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Acute cholecystitis
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'Lecture: Dr.Mohammad Kamal Aktar

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  1. 1. Cholecystitis
  2. 2. Cholecystitisusually presentsas a pain in theright upperquadrant orepigastric region.
  3. 3. Symptomatically it differs frombiliary colic by the presence of aninflammatory component (fever,increased white cell count ).
  4. 4. This pain is initiallyintermittent, but later usuallypresents as constant andsevere
  5. 5. During the initial stages,the pain may be felt in anarea totally separate fromthe site of pathology,known as referred pain.
  6. 6. The pain is originallylocated in the right upperquadrant but the referredpain may occur in theright scapula region (Boassign).
  7. 7. This may also present with theabove mentioned pain aftereating greasy or fatty foodssuch as pastries, pies, and friedfoods.
  8. 8. This is usuallyaccompanied by diarrhea,vomiting and nausea. Thegallbladder may be tenderand distended.
  9. 9. More severe symptoms such as highfever, shock and jaundice indicate thedevelopment of complications suchas abscess formation, perforation orascending cholangitis. Anothercomplication, gallstone ileus, occurs ifthe gallbladder perforates and formsa fistula with the nearby small bowel,leading to symptoms of intestinalobstruction.
  10. 10. Chronic cholecystitismanifests with non-specific symptoms suchas nausea, vagueabdominal pain, belching,and diarrhea.
  11. 11. CausesCholecystitis is often caused bycholelithiasis (the presence ofcholeliths, or gallstones, in thegallbladder), with choleliths mostcommonly blocking the cystic ductdirectly. This leads to inspissation(thickening) of bile, bile stasis, andsecondary infection by gut organisms,predominantly E. coli and Bacteroides
  12. 12. The gallbladders wall becomesinflamed. Extreme cases mayresult in necrosis and rupture.Inflammation often spreads to itsouter covering, thus irritatingsurrounding structures such asthe diaphragm and bowel.
  13. 13. Less commonly, in debilitated andtrauma patients, the gallbladder maybecome inflamed and infected in theabsence of cholelithiasis, and isknown as acute acalculouscholecystitis. This can arise inpatients with anorexia nervosa, asthe lack of stimulation of thegallbladder leads to an infectiousprocess.
  14. 14. Stones in the gallbladder maycause obstruction and theaccompanying acute attack. Thepatient might develop a chronic,low-level inflammation whichleads to a chronic cholecystitis,where the gallbladder is fibroticand calcified.
  15. 15. DiagnosisCholecystitis is usuallydiagnosed by a history of theabove symptoms, as well asexamination findings:
  16. 16. fever (usually lowgrade inuncomplicatedcases)
  17. 17. tender right upperquadrant with orwithout Murphys sign
  18. 18. Ortners sign —tenderness when handtaps the edge of rightcostal arch
  19. 19. Georgievskiy — Myussis sign(phrenic nerve sign) — painwhen press between edgesof sternocleidomastoid
  20. 20. Boas sign — Increasedsensitivity below the rightscapula (also due to phrenicnerve irritation).
  21. 21. Subsequent laboratory andimaging tests are used toconfirm the diagnosis andexclude other possible causes.Ultrasound can assist in thedifferential
  22. 22. Differential diagnosis[edit] Acute cholecystitis Differential diagnosis Acute cholecystitis Acute cholecysitis as seen on ultrasound. This should be suspected whenever there is acute right upper quadrant or epigastric pain,
  23. 23. other possible causesinclude:Perforated peptic ulcerAcute peptic ulcerexacerbationAmoebic liver abscessAcute amoebic liver colitis
  24. 24. Acute pancreatitisAcute intestinal obstructionRenal colicAcute retro-colic appendicitis
  25. 25. Chronic cholecystitisThe symptoms of chronic cholecystitis arenon-specific, thus chronic cholecystitis maybe mistaken for other common disorders:Peptic ulcerHiatus herniaColitisFunctional bowel syndrome, is definedpathologically by the columnar epitheliumreaching down to the muscular layer.
  26. 26. Quick DifferentialBiliary colic — Caused by obstruction of thecystic duct. It is associated with sharp andconstant epigastric pain in the absence of fever,and there is usually a negative Murphys sign.Liver function tests are within normal limitssince the obstruction does not necessarilycause blockage in the common hepatic duct,thereby allowing normal bile excretion fromthe liver. An ultrasound scan is used to visualisethe gallbladder and associated ducts, and alsoto determine the size and precise position of
  27. 27. Cholecystitis — Caused by blockage of the cystic duct withsurrounding inflammation, usually due to infection.Typically, the pain is initially colicky (intermittent), andbecomes constant and severe, mostly in the right upperquadrant. Infectious agents that cause cholecystitisinclude E. coli, Klebsiella, Pseudomonas, B. fragilis andEnterococcus. Murphys sign is positive, particularlybecause of increased irritation of the gallbladder lining,and similarly this pain radiates (spreads) to the shoulder,flank or in a band like pattern around the lower abdomen.Laboratory tests frequently show raised hepatocellularliver enzymes (AST, ALT) with a high white cell count(WBC). Ultrasound is used to visualise the gallbladder andducts.
