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cholecytitis final.pptx

This document discusses cholecystitis, or inflammation of the gallbladder. It begins by describing the anatomy of the hepatobiliary system and gallbladder. It then explains the types of cholecystitis, including acute calculous cholecystitis caused by gallstones blocking the cystic duct. Clinical features include right upper quadrant pain. Diagnosis involves ultrasound and blood tests. Treatment ranges from antibiotics and fluids for mild cases to early laparoscopic cholecystectomy for moderate or severe cases. Complications include gangrenous or perforated cholecystitis if not treated promptly.

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CHOLECYSTITIS
ANATOMY OF HEPATOBILIARY SYSTEM • Inside liver multiple intrahepatic biliary radicals join to form right and left hepatic ducts • Right and Left hepatic duct joins to form Common hepatic duct(CHD) • Cystic duct and CHD=> Common Bile duct (CBD) • CBD and Pancreatic duct opens in to Duodenum (2nd Part)
ANATOMY 0F GALL BLADDER • Pear-shaped structure • Dimension: 7.5–12 cm long • Normal capacity: about 25–30 mL • Lies on the underside of the liver at the junction of the right and left lobes of the liver • Anatomical parts: a fundus, a body and a neck that terminates in a narrow infundibulum • Blood supply: Cystic artery (a branch of right hepatic artery)
ANATOMY Calot’s Triangle • Hepatobiliary triangle • Border •Superior- inferior surface of the liver • Lateral- by the cystic duct and the medial border of the gallbladder •Medial- by the common hepatic duct • Content •Cystic artery •Lymph node of Lund
FUNCTIONS OF GALL BLADDER •A reservoir for bile • Concentration of bile by active absorption of water, sodium chloride and bicarbonate via the mucous membrane of the gallbladder • Secretion of mucus – approximately 20 mL is produced per day
CHOLECYSTITIS • Cholecystitis is inflammation of gall bladder • Types – Acute Cholecystitis • Acute Calculus Cholecystitis • Acute acalculus Cholecystitis – Chronic Cholecystitis • Reccuernt attack of cholecystitis lead to chronic cholecystitis
ACUTE CHOLECYSTITIS • Acute cholecystitis is associated with gallbladder stone in 90 to 95% of cases • Blockage of cystic duct in absence of stone - Acalculous cholecystitis • < 1 % of acute cholecystitis – tumour obstructing the cystic duct • In severe cases 5 to 10 % of inflammatory process progress and leads to ischemia and necrosis of the Gallbladder
ACUTE CALCULOUS CHOLECYSTITIS
GALLSTONES (CHOLELITHIASIS) •Most common biliary pathology •Asymptomatic in the majority of cases (>80%) • Approximately 2-3% of asymptomatic patients will develop symptoms requiring surgery per year. • Complicated gallstone disease – 3-5% of symptomatic patients
GALLSTONES (CHOLELITHIASIS) • Types  Cholesterol stones  Pigment stones  Black pigment stones  Brown pigment stones  Mixed stones
GALLSTONES (CHOLELITHIASIS) • Cholesterol stones • Contain 51–99% pure cholesterol plus an admixture of calcium salts, bile acids, bile pigments and phospholipids • Bile is supersturated with cholesterol– precipitation of insoluble cholesterol crystals • Old age, OCP, obesity • Most common with 5F (female, fatty, fertile, familial, age more than 40).
GALLSTONES (CHOLELITHIASIS) Pigment stones •Stones containing <30% cholesterol • Black pigment stones: insoluble bilirubin pigment polymer mixed with calcium phosphate and calcium bicarbonate •associated with haemolysis • Brown pigment stones: contain calcium bilirubinate, calcium palmitate and calcium stearate, as well as cholesterol •form in the bile duct and are related to bile stasis and infected bile • associated with the presence of foreign bodies within the bile ducts or parasites
Pathophysiology
• Stone Impaction in Gall bladder or Cystic duct – Temporary impaction • Biliary colic – Impaction not relieved • bile is get trapped in gall bladder – >Inflammation of gall bladder » Oedema and subserosl haemorrhage • Acute Cholecystitis • Without resolution • Intramural presseure exceeds arterial pressure-> gall bladder ischemia and necrosis -> acute gangreneous cholecystitis • If infected with gas forming organism -> acute emphysematous cholecystitis.
