Acute cholecystitis.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Acute Cholecystitis

3. Acute Cholecystitis Biliary colic and cholecystitis are in the spectrum of biliary tract disease. This spectrum ranges from asymptomatic gallstones to biliary colic, cholecystitis , choledocholithiasis , and cholangitis .

4. Acute Cholecystitis:Definition Acute Inflammation of Gall Bladder.

5. Etiology

6. Etiology Gall stones. Gallstones can be divided into categories: Cholesterol stones pigment stones Mixed. Most patients with gallstones are asymptomatic. Stones may temporarily obstruct the cystic duct.

7. Mechanism

8. Mechanism Cholecystitis occurs when obstruction at the cystic duct is prolonged (usually several hours) resulting in inflammation of the gallbladder wall. Acute cholecystitis develops in approximately 20% of patients with biliary colic if they are left untreated.

9. Calculous Cholecystitis

10. Calculous Cholecystitis "fair,, fat, and fertile female of forty" 

11. Acalculous cholecystitis Risk factors for acalculous cholecystitis – diabetes HIV infection vascular disease total parenteral nutrition prolonged fasting intensive care unit (ICU) patient.

12. Symptoms

13. Symptoms Abdominal Pain. Nausea, Vomiting, Low-grade fever 

14. Signs

15. Signs Epigastric or right upper quadrant tenderness and abdominal guarding The Murphy sign (an inspiratory pause on palpation of the right upper quadrant) 

16. D/D

17. D/D Aneurysm, Abdominal Cholangitis Gastroenteritis Hepatitis Mesenteric Ischemia Myocardial Infarction Obstruction, Small Bowel Pancreatitis Pregnancy, Eclampsia Pregnancy, Urinary Tract Infections Cholelithiasis and renal calculi Diverticular and inflammatory bowel disease

18. Diagnostic Studies Ultrasonography and nuclear medicine studies . Ultrasonography is usually favored as the initial test hepatobiliary scintigraphy . Plain radiography, computed tomography (CT) scans, and endoscopic retrograde cholangiopancreatography (ERCP) are diagnostic adjuncts.

19. General ultrasonographic features

20. General ultrasonographic features Gallstones or sludge and one or more of the following conditions: Gallbladder wall thickening (>2-4 mm) - Gallbladder distention Pericholecystic fluid from perforation or exudate Air in the gallbladder wall (indicating gangrenous cholecystitis ) Ultrasonographic Murphy sign (86-92% sensitive, 35% specific) - pain when the probe is pushed directly on the gallbladder (not related to breathing)

21. Nuclear Medicine HIDA and diisopropyl iminodiacetic acid (DISIDA) scans are functional studies of the gallbladder. 

22. Management

23. Management Hospitalise . NPO IV fluids Antibiotics Analgesics Antispasmodic Antiemetics

24. Operative Therapy

25. Operative Therapy Historically, cholecystitis was operated on emergently, resulting in increased mortality. The current practice is to cool off the gallbladder and perform a cholecystectomy after several days or to readmit the patient at a later date. Indications for urgent surgical intervention include patients with complications such as empyema , emphysematous cholecystitis , or perforation. Emergent cholecystectomy is usually performed in 20% of such cases.

26. Operative Therapy Gold standard of Cholecystectomy now is laparoscopic cholecystectomy . Recent evidence favours early cholecystectomy .

27. Complications

28. Complications Gallbladder gangrene Cholangitis , Sepsis, Pancreatitis, Hepatitis Gallbladder perforation Gallbladder enteric fistula 

29. Acalculous cholecystitis  

30. Acalculous cholecystitis   Acalculous cholecystitis occurs in critically ill patients and localized pain and tenderness can sometimes not be present. Patients with burns or sepsis and postoperative and trauma patients are all at risk for acalculous cholecystitis .

31. Acalculous cholecystitis   Acalculous cholecystitis is an inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction   . It is a severe illness that is a complication of various other medical or surgical conditions . The condition causes approximately 5%-10% of all cases of acute cholecystitis and is usually associated with more serious morbidity and higher mortality

32. Acalculous cholecystitis   It is most commonly observed in the setting of very ill patients HIV infection.   Severe Burn mechanical ventilation sepsis or severe burn injuries severe trauma     pregnancy cardiovascular disease diabetes  intensive care units

33. Acalculous cholecystitis   aortic dissection.   complication of hepatitis A.

34. Acalculous cholecystitis   higher incidence of gangrene and perforation.  imaging studies is a distended acalculous gallbladder with thickened walls (>3-4 mm) with or without pericholecystic fluid. 