  28. 28. Choledocholithiasis — This refers to blockage of the commonbile duct where a gallstone has left the gallbladder or hasformed in the common bile duct (primary cholelithiasis). Aswith other biliary tree obstructions it is usually associatedwith colicky pain, and because there is direct obstruction ofbiliary output, obstructive jaundice. Liver function tests willtherefore show increased serum bilirubin, with highconjugated bilirubin. Liver enzymes will also be raised,predominately GGT and ALP, which are associated with biliaryepithelium. The diagnosis is made using endoscopicretrograde cholangiopancreatography (ERCP), or the nuclearalternative (MRCP). One of the more serious complications ofcholedocholithiasis is acute pancreatitis, which may result insignificant permanent pancreatic damage and brittlediabetes.
  29. 29. Cholangitis — An infection of entire biliary tract,and may also be known as ascending cholangitis,which refers to the presence of pathogens thattypically inhabit more distal regions of the bowel[3]Cholangitis is a medical emergency as it may be lifethreatening and patients can rapidly succumb toacute liver failure or bacterial sepsis. The classicalsign of cholangitis is Charcots triad, which is rightupper quadrant pain, fever and jaundice. Liverfunction tests will likely show increases across allenzymes (AST, ALT, ALP, GGT) with raised bilirubin.As with choledocholithiasis, diagnosis is confirmedusing cholangiopancreatography.
  30. 30. InvestigationsBloodLaboratory values may be notable for an elevatedalkaline phosphatase, possibly an elevatedbilirubin (although this may indicatecholedocholithiasis), and possibly an elevation ofthe WBC count. CRP (C-reactive protein) is oftenelevated. The degree of elevation of theselaboratory values may depend on the degree ofinflammation of the gallbladder. Patients withacute cholecystitis are much more likely tomanifest abnormal laboratory values, while inchronic cholecystitis the laboratory values arefrequently normal.
  31. 31. RadiologySonography is a sensitive and specific modality for diagnosisof acute cholecystitis; adjusted sensitivity and specificity fordiagnosis of acute cholecystitis are 88% and 80%,respectively. The diagnostic criteria are gallbladder wallthickening greater than 3mm, pericholecystic fluid andsonographic Murphys sign. Gallstones are not part of thediagnostic criteria as acute cholecystitis may occur with orwithout them.The reported sensitivity and specificity of CT scan findings arein the range of 90–95%. CT is more sensitive thanultrasonography in the depiction of pericholecysticinflammatory response and in localizing pericholecysticabscesses, pericholecystic gas, and calculi outside the lumenof the gallbladder. CT cannot see noncalcified gallbladdercalculi, and cannot assess for a Murphys sign.
  32. 32. Hepatobiliary scintigraphy with technetium-99m DISIDA (bilirubin) analog is also sensitiveand accurate for diagnosis of chronic andacute cholecystitis. It can also assess theability of the gall bladder to expel bile (gallbladder ejection fraction), and low gallbladder ejection fraction has been linked tochronic cholecystitis. However, since mostpatients with right upper quadrant pain donot have cholecystitis, primary evaluation isusually accomplished with a modality that candiagnose other causes, as well.
  33. 33. Treatment for cholecystitis willdepend on your symptoms andyour general health. People whohave gallstones but dont have anysymptoms may need no treatment.For mild cases, treatment includesbowel rest, fluids and antibioticsgiven through a vein, and painmedicine.
  34. 34. The main treatment for acutecholecystitis is surgery to removethe gallbladder (cholecystectomy).Often this surgery can be donethrough small incisions in theabdomen (laparoscopiccholecystectomy), but sometimes itrequires a more extensive operation
  35. 35. Sometimes acute cholecystitis is causedby one or more gallstones getting stuckin the main tube leading to theintestine, called the common bile duct.Treatment may involve an endoscopicprocedure (endoscopic retrogradecholangiopancreatography, or ERCP) toremove the stones in the common bileduct before the gallbladder is removed.
  36. 36. Supportive measures are usually instituted prior tosurgery. These measures include fluidresuscitation and antibiotics. Antibiotic regimensusually consist of a broad spectrum antibiotic suchas piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate(Timentin), or a cephalosporin (e.g.ceftriaxone)and an antibacterial with good coverage(fluoroquinolone such as ciprofloxacin) andanaerobic bacteria coverage, such asmetronidazole. For penicillin allergic patients,aztreonam and clindamycin may be used.
  37. 37. In cases of severe inflammation, shock, or ifthe patient has higher risk for generalanesthesia (required for cholecystectomy), themanaging physician may elect to have aninterventional radiologist insert apercutaneous drainage catheter into thegallbladder (percutaneous cholecystostomytube) and treat the patient with antibioticsuntil the acute inflammation resolves. Acholecystectomy may then be warranted if thepatients condition improves.
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'Lecture: Dr.Mohammad Kamal Aktar


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