PATHOPHYSIOLOGY
ACUTE ACALCULOUS CHOLECYSTITIS
ACUTE ACALCULOUS CHOLECYSTITIS •<10% ofAcute cholecystitis •Related to: •Critically ill patients (sepsis, hypotension) •Elderly •Leukemia, SLE •Immunodeficient patients (AIDS) •Parenteral nutrition
CLINICAL FEATURES •Right upper quadrant or epigastric pain •May radiate to right back and interscapular area •Fever; nausea and vomiting • Other symptoms include dyspepsia, flatulence, and food intolerance, particularly to fats •Palpable tender mass at the right upper quadrant •Murphy’s sign – The voluntary arrest of inspiration with deep palpation on the right costal margin ( at the tip of 9th rib)
CLINICAL FEATURES • Tenderness and a positive murphy’s sign help distinguish acute cholecystitis from biliary colic • In contrast to biliary colic pain, the pain of acute cholecystitis does not subside • Persists for several days
DIFFERENTIAL DIAGNOSIS •Hepatitis •Cholangitis •Peptic ulcer disease •Pancreatitis •Myocardial ischemia •Pneumonia •Appendicitis
LABORATORY INVESTIGATIONS • CBC, CRPAND LIVER FUNCTION TESTS • Associated with leukocytosis and moderately elevated liver function tests •Laboratory evaluation reveals leukocytosis (12000-15000/mL) •High TLC (>20,000/mL) suggest a complicated form of cholecystitis like Gangrenous cholecystitis, perforation, associated cholangitis •Anormal TLC doesn’t rule out the disease
DIAGNOSTIC CRITERIA
TOKYO GUIDELINES FOR SEVERITY GRADING OF ACUTE CHOLECYSTITIS
GRADE III – SEVERE • Associated with dysfunction of any one of the following organs/systems: •Cardiovascular dysfunction – Hypotension requiring treatment with dopamine >5 μg/kg/min, or any dose of norepinephrine •Neurological dysfunction – Decreased level of consciousness •Respiratory dysfunction – PaO2/FiO2 ratio <300 •Renal dysfunction – Oliguria; creatinine >2.0 mg/dL •Hepatic dysfunction – Prothrombin time (PT-INR) >1.5 •Haematological dysfunction – Platelet count <100,000/mm3
GRADE II – MODERATE •Associated with any one of the following conditions: •Elevated white cell count (>18 000/mm3) •Palpable tender mass in the right upper abdominal quadrant •Duration of complaints >72 hours • Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)
GRADE I – MILD •Does not meet the criteria of grade II or grade III acute cholecystitis. • Grade I can also be defined as acute cholecystitis in a healthy person with no organ dysfunction and mild inflammatory changes in the gallbladder • Making cholecystectomy a safe and low-risk operative procedure
DIAGNOSIS Ultrasonography •Ultrasonography is sensitive, inexpensive and a reliable tool •Sensitivity of 85% and specificity of 95% •Effective in documenting gallbladder stone •Can show GB wall thickening and pericholecystic fluid •Both are highly suggestive of cholecystitis •In addition sonographic murphy’s sign also supports the diagnosis
DIAGNOSIS Hepatobiliary iminodiacetic acid (HIDA) scan • HIDAscan is useful in the diagnosis of atypical cases • Lack of filling of gall bladder after 4 hours indicates an obstructed cystic duct • In case of clinically suspected acute cholecystitis, confirms diagnosis with sensitivity and specificity of 95% • Conversely a normal HIDAscan with a clear filling of the gallbladder can rule out the diagnosis
DIAGNOSIS CECT SCAN ABDOMEN •CT may show similar finding to that of USG •But is less sensitive than USG for the diagnosis •An accurate history and physical examination •Along with supporting laboratory studies and an ultrasound Makes the diagnosis of acute cholecystitis
TREATMENT • Largely depend on the severity of disease and physiologic status of the patient • Vary from immediate surgical intervention to conservative management • Definitive treatment – Cholecystectomy, whether open or laparoscopic
TREATMENT Conservative • Nil per mouth (NPO) and intravenous fluid administration until the pain resolves • Administration of analgesics • Administration of antibiotics • broad-spectrum antibiotic effective against gram-negative aerobes is most appropriate (e.g. cefazolin, cefuroxime, ceftriaxone or ciprofloxacin)
