Acute and chronic lithiatic and non lithiatic cholecystitis by Mohammad Mujib Munir Zai 4th year surgical residency program Kabul afghanistan

1. Acute & Chronic Lithiatic
And Non Lithiatic
Cholecystitis
By:Moh.Mujib Munirzai
Amiri Medical Complex
Date:19/11/2016

2. ACUTE CHOLECYSTITIS
• Acute cholecystitis is inflammation of the
gallbladder that develops over hours, usually
because a gallstone obstructs the cystic duct.
• Most patients have had prior attacks of biliary
colic or acute cholecystitis.
• Pain lasts longer (i.e. >6hr) than in biliary
colic and more severe.
• Acute cholecystitis begins to subside in 2 to 3
days and resolves within 1 week in 85% of
patients.

3. Pathogenesis
• Obstruction of the cysticduct
• Brief impaction may cause pain only
• Inflammationthe gallbladder
– Enlarged
– Tense
– Reddened
– Wallthickening
– Exudate of peri-cholecystic fluid

4. • BACTERIA
– E.coli
– Enterococci
– Anerobes(bacteriods)
– klebsilla
• The wall of the gallbladder may undergo
necrosis and gangrene (gangrenous
cholecystitis).
• Bacterial super-infection with gas-forming
organisms may lead to gas in the wall or
lumen of the gallbladder(emphysematous
cholecystitis).

8. Diagnosis
• Clinical findings
• The main symptom of uncomplicated
– biliarycolic
– caused by the obstruction of the gallbladder neck bya stone.
• The pain is characteristically
• Episodic
• Severe
• Located in the epigastrium or RUQ.
• Radiates into the back
– It frequentlyfollows after
• food intake or comes on at night.
• Accompanied by nauseaand vomiting.

9. Diagnosis
• Physical Exam:
• Murphy's sign
– The arrest of inspirationwhile palpating the gallbladder
during a deep breath.
• Palpable gallbladder because of fibroses,
empyema and hydrops GB

10. Diagnosis
• B. Laboratory finding
• Leukocytosis or normal WBC
• Serum bilirubin mildly high
• Alkalinphosphatas mildly high
• Amylase high
• C. Imaging studies
– Plain X-ray in 15% calcium stones
– Ultrasound studies is very sensitive and shows: stones, sludge,
wall thickness, perigalbladder collection, subhepatic collections
– Ultrasound Murphy sign will be positive

11. USG
• Sensitive
• Inexpensive
• Reliable
» Sensitivity 85% and Specificity 95%
What will you look in USG?
1.GallStone
2.Pericholecystic fluid
3.GB wall thickening
4.Sonographic murphy’s sign

12. Ultrasound Pictures

13. Differential diagnosis
• Acute peptic ulcer with or without
perforation, by radiography abdomen with
pneumopritoneum
• Acute appendicitis specially in subhepatic
location by scan, ultrasound
• Acute pancreatitis by lipase, CT Scan

14. Complications
1. empyema( supporative cholecystitis)
Thick wall GB, fever, toxication,
chills, WBC
Treatment: urgent
cholecystectomy or
cholecystostomy

15. 2. perforation
a. Pericholecystic abscess: is common, palpable mass,
toxication, fever, WBC . Treats by cholecystectomy in
poor condition subcutaneous cholecystostomy.
b. Free perforation: occurs in1-2% in early gangrene
before adhesion formation and in rupture of localized
abscess with sudden pain.
3. Cholecystoenteric fistula: with stomach, duodenum,
colon adherent and necrosis and then fistula formation,
gallstone ileus, malabsorption and steatorhea. In most
cases fistula has no significant symptoms and clinic.
Gangrene and
perforation

16. 3 main things to take therapeutic
decision:
I. Diagnosis is established
II. Susceptible general condition by
coexistent diseases
III. Sigs of local complications of acute
cholecystitis

17. Emergency cholecystectomy perform
in:
 Empyema gallbladder: high fever, leukocytosis, chills
 Nonlithiatic cholecystitis
 Signs of local complications of acute cholecystitis:
subhepatic local collection, perigalbladder collection,
sludge bile
 Free perforation: sudden abdominal pain on the period of
acute cholecystitis
 All patients needs urgent cholecystectomy, but in poor
condition patients percutaneous cholecystostomy
advised

18. Management of Acute Cholecystitis
1. NPO
2. RYLES TUBE ASPIRATE
3. IV Fluids
4.BROAD SPECTRUM ANTIBIOTICS
5.IV ANALGESICS
6. OBSERVATION

19. Surgery in a/c Cholecystitis
When presents within 2 to 3 days LAP CHOLECYSTECTOMY
When presents more than 3 days INTERVAL CHOLECYSTECTOMY
after 6 weeks
Empyema, Persisting and Progressing Symptoms EMERGENCY
CHOLECYSTECTOMY

20. Acute acalculous cholecystitis
• 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
• Emergent operation is needed

21. Chronic Cholecystitis
• Long-standing gallbladder inflammation almost
always due to gallstones.
• Chronically Inflammed Thickened Gallbladder
which is NONFunctioning NONdistending
• Extensive calcification due to fibrosis is called
porcelain gallbladder.

28. Complications
• CBD Stones
• Cholangitis
• Pancreatitis
• Mirizzi’s Syndrome

29. Treatment of Chronic Cholecystitis is
CHOLECYSTECTOMY

30. summary
Cholecystectomy is preferable method for
treatment of acute cholecystitis
In poor condition patients percutaneous
cholecystostomy advised
Just evacuation of bile is enough not
stones
Post improving of general condition
cholecystectomy should be done

31. THANKS FROM YOUR PATIANCE