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- 1. CHOLECYSTITIS SATURDAY SURGICAL UNIT PRESENTATIONBY DR.PHANEENDRA HOU-DR.RAM SIR AP-DR.DMP SIR
- 2. Inflammation ofgallbladder Most commonly associated with gallstones
- 3. CAUSES Gallstones Tumours Chemical irritants Bile duct block due to kinking or scarring Infections- viral or bacterial Decreased blood flow to the GB due any severe illness
- 4. TYPES ACALCULUS Without evidenceof gallstone or cystic duct obstuction Cholesterosis (strawberry GB) Cholesterol polyposis(pseudopolyps) Cholecystitis glandularis proliferans GB diverticulosis Bacterial invasion Pancreatic reflux Typhoid of GB CALCULUS With evidence of gallstones 80% are of cholesterol type.
- 5. Acalculous cholecystitisis common in chronically icu admitted patients Conditions and management leading to cholestasis Prolonged NBM Prolonged fasting Patients on prolonged TPN
- 6. Cholesterol laden macrophagesaggregation in mucosa (strawberry gall bladder) Cholesterol polyps of GB
- 7. Emphysematous cholecystitis Emphysematous cholecystitis(clostridialcholecystitis) Acute infection caused by gas forming Surgical emergency
- 8. Cholecystitis glandularis proliferans Circumscribed diffuse thickening of wall of chronically inflamed GB Excessive proliferation and invasion of wall by epithelium Formation of crypts(Rokitansky aschoff sinuses) which dilate to form cysts may be referred as adenomatous polyp, cystadenoma, cholesterol cyst papilloma, Adenomyoma
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- 10. Bacteria causing cholecystitis E-coli Klebsiella S.fecalis Salmonella Clostridia anaerobes (clostridium welchii) causes emphysematous cholecystitis
- 11. ACUTE Sudden inflammationof GB causing marked abdominal pain often with nausea vomiting and fever
- 12. CHRONIC Low intensityinflammation of GB that lasts a long time May be caused by repeated attacks of cholecystitis Symptoms include only mild intermittent abdominal pain or no symptoms at all Damage to the walls of GB leads to thickened and scarred GB which ultimately shrink and looses the ability to store and release bile
- 13. PATHOGENESIS Gallstone obstructthe bile flow Irritation and raised pressure of GB due to build up of bile Inflammation and distension of GB causing oedema of GB (bacterial and chemical) Blood flow compromise causing cholecystitis
- 14. CLINICAL MANIFESTATIONS Severepain in right upper quadrant Spreading to right shoulder or back Nausea Vomiting Fever Jaundice and clay coloured stool may occur if CBD gets blocked
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- 17. Staging based onmorphology Catarrhal- Involving only mucosa Phlegmonous- Inflamation penetrating deeper layers Gangrenous Gangrenous perforation
- 18. COMPLICATED CHOLECYSTITIS Empyema Mucocele Pancreatitis Icterus Hepatitis Cholangitis Peritonitis
- 19. COMPLICATIONS OF ACUTECALCULOUS CHOLECYSTITIS Perforation Usually in the fundus or in neck causing peritonitis Can cause cholecystoduodenal, cholecystointestinal or Cholecystobiliary fistula Pericholecystic abscess Fistula Gall stone ileus (Riggler’s triad) Gall stone pancreatitis Obstruction of cbd Empyema GB Ascending cholangitis Septicemia Emphysematous GB Gangrenous GB
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- 21. DIAGNOSIS AND EVALUATION USG-highlights any gallstones and may show the condition of the GB BLOOD INVESTIGATIONS- high wbc count: raised crp and esr indicates inflamation LFT- raised bilurubin Raised s-amylase CT SCAN- may reveal signs of cholecystitis Hepatobiliary iminodiacetic acid scan (HIDA)- creates pictures of liver GB biliary tract and small intestine: The HIDA scan should be done when usg is not diagnostic and when there is clinical signs of acute cholecystitis
- 22. Per cutaneousTranshepatic Cholecystography (PTC) ERCP MRCP
- 23. USG Sensitive 85%specificity 95% Inexpensive and reliable What to look for in usg….? GallStone Pericholecystic fluid (exudative in acute cholecystitis) GB wall thickening Sonographic murphy’s sign
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- 25. Non visualisationof GB on HIDA scan with in 1 hour along with clinical signs is diagnostic of acute cholecystitis (without clinical signs-cystic duct obstruction) Non visualisation of intestine points towards cbd obstruction Its importance lies in diagnosing acalculos cholecystitis
- 26. DIFFERENTIAL DIAGNOSIS Common Acutepancreatitis Perforated duodenal/gastric peptic ulcer Appendicitis Rare Pyelonephritis Hepatitis MI Pneumonitis
- 27. Treatment (conservative approach) NBM: To rest the GB Ryle’s tube insertion and aspiration of gastric acid decreases the secretion of bile and spasm of bladder may come down Fat free diet Antibiotics to treat infection Analgesics
- 28. Indications for stoppingconservative management and early cholecystectomy Pain and tenderness dot decreasing and spreading Incresing gb size Increasing pulse Geriatric patient Another attack with in 48-72 hours of diagnosis
- 29. SURGICAL APPROACH ERCPWITH STONE REMOVAL/STENTING EMERGENCY CHOLECYSTECTOMY INTERVAL CHOLECYSTECTOMY LAPAROSCOPIC SOS OPEN PERCUTANEOUS CHOLECYSTOSTOMY OPEN CHOLECYSTOSTOMY ENDOSCOPIC US GUIDED CHOLECYSTODUODENOSTOMY
- 30. INDICATIONS OF EMERGENCY CHOLECYSTECTOMY Empyema GB- High grade fever with chills, leucocytosis Signs of local complications- PeriGB collection, Sub hepatic local collection Failure of medical management Emphysematous cholecystitis Perforation Peritonitis Acute pancreatitis Obstructive suppurative cholangitis
- 31. Indications for percutaneousdrainage Seldom a first line mx Patients too ill to tolerate alternate procedures Poor surgical candidates Unexplained sepsis in terminally ill patients Access to or drainage of biliary tree following failed ercp
- 32. Percutaneous cholecystostomy Schematicrepresentation Fluoroscopy image
- 33. Relatively lesscomplications and less painful Indicated in patients where even percutaneous cholecystostomy is not suitable Endoscopic ultrasound guided cholecystoduodenostomy
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