Managment of CHOLECYSTITIS and complications .pptx

Pearls and Pitfalls
� Although symptoms from appendicitis develop most commonly in the right lower quadrant,
patients with long appendices or mobile cecums can develop pain throughout the abdomen.
� When treating suspected appendicitis in women, preoperative computed tomography or laparo�scopic approach may be of great value given the broader possible differential diagnosis.
� Consider three diagnostic elements separately: history, physical examination, and laboratory/
radiologic investigations. If two of the three support the diagnosis of appendicitis, the patient
warrants operative evaluation.
� Computed tomography clearly demonstrating intraluminal contrast filling of the entire appendix
excludes the diagnosis of appendicitis.
� Patients with a prolonged history of symptoms or a palpable mass suggestive of contained
perforation may be best treated with non-operative management rather then urgent operation.
� The diagnosis of appendicitis can be challenging to establish in pregnant and immunocompro�mised patients; optimally, operative management should not be delayed in these patient groups.
� Care must be taken to identify with certainty the appendiceal-cecal junction to ensure complete
appendectomy. Cecal mobilization may be required.
� Data establishing the role of interval appendectomy following successful nonoperative manage�ment of perforated appendicitis is evolving. Interval appendectomy may not be necessary for all
patients.
Early Uncomplicated Appendicitis
Presentation
The typical patient with early appendicitis will present with vague periumbilical pain and anorexia
during the first 24 h of symptoms. The pathophysiology of appendicitis is due to intraluminal
appendiceal obstruction, most commonly from an appendiceal fecolith. Early in the course of the
disease, the inflammation is limited to the visceral peritoneum, which does not localize the pain to
the source in the right lower quadrant and results, instead, in vague discomfort. Patients may also give
a history of nausea or vomiting, but patients with appendicitis usually describe the pain as preceding
the nausea and vomiting. When nausea and vomiting occur first, gastroenteritis should be suspected.
As the depth of inflammation progresses and begins to involve the pPearls and Pitfalls
� Although symptoms from appendicitis develop most commonly in the right lower quadrant,
patients with long appendices or mobile cecums can develop pain throughout the abdomen.
� When treating suspected appendicitis in women, preoperative computed tomography or laparo�scopic approach may be of great value given the broader possible differential diagnosis.
� Consider three diagnostic elements separately: history, physical examination, and laboratory/
radiologic investigations. If two of the three support the diagnosis of appendicitis, the patient
warrants operative evaluation.
� Computed tomography clearly demonstrating intraluminal contrast filling of the entire appendix
excludes the diagnosis of ap

1. By Menilik Merid (MD) January 2006

2. Introduction Classification Incidence Risk factors Causal factors Pathogenesis Clinical presentation Complications Investigations Management Management of CBD stones

3. Most common biliary pathology > 1 million new cases each year > 600,000 cholecystectomies done Western world – cholesterol stones (70%) Worldwide – pigment stones dominate

4. Based on stone composition,location, and etiology. Composition Cholesterol Pigment Mixed Location GB Extra hepatic BD Intra hepatic BD Major elements – cholesterol,bile pigments, calcium. Others – Fe, P, CO 3 , mucus,debris

5. Fat, fertile, flatulent, female of fifty. In europe 30% of women > 60 yrs have GS Few studies in Africa Ethiopia – Armed forces hospital F:M 4.8 : 1 16 - 72 yrs ( Av. 37 yrs)

6. RISK FACTORS - Age -children with haemolytic dis . &/ or SBS , TPN ---- increase PGS - Gender & hormones -biliary Sy --- in second & third trimes -post partem acute cholecystitis - Obesity & rapid wt loss ->50% women 45-50yrs hx of GSD -Diabetes melitus -Acute cholecystitis & post-op septic comp - cirrhosis - Vagotomy & TPN

7. Causal Factors -Multifactorial - metabolic,infectious,& stasis -Cholesterol & mixed stone -GB ‘bystander’ -occurs in three stages -cholestrol saturation,nucleation,& stone growth -Cholesterol saturation -mixed bile acids,lecitin& colestrol…micelles - any alteration …cholesterol precipitation - due to increased quantity or alteration of the vehicle …critical step - supersaturation can occur due to -secretion of hepatic bile with either high cholesterol or low bile acids or lecithin…litogenic bile

