Acute cholecystitis by-Dr. Raju.pptx kist

Acute cholecystitis

1. ACUTE CHOLECYSTITIS Dr. Raju Khatiwada Resident General surgery KISTMCTH

2. C ontents Surgical anatomy Introduction (Gallstone, types and formation) Acute cholecystitis Pathophysiology Clinical features Investigations (laboratory and Imaging) Tokyo guideline 2018 Management Complications References

3. Surgical anatomy The gallbladder is a pear-shaped sac M easures around 7.5 to 12 cm long A verage capacity of 25-30 Ml The gallbladder is a partially intraperitoneal structure that lies attached to the undersurface of the liver on segments IVB and V. Anatomical divisions: F undus, body and neck, which terminates in a narrow infundibulum Blood supply: Cystic artery (a branch of right hepatic artery) Bailey and love textbook of surgery - 2 7 th edition

4. Cystic artery Occasionally, an accessory cystic artery arises from the gastroduodenal artery. In 15% of cases the right hepatic artery and/ or the cystic artery crosses in front of the common hepatic duct and the cystic duct In 20% of the population, there is an accessory or replaced right hepatic artery The most dangerous anomalies are: where the hepatic artery takes a tortuous course on the front of the origin of the cystic duct (Figure 67.2b), or T he right hepatic artery is tortuous and the cystic artery short (Figure 67.2c). The tortuosity is known as the ‘ caterpillar turn ’ or ‘ Moynihan’s hump ’.

5. Schwartz textbook of surgery, 11th E dition.

6. Bailey and love textbook of surgery -27 th E dition

7. Cystic duct The cystic duct is about 3cm in length The lumen is usually 1–3mm in diameter The mucosa of the cystic duct is arranged in spiral folds known as the valves of Heister and the wall is surrounded by a sphincteric structure called the sphincter of Lütkens The cystic duct joins the supraduodenal segment of the common hepatic duct in 80% of cases. Sabiston’s textbook of surgery-21 st Edition

8. Calot’s triangle H epatobiliary triangle Superiorly: by the inferior surface of the liver Laterally: by the cystic duct and the medial border of the gallbladder and Medially: by the common hepatic duct. It is an important surgical landmark as the cystic artery usually can be found within its boundaries Bailey and love textbook of surgery -27 th E dition

9. Introduction Gallstones are the most common biliary pathology. It is estimated that gallstones affect 10–15% of the population in Western societies. In Nepal, the overall prevalence of gallstone disease is around 2.44% - 6.45% 1 They are asymptomatic in the majority of cases (>80%) Approximately 1–2% of asymptomatic patients will develop symptoms requiring surgery per year Acute calculus cholecystitis (ACC) is the first clinical presentation in 10–15% of the cases 2 Cholecystectomy one of the most common operations performed by general surgeons.

10. In one systematic review, acute cholecystitis developed in 6 to 11 percent of patients with symptomatic gallstones over a median follow-up of 7 to 11 years Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg. 1993 Apr;165(4):399-404. doi : 10.1016/s0002-9610(05)80930-4. PMID : 8480871.

11. Gallstone Gallstones can be divided into three main types: Cholesterol P igment (brown/black) or M ixed stones. In the USA and Europe 80% are cholesterol or mixed stones In Asia 80% are pigment stones. Cholesterol or mixed stones contain 51–99% pure cholesterol plus an admixture of calcium salts, bile acids, bile pigments and phospholipids Sabiston’s textbook of surgery-21 st Edition

12. Causal factors in gallstone formation Four major factors explain most gallstone formation: S upersaturation of secreted bile, C oncentration of bile in the gallbladder, C rystal nucleation, and G allbladder dysmotility

13. Bailey and love textbook of surgery -27 th E dition

14. 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 – tumor obstructing the cystic duct Definition: Acute cholecystitis is the result of a blockage of the cystic duct and is called acute calculous cholecystitis when the blockage is by a stone.