TREATMENT Surgery (Cholecystectomy) • The timing of surgery in acute cholecystitis remains controversial. • Has long been a source of debate • With many units favouring an early intervention within the first week (5-7 days) • Others suggest that a delayed approach is preferable 6-10 weeks after initial medical management
TREATMENT Surgery (Cholecystectomy) • Several studies have shown early cholecystectomy should be recommended, as it offers • Adefinitive solution in one hospital admission • Quicker recovery time • Similar or fewer complication rates • Quicker return to work • Laproscopic cholecystectomy is the procedure of choice • Conversion rate to open cholecystectomy has fallen to less than 5%
TREATMENT Percutaneous Cholecystostomy • When patients are medically unfit for surgery, due to severity of illness and medical comorbidities • Antibiotics and biliary decompression with percutaneous cholecystostomy tube placement by a radiologist under ultrasound control can be done • The tube can be removed once the tract is mature and cholangiography shows patent cystic duct • Elective cholecystectomy can be scheduled around 6-8 weeks in such cases
COMPLICATIONS Gangrenous cholecystitis • Most common complication (20% of cases) • Particularly in older patients • Patients with diabetes • Who delay seeking treatment • Presence of a sepsis-like picture in addition to other signs of cholecystitis suggests the diagnosis
COMPLICATIONS Perforation of gall bladder • Results in approximately 10 % of cases • Occurs at the fundus after the development of gangrene • Often localized by omentum • Resulting pericholecystic abscess • Less commonly free perforation into the peritoneum, leading to generalized peritonitis
COMPLICATIONS Emphysematous cholecystitis • Caused by secondary infection of the gallbladder with gas forming organisms • Usually present with RUQ pain, nausea/vomiting and low grade fever • Crepitus in the abdominal wall adjacent to gallbladder, may rarely be detected but is an important clue for diagnosis
COMPLICATIONS Cholecystoenteric fistula • Passage of a gallstone, usually larger than 2.5 cm through a cholecystoenteric fistula • Lead to the development of mechanical bowel obstruction • Usually in the narrowest part of the terminal ileum ( gall stone ileus)
COMPLICATIONS • MIRRIZI SYNDROME • Large gall bladder stone impacted at hartmen’s pouch or at cystic duct -> compression over common hepatic duct (CHD)
Pre-requisite conditions • Cystic duct that course parallel to the CHD • Impacted stone in the GB neck or cystic Duct • Obstruction of CHD caused by the stone or inflammatory process • Low insertion of cystic duct
Classification • Type I : external compression of the bile duct by a large stone or stones impacted in the cystic duct or in the Hartmann’s pouch • Type II : cholecystobiliary fistula resulting from erosion of the bile duct wall by a gallstone, the fistula must involve less than one-third of the circumference of the bile duct • Type III : cholecystobiliary fistula involving up to two-thirds of the bile duct circumference • Type IV : cholecystobiliary fistula with complete destruction of the bile duct wall with the gallbladder completely fused to the bile duct forming a single structure with no recognizable dissection planes between both biliary tree structures
• Mirizzi type V, includes the presence of a cholecystoenteric fistula • together with any other type of Mirizzi • Type Va : includes a cholecystoenteric fistula without gallstone ileus • Type Vb : cholecystoenteric fistula complicated by gallstone ileus
Classifications cont.
TREATMENT • Type I - total/ subtotal cholecystectomy • Type II - subtotal cholecystectomy + choledocoplasty • Type III - subtotal cholecystectomy + choledocoplasty +/- bilioenteric anastomosis • Type IV - bilioenteric anastomosis (A hepaticojejunostomy en-Y-de- Roux is preferred) • Type V- – A - Subtotal/total cholecystectomy, primary repair over the bilioenteric fistula – B - Treat the acute condition first. Underlying cause 3 months later
COMPLICATIONS Obstructive jaundice • When gall bladder stone get impacted in to CBD and obstruct bile flow to GIT.
