCUMULATION OF BILIRUBIN)

• USE ULTRASOUND FOR THE INVESTIGATION OF BILESTONES, RADIOLUSCENT ONES CANNOT BE SEEN ON AN X-RAY.

RISK FACTORS FOR CHOLELITHIASIS.

• AGE: INCREASED RISK WITH ADVANCED AGE (FROM 40 YEARS)• OESTROGEN: INCREASES HMGCoA REDUCTASE ACTIVITY AND INCREASE LIPID

RECEPTORS ON HEPATOCYTES INCREASING CHOLESTEROL UPTAKE.• CLOFIBRATE: ALSO INCREASES HMGCoA REDUCTASE ACTIVITY AND REDUCES

CONVERSION OF CHOLESTEROL TO BILE ACIDS.• NATIVE AMERICAN ETHNICITY (PIMA, HOPI AND NAVAJO)• CROHNS DISEASE: ILEUM• CIRRHOSIS: REDUCED BILE ACID PRODUCTION BY HEPATOCYTES.• OBESITY: FAVOURS STASIS• FEMALE GENDER• ORAL CONTRACEPTIVES.• PREGNANCY.• INBORN DISORDERS OF BILEACID METABOLISM• BILIARY TRACT INFECTION.MEMORY TOOL: FAT, FEMALE, FERTILE, FORTY.

FINALLY, BACK TO CHOLECYSTISIS

• THIS IS THE MOST COMMON MAJOR COMPLICATION OF GALLSTONES AND THE MOST COMMON REASON FOR EMERGENCY CHOLECYSTECTOMY.

• OTHER COMPLICATIONS INCLUDE: BILIARY COLIC, ASCENDING CHOLANGITIS, GALLSTONE ILEUS, GALL BLADDER CANCER.

TYPES OF CHOLECYSTITIS

1. ACUTE: ACUTE ACALCULOUS CHOLECYSTITIS. ACUTE CALCULOUS

CHOLECYSTITIS.

2. CHRONIC: CHRONIC ACALCULOUS CHOLECYSTITIS AND

CHRONIC CALCULOUS CHOLECYSTITIS.

ACUTE CALCULOUS CHOLECYSTITIS

• CAUSED BY CHOLELITHIASIS

• MAJOR CAUSE OF EMERGENCY CHOLECYSTECTOMY.

• STONE IN CYSTIC DUCT, CONSTANT CONTRACTION OF GALLBLADDER TO EJECT BILE, INCREASED PRESSURE SQUEEZES BLOOD VESSELS IN THE WALL OF THE GALL BLADDER, ISCHEMIA OF VESSELS IN THE WALL OF THE GALLBLADDER BECAUSE OF REDUCED BLOOD FLOW, BACTERIAL OVERGROWTH AND INFLAMMATION.

CLINICAL PRESENTATION OF ACUTE CALCULOUS GALLBLADDER.

• PRESENTS WITH SEVERE RUQ PAIN LASTING FOR MORE THAN 6 HOURS AND RADIATING TO THE RIGHT SCAPULA.

• FEVER WITH LEUKOCYTOSIS

• NAUSEA AND VOMITTING.

• INCREASED SERUM ALP (GALLBLADDER AND BILIARY TRACT EPITHELIUM HAVE ALP).

• HYPERBILIRUBINEMIA SUGGESTS OBSTRUCTION TO COMMON BILE DUCTS, INCREASED AST/ALT.

• INCREASED SERUM AMYLASE SUGGESTS ASSOCIATED PANCREATITIS.

• DON’T FORGET CHARCOTTS TRIAD: FEVER, JAUNDICE AND RUQ PAIN.

• THERE IS A RISK OF RUPTURE IF LEFT UNTREATED.

ACUTE ACALCULOUS CHOLECYSTITIS

• NOT CAUSED BY GALLSTONES.

• (5-12)% OF CHOLECYSTECTOMY DONE FOR ACUTE ACALCULOUS CHOLECYSTITIS HAVE NO GALLSTONES.

• CAUSES: AFTER MAJOR NON-BILIARY SURGERY, SEPSIS, BURNS, TRAUMA, DEHYDRATION, SLUDGING, VASCULAR PROBLEMS, BACTERIAL INFECTION.

• DIAGNOSIS: DETECTION OF GALLSTONE IN ULTRASOUND AND EVIDENCE OF A THICKENED GALLBLADDER WALL.

PRESENTATION OF ACUTE ACALCULOUS CHOLECYSTITIS.

• SYMPTOMS ARE MOST TIMES BEING MASKED BY THE SEVERE CLINICAL CONDITION OF THE PATIENT.