15. Pathophysiology Obstruction of the cystic duct by a gallstone Initially, acute cholecystitis is an inflammatory process, probably mediated by the mucosal toxin lysolecithin as well as bile salts and platelet-activating factor An increase in prostaglandin synthesis amplifies the inflammatory response T he gallbladder wall becomes grossly thickened and reddish with subserosal hemorrhages. Pericholecystic fluid often is present. In severe cases, about 5% to 10%, the inflammatory process progresses and leads to ischemia and necrosis of the gallbladder wall

16. Pathophysiology Secondary bacterial contamination is thought to occur in only 15% to 30% of patients (emphysematous cholecystitis) With some severe infections, gangrenous cholecystitis can develop, and an abscess or perforation may occur Occasionally, prolonged impaction of a stone in the cystic duct can lead to a distended gallbladder that is filled with colorless, mucoid fluid, known as a mucocele   Empyema may be a sequel to acute cholecystitis or the result of a mucocoele becoming infected

17. Clinical features About 80% of patients with acute cholecystitis give a history compatible with chronic cholecystitis. Acute cholecystitis often begins as an attack of biliary colic with relapsing and remitting pain in the right upper quadrant or epigastrium that may radiate to the right back or interscapular area. In contrast to biliary colic, the pain of acute cholecystitis does not subside (greater than four to six hours) Associated complaints may include fever, nausea, vomiting, and anorexia. There is often a history of fatty food ingestion one hour or more before the initial onset of pain.

18. Physical examination  Murphy's sign: POSITIVE Murphy’s sign has a high sensitivity for acute cholecystitis but is not specific. In one study, using Cholescintigraphy as the gold standard, the sensitivity and specificity of a positive Murphy's sign were 97 and 48 percent, respectively  Singer AJ , McCracken G, Henry MC, Thode HC Jr , Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med . 1996 Sep;28(3):267-72. doi : 10.1016/s0196-0644(96)70024-0. PMID : 8780468.

19. Laboratory findings Laboratory evaluation commonly reveals a mild to moderate leukocytosis (12,000–15,000 cells/mm3). An unusually high WBC count (>20,000 cells/mm3) suggests a complicated form of cholecystitis such as gangrenous cholecystitis, perforation, or associated cholangitis. N ormal WBC does not rule out the diagnosis. In uncomplicated acute cholecystitis, serum liver chemistries are usually normal M ild elevation of serum bilirubin (<4 mg/mL) may be present along with mild elevation of alkaline phosphatase, transaminases, and amylase

20. Imaging Transabdominal 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 Sabiston’s textbook of surgery-21 st Edition

21. USG finding in acute cholecystitis Gallbladder wall thickening (greater than 4 to 5 mm) Pericholecystic fluid, or edema (double wall sign). A "sonographic Murphy's sign" is similar to the Murphy's sign elicited during abdominal palpation, except that the positive response is observed during palpation with the ultrasound transducer. This is more accurate than hand palpation because it can confirm that it is indeed the gallbladder that is being pressed by the imaging transducer when the patient catches his or her breath

22. Schwartz textbook of surgery, 11th E dition.

23. Hepatobiliary iminodiacetic acid (HIDA) scan In atypical cases , a HIDA scan may be used to demonstrate obstruction of the cystic duct, which definitively diagnoses acute cholecystitis. Lack of filling of the gallbladder after 4 hours indicates an obstructed cystic duct and, in the clinical setting of suspected acute cholecystitis, confirms the diagnosis with a reported sensitivity above 90% Hunter JG. Acute cholecystitis revisited: get it while it’s hot. Ann Surg . 1998;227(4):468-469

24. Sabiston’s textbook of surgery-21 st Edition

25. CT scan CT may show similar finding to that of USG But is less sensitive than USG for the diagnosis CT is done to rule out complications of acute cholecystitis  The sensitivity of abdominal CT for acute cholecystitis is 94 percent but its specificity is low (59 percent) 3

26. MRCP The role of MRCP in the diagnosis of acute cholecystitis was evaluated in a series that included 35 patients with symptoms of acute cholecystitis who underwent both ultrasound and MRCP prior to cholecystectomy MRCP was superior to ultrasound for detecting stones in the cystic duct (sensitivity 100 versus 14 percent) but was less sensitive than ultrasound for detecting gallbladder wall thickening (sensitivity 69 versus 96 percent). Park MS, Yu JS , Kim YH , et al. Acute cholecystitis: comparison of MR cholangiography and US. Radiology . 1998 Dec;209(3):781-5. doi : 10.1148/radiology.209.3.9844674. PMID : 9844674.

