Acalculous Cholecystitis.pptx Acalculous cholecystitis is defined as cholecystitis that occurs without a gallstone.

Acalculous cholecystitis is defined as cholecystitis that occurs without a gallstone.
This typically occurs in critically ill patients due to a combination of factors (e.g. bile stasis and hypoperfusion).
Acalculous cholecystitis often goes unrecognized initially, because of intubation and sedation. This can lead to a high rate of progression to gallbladder necrosis (50%) and perforation (10%).The term “necrotizing cholecystitis” has been proposed for this disease, to emphasize its potentially malignant course

1. Acalculous Cholecystitis Acute inflammation of the gallbladder can occur without gallstones. Acalculous cholecystitis typically develops in critically ill patients in the intensive care unit. The symptoms and signs depend on the condition of the patient, but in the alert patient, they are similar to acute calculous cholecystitis, with right upper quadrant pain and tenderness, fever, and leukocytosis. Ultrasonography is usually the diagnostic test of choice, as it can be done bedside in the intensive care unit.

2. Acalculous Cholecystitis Abdominal CT scan can aid in the diagnosis of acalculous cholecystitis and additionally allows imaging of the abdominal cavity and chest to rule out other sources of infection. Acalculous cholecystitis requires urgent intervention. Percutaneous ultrasound- or CT-guided cholecystostomy is the treatment of choice for these patients, as they are usually unfit for surgery. About 90% of patients will improve with the percutaneous cholecystostomy.

3. Biliary Cysts Choledochal cysts are congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree. They are rare—the incidence is between 1:100,000 and 1:150,000 in populations of Western countries—but are more commonly seen in populations of Eastern countries. Choledochal cysts affect females three to eight times more often than males. The cause is unknown. Choledochal cysts are classified into five types.

4. Biliary Cysts

5. Biliary Cysts

6. Biliary Cysts Ultrasonography or CT scanning will confirm the diagnosis, but endoscopic cholangiography, transhepatic cholangiography, or MRC is required to assess the biliary anatomy and to plan the appropriate surgical treatment. For types I, II, and IV, excision of the extrahepatic biliary tree, including cholecystectomy, with a Roux-en-Y hepaticojejunostomy is ideal. In type IV, additional segmental resection of the liver may be appropriate, particularly if intrahepatic stones, strictures, or abscesses are present or if the dilatations are confined to one lobe.

7. Sclerosing Cholangitis Sclerosing cholangitis is an uncommon disease characterized by inflammatory strictures involving the intrahepatic and extrahepatic biliary tree. It is a progressive disease that eventually results in secondary biliary cirrhosis. Sometimes, biliary strictures are clearly secondary to bile duct stones, acute cholangitis, previous biliary surgery, or toxic agents, and are termed secondary sclerosing cholangitis. Autoimmune reaction, chronic low-grade bacterial or viral infection, toxic reaction, and genetic factors have all been suggested to play a role in its pathogenesis

8. Sclerosing Cholangitis The human leukocyte antigen haplotypes HLA-B8, -DR3, -DQ2, and -DRw52A, commonly found in patients with autoimmune diseases, also are more frequently seen in patients with sclerosing cholangitis than in controls. The mean age of presentation is 30 to 45 years, and men are affected twice as commonly as women. The usual presentation is intermittent jaundice, fatigue, weight loss, pruritus, and abdominal pain. Symptoms of acute cholangitis are rare, without preceding biliary tract intervention or surgery

9. Sclerosing Cholangitis The clinical presentation and elevation of alkaline phosphatase and bilirubin may suggest the diagnosis, but ERC, revealing multiple dilatations and strictures (beading) of both the intra- and extrahepatic biliary tree, confirms it. The hepatic duct bifurcation is often the most severely affected segment. There is no known effective medical therapy for primary sclerosing cholangitis and no known curative treatment. Corticosteroids, immunosuppressants, ursodeoxycholic acid, and antibiotics have been disappointing. Surgical management with resection of the extrahepatic biliary tree and hepaticojejunostomy has produced reasonable results in patients with extrahepatic and bifurcation strictures.

10. Stenosis of the Sphincter of Oddi A benign stenosis of the outlet of the common bile duct is usually associated with inflammation, fibrosis, or muscular hypertrophy. The pathogenesis is unclear, but trauma from the passage of stones, sphincter motility disorders, and congenital anomalies have been suggested. Ampullary manometry and special provocation tests are available in specialized units. If the diagnosis is well established, endoscopic or operative sphincterotomy will yield good results

11. Bile Duct Strictures Patients with bile duct strictures most commonly present with episodes of cholangitis. Less commonly, they may present with jaundice without evidence of infection. Liver function tests usually show evidence of cholestasis. An ultrasound or a CT scan will show dilated bile ducts proximal to the stricture, as well as provide some information about the level of the stenosis. Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the standard of care with good or excellent results in 80% to 90% of patients.

12. Bile Duct Strictures Benign bile duct strictures can have numerous causes. The vast majority were caused by operative injury, most commonly by laparoscopic cholecystectomy. Bile duct strictures that go unrecognized or are improperly managed may lead to recurrent cholangitis, secondary biliary cirrhosis, and portal hypertension