Aetiopathogenesis and management of calculus cholecystitis

calculus, cholecystitis, gallbladder stone, jaundice,

1. AETIOPATHOGENESIS AND MANAGEMENT OF CALCULUS CHOLECYSTITIS DR BASHIR YUNUS GENERAL SURGERY UNIT PRESENTATION 22-Feb-15 [email protected] 1

2. OUTLINE INTRODUCTION DEFINITION EPIDEMIOLOGY RELEVANT ANATOMY AETIOLOGY PATHOGENESIS MANAGEMENT HISTORY PHYSICAL EXAMINATION INVESTIGATIONS TREATMENT COMPLICATIONS CONCLUSION 22-Feb-15 [email protected] 2

3. INTRODUCTION Cholecystitis is the inflammation of the gall bladder. Calculus cholecystitis results from obstruction by gall stone and is the commonest cause of cholecystitis. EPIDEMIOLOGY (Fat , Fair, Female, Fertile, at Fourty ) 90% of patient with acute cholecystitis is associated with calculus obstruction . Cholelithiasis is common in western countries. 10% of adult white hours gall stones . 60% of patients are women. It afflicts more than 20million Americans annually. Most are silent. Only 20% develop acute cholecystitis 22-Feb-15 [email protected] 3

4. 22-Feb-15 [email protected] 4 RELEVANT ANTOMY Pear shape organ that lie at the underside of the liver between the right and left lobe 7.5-12cm long Capacity about 25-30ml Cystic duct is 3cm in length, 1-3mm in diametre CHD 2.5cm CBD 7.5cm

5. RELEVANT ANATOMY 22-Feb-15 [email protected] 5

6. 22-Feb-15 [email protected] 6 Calot triangle Should be identified during cholecystectomy to avoid damage to extrahepatic biliary system

7. 22-Feb-15 [email protected] 7 Blood supply

8. AETIOLOGY Three factors are important in the formation of gall stones Metabolic ; reduction of bile salt cholesterol ratio below 13:1 e.g avitaminosis A or excessive gallbladder absorption in ifection Infection; streptococci, E.coli , salmonella, Cl. welchi Bile stasis; stasis enable gall stone to grow Types of stone; Cholesterol (20%) Pigment (5%) Mixed (75%) 22-Feb-15 [email protected] 8

9. Risk factors Cholesterol stones: Obesity, age <50 Estrogens: female, multiparity , OCPs Commer in western/ developed countries Terminal ileal resection or disease ( Crohn’s Disease) Impaired gallbladder emptying: starvation, DM type 1 Rapid weight loss: rapid cholesterol mobilization and biliary stasis Inborn error of bile salt metabolism hyperlipidemia Pigment stones : Commoner in Asia and Africa More in rural than urban area Chronic (contains calcium bilirubinate ): Cirrhosis Chronic hemolysis Biliary stasis (strictures, dilation, biliary infection ) Associated with GI disoders eg

10. PATHOGENESIS CHOLECYSTITIS When stone becomes impacted in the cystic duct the gall bladder becomes inflamed(chemical and bacterial inflammation). The mucous membrane is swollen and the wall thickened. The event may now take several turns the mucous membrane may become lifted away from the sides of the stone wedged in the neck of the gall bladder, so that the muco -purulent content of the bladder drain into the common bile duct. The attack is then temporarily arrested. Impaction may persist leading to empyema of the gall bladder. May perforate (rare- due thickening of wall from recurrent cholecytitis , seen diabetic and elderly) Gangrene of the gall bladder- interference to blood supply Empyema and inflammatory mass Mirzzi syndrome 22-Feb-15 [email protected] 10

11. Pathogenesis of acute calculous cholecystitis Distended gall bladder Prostaglandin released Mucosal and mural inflammation Increase intraluminal pressure Compromise mucosal blood flow

12. MANAGEMENT HISTORY Pain Epigastric Right hypochondrial Sudden onset Associated with fatty meals Nausea and vomiting Fever Jaundice +/- Transient Usually sets in 2 nd or 3 rd day of the illness Marked or persistent in choledocholithiasis 22-Feb-15 [email protected] 12

13. PHISICAL SIGNS Pyrexia Tenderness, rebound tenderness and guarding or rigidity are found in the right hypochondrium. Omental phlegmon - mass gallbladder and omentum , at the right hypochodrium , as pain subside. It may turn out to be an empyema or carcinoma especially in the elderly. Positive Murphy’s sign Positive Boas sign; tenderness over the 9 th - 11 th right ribs posteriorly 22-Feb-15 [email protected] 13

