Based on the limited information provided, this case is most consistent with acute cholangitis. The classic triad of right upper quadrant pain, jaundice, and fever is seen in about 70% of cases of acute cholangitis. Further workup would be needed to identify the underlying cause, such as gallstones in the common bile duct or a stricture. Treatment would involve antibiotics and consideration of ERCP for drainage or stenting.

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 CENTRE
HON SURGEON GODREJ MEMORIAL HOSPITAL
HON. ASS PROF GRANT MED. COLLEGE
HON.SURGEON JJ. HOSPITAL
EX-ASST. PROF L.T.M.GEN. HOSPITAL

2. ANATOMY OF GIT
FOREGUT
MIDGUT
HINDGUT
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

3. PATHOPHYSIOLOGY
OBSTRUCTION
STASIS
DISTENTION
INCREASE IN INTRALUMINAL PRESSURE
STIMULATION OF INFLAMATORY
MEDIATORS
COMMENSALS BECOME VIRULENT
INFECTION
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

5. DEFINITION
Inflammation of gall bladder is
called
ACUTE CHOLECYSTITIS .
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

6. CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

7. CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

8. INCIDENCE
COMMON IN FERTILE
FATTY
ABOVE FORTY
FEMALES
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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 bladder
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

10. BACTERIAL INFECTION
E-coli
Klebsiella
S.faecalis
Salmonella
Clostridia Anaerobes
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

11. SEVERE ILLNESS
Ileus
Sepsis
Severe burns/injuries
Starvation
Multiple blood transfusions
CARCINOMA
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

12. PATHOLOGY
INFLAMMATION
LOCALIZATION
• Ileus
• Movement of omentum
• Loops of intestine
RESOLUTION
EMPYEMA
MUCOCELE
PERFORATION
 GENERALIZED PERITONITIS
LOCAL ABSCESS
FISTULA
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

13. CLINICAL FEATURES
PAIN
SITE - RIGHT HYPOCHONDRIUM
TYPE - COLICKY
ONSET – SUDDEN
DURATION – MORE THAN 12 hrs
RADIATION
 BACK
 SHOULDER
 RIGHT HYPOCHONDRIUM
 LEFT HYPOCHONDRIUM
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

14. PRECIPITATING FACTORS
 Fatty Food
 Movement
 Breathing
RELIEVING FACTORS
 Analgesics
FEVER
NAUSEA/VOMITING
DISTENTION/CONSTIPATION
JAUNDICE
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

15. SIGNS
GENERAL
 TACHYCARDIA
 PYREXIA
LOCAL
TENDERNESS - RT HYPOCHONDRIUM
RIGIDITY - RT HYPOCHONDRIUM
MURPHY’S SIGN
MASS
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

16. INVESTIGATIONS
BLOOD COMPLETE PICTURE
 LEUCOCYTOSIS
URINE
 BILIRUBIN
PLAIN X-RAY ABDOMEN
 Radioopaque gall stones
ULTRASONOGRAPHY
 Dilatation of billiary tree
 Stones
 Fluid
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

18. ABDOMINAL ULTRASOUND SHOWING GALL DILIP S.RAJPAL
CONSULTANT GEN. SURGEON DR
STONES
LAPROSCOPIST & COLOPROCTOLOGIST

19. DIFFERENTIAL DIAGNOSIS
COMMON
 ACUTE PANCREATITIS
 PERFORATED DUODENAL ULCER
 PERFORATED PEPTIC ULCER
 APPENDICITIS
RARE
ACUTE PYELONEPHRITIS
HEPATITIS
MYOCARDIAL INFARCTION
PNEUMONITIS
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

20. COMPLICATIONS
EMPYEMA
PERFORATION
 PERITONITIS
ABSCESS
FISTULA
MUCOCELE
ACUTE PANCREATITIS
GALL STONE ILEUS
OBSTRUCTIVE JAUNDICE
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

21. Definitions
Symptomatic Wax/waning postprandial epigastric/RUQ
cholelithiasis pain due to transient cystic duct
obstruction by stone, no fever/WBC,
normal LFT
Acute Acute GB inflammation due to cystic duct
cholecystitis obstruction. Persistent RUQ pain +/-
fever, ↑WBC, ↑LFT, +Murphy’s =
inspiratory arrest
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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 shock
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

24. Case 1
→ denotes
gallstones
→
→ ► denotes the
acoustic
shadow due to
► absence of
reflected sound
waves behind
the gallstone
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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
cholecystectomy
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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 resolve
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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
cholecystectomy
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

30. Case 3
Curved arrow
– Two small stones
at GB neck
◄
Straight arrow
– Thickened GB wall
◄
– pericholecystic fluid
= dark lining
outside the wall
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

31. Case 3
→ denotes the
→ GB wall
► thickening
► denotes the
fluid around the
GB
GB also appears
distended
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

32. Acute calculous cholecystitis
Persistent cystic duct obstruction leads to
GB distension, wall inflammation &edema
Can lead to:empyema, gangrene, rupture
Pain usu. persists >24hrs & a/w
N/V/Fever
Palpable/tender or even visible RUQ mass
Nuclear HIDA scan shows nonfiling of GB
– If U/S non-diagnostic, obtain HIDA
Tx: NPO, IVF, Abx (GNR & enterococcus)
Sg: Cholecystectomy usu within 48hrs
DR DILIP S.RAJPAL

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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 & COLOPROCTOLOGIST
CONSULTANT GEN. SURGEON
LAPROSCOPIST
DR DILIP S.RAJPAL

35. Complications of acute cholecystitis
Empyema of Pus-filled GB due to bacterial
gallbladder proliferation in obstructed GB. Usu.
more toxic, high fever
Emphysematous More commonly in men and diabetics.
cholecystitis Severe RUQ pain, generalized sepsis.
Imaging shows air in GB wall or lumen
Perforated Occurs in 10% of acute chol’y, usually
gallbladder 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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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 ERCP
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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 laparotomy
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

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.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST

41. Gallstone pancreatitis
35% of acute pancr 2ndary to stones
Pathophysiology
– Reflux of bile into pancreatic duct and/or
obstruction of ampulla by stone
ALT > 150 (3-fold elevation) has 95%
PPV for diagnosing gallstone pancreatitis
Tx: ABC, resuscitate, NPO/IVF, analgesic
Once pancreatitis resolving, ERCP w
stone extraction/sphincterotomy
Cholecystectomy before hosp discharge

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 early
CONSULTANT GEN. SURGEON DR DILIP S.RAJPAL
LAPROSCOPIST & COLOPROCTOLOGIST