8. Nucleation -cholesterol monohydrate crystals form & agglomerate …macroscopic stones -promoters or retarding agents -heat labile GP in the bile as potential pronucleating factors(e.g GB mucus ) - Stasis of bile in the GB -dec. GB motility & emptying -inc.CD resistance -inc. calcium - PG synthesis -alteration in GBsecretion &absorption Stone Growth - Due to cholesterol precipitation & agglomeration

9. P athogenesis of PGS -Altered solubilization of unconjugated bilirubin with precipitation of ca bilirubinate & insoluble salts -either brown or black - brown stones _in Asia -secondary to infection -release of beta glucuronidase - black stones -pts with haemolytic dis . & cirrhosis

10. Nucleating agents Mucus Glycoprotein Infection Supersaturated bile Age Sex Genetics Obesity Diet Absorption/EHC Deoxycholate SBS Fecal flora Ileal resection Cholestiramine Impaired GB function Emptying Absorption Excretion

11. Clinical Presentation I. Asymptomatic (incidental) II. Symptomatic or comp. of GS I. asymptomatic GS Dx incidentally > 50% of pts with GS 25% of pts within 5 yr…symptoms that need intervention -2-5 % annual biliary incidence of pain II.Symptomatic GS -Colic…misnomer -sudden onset (30-60min) after meal -increased freq. & intensity with time - 6-10% risk of recurrent sy each year -2% risk of comp. -large solitary stones…acute cholecystitis - multiple stones<4 cm…acute pancreatitis

12. C omplications of GS -due to mov’t of stones & infection IN THE GALLBLADDER -silent stones - chronic cholecystitits - acute cholecystitis -gangrene -perforation -biliary peritonitis -biliary-enteric fistula -empyema -mucocele -malignancy IN THE BILE DUCTES -obs.jaundice -cholangitis -acute pancreatitis IN THE INTESTINE -acute intestinal obs.(GS ileus)

13. CHRONIC CHOLECYSTITIS - incompletely resolved AC - contracted fibrotic GB - may follow cholesterolosis ( strawberry GB ) & adenomyomatosis -dyspepsia … belching , flatus , abd bloating ,fullness epigastric burning & N & V A CUTE CHOLECYSTITIS -most common comp of GSD - in 95%.... GS impacted at Hartman’s pouch obs CD …… acute inflammation of GB -50% bacteria cultured - middle aged & elderly -Hx of episodic biliary colic pain… Unremitting for days

14. Cont’ d -RUQ + N & V - fever & localized tenderness …. Main C/F ( AC vs biliary colic ) - persistence of RUQ pain .> 4 hrs P/E - direct & rebound tenderness & guarding - Murphy’s sign ( 50% ) - mass in RUQ … 20% -WBC.12000-15000 in uncomplicated cases -> 20000…gangrene , perforation & cholangitis

15. DDx -perforated PUD -AMI -appendicitis -cholangitis -lobar pneumonia -pancreatitis -hepatitis -pyelonephritis ACALCULAS CHOLECYSTITIS - pts with major abd & thoracic surgery & TPN -recovering from major trauma -severe burns - in ICU P pts MR40-60% Acute emphysematous cholecycistitis -serious form of AS -cx by gas in the lumen or wall of the GB -in the elderly pts - 25% have DM -CF as AC but pts are more toxic -DX ….air in the gallblader or wall on plain abd. Film -GS in 75% of pts

16. Sequels of acute cholecystitis - MUCOCELE (hydrops) of the GB -due to chronic obs. Of the CD by GS & evidence of chronic obs -GB distended by mucus…palpable mass on the RUQ - Empyema of the GB - If the acutely inflamed GB is invaded by bacteria - intraluminal abscess of the GB - increased local tenderness & wbc - in elderly pts,DM or immunosuppresed - Perforation of the GB - most common comp of AC (5-15%) -Types___ 1.acute free perforation (MR>50%) 2.subacute perforation with abscess formation or fistula -Causes___chronic inflammation,GBischemi,&immunosupp. - pts with free perforation of GB -acute abd…..Rx..urgent operation

