Acute Cholecystitis

Acute Cholecystitis

1. ACUTE CHOLECYSTITIS Prepared by: Dr. Sanish Manandhar 1st-year Resident (General Surgery) Mentor: Dr. Ellina Dangol

2. ANATOMY 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 divisions: a fundus, a body and a neck that terminates in a narrow infundibulum Blood supply: Cystic artery (a branch of right hepatic artery)

3. 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

4. FUNCTIONS 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

5. 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

6. ACUTE CALCULOUS CHOLECYSTITIS

7. 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 Cholecystectomy is one of the most common operations performed by general surgeons Complicated gallstone disease – 3-5% of symptomatic patients

8. GALLSTONES (CHOLELITHIASIS) Types Cholesterol stones Pigment stones Black pigment stones Brown pigment stones Mixed stones

9. GALLSTONES (CHOLELITHIASIS) Cholesterol stones Contain 51–99% pure cholesterol plus an admixture of calcium salts, bile acids, bile pigments and phospholipids Altered level of cholesterol, bile acid and lecithin in bile – precipitation of insoluble cholesterol crystals Old age; OCP; obesity; clofibrate – increases cholesterol secretion Oestrogen ; ileal resection; cholestyramine – reduces the bile salt concentration

10. TRIANGLE OF SOLUBILITY

11. 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

12. PATHOPHYSIOLOGY

13. ACUTE ACALCULOUS CHOLECYSTITIS <10% of Acute cholecystitis Related to: Critically ill patients (sepsis, hypotension) Elderly Leukemia, SLE Immunodeficient patients (AIDS) Parenteral nutrition

14. PRESENTATION 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

15. PRESENTATION 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

16. PRESENTATION 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 Gangrenous cholecystitis, perforation, associated cholangitis A normal TLC doesn’t rule out the disease

17. DIAGNOSTIC CRITERIA

18. TOKYO GUIDELINES FOR SEVERITY GRADING OF ACUTE CHOLECYSTITIS

19. 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 – P aO2/FiO2 ratio <300 Renal dysfunction – Oliguria; creatinine >2.0 mg/dL Hepatic dysfunction – Prothrombin time (PT-INR) >1.5 H aematological dysfunction – Platelet count <100,000/mm3

20. 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)

21. 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

22. DIFFERENTIAL DIAGNOSIS Hepatitis Perihepatitis (Fitz Hugh Curtis syndrome) Cholangitis Peptic ulcer disease Pancreatitis Myocardial ischemia Pneumonia Appendicitis

23. 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

24. DIAGNOSIS Hepatobiliary iminodiacetic acid (HIDA) scan HIDA scan 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 HIDA scan with a clear filling of the gallbladder can rule out the diagnosis

25. DIAGNOSIS 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

26. 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

27. 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)

28. 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

29. TREATMENT Surgery (Cholecystectomy) Several studies have shown early cholecystectomy should be recommended, as it offers 1. A definitive solution in one hospital admission 2. Quicker recovery time 3. Similar or fewer complication rates 4. Quicker return to work Laproscopic cholecystectomy is the procedure of choice Conversion rate to open cholecystectomy has fallen to less than 5%

30. 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

31. COMPLICATIONS Gangrenous cholecystitis Most common complication (20% of cases) Particularly in older patients Patients with diabetes Who delay seeking therapy Presence of a sepsis-like picture in addition to other signs of cholecystitis suggests the diagnosis

32. COMPLICATIONS Perforation 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

33. 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

34. 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

35. REFERENCES Bailey and love,short practice of surgery 27 th edition Sabiston ,text book of surgery 21th edition Schwartz 11 th edition

36. THANK YOU!!!