CHOLEDOCHOLITHIASIS
▶ DEFINITION: STONES INSIDE THE COMMON BILE DUCT AND BILLIARY TREE. ▶ Important Cause for developing Obstructive Jaundice
CLASSIFICATION ▶ PRIMARY: Formed in CBD and biliary tree itself  Rare  Brown pigment or mixed type stones..  Multiple, often sludge like, extends into hepatic duct.
PRIMARY STONES * Etiology:  Defective pathophysiology of biliary tree causing stasis, biliary dyskinesia, benign biliary stricture, sclerosing cholangitis, biliary dilatation etc.  Congenital conditions like Caroli’s disease, choledochal cyst.  Infections & infestations like clonorchiasis, ascariasis.  Others: Low protein diet, malnutrition, obesity, females, old age.
▶Secondary: They are from gallbladder (gall stones), pass through Cystic Duct to CBD. Here CBD & biliary tree are otherwise normal.  Common  black pigment stones/cholesterol stones (75% are cholesterol & 15% are pigment stones)  15% of gall stone disease  Secondary stones are better and easier to manage than primary stones  Commonly gall stones get impacted in supraduodenal portion of the CBD.
CLINICAL FEATURES ▶ 50% asymptomatic ▶ Biliary colic because of CBD obstruction by stone – pain in Right Hypochondrium & Epigastrium  Jaundice due to choledocholithiasis more likely to be painful with rapid distension of biliary duct Stimulating pain fibres. ▶ Clinical Manifestations of jaundice like scleral icterus, clay coloured stool, Dark coloured urine, pruritis etc..  Jaundice most common symptom of choledocholithiasis. ▶ Fever with chills & rigor also common ..
CLINICAL FEATURES CONTD. ▶ Charcot’s Triad.:-  Intermittent Fever with chills  Intermittent jaundice &  Intermittent colicky pain.... Feature of Ascending Cholangitis.. If untreated may progress to Septic Shock.. ▶ Reynold’s Pentad.:-  hypotension &  altered mental status with Charcot’s Triad.  Both evidence of shock from a biliary source.. Found in Suppurative Cholangitis.
CLINICAL FEATURES CONTD. ▶ A palpable gall bladder is unusual in patients with obstrucive jaundice from CBD stone because the obstruction causes inflammation, thickenning, fibrosis, contraction & nondistensible gall bladder.. ▶ COURVOISIER’S LAW: “In a patient with Jaundice if gall bladder is palpable , it is not due to stones.” • Exceptions to this Rule:  Double impacted stone-one in CBD & one in Cystic Duct, with mucocele of gall bladder .  Large stone in Hartman’s Pouch  Empyema Gall bladder.
COMPLICATIONS ▶ Liver Dysfunction & Biliary atresia ▶ White Bile formation & liver failure ▶ Suppurative Cholangitis ▶ Liver abscess ▶ Septicemia ▶Pancreatitis if CBD stone is near sphincter of Oddi blocking drainage of Bile & Pancreatic Duct..
INVESTIGATIONS • RADIOLOGICAL:  USG Abdomen:  It may show Gallstones,  Dilated CBD>8mm with symptoms ,  Dilated CBD even without biliary colic in presence of gall stones highly suggestive of biliary obstruction  Sensitivity for gall stones only 65%
 MRCP (Magnetic Resonance Cholangiopancreatography):-  Non contrast non invasive imaging method better than ERCP in Diagnostic tool in biliary & pancreatic diseases  It delineates biliary tree anatomy & pathology clearly  but not therapeutic  Highly(>90%) sensitive & almost 100% specific..
CT Scan:- ▶ It shows stones , location, ductal stricture or block , ductal dilatation, intra hepatic biliary changes & stones. ▶ Helical CT cholangiography is also useful but bilirubin level should be normal which is the limitation.
 EUS(Endoscopic Ultrasonography):- Useful & accurate but is invasive  PTC(Percutaneous Transhepatic Cholangiography):- done only when indicated like in case of previous Gastrectomy , failed ERCP. Not routinely done..  ERCP(Endoscopic Retrograde Cholangio Pancreatography):- now a days mostly Therapeutic use..
