Acute cholecystitis.
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Acute cholecystitis.

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    Acute cholecystitis. Acute cholecystitis. Presentation Transcript

    • Acute cholecystitis
      • Sergey Usov M.D.
    • Gallbladder anatomy
    • Gallbladder anatomy
    • Acute cholecystitis
      • Definition:
      • Acute cholecystitis is an inflammation of a gall-bladder.
    • Etiology and pathogenesis.
      • In etiology of cholecystitis major factors are the following: cholelithiasis, infection. Problems with bile passage through the cystic duct from gallbladder to the common bile duct due to stenosis or obstruction of cystic duct with inflammation process around a cervix of the gallbladder there are.
    • Causes of cholecystitis
      • All reasons of acute cholecystitis causes are divided in two groups:
      • cholecystitis with formation of calculi (gall stones) - 80%.
      • Non calculi cholecystitis – 20%.
    • What is that? It might be pineapple ?
    • What is that? It might be precious stone?
    • What is that? It might be jewel?
    • No! This is a gall-stone.
    • No! This is a gall-stone
    • No! This is a gall-stone again No! This is a gall-stone again No! This is a gall-stone again
    • Causes of cholecystitis
      • Non calculi cholecystitis is conditioned:
      • by gram-positive and gram-negative infections - 10%.
      • or blood supply disturbance of the wall gallbladder – 5%.
    • Other causes of cholecystitis
      • microbes: C olibacillus, Proteus, Staphylococcus, Enterococcus and mixed form bacteria.
      • It is particular form of acute cholecystitis (5%) due to:
      • acute pancreatitis (pancreatogenic)
      • or parasitogenic diseases.
    • Pathomorphology of acute cholecystitis
      • The wall of gall-bladder is thickened, edematous, and hyperemic with stratification of fibrin and the gall bladder fills with pus
    • Pathomorphology of cholecystitis
      • The catarrhal acute cholecystitis develops to phlegmonous and suppuration inflammation.
      • Progress of inflammation process can lead to gangrene of the gall bladder.
    • Gangrenous cholecystitis
    • Necrosis of the gall bladder.
    • Classification:
      • A. acute calculi cholecystitis (with presence gall stones)
      • B. acute non - calculi cholecystitis (without gall stones)
      • 1. Catarrhal
      • 2. Phlegmonous
      • 3. Gangrenous
      • 4. Perforated
    • Complication:
      • peritonitis (local, widespread, general)
      • cholangitis (inflammation process into the bile duct)
      • empyema of gall bladder
      • abscess around the gall bladder
      • hydrops of gall bladder
      • mechanical jaundice
      • hepatitis or hepato-renal insufficiency
    • Clinical management:
      • Acute cholecystitis usually begins after violation of a diet: intake of spice or fried food, plenty fatty eating.
    • Pain syndrome .
      • Main symptom of acute cholecystitis is severe pain in right hypochondrium and epigastric area with radiation to right half of the chest and right shoulder. When a hypertension in a gall bladder and bile ducts progresses the pain syndrome is strongly expressed and becomes attack-like in character, but this clinical phenomenon is named as biliary colic.
    • Dyspepsia syndrome :
      • Frequent symptoms which disturb a patient are nausea and repeated vomiting with bile. Later feeling of fullness of abdomen, delay of emptying bowel and gases are often followed.
    • Objective examination
      • A doctor can observe slight icterus skin or sclera during examination in many patients. Tongue is whites-grey in colour. Patients complain of a dryness of mouth. In difficult cases the tongue is usually dry, assessed white stratification with yellow spot.
    • Objective examination
      • Increase of body’s temperature (to 37,5 C) in brief period is insignificant in catarrhal cholecystitis and with destructive forms the temperature could be higher (38C). The fever in the range of 37,7-38,8 is marked inflammation and toxemia. Tachycardia testifies the degree of intoxication.
    • Objective examination
      • The upper part of abdomen is strongly tense and often palpable mass develops in the hypochondrium region or projection of the gall bladder. By superficial and deep palpation right hypochondrium area a tenderness of the abdominal wall, increased size of gall bladder are exposed. An inflamed gall bladder wrapped in inflammatory adhesions with adjacent organs, especially the omentum.
    • The following symptoms are diagnosed in acute cholecystitis:
      • Murphy’s sign is a delay of breathing during palpation of gall bladder on inspiration.
      • Kehr’s sign is increase of pain with pressure on the area of gall bladder, especially on deep palpation.
      • Ortner’s sign is tenderness on light percussion at right costal margin by edge of the hand.
    • Diagnostic program:
      • Laboratory analysis . Leukocytes from 10.0/L and more, shift of leukocyte formula to the left, lymphopenia and increased ESR.
      • Sonographic examination of gall bladder can reveal the increase in its sizes, bulge of walls, development of perivesical abscesses, presence or absence of bile sludge and stones.
      • X-ray examination with observe of abdominal cavity organs can identify free gas in abdominal cavity and X-ray photography-positive of the gall stones.
    • Cholecystography
    • Cholecystography with contrast agent
    • CT investigation
    • Ultrasonography
    • Ultrasonography
    • Ultrasonography
    • Ultrasonography
    • Cholangiography
    • Differential diagnosis
      • T hese should be suspected whenever the acute pain at right upper quadrant of abdomen is appeared .
        • Perforated peptic ulcer
        • - Acute amoebic liver abscess
        • Acute pancreatitis
        • Acute intestinal obstruction
        • Renal colic
        • Acute retrocolic appendicitis
        • Myocardial infarction
        • Basal pneumonia
    • Treatment
      • For most patients the definitive treatment is surgical removal of the gallbladder. Supportive measures are bas ed in the meantime to prepare the patient for surgery. The in fusion of fluid and antibiotics should be given . Antibiotic regimens usually consist of a broad spectrum antibiotic such as a cephalosporin (e.g. ceftriaxone ) and an antibacterial with good coverage against anaerobic bacteria , such as metronidazole .
    • The surgery
      • Gallbladder removal, cholecystectomy , can be accomplished via open surgery or a laparoscopic procedure. Laparoscopic procedures ha s less morbidity and a shorter recovery period . Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. Open procedure may also be done if the surgeon could meet with a difficult clinical cases .
    • Consequently, L aparoscopic cholecystectomy is the Gold standard for the gall bladder planed surgery.
      • Film 5 min.
    • Urgent operations need the open surgical approach and handmade a gall bladder surgery.
      • Film 10 min.
    • C holecystostomy
      • In cases of severe inflammation, shock, or if the patient has higher risk for general anesthesia (required for cholecystectomy ), the managing physician should t ake a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the patient with antibiotics until the acute inflammation resolves.
    • C holecystostomy
    • The surgery
      • Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult
      • Film 5 min.
    • Complications a f ter cholecystectomy
      • bile leak ("biloma")
      • bile duct injury Open and laparoscopic surgeries have essentially equal rate of injuries, but the recent trend is towards fewer injuries with laparoscopy. It may be that the open cases often result because the gallbladder is too difficult or risky to remove with laparoscopy)
      • Intraabdominal abscess
      • wound infection
      • bleeding (liver surface and cystic artery are most common sites)
      • hernia
      • deep vein thrombosis / pulmonary embolism (unusual- risk can be decreased through use of sequential compression devices on legs during surgery)
    • Thank you!
      • Sergey Usov M.D.