27. Grading system There have been multiple grading systems evaluating severity of cholecystitis, M ost commonly the Tokyo Guidelines and The American Association for the surgery of Trauma ( AAST ) Emergency General Surgery ( EGS ) guidelines. AAST EGS categorizes acute cholecystitis into five grades, grade 1 being localized inflammation , to grade 5 with pericholecystic abscess, bilioenteric fistula , and peritonitis.

28. TG18 diagnostic criteria for acute cholecystitis 4 A. Local signs of inflammation etc. (1) Murphy's sign, (2) RUQ mass/pain/tenderness B. Systemic signs of inflammation etc. (1) Fever, (2) elevated CRP, (3) elevated WBC count C. Imaging findings Imaging findings characteristic of acute cholecystitis Suspected diagnosis:  one item in A + one item in B Definite diagnosis:  one item in A + one item in B + C

29. TG18/TG13 severity grading for acute cholecystitis

30. Grade III (severe) acute cholecystitis “Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems: 1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of norepinephrine 2. Neurological dysfunction: decreased level of consciousness 3. Respiratory dysfunction: PaO 2 /FiO 2  ratio <300 4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl 5. Hepatic dysfunction: PT-INR >1.5 6. Hematological dysfunction: platelet count <100,000/mm 3

31. Grade II (moderate) acute cholecystitis “Grade II” acute cholecystitis is associated with any one of the following conditions: 1. Elevated WBC count (>18,000/mm 3 ) 2. Palpable tender mass in the right upper abdominal quadrant 3. Duration of complaints >72 h a 4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

32. Grade I (mild) acute cholecystitis “Grade I” acute cholecystitis does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure

33. 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

34. Conservative management Nil per mouth (NPO) and I ntravenous 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) A pproximately 20% of patients initially admitted for nonoperative management failed to respond to medical treatment before the planned interval cholecystectomy and required surgical intervention .

35. Surgery (Cholecystectomy) The timing of surgery in acute cholecystitis remains controversial. With many units favoring 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 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

36. 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

37. Complications of acute cholecystitis Gangrenous cholecystitis Perforation Emphysematous cholecystitis Cholecystoenteric fistula Gallstone ileus Gall bladder Mucocele Empyema of the gallbladder

38. References Chaudhary S. Epidemiology of Gall Stone Diseases among Patients attending Surgical Department of a Tertiary Care Hospital in Nepal. Janaki Med Coll J Med Sci . 2020;8(1):50–5. Pisano M, Allievi N, et al. World Journal of Emergency Surgery . Available from: https://doi.org/10.1186/s13017- 020-00336-x Benarroch-Gampel J, Boyd CA, et al, Overuse of CT in patients with complicated gallstone disease. J Am Coll Surg . 2011 Oct;213(4):524-30. doi : 10.1016/j.jamcollsurg.2011.07.008. Epub 2011 Aug 20. PMID: 21862355; PMCID: PMC3356270 . 4. Yokoe M, Hata J, et al, Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54. doi : 10.1002/jhbp.515. Epub 2018 Jan 9. PMID: 29032636.

39. References Williams N, O’Connell PR, McCaskie AW. Bailey & Love’s Short Practice of Surgery . 27 th edition. Florida (US): CRC Press; 2017. Chapter 6 7 , The gallbladder and bile ducts ; p. 1 188 - 1211 . Townsend CM et al. Sabiston: Textbook of Surgery: The Biological Basis of Modern Surgical Practice . 21 st edition. Missouri (US): Elsevier; 2022. Chapter 5 5 , biliary system ; p. 1 489 - 1527. Brunicardi FC et al. Schwartz's Principles of Surgery , 11 th edition Mc Graw -Hill Education; 2019 Chapter 32, gallbladder and the extrahepatic biliary system. P. 1393- 1423.

40. THANK YOU!