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Acute cholecystitis..

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Acute cholecystitis..

  1. 1. ACUTE CHOLECYSTITIS Assistant professor : pechyonkin Student: raza sarif Group : 414 A
  2. 2. DEFINITION Inflammation of gall bladder is called ACUTE CHOLECYSTITIs
  3. 3. INCIDENCE • COMMON IN FERTILE • FATTY • ABOVE FORTY • FEMALES lydia shum
  4. 4. Etiology Obstruction Bacterial invasion Trauma and chemical irritation Pancreatic reflex
  5. 5. Etiology 1 CALCULOUS
  6. 6. etiology 2 ACALCULOUS  Cholesterosis(strawberry gall bladder)  Cholesterol polyposis of gall bladder  Cholecystitis glandularis proliferans  Diverticulosis of gall bladder  Typhoid of gall bladder
  7. 7. etiology BACTERIAL INFECTION  E-coli  Klebsiella  S.faecalis  Salmonella  Clostridia Anaerobes 
  8. 8. classification • On etiology: calculous,acalculous,emphysamatous • On inflammation:simple,destructive Emphysamatous
  9. 9. classification • On morphology: catarhal,phlegmonous,gangrenous,gan grenous perforation
  10. 10. Clinical Findings Symptoms: 1. Abdominal pain Where When How
  11. 11. Abdominal pain • SITE - RIGHT HYPOCHONDRIUM • TYPE - COLICKY • ONSET – SUDDEN • DURATION – MORE THAN 12 hrs • RADIATION  BACK  SHOULDER  RIGHT HYPOCHONDRIUM  LEFT HYPOCHONDRIUM
  12. 12. Symptoms: 2 gastrointestinal Nausea, bilious vomiting Abdominal distension Belching or flatulence 3. Fever
  13. 13. Acute cholecystitis in elderly and old patients is characterized by quickly developing intoxication syndrome
  14. 14. signs • GENERAL  TACHYCARDIA  PYREXIA From MMWR – Aug 2004
  15. 15. • Local  TENDERNESS - RT     HYPOCHONDRIUM RIGIDITY - RT HYPOCHONDRIUM MURPHY’S SIGN BOAS SIGN MASS From MMWR – Aug 2004
  16. 16. murphy’s sign
  17. 17. Boas sign • An area of hyperasthesia between 9th and 11th rib posteriorly right side is a feature
  18. 18. Ortner sign
  19. 19. Kera sign
  20. 20. • Mussi sign • Shotkin blumber sign
  21. 21. Laboratory findings Elevated leukocyte count Elevated serum bilirubin Elevated amylase level
  22. 22. Instrumental investigation • PLAIN X-RAY ABDOMEN Radioopaque gall stone
  23. 23. • ULTRASONOGRAPHY  Dilatation of billiary tree  Stones  Fluid
  24. 24. Common bile duct dialation
  25. 25. Intra hepatic duct dialation
  26. 26. Gall stone
  27. 27. GALL BLADDER RADIONUCLIDE SCAN ORAL CHOLECYSTOGRAM PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP
  28. 28. HIDA SCAN HIDA IS HEPATIC IMINODIACETIC ACID due to edema of cystic duct HIDA Does not enter in gall bladder hence nonvisualization of gall bladder is diagnostic of acute cholecystitis Its imortance lies in diagnostic of acalculous cholecystitis
  29. 29. HIDA SCAN SHOWING NONVISUALIZATION OF GALL BLADDER
  30. 30. ERCP showing mirizzi syndrome
  31. 31. DIFFERENTIAL DIAGNOSIS common     ACUTE PANCREATITIS PERFORATED DUODENAL ULCER PERFORATED PEPTIC ULCER APPENDICITIS
  32. 32. RARE ACUTE PYELONEPHRITIS HEPATITIS MYOCARDIAL INFARCTION PNEUMONITIS
  33. 33. complication • •  • • • • • • EMPYEMA PERFORATION PERITONITIS ABSCESS FISTULA MUCOCELE ACUTE PANCREATITIS GALL STONE ILEUS OBSTRUCTIVE JAUNDICE
  34. 34. Treatment Nonsurgical or preoperative management Intravenous fluids Nasogastric tube Broad spectrum antibiotics
  35. 35. • Naspgastric tube: ryle’s tube admistration immediately continued 3 to 5 days.aspirating HCL decreases the secretion of bile.spasm of bladder may come down intravenous fluid: in the beginning 5 % dexrose saline may be started but subsquently fluid may be changed according to electrolyte balance of paitent Analgesic +anticholinergic given to reduce spasm
  36. 36. Antibiotic broad spectrum to cotrol inflammation.combination of ampicillin+clindamycin+ and aminoglycoside is good.
  37. 37. • Conservative treatment stopped and early cholecystectomy advised 1)pain and tenderness spread across the abdomen 2)gall bladder increases in size 3)Pulse rate continuse to rise 4)In very elderly patient
  38. 38. Surgical Treatment 1.Attack within 48-72 h of diagnosis 2.Deterioration in patient’s general condition 3.Complications are present Perforation Peritonitis Acute obstructive suppurative cholangitis Acute pancreatitis
  39. 39. Surgical methods • Open cholecystectomy • Laparoscopic cholecystectomy
  40. 40. • Two method in cholecystectomy: duct first method: the cystic duct and artery are first dissected and divided fundus first method: in which dissection is started from fundus and gradually proceed toward cystic duct
  41. 41. Operative problems 1)CBD and right hepatic artery injury during the operation of fundus first method 2)Slipped of clip or ligature may lead to profuse bleeding
  42. 42. 3)Biliary leakage from some unknown duct which may lead to syndrome known as waltman-walter syndrome this syndrome is menifested by chest pain or upper abdominal pain,low BP,tachycardia.it mimics coronory thrombosis,pulmonary embolism.this condition is fatal so immediately reexplored the abdomen
  43. 43. Postoperative treatment 1)Drainage is removed after 48 hours or it may be kept for longer period 2)Gastric aspiration and IV fluid is continued until the peristalsis of intestine is come back
  44. 44. THANK U СПAСИБO

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