ACUTE CHOLECYSTITIS

Content
Anatomy
Bile
Stone formation & types
Acute cholecystitis
- Calculus
- Acalculus
Sign & symptoms
Differential diagnosis
Diagnostic investigation
Complication
Management
Summery
Questions

ANATOMY
The gallbladder is located in the right upper quadrant of the abdomen beneath the liver.
The cystic duct exits at the neck of the gallbladder and joins the common hepatic duct to form the common bile duct.

ANATOMY
CBD empty into the duodenum at the ampulla of Vater. This is surrounded by the sphincter of Oddi, which regulates bile flow into the duodenum .

ANATOMY
Blood supply is from the cystic artery.
Celiac A. Hepatic A. Rt. Hepatic A. Cystic A.
The cystic vein drain directly into portal vein.

Nerve Supply :
Sympathetic and parasympathetic vagal fibers
the celiac plexus.
Lymph Drainage:
The lymph drains into a cystic lymph node situated near the neck of the gallbladder. From here, the lymph vessels pass to the hepatic nodes along the course of the hepatic artery and then to the celiac artery.

Bile
Bile produced in the liver is stored in the gallbladder.
The function of bile is emulsify FAT
Cholecystokinin stimulates gallbladder contraction and release of bile into the duodenum.

Bile
The spiral valves of Heister in the cystic duct prevent bile reflux into the gallbladder.
Bile composed of
Cholesterol
Lecithin (phospholipid)
Bile acid
Bilirubin

Stones formation
Imbalance of cholesterol and its solubilizing agents, bile salts and lecithin concentrations
If hepatic cholesterol secretion is excessive then bile salts and lecithin are “overloaded”, supersaturated cholesterol precipitates and can form gallstones

Types of Stones
Cholesterol stones
Pigment stones
Mixed stones

Cholesterol Stones

Pigment stones

Mixed stones:

Acute
Cholecystitis

Acute Cholecystitis
Inflammation of the gallbladder, resulting from :
Obstruction of cystic duct by gallstone( 80% )
Acalculous ( 20% )

Acute Cholecystitis
Cholecystitis with stones most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms.
The most common organisms cultured during acute cholecystitis are Escherichia coli, Klebsiella, enterococci, Bacteroides fragilis, and Pseudomonas.

Acute Cholecystitis
The gallbladder shows congestion, thickening of the wall by edema and mucosal ulceration.

Pathogenesis:

Acute cholecystitis without gallstone may occur in a variety of condition it may be due to :
• Dehydration, prolonged fasting, TPN
• Systemic disease
• Generalized sepsis, trauma
• Kinking or fibrosis of the gallbladder
• Thrombosis of the cystic artery
• Sphincter spasm with obstruction of the biliary and pancreatic ducts
• Collagen vascular disease, DM, immunosuppressed
ACALCULOUS CHOLECYSTITIS

Hx
Age 30-60 yrs
mostly ♀
Sudden pain in RUQ, often radiate through the back to the tip of Rt. Scapula
Pain is continuous, last >6 hrs
Exacerbated by moving and breathing
N/V
Dark urine, pale stools, itchy skin in case of obstructive jaundice.

Hx:

Signs & Symptoms
Anorexia.
Low grade fever ( < 38.5 C)
Tachycardia
Positive Murphy’s sign
Palpable gallbladder (in 1/3 of patients)

P/E
Pt distressed by pain and lies quitely breathing shallowly.
Tachycardia and Pyrexia
Tenderness & guarding in Rt. Hypochondrium
Boas’ sign
Murphy sign
± jaundice
Rebound

Physical features of enlarged GB
It appears from beneath the tip of the Rt. 9th rib
Smooth & hemi-ovoid
Moves with respiration
There is no space between the lump and the edge of the liver
Dull to percussion

Differential diagnosis
Perforating or penetrating peptic ulcer.
Myocardial infraction
Pancreatitis
Hiatus hernia
RLL pneumonia
Appendicitis
Hepatitis

Lab Investigations
Leukocystosis
Mild Hyperbillirubinemia
Mild ↑ AST, ALT, ALP
Moderate ↑ Lipase & Amylase

US
Distended gallbladder
Thickened gallbladdr wall
Pericholecystic fluid collection
US Murphy’s sign ( + in 98% of pts)

Biliary scintigraphy (hydroxyiminodiacetic acid) (HIDA) scan:
Is the gold standard investigation when the diagnosis remains in doubt after ultrasound scanning.

(HIDA) scan:
The patient is given an intravenous injection of radiolabelled hydroxyiminodiacetic acid and then the abdomen is scanned; in patients with acute cholecystitis, the gallbladder lumen will not take up any radioactive isotope one to two hours after injection and therefore the gall bladder will not be visible on the scan.

(HIDA) scan:

Complication
- Cholecystentiric fistula formation
- Gallstone illeus
- Perforation (may cause localized abscess or generalized peritonitis [ after 3 days of onset ] )
- Empyema of gallbladder.
- Gangrene

Mx
NPO
IVF
IV Analgesia (pethidine)
IV Abx (cefuroxime)
NGT
Parental Analgesics
Optimal Rx is cholecystectomy within 3 days of the onset of symptoms.
Pts who are poor candidates for surgery can undergo cholecystostomy (drainage of gallbladder contents)

Calot’s Triangle
Superiorly: Lower edge of the liver
Laterally: Cystic Duct
Medially: Common Hepatic Duct

Acute Cholecystits vs. Billiary Colic
Duration, Symptoms ?

Surgery

Laproscopic

Questions