14. INVESTIGATION Abdominal Uss ; Calculi cast acostic shadow (80-90%) Thickening wall mucosa Distended gall bladder with serosal oedema (halo sign) Pericystic collection of fluid Plain X-ray Opacity (10-20%) Gas seen in gall bladder or biliary passage ; suggests infection by anaerobes or passage of stone into the duodenum Full blood count ; leucocytosis LFT; slight elevation of serum transaminase, elevataed alkaline phosphatase, bilirubin Elevated serum amylase 22-Feb-15 [email protected] 14

15. TREATMENT The general accepted practice is non-operative management in the acute phase followed by cholecystectomy . (interval or delayed cholecystectomy 6 weeks after inflammation has subsided) Argument ; Majority of patients settle on conservative measures Dissection of inflammed area could lead to spread of infection With inflammation there is anatomical anomalies with risks of error Patient with high risk of perforation are frequently identifiable(diabetic and aged) However, in recent years, early operation is increasingly offered. Following conservative measures, patient is operated as elective in the next available operation list in few days. 22-Feb-15 [email protected] 15

16. NON-OPERATIVE REST THE INFLAMMED GALLBLADDER NPO, N-G tube aspiration IV fluids Anticholinergic drugs; propantheline 15mg i.m 8hourly or atropine 0.6mg i.m 8hourly for more rapid action SEDATION + analgesia Pethidine 100mg i.m NSAID suppresses pain from tension within the biliary system ANTIBIOTICS Broad spectrum and bactericidal. Third generation cephalosporines are agent of choice 22-Feb-15 [email protected] 16

17. CONTRA-INDICATIONS TO CONSERVATIVE TREATMENT Signs of incipient perforation ; temperature and pulse not improving in 24-36hours. Pain and tenderness persist across the abdomen. Spreading gangrene of the gallbladder with redness and oedema of the overlying skin Presence of inflammatory mass in the right hypochondrium Mucocele Detection of gas in the extrabiliary system Detection of intestinal obstruction 22-Feb-15 [email protected] 17

18. OPERATIVE Cholecystectomy The gall bladder and cystic duct are removed by transection and dissection of the cystic duct close to the common bile duct Types ; Open or laparoscopic Principles ; Adequate exposure Exclude concomitant pathology of neighboring structures- preliminary laparotomy Defining anatomy Adequate hemostasis 22-Feb-15 [email protected] 18

19. laparoscopic Newer, fewer post op complication, shorter hospital stay Absolute contraindications I. Sepsis including cholangitis 2. Diffuse peritonitis 3. Bleeding diathesis . Relative contraindications I. Previous upper abdominal surgery 2. Acute cholecystitis 3. Choledocholithiasis 4. Gallstone pancreatitis 5. Co-existent carcinoma, diverticular and inflammatory bowel disease 6. Cirrhosis 7. Significant anaesthetic risks 8. Minor bleeding disorder ( eg . aspirin intake) 9. Pregnancy 10. Obesity. 23-Feb-15 [email protected] 19

20. When to convert to open Unclear anatomy No tissue plane Uncontrollable bleeding Accidental damage Equipment failure Lack of progress 23-Feb-15 [email protected] 20

21. Cholecystostomy The fundus of the gall bladder is opened and stone removed with a forceps self retaining catheter place and exteriorised via a separate wound. Elective cholecystectomy the performed in 3-6 weeks Unfit – severely ill Elderly Empyema Persistent and progressive symptoms . Better option as chances of injury to adjacent structures is higher in emergency cholecystectomy 22-Feb-15 [email protected] 21

22. POST OP COMPLICATIONS Iatrogenic bile duct injury Post op bile leak Haemorrhage Retained stone Post cholecystectomy syndrome Inadvertent bowel injury Subcutaneous emphysema Anaesthetic complication

23. DIFFERENTIAL DIAGNOSIS ACUTE CHOLECYSTITIS Acute appenditis Perforated peptic ulcer Acute pancreatitis Acute pyelonephritis Myocardial infarction Right lobar pneumonia 22-Feb-15 [email protected] 23

24. PROGNOSIS Overall reported mortality of acute cholecystitis is 2-3% with much higher figures (10%) in patient over 70. This is largely due to incidental cardiorespiratory disease and complication. 22-Feb-15 [email protected] 24

25. references Steven M. strasberg , MD; acute calculus cholecystitis. The new England jornal of Medicine 2008; 358:2804-11 E.A Badoe et al, “ Principles and Practice of surgery including pathology in the tropics ” 4 th edition, Assembly of God Literature Center ltd, 2009 Bailey and Love’s “Short Practice of Surgery” 26 th edition CRC press Taylor and Francis group. 2013 www.slideshare .net www.wikepedia .org 23-Feb-15 [email protected] 25