CHOLECYSTITIS

Bernard M. Jaffe, M.D.Professor of Surgery,

Emeritus

GALLBLADDER• Major Function- Concentrate, Store Bile• Supplied by Cystic Artery • Off Right Hepatic Artery• Off Common Hepatic Artery• Off Celiac Trunk• Many Arterial Variations• Replaced Right Hepatic Takes Off From

Superior Mesenteric

DUCTS• Right and Left Hepatic Ducts Join• ↓• Common Hepatic Duct• Cystic Duct Comes Off• ↓• Common Bile Duct• ↓• Ampulla, Duodenum

GALLSTONES• Autopsy Prevalence 11-36%• Female:Male Ratio is 3:1• First Degree Relatives Have Twice the

Rate• Cholecystectomy One of Commonest

Operations

PREDISPOSING FACTORS• Obesity• Pregnancy• Dietary Factors• Crohn’s Disease, Ileal Resection• Hemolytic Diseases• Gastric Surgery

GALLSTONE CONSTITUENTS• Bilirubin• Bile Salts• Phospholipids• Cholesterol• Calcium

CHOLESTEROL STONES• Most Common Type• Rarely Pure, >70% Cholesterol• Precipitation from Supersaturated Bile• Usually Multiple, Variable Sizes• Hard and Facetted to Irregular and Soft• Color White/Yellow to Brown/Black• Only 10% are Radio-opaque

PIGMENT STONES• <20% Cholesterol• Dark Because of Calcium Bilirubinate• Usually Tiny to Small • Invariably Multiple• Two Types- Black Stones• Brown Stones

BLACK STONES• Form ONLY in Gall Bladder• Secondary to Hematologic Diseases• Spherocytosis• Sickle Cell Disease• Thalassemia• Common in Cirrhosis• More Common in Asia

BROWN STONES• Form in Gall Bladder AND Bile Ducts• Small, Soft, Often Mushy• Secondary to Bacterial Infection

Caused by Bile Stasis• Bacterial Cell Walls Prominent in

Stones• More Common in Asia

NATURAL HISTORY• Most Are Asymptomatic• Asymptomatic Stones Detected On

Evaluation For Other Illnesses• Ultrasound• CT• Plain Abdominal X-Ray• Laparotomy• 2/3 Stay Asymptomatic >20 Years •

COMPLICATIONS• Biliary Colic- Initial Symptom• Acute Cholecystitis• Choledocholithasis• Cholangitis• Biliary Pancreatitis• Cholecysto-Duodenal Fistula• Gall Bladder Carcinoma

CHOLECYSTECTOMY• Indicated for Symptomatic Patients• Rare Indications in Asymptomatic Ones • Elderly Diabetics• Before Transplantation• Isolation From Medical Care• Gallbladder Polyp (Controversial)• Porcelain Gall Bladder Absolute

Indication

CHRONIC CHOLECYSTITIS• Recurrent Attacks of Pain• Frequently After a Meal (Fatty?)• Radiates to Back and Shoulder• Nausea and Vomiting• Gall Bladder- Minor Inflammation to

Small, Shrunken With Fibrosis, Adhesions

• Mucosa Becomes Atrophied

DIAGNOSIS• Stones on Ultrasound• Gall Bladder May Have Sludge• Cholesterolosis- Strawberry Gall

Bladder• Adenomyomatosis- Thick Wall• Normal Ducts• Cholecystectomy Cures >95%

ACUTE CHOLECYSTITIS• Obstruction of Cystic Duct By Stone• Gall Bladder Distention, Inflammation,

Edema• Mucus Secretion- Hydrops, Milk of Bile

(Pearly White)• 5-10% Progress to Ischemia, Necrosis• Perforation Occurs in Body (Widest Part)

MANIFESTATIONS• Biliary Colic → Lasting, Constant Pain• Anorexia, Nausea, Vomiting, Fever• Focal RUQ Tenderness, Guarding• Murphys’ Sign is Suggestive• Palpable Gall Bladder is Diagnostic• Normal LFTs, ?Minimal Bilirubin Elevation• White Blood Cell Count Often Elevated

DIAGNOSIS• Ultrasound• Stones• Thickened Gall Bladder Wall• Distended Gall Bladder• Peri-Cholecystic Fluid• Sonographic Murphy’s Sign• If HIDA Scan Fills Gall Bladder- Precludes

Diagnosis

TREATMENT• Antibiotics- Gram Negative and

Anaerobic Coverage• Early laparoscopic Cholecystectomy• Late Presentation >4-5 Days-

Antibiotics Alone with Delayed Cholecystectomy• Very Ill, Elderly patients- Percutaneous

Cholecystostomy

LAP CHOLE• Mortality 0.1%, Morbidity 0.3%• Can Add Choledochotomy• Conversion to Open in Acute Disease

Reasons for Conversion• Inability to Visualize Adhesions• Duct Injury Bleeding • Abnormal Anatomy

CHOLEDOCHOLITHIASIS• Primary Stones Form in Ducts• Associated with Biliary Dysfunction,

Infection• Brown Stones• Secondary Stones Form in Gall Bladder• Migrate to Common Bile Duct• 6-12% Cholelithiasis Patients• 20-25% in Patients >60

MANIFESTATIONS• Symptomatic or Can Be Silent• Colicky Pain, Nausea, Vomiting, ICTERUS• Stones Single or Multiple, Small or

Large• Can Cause Common Duct Obstruction• Cholangitis• Biliary Pancreatitis

DIAGNOSIS• Elevated Bilirubin, Alkaline Phosphatase,

Transaminases• Ultrasound- Dilated Ducts• Magnetic Resonance Cholangiogram-

Sensitivity 95%, Specificity 89%• ERCP- Successful >90%, Morbidity <5%• Therapeutic and Diagnostic

TREATMENT• ERCP With Sphincterotomy• Common Bile Duct Exploration• Open or Laparoscopic• T-Tube Left in Place• Missed Stones Can Be Retrieved

Choledochoscope

CHOLANGITIS• Ascending Infection Associated With Bile

Duct Obstruction• Commonest Organisms• E. coli• Klebsiella• Strep faecalis• Bacteroides• 5-10% Mortality

MANIFESTATIONS• Charcot’s Triad• Abdominal Pain• Jaundice• Fever• Reynold’s Pentad• Same Plus Septic Shock• Mental Status Changes

TREATMENT• Immediate Antibiotics, Resuscitation• Duct Drainage (Cholangitis is Closed

Space Infection)• ERCP With Sphincterotomy• Percutaneous Transhepatic

Cholangiogram With Catheter Placement

• Open Common Duct Exploration