17. Cont’d -Patients with GB perforation & fistula formation -most common variant -difficult to manage -abn. Communication b/n the fundus & the duodenum ( CDF , CCF , CGF ) GS ileus - mechanical int. obstruction due to impaction of one or more GS in the GIT - < 2% OF mechanical small bowel obs. - F > M - terminal ileum , sigmoid colon , duodenum ->2cm in diameter -plain abd. Film … triad of - air in the biliary tree - small bowel obs. -stone in RLQ

18. INVESTIGATION AND DIAGNOSIS 1. History & P/E 2. Standard base line investigation - CBC -LFT ….. Early increase in AST ….. Later decrease in AST & mild increase in Alk. Phos. ….. Persistent increase in Alk. Phos. … CBD obs. -Serum Amylase ….. Acute pancreatitis - Blood culture 3. Plain radiography - 10% of GS are radio opaque -not routinely indicated -in acutely ill pts to R/O perforated viscus

19. Plain radiography cont’d … -Acute pancreatitis as comp . - distended small bowel loops & transverse colon - Gas in the GB or BD -Non radiopaque stones….. ‘Mercedes Benz’ sign 4. ULTRASOUND - key investigation - accurse 95% -primary screening procedure -can show us…. Calculi with acoustic shadow … thickened wall , distension of GB … serosal oedema or an empyema … localized pericholecystic collection … dilated CBD

20. 5.OCG -accuracy of 97-99% -GS < 2mm in diam. Can be missed -replaced by U/S -used to assess GB function -peak opacification at 14-19 hrs. 6.IV CHOLANGOGRPHY - to see extrahepatic biliary tree -effective in jaundiced pts. 7.CT & MRI - to R/O pancreatic head tumour 8.SCINTOGRAPHY … to Dx acute cholecystitis

21. 9. PTC & ERCP - in pts with comp. acute biliary dis. & jaundice - clotting studies before PTC - prophylactic antibiotics -indicated in pts. - known GBS with increased bilirubin >10 mg/dl - Sx pts with previous cholecystectomy - pts with biliary Sx & inconclusive evidence

22. Management of acute cholecystitis A. Conservative Rx i. relief of pain -NSIAD -opiates & morphine - i.v fluids if DHN ii. Control of nausea & vomiting -keep NPO -ant emetics -NG tube iii. Control of fever -broad spectrum Abs( blood culture) -cephalosporin's & aminoglycosides -most pts respond within 48 hrs - after 6-8 wks elective cholecystectomy Disadvantages -inc.hospital stay,health cost, morbidity

23. Expectant - Prophylactic cholecystectomy not indicated -immunosuppresed and DM II. Mx of acute cholecystitis A. conservative Rx (symptomatic Rx) i. relief of pain -NSAID -Opiates and morphine -I.V fluids if DHN ii. Control of nausea and vomiting -keep NPO -anti-emetics -NG tube iii. Control of fever -broad spectrum Abs( BLOOD CULTURE) -cephalosporin's & aminoglicosides -most pts respond within 48 hrs -after 6-8 wks elective operation

24. B. Definitive Rx I. Removal of GB & stones -open cholecystectomy - laparoscopic cholecysectomy - minicholecystectomy II. Removal of GS alone - medically - other procedures a. Emergency cholecystectomy - pts not settling within 48 hrs - pts with DM to prevent gangrene b. Early elective cholecystectomy -AC after 24-48 hrs -after acute cond. Is settled ( 3-5 dys after admission) c. Subtotal cholcystectomy -for sever inflammation of fibrosis - portal HTN

25. d.Elective ( conventional) cholecystectomy - done by Langenbeck in 1882 -decreased morbidity ( 0.2% comp) -dec. mortality < 0.5 % Indications - recurrent biliary colic - AC -GB neoplasms - porcelain GB - absolute or relative c/I for laparoscopic - pregnancy - morbid obesity -previous abd. Surgery -cirrhosis & portal HTN - small fibrotic GB - COPD - Intra-op laparoscopic compo. - excessive bleeding - visceral injury ( colon,BD)