Peroperative cholangiography ▶ During cholecystectomy, a catheter can be placed in the cystic duct and contrast injected directly into the biliary tree. ▶ This defines the anatomy and mainly is used to exclude the presence of stones within the bile ducts. ▶ Review the images intraoperatively. ▶ Irrespective of the technique used, the operating table should be tilted head down approximately 20° to facilitate filling of the intrahepatic ducts. In addition, care should be taken while injecting contrast not to introduce air bubbles into the system as these may give the appearance of stones and lead to a false-positive result.
Peroperative cholangiography
LABORATORY: ▶ CBC- TC WBC ▶ Platelet Count:- ▶ LFT:-  S. Bilirubin- raised  S. ALP & GGT- Alk po4 raised  S. ALT & AST- may be raised .  S. Protein-  Prothombin Time- ▶ S. Amylase- ▶ S. Lipase- ▶ Urine-
TREATMENT ▶ If facilities available, Advise Endoscopic Sphincterotomy & Bile duct stone extraction by a Dormia basket catheter introduced through the Endoscope followed by Laparoscopic Cholecystectomy. ▶ In absence of such facilities, Conventional Open Cholecystectomy with Bile duct exploration is the standard choice..
TREATMENT ▶ ERCP(Endoscopic Retrograde CholangioPancreatography):-  Endoscopic Sphincterotomy with stone extraction.  Patient with highest risk such as those with cholangitis or jaundice should undergo ERCP.  More than 50% of all patients have recurrent symptoms of biliary tract disease if they are not also treated by cholecystectomy..
TREATMENT  More than 1/3rd of all the patients will eventually require Cholecystectomy , suggesting that Cholecystectomy should be offered to the patient.  Among the older patients(>70 yrs) the rate of symptom recurrence is only 15%, so Cholecystectomy can be offered selectively to the patient..
ERCP
Laparoscopic CBD Exploration ▶ At the time of cholecystectomy, intraoperative cholangiography will help to identify choledocholithiasis. ▶ Laparoscopic common duct exploration can then be performed in an attempt to manage all calculous biliary tract disease in one setting, without the need for an additional anesthetic or procedure. ▶ Access to the common duct with a small-caliber cholangioscope is provided through the cystic duct, or through a separate incision in the common duct itself.
Open CBD exploration ▶ The frequency of Open exploration has decreased. ▶ This should be used when endoscopic and laparoscopic means are not feasible for documented common duct stones or when concomitant biliary drainage is required. ▶ Open exploration carries a low morbidity (8% -15%) and mortality (1% - 2%), with a low rate of retained stones (<5%).
Open CBD Exploration CONTD. •Impacted stones at the ampulla present a difficult problem for ERCP and common duct exploration. With unsuccessful attempts to remove an impacted stone in the setting of a nondilated biliary tree, a transduodenal sphincteroplasty can provide drainage. •In a similar setting but with a dilated biliary tree, drainage of the biliary tree through a separate choledochoenterostomy can be successful. The two options for drainage are a •Choledochoduodenostomy & • Roux-en-Y choledochojejunostomy
Open CBD Exploration CONTD. ▶ Choledochoduodenostomy:- Anastomosis to the duodenum can be performed rapidly with a single anastomosis ..  Advantage: It allows further Endoscopic evaluation of the biliary tree.  Disadvantage : The bile duct distal to the anastomosis does not drain well & may collect debris that obstructs the anastomosis or the pancreatic duct, a process known as sump syndrome.
Choledochoduodenostomy
MANAGEMENT OF REATAINED CBD STONES ▶ Burhene Technique ▶ ERCP ▶ Flushing through T Tube ▶ Reoperation :-- Transduodenal Sphincteroplasty or Choledochojejunostomy In case of RECURRENT STONES:-- ERCP or Reoperation
T TUBE CHOLANGIOGRAPHY ▶ After choledochotomy, stones are removed using Des jardin‘s choledocholithotomy forceps. ▶ Bake’s CBD dilator is used to confirm the CBD patency. ▶ T-tube (Kehr's) is then placed in the CBD and kept for 14 days.
•After 14 days a postoperative T-tube cholangiogram is done to see for free flow of dye into the duodenum, so that T-tube can be removed. •If T-tube cholangiogram shows persistent stone, it Can be extracted after 6 weeks, through a basket (Dormia) or catheter (Fogarty) through the track or through a choledochoscope. Retained stones can also be removed through ERCP .
T TUBE CHOLANGIOGRAPHY
cholecytitis final.pptx