Acute Cholecystitis DR DILIP S.RAJPAL

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Acute Cholecystitis DR DILIP S.RAJPAL

  1. 1. ACUTE CHOLECYSTITIS DR DILIP S.RAJPAL MS, MAIS, FICS(USA), FMAS, Dipl. In Laproscopic surgery, Fellow in Robotic & Lap. Colo-Rectal Surgery(korea univ.) CONSULTANT GEN. SURGEON LAPROSCOPIST & COLOPROCTOLOGIST HON SURGEON NOVA MEDICAL CENTREHON SURGEON GODREJ MEMORIAL HOSPITAL HON. ASS PROF GRANT MED. COLLEGE HON.SURGEON JJ. HOSPITAL EX-ASST. PROF L.T.M.GEN. HOSPITAL
  2. 2. ANATOMY OF GIT FOREGUT MIDGUT HINDGUTCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  3. 3. PATHOPHYSIOLOGY OBSTRUCTION STASIS DISTENTION INCREASE IN INTRALUMINAL PRESSURE STIMULATION OF INFLAMATORY MEDIATORS COMMENSALS BECOME VIRULENT INFECTIONCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  4. 4. VISCERAL PAIN DULL, CRAMPY OR ACHING PAIN. GEOMETRIC FORCES SUCH AS DISTENTION, STRETCHING, TRACTION, CONTRACTION & CERTAIN CHEMICALS GIVE RISE TO PAIN. ALWAYS FELT IN MIDLINE.CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  5. 5. DEFINITION Inflammation of gall bladder is called ACUTE CHOLECYSTITIS .CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  6. 6. CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  7. 7. CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  8. 8. INCIDENCE COMMON IN FERTILE FATTY ABOVE FORTY FEMALESCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  9. 9. AETIOLOGY 1 CALCULOUS Obstruct cystic duct ACALCULOUS Cholesterosis(strawberry gall bladder) Cholesterol polyposis of gall bladder Cholecystitis glandularis proliferans Diverticulosis of gall bladder Typhoid of gall bladderCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  10. 10. BACTERIAL INFECTION E-coli Klebsiella S.faecalis Salmonella Clostridia AnaerobesCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  11. 11. SEVERE ILLNESS Ileus Sepsis Severe burns/injuries Starvation Multiple blood transfusions CARCINOMACONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  12. 12. PATHOLOGY INFLAMMATION LOCALIZATION • Ileus • Movement of omentum • Loops of intestine RESOLUTION EMPYEMA MUCOCELE PERFORATION  GENERALIZED PERITONITIS LOCAL ABSCESS FISTULACONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  13. 13. CLINICAL FEATURES PAIN SITE - RIGHT HYPOCHONDRIUM TYPE - COLICKY ONSET – SUDDEN DURATION – MORE THAN 12 hrs RADIATION  BACK  SHOULDER  RIGHT HYPOCHONDRIUM  LEFT HYPOCHONDRIUMCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  14. 14. PRECIPITATING FACTORS  Fatty Food  Movement  Breathing RELIEVING FACTORS  Analgesics FEVER NAUSEA/VOMITING DISTENTION/CONSTIPATION JAUNDICECONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  15. 15. SIGNS GENERAL  TACHYCARDIA  PYREXIA LOCAL TENDERNESS - RT HYPOCHONDRIUM RIGIDITY - RT HYPOCHONDRIUM MURPHY’S SIGN MASSCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  16. 16. INVESTIGATIONS BLOOD COMPLETE PICTURE  LEUCOCYTOSIS URINE  BILIRUBIN PLAIN X-RAY ABDOMEN  Radioopaque gall stones ULTRASONOGRAPHY  Dilatation of billiary tree  Stones  FluidCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  17. 17. GALL BLADDER RADIONUCLIDE SCAN ORAL CHOLECYSTOGRAM PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  18. 18. ABDOMINAL ULTRASOUND SHOWING GALL DILIP S.RAJPALCONSULTANT GEN. SURGEON DR STONESLAPROSCOPIST & COLOPROCTOLOGIST
  19. 19. DIFFERENTIAL DIAGNOSIS COMMON  ACUTE PANCREATITIS  PERFORATED DUODENAL ULCER  PERFORATED PEPTIC ULCER  APPENDICITIS RARE ACUTE PYELONEPHRITIS HEPATITIS MYOCARDIAL INFARCTION PNEUMONITISCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  20. 20. COMPLICATIONS EMPYEMA PERFORATION  PERITONITIS ABSCESS FISTULA MUCOCELE ACUTE PANCREATITIS GALL STONE ILEUS OBSTRUCTIVE JAUNDICECONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  21. 21. DefinitionsSymptomatic Wax/waning postprandial epigastric/RUQcholelithiasis pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFTAcute Acute GB inflammation due to cystic ductcholecystitis obstruction. Persistent RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrestCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  22. 22. Chronic cholecystitis -Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis. No fever/WBC. Acalculous cholecystitis -GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Choledocho-lithiasis -Gallstone in the common bile duct (primary means originated there, secondary = from GB) Cholangitis -Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shockCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  23. 23. Case 1 46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now. No prior episodes Minimal RUQ tenderness, no Murphy’s WBC 8, LFT normal RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  24. 24. Case 1 → denotes gallstones → → ► denotes the acoustic shadow due to ► absence of reflected sound waves behind the gallstoneCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  25. 25. Symptomatic cholelithiasis aka “biliary colic” The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes Pain usually lasts 1-5 hrs, rarely > 24hrs Ultrasound reveals evidence at the crime scene of the likely etiology: gallstones Exam, WBC, and LFT normal in this case Treatment: Laparoscopic cholecystectomyCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  26. 