26. B.Laparoscopic cholecystectomy - ’Pt. friendly’ -Muhe in 1985 -since 1988….choice of Rx -gold standard op. for GB cond. -mortality o.1-0.5% -Comps. -either laparoscopy itself or comp. of cholecystectomy op. -Laparoscopy comps. -when creating pneumoperitonium -major vascular injury 2%(IVC 0.1%) -major visceral injury (colon,duodenum) -BD injury <1.5% -conversion rate 3-7% . For pts with AC >20%

27. Advantages - Dec. hospital stay - quicker return to normal activity - dec. wound infection - dec. contact with pts blood and body fluids - dec, pain - good cosmetic results C. Small Incision cholecystectomy (Sheffeilds) - compares to laparoscopic cholecystectomy - transverse 5 cm +/- 2cm skin incision

28. B.Removal of GS alone i.Medical a. Dissolution Rx - in 1920s - dissolution agents (CDCA’& UDCA ) -both orally taken -for pure cholesterol stones -long term Rx 9(6_ 36 months ) -complete stone dissolution 13.5% -26% partial dissolution -CDCA dissolves bile, dissolves cholesterol, specific inhibitor of HMG- CoA reductase -ideal candidates .thin ,young, females, with tiny stones(0.5cm) .radiolucent floating stones (pure cholesterol ) .BMI < 30 .<5% of pts meet this criteria -life long maintenance Rx Disadvantages -inc. time of Rx -inc. recurrence rate(50% at 5 yr ) -diarrhea &hepatic toxicity -leaves GB in-situ

29. b.Contact dissolution -solvents directly in to the GB -late 1980s -PTC -methyl- tert –butyl ether (MTBE)….dissolves cholesterol -Selection criteria .high risk pts. With symptomatic GS dis. .who refuse op. .pts. With patent CD on OCG or scintigraphy -recurrence in 10% at 30 months c.Lithotripsy (ESWL) -Advantages .dec. hospitalization .avoidance of surgery .inc. acceptance by pts -preliminary studies .stone free rate of >/= 90% (ESWL & litholitic Rx)

30. Munich’s selection criteria for ESWL -functional GB -max. 3 stones -no pregnancy / obese -pure cholesterol stones -normal LF only 16% meet this criteria -10% comp. of CBD obst. d.Cholecystostomy -very critical pts. (bed side using LA) -Rx of choice for AC when pts. Cond.n does’t allow cholecystectomy -generalized peritonitis due to perforated GB

31. Primary stones-Common in tropics -Infestations by A. lumbricoids and Chlorensis sinesis --Prolonged biliary obstruction Most CBD stones originate in the GB Consequences of duct stone Obst. Jaundice Infection Cholangitis=> fever, Jaundice, RUQ pain Complications Impaired LF =>Biliary cirrhosis Suppurative cholangitis=>liver abscess

32. DDx of CBD stones Pancreatic Ca, Drug induced jaundice,Primary biliary cirrhosis,Hepatitis (viral) Investigations LFT, U/S, ERCP, PTC, MRI, CT CBD exploration and drainage Indications=> CBD stones seen on cholangiography, Palpated CBD stones, ascending cholangitis with CBD stones Cholangiography indications=> dilated CBD, Hx of jaundice, abnormal LFT, multiple GB stones

33. Rx options for CBD Stones I. Non surgical i. Endoscope sphincterotomy -Spontaneous passage - Extraction with baloons/ baskets Additional measures=> mechanical/ laser lithotripsy, nasobiliary intubations with irrigation of CBD using monoctanoin ii. ESWL=> with addition of bile salts II. Surgical i. Laparoscopic CBD exploration---Via CD or direct choledochostomy ii. Open surgical exploration => supraduodenal exploration with T-tube drainage iii.Alternatives - External choledochoduodenostomy - Transduodenal sphincteroplasty

34. Rx of retained stones Extraction via T-tube tract (4-6 weeks) 95% success rate, 4% morbidity,no mortality 2. Percutaneous via trans hepatic route 3. Endoscopically with the assistance of sphincterotomy 4. Dissolution with monooctanoic acid solvent 5. Fragmentation with lithotripsy or a combination of the above

35. Baily and Loves, 24 th edition Maingot`s Abdominal operations Schwartz`s Principles of Surgery, 8 th edition Gall stones by Ralph, 3 rd edition Up to Date eMedicine

36. Thank You!!!