35. Acalculous cholecystitis   Pathophysiology B ile stasis and increased lithogenicity Increased bile viscosity due to fever and dehydration  Prolonged absence of oral feeding resulting in a decrease or absence of cholecystokinin-induced gallbladder contraction.  Gallbladder wall ischemia that occurs because of a low-flow state due to fever, dehydration, or heart failure

36. Acalculous cholecystitis   Epidemiology 5-10% of all cases of acute cholecystitis . all races slight male predominance, unlike calculous cholecystitis , which has a female predominance . any age, although a higher frequency is reported in persons in their fourth and eighth decades of life.

37. Acalculous cholecystitis   Prognosis The prognosis of patients with acalculous cholecystitis is guarded . mortality range is 10%-50% for acalculous cholecystitis as compared to 1% for calculous cholecystitis .

38. Acalculous cholecystitis   Complications Perforation gangrene of the gallbladder extrabiliary abscess 

39. Acalculous cholecystitis   Differential Diagnoses Sepsis with biliary tract infection Acquired immunodeficiency syndrome (AIDS) cholangiopathy Total parenteral nutrition (TPN)-associated liver disease

40. Acalculous cholecystitis   Differential Diagnoses Sepsis with biliary tract infection Acquired immunodeficiency syndrome (AIDS) cholangiopathy Total parenteral nutrition (TPN)-associated liver disease

41. Acalculous cholecystitis   Investigations C omplete blood cell (CBC) count , Liver function studies, Blood culture abdominal ultrasonography computed tomography (CT) scanning.

42. Management of Acalculous cholecystitis  

43. Management of Acalculous cholecystitis   Cholecystectomy open or lap for surgical candidates, For patients who are not surgical andidates , perform percutaneous cholecystostomy . endoscopic gallbladder stent placement between the gallbladder and the duodenum by ERCP  

44. Emphysematous Cholecystitis   Known less commonly as clostridial cholecystitis . 1% of all cases of acute cholecystitis . A cute infection of the gallbladder wall caused by gas-forming organisms. C haracterized by early gangrene, perforation of the gallbladder and high mortality. 

45. Emphysematous Cholecystitis   diagnosis is made by the radiographic presence of air within the gallbladder wall or lumen

46. Emphysematous Cholecystitis   Elderly males, especially diabetics, are particularly susceptible to clostridial cholecystitis  

47. Emphysematous Cholecystitis   Etiology and Pathophysiology : four factors Vascular compromise of the gallbladder Cholelithiasis Impaired immune protection Infection with gas-forming organisms Klebsiella   species   Escherichia coli,  and  Klebsiella  species .  Less frequently, enterococci and anaerobic streptococci

48. Emphysematous Cholecystitis   Presentation Typically a man older than 60 years, often with type II diabetes mellitus—often have deceptively mild clinical findings that are frequently indistinguishable from acute cholecystitis . The insidious nature of this disease may mislead the clinician, and the patient may unsuspectingly rapidly deteriorate with sudden cardiovascular collapse and even death.

49. Emphysematous Cholecystitis   Symptoms: right upper quadrant pain and fever right upper quadrant pain and fever. The pain is localized to the right upper quadrant and often radiates to the back, but it is unrelated to position or physical activity. The patient may also complain of generalized abdominal pain consistent with peritonitis. Nausea and vomiting occur less frequently.

50. Emphysematous Cholecystitis   Symptoms: In addition, an antecedent history of self-limited episodes of pain may be present. E lderly patients may develop acute intra-abdominal disorders with little or no localizing symptoms or signs .

51. Emphysematous Cholecystitis   Signs: an elderly patient with fever and tachycardia ,   obtunded   septic shock hypotensive , Jaundice +-- tenderness in the right upper quadrant diffuse tenderness

52. Emphysematous Cholecystitis   Signs: enlarged tense gallbladder may be palpable. Bowel sounds are diminished or absent,  Transient relief of right upper quadrant pain followed by the appearance of peritoneal signs is the hallmark of perforation . Major fluid sequestration (ie, "third-spacing" of fluid), florid septic shock, or peritonitis may occur as later clinical presentations.

53. Emphysematous Cholecystitis   Differential: Clinical and radiologic Clinical: acute cholecystitis ( nonemphysematous ), both calculous and acalculous , bacterial sepsis Peritonitis Abdominal sepsis. .

54. Emphysematous Cholecystitis   Differential: Radiologic Gas in the biliary tree , Biliary-enteric fistula (spontaneous or surgical ); after ERCP, especially following a sphincterotomy ;  cholangitis caused by gas-forming organisms.

55. Emphysematous Cholecystitis   Imaging: X-Ray USG CT MRI

56. Emphysematous Cholecystitis   Treatment: Prompt cholecystectomy.

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