• NORMALLY A DIAGNOSIS OF EXCLUSION.

CHRONIC CHOLECYSTITIS• GALLSTONES DO NOT HAVE DIRECT ROLE AS A CAUSE OF

INFLAMMATION IN CHRONIC CHOLECYSTITIS.

• THIS IS USUALLY CAUSED BY SUPERSATURATION OF BILE WHICH EXPOSES THE PATIENT TO CHRONIC INFLAMMATION AND IN MOST CASES STONE FORMATION.

• BOTH THE ACALCULOUS FORM AND CALCULOUS FORM PRESENT WITH THE SAME SYMPTOMS AND MORPHOLOGY.

• MAY DEVELOP AS A RESULT OF REPEATED BOUTS OF ACUTE CHOLECYSTITIS OR MAY DEVELOP INDEPENDENT OF THE ACUTE FORM.

PRESENTATION OF CHOLECYSTITIS

• VAGUE RUQ PAIN THAT IS EXCARCEBATED AFTER A MEAL.

• NAUSEA, VOMITTING AND INTOLERANCE TO FATTY FOODS.

• HISTOLOGY OF THE GALLBLADDER MIGHT SHOW ROKITANSKY ASCHOFF SINUS FORMATION (OUTPOUCHINGS OF THE GALLBLADDER MUCOSA DOWN THE SMOOTH MUSCLE LAYER)

ROKITANSKY-ASCHOFF SINUSES

DIAGNOSIS OF CHRONIC CHOLECYSTISIS

• DIAGNOSIS IS MADE BASED ON THE RESECTION OF THE GALLBLADDER IN THIS CASE.

• IT COULD ALSO BE BY ULTRASONOGRAPHY WHICH WOULD SHOW GALLSTONES, DILATION OF BILE DUCT WITH EVIDENCE OF GALLBLADDER WALL THICKENING.

COMPLICATIONS OF CHRONIC CHOLECYSTISIS.

• BACTERIAL SUPERINFECTION WITH CHOLANGITIS OR SEPSIS.

• GALLBLADDER RUPTURE AND LOCAL ABSCESS FORMATION. PERITONITIS CAN ALSO OCCUR AS A RESULT.

• BILIARY ENTERIC (CHOLECYSTENTERIC) FISTULA, WITH DRAINAGE OF BILE INTO ADJACENT ORGANS, ENTRY OF BACTERIA AND AIR INTO BILIARY TREE AND POSSIBLE GALLSTONE ILEUS.

• COMPLICATIONS OF PREVIOUS ILLNESSES WITH CARDIAC, RENAL, PULMONARY OR LIVER DECOMPENSATION.

PORCELIAN GALLBLADDER

• PORCELIAN GALLBLADDER IS A LATE COMPLICATION OF CHRONIC CHOLECYSTITIS AND IS CHARACTERISED BY THE FORMATION OF DYSTROPHIC CALCIFICATIONS OF THE GALLBLADDER.

• HIGH RISK OF CAUSING GALLBLADDER CANCER (MOSTLY ADENOCARCINOMAS)

PORCELIAN GALLBLADDER

TIPS FOR BOARD QUESTIONS• PAIN+JAUNDICE: GALLSTONES

• PAIN+NO JAUNDICE: CYSTIC DUCT STONES

• NO PAIN/TENDERNESS+ JAUNDICE: CARCINOMA (COURVOISIER LAW)

• NOTE: GALLBLADDER CARCINOMA PRESENTS AS CHOLECYSTISIS IN ELDERLY WOMEN (>70). NORMAL AGE FOR CHOLECYSTISIS IS BETWEEN 40-50.

• IF YOU SEE AN OLD WOMAN PRESENTING WITH CHOLECYSTISIS THINK GALLSTONE CARCINOMA.

THANK YOU!

• WE NEVER REALLY FAIL UNTIL WE GIVE UP, DON’T GIVE UP.(PUSH IT TO THE LIMIT!!!- RICK ROSS)

• QUESTIONS?

REFERRENCES.

• ROBBINS BASIC PATHOLOGY

• DR JEEVANS SLIDES (BILIARY TRACT PATHOLOGY)

• RAPID REVIEW PATHOLOGY GOLJAN (4TH EDITION)

• ‘CHOLECYSTOENTERIC FISTULA IS NOT A CONTRAINDICATION FOR SURGERY’ BY (L.ANGRISANI ET. AL)

• ‘CHOLESTYRAMINE, QUESTRAN, QUESTRAN LIGHT’ BY (O.OGBRU)