ACUTE CHOLECYSTITIS

Assistant professor : pechyonkin

Student: raza sarif

Group : 414 A

Inflammation of gall bladder is called ACUTE CHOLECYSTITIs

DEFINITION

• COMMON IN FERTILE

• FATTY

• ABOVE FORTY

• FEMALES lydia shum

INCIDENCE

· Obstruction

· Bacterial invasion

· Trauma and chemical irritation

· Pancreatic reflex

Etiology

Etiology

1 CALCULOUS

etiology

2ACALCULOUS Cholesterosis(strawberry gall

bladder) Cholesterol polyposis of gall

bladder Cholecystitis glandularis

proliferans Diverticulosis of gall bladder Typhoid of gall bladder

etiology

BACTERIAL INFECTION E-coli Klebsiella S.faecalis Salmonella Clostridia Anaerobes

classification

• On etiology: calculous,acalculous,emphysamatous

• On inflammation:simple,destructive

Emphysamatous

classification• On morphology:

catarhal,phlegmonous,gangrenous,gangrenous perforation

Clinical Findings Symptoms: 1. Abdominal pain

· Where· When· How

Abdominal pain

• SITE - RIGHT HYPOCHONDRIUM• TYPE - COLICKY• ONSET – SUDDEN• DURATION – MORE THAN 12 hrs • RADIATION BACK SHOULDER RIGHT HYPOCHONDRIUM LEFT HYPOCHONDRIUM

Symptoms:

· 2 gastrointestinal

· Nausea, bilious vomiting · Abdominal distension · Belching or flatulence

3. Fever

Acute cholecystitis in elderly and old patients is characterized by quickly developing intoxication syndrome

signs

• GENERAL TACHYCARDIA PYREXIA

From MMWR – Aug 2004

From MMWR – Aug 2004

• Local TENDERNESS - RT

HYPOCHONDRIUM RIGIDITY - RT HYPOCHONDRIUM MURPHY’S SIGN BOAS SIGN MASS

murphy’s sign

Boas sign

• An area of hyperasthesia between 9th and 11th rib posteriorly right side is a feature

Ortner sign

Kera sign

• Mussi sign• Shotkin blumber sign

· Elevated leukocyte count

· Elevated serum bilirubin

· Elevated amylase level

Laboratory findings

Instrumental investigation

• PLAIN X-RAY ABDOMEN

Radioopaque gall stone

• ULTRASONOGRAPHY Dilatation of billiary tree Stones Fluid

Common bile duct dialation

Intra hepatic duct dialation

Gall stone

GALL BLADDER RADIONUCLIDE SCAN

ORAL CHOLECYSTOGRAM

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP

HIDA SCAN

HIDA IS HEPATIC IMINODIACETIC ACID

due to edema of cystic duct HIDA

Does not enter in gall bladder hence nonvisualization of gall bladder is diagnostic of acute cholecystitis

Its imortance lies in diagnostic of acalculous cholecystitis

HIDA SCAN SHOWING NONVISUALIZATION OF GALL BLADDER

ERCP showing mirizzi syndrome

DIFFERENTIAL DIAGNOSIS

common ACUTE PANCREATITIS PERFORATED DUODENAL ULCER PERFORATED PEPTIC ULCER APPENDICITIS

RARE

ACUTE PYELONEPHRITIS

HEPATITIS

MYOCARDIAL INFARCTION

PNEUMONITIS

complication• EMPYEMA• PERFORATION PERITONITIS• ABSCESS• FISTULA• MUCOCELE• ACUTE PANCREATITIS• GALL STONE ILEUS• OBSTRUCTIVE JAUNDICE

Treatment

Nonsurgical or preoperative

management

· Intravenous fluids

· Nasogastric tube

· Broad spectrum antibiotics

• Naspgastric tube:

ryle’s 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 paitent

Analgesic +anticholinergic given to reduce spasm

Antibiotic

broad spectrum to cotrol inflammation.combination of ampicillin+clindamycin+ and aminoglycoside is good.

• Conservative treatment stopped and early cholecystectomy advised

1)pain and tenderness spread across the abdomen

2)gall bladder increases in size

3)Pulse rate continuse to rise

4)In very elderly patient

Surgical Treatment

1.Attack within 48-72 h of diagnosis

2.Deterioration in patient’s general condition

3.Complications are present

Perforation

Peritonitis

Acute obstructive suppurative cholangitis

Acute pancreatitis

Surgical methods

• Open cholecystectomy• Laparoscopic cholecystectomy

• 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

Operative problems

1)CBD and right hepatic artery injury during the operation of fundus first method

2)Slipped of clip or ligature may lead to profuse bleeding

3)Biliary leakage from some unknown duct which may lead to syndrome known as waltman-walter syndrome

this syndrome is menifested 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

Postoperative treatment

1)Drainage is removed after 48 hours or it may be kept for longer period

2)Gastric aspiration and IV fluid is continued until the peristalsis of intestine is come back

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