26. Spectrum of Gallstone Disease Cholelithiasis Symptomatic cholelithiasis can be a herald to:Asymptomatic Symptomatic – an attack of cholelithiasis cholelithiasis acute cholecystitis – or ongoing chronic Chronic Acute cholecystitis calculous calculous cholecystitis cholecystitis May also resolveCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  27. 27. Case 2 Same case, except pt has had multiple prior attacks of similar RUQ pain No fever or WBC Ultrasound reveals gallstones, thickened GB wall, no pericholecystic fluid Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  28. 28. Chronic calculous cholecystitis Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones Overtime, leads to scarring/wall thickening Treatment: laparoscopic cholecystectomyCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  29. 29. Case 3 Same pt, now > 24hrs of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever Exam: Palpable, tender gallbladder, guarding, +Murphy’s = inspiratory arrest WBC 13, Mild ↑LFT U/S: gallstones, wall thickening (>4mm), GB distension, pericholecystic fluid, sonographic Murphy’s sign (very specific) Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  30. 30. Case 3 Curved arrow – Two small stones at GB neck ◄ Straight arrow – Thickened GB wall ◄ – pericholecystic fluid = dark lining outside the wallCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  31. 31. Case 3 → denotes the → GB wall ► thickening ► denotes the fluid around the GB GB also appears distendedCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  32. 32. Acute calculous cholecystitisPersistent cystic duct obstruction leads toGB distension, wall inflammation &edemaCan lead to:empyema, gangrene, rupturePain usu. persists >24hrs & a/wN/V/FeverPalpable/tender or even visible RUQ massNuclear HIDA scan shows nonfiling of GB– If U/S non-diagnostic, obtain HIDATx: NPO, IVF, Abx (GNR & enterococcus)Sg: Cholecystectomy usu within 48hrs DR DILIP S.RAJPAL
  33. 33. Case 4 87yo M critically ill, on long-term TPN w RUQ pain, fever, ↑WBC Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  34. 34. Acute acalculous cholecystitis In 5-10% of cases of acute cholecystitis Seen in critically ill pts or prolonged TPN More likely to progress to gangrene, empyema, perforation due to ischemia Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin Tx: Emergent cholecystectomy usu open If pt is too sick, perc cholecystostomy tube and interval cholecystectomy later on & COLOPROCTOLOGISTCONSULTANT GEN. SURGEONLAPROSCOPIST DR DILIP S.RAJPAL
  35. 35. Complications of acute cholecystitisEmpyema of Pus-filled GB due to bacterialgallbladder proliferation in obstructed GB. Usu. more toxic, high feverEmphysematous More commonly in men and diabetics.cholecystitis Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumenPerforated Occurs in 10% of acute chol’y, usuallygallbladder becomes a contained abscess in RUQ Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  36. 36. Case 5 46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers Known history of cholelithiasis Exam: unremarkable WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg Ultrasound: Gallstones, CBD stone, dilated CBD > 1cm Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  37. 37. Choledocholithiasis Can present similarly to cholelithiasis, except with the addition of jaundice DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain Tx: Endoscopic retrograde cholangiopancreatography (ERCP) – Stone extraction and sphincterotomy Interval cholecystectomy after recovery from ERCPCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  38. 38. Case 6 46yo F p/w fever, RUQ pain, jaundice (Charcot’s triad) If also altered mental status and signs of shock = Raynaud’s pentad VS tachycardic, hypotensive ABC’s, Resuscitate – 2 large bore IV, Foley, Continuous monitor – 1-2L fluid bolus, repeat until resuscitated Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  39. 39. Cholangitis Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures Charcot’s triad seen in 70% of pts May lead to life-threatening sepsis and septic shock (Raynaud’s pentad) Tx: NPO, IVF, IV Abx Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC) Used to require emergency laparotomyCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  40. 40. Case 7 46yo F p/w persistent epigastric & back pain Known history of symptomatic gallstones No EtOH abuse Exam: Tender epigastrum Amylase 2000, ALT 150 Ultrasound: Gallstones Diagnosis: ?CONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST
  41. 41. Gallstone pancreatitis35% of acute pancr 2ndary to stonesPathophysiology– Reflux of bile into pancreatic duct and/or obstruction of ampulla by stoneALT > 150 (3-fold elevation) has 95%PPV for diagnosing gallstone pancreatitisTx: ABC, resuscitate, NPO/IVF, analgesicOnce pancreatitis resolving, ERCP wstone extraction/sphincterotomyCholecystectomy before hosp discharge
  42. 42. Take Home Points As always, ABC & Resuscitate before Dx Understanding the definitions is key Is this acute cholecystitis? (fever, WBC, tender on exam with positive Murphy’s) Or simply cholelithiasis vs ongoing chronic cholecystitis? (no fever/WBC) Is patient sick or toxic-appearing, to suspect empyema, gangrene or even perforation? Elicit h/o jaundice, acholic stools, tea-colored urine Rule out cholangitis, because this will kill the patient unless dx & tx earlyCONSULTANT GEN. SURGEON DR DILIP S.RAJPALLAPROSCOPIST & COLOPROCTOLOGIST

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