Surgical Procedures/Abdominal Surgery/Cholecystitis

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Cholecystitis

Introduction:[edit]

• It is an inflammation of gall bladder.
• Almost always occurs in association with gallstone.
• It is one of the most common indications for abdominal surgery.
• Its epidemiologic disturbance closely parallels to gallstone.

Types of Cholecystitis:[edit]

  • Calculus Cholecystitis.

            Inflammation of the gallbladder in the presence of gallstones.

  • It is classical to subdivide further:
    • Acute Calculus Cholecystis.
    • Chronic Calculus Cholecystis.


  • Acalculous Cholecystitis.

            Inflammation of the gallbladder in the absence of gallstones.
            Give rise to clinical picture similar to calculus cholecystitis.

  • It is classical to subdivide further:
    • Acute Acalculous Cholecystitis.
    • Chronic Acalculous Cholecystitis.

Acute Calculus Cholecystitis: [edit]

  • Precipitated 90% of the time by gallstone obstruction of the:
    • Neck of the gallbladder.
      • Gallstone impacted in Hartmann's pouch.
    • Cystic duct.
  • Caused by Bile infections:
    • E.coli.
    • Klebsiella sp.
    • Streptococcus faecalis (Keighley).
    • Strict anaerobes, e.g. Bacteroides sp.
    • Gas forming organisms, e.g. clostridia.
    • Typhoid infection.
  • It is the primary complication of gallstones.
  • One of the most common reasons for emergency cholecystectomy.


Sequel of Acute Cholecystitis attack:[edit]

  • When a certain degree of distension of the gall bladder has been reached, the mucous membrane tends to be lifted away from the sides of the stone and, as a consequence, the stone may slip back into the body of the gallbladder, and any mucoid (from a mucocele) or mucopurulent contents of the gallbladder escape by way of the cystic duct.
  •  Less frequently, the impaction persists and an empyema (pyocele) of the gallbladder results.
  •  On rare occasions, the distended, inflamed gallbladder perforates.

Clinical features of acute calculus cholecystitis:[edit]

  • The onset is sudden.
  • Pain is located in mainly in the right hypochondrium.

Diagnosis of Acute Calculus Cholecystitis:[edit]

  • Ultrasonography will confirm the diagnosis.

Chronic calculus cholecystitis: [edit]

Clinical features:

  • Right Hypochondrial pain.
    • Radiation to between the shoulder blades is frequent and it may associated with nausea and vomiting. Fatty foods often precipitate it.
    • During an attack, tenderness in the hypochondrium is present.
    • Murphy's sign may be (+).
    • The temperature and white blood count are elevated.
    • Flatulent dyspepsia:

Diagnosis:

  • Ultrasonography is usually the only investigation needed to show gallstones.
  • A bile duct >8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation.

Acute Acalculous Cholecystitis: [edit]

  • Particularly seen in patients recovering from:
    • Major surgery.
    • Trauma.
    • Burns.

NB!    In these patients the diagnosis is often missed and the mortality rate is 20 %.

  • Diagnosis:
    • Oral cholecystography is more useful than Ultrasonography in those presenting with chronic symptoms.
    • Radioisotope scanning for presenting with acute symptoms.
    • Cholesterol crystals in duodenal aspirate may also help.

Treatment: [edit]

Treatment of choice:

  • Laparoscopic cholecystectomy.
  • Open cholecystectomy.
  • Percutaneous transhepatic placement of a cholecystostomy tube.