cholecystitis and other gall bladder disorders 1.pdf

AMANYIRE DICKSON
REG NO. : BMS/7925/163/DU
MBChB V - KIU – WC
SUPERVISOR
DR. MUYINDA ASAD
CARDIOLOGIST 20TH FEBRUARY, 2023

OUTLINE
1. CASE PRESENTATION
2. ANATOMY
3. GENERAL ASPECTS
4. EPIDEMIOLOGY
5. PATHOPHYSIOLOGY & AETIOLOGY
6. CLINICAL FEATURES
7. DIAGNOSIS
8. TREATMENT
9. COMPLICATIONS
10. PRE- & POSTCHOLECYSTECTOMY
SYNDROMES
11. OTHER GALL BLADDER DIOSRDERS
» Steady, severe pain and tenderness in the
right hypochondrium or epigastrium.
» Nausea and vomiting.
» Fever and leukocytosis.
ESSENTIALS FOR DIAGNOSIS
ACUTE CHOLECYSTITIS
12. REFERENCES
13. QUIZ

1. CASE PRESENTATION
Mrs. G.B. is a 38 year old female who presents to the
emergency department with complaints of severe
abdominal pain. G.B reports that she has had
similar pain intermittently over the past week,
however, tonight her pain has become constant and
unbearable.
She reports that the pain usually starts on the right side of her abdomen and radiates
to her back. The pain makes it hard to take deep breaths and often occurs at night after
eating dinner. G.B’s pain prevents her from sleeping and usually lasts several hours. She
reports nausea but no vomiting with her pain tonight, and explains that she has taken
ibuprofen and antacids but neither have helped her symptoms.

1. CASE PRESENTATION (Contd…..)
Past Medical History
Obesity, patient with a BMI of 31, Mother of 2 children, ages 3 and 5 years, Gestational
diabetes with both pregnancies, Hypertension, diagnosed 1 year ago, mild and not
treated with medication at this time, Cesarean section, age 35 and 33
Pertinent Family-Social History
Mother with a history of obesity, hypertension, and gallstones, alive age 70, Brother with
a history of obesity, alive age 41. Sister alive and healthy age 36. Does IT assistance for a
local hospital, where she has worked for 10 years. Patient’s hobbies include reading,
knitting, and baking. Patient reports difficulty with attempts at weight loss, prefers
to not go to the gym or be seen working out in public environment.

1. CASE PRESENTATION (Contd…..)
Physical Exam
HR: 106, RR: 16, BP: 148/95, Temp: 38.1° c. G.B.
appears uncomfortable and is sweating. G.B. reports it
feels better for her to lie in bed and not move. When
G.B. is assessed, the right side of her abdomen below
her rib cage is palpated during inspiration.
She reports increased pain to the point that she gently pushes the examiner’s hands away.
Laboratory Findings
Abnormal Laboratory Values
WBC – 15.4
CRP – 18.3
Normal Laboratory Values
Hgb, Hct, Platelets, AST, ALT, ALP, GGT
Amylase, Lipase, serum HCG – not present

CHOLECYSTITIS
 Inflammation of the gallbladder wall
 Cholecystitis is associated with gallstones [cholelithiasis] in
over 90% of cases
 Acalculous cholecystitis is also not uncommon
3. GENERAL ASPECTS

3. GENERAL ASPECTS (Contd….)
 Acute vs Chronic cholecystitis
 Calculous vs Acaluculous cholecystitis
CLASSIFICATION OF CHOLECYSTITIS

 Usually follows obstruction of the cystic duct by a stone.
 Inflammatory response can be evoked by three factors
1. Mechanical inflammation
2. Chemical inflammation
3. Bacterial inflammation,
• May play a role in 50–85% of patients with acute cholecystitis.
Acute Cholecystitis

 In 5–10% of patients with acute cholecystitis.
 In >50% of such cases, underlying explanation is not found.
 Increased risk for developing acalculous cholecystitis in with
• Prolonged fasting,
• Serious trauma or burns,
• The postpartum period following prolonged labor, and
• Orthopedic and other non-biliary major surgical
Acalculous Cholecystitis

 Chronic inflammation of the gallbladder wall is almost always
associated with the presence of gallstones and
 Thought to result from repeated bouts of subacute or acute
cholecystitis or from persistent mechanical irritation of the
gallbladder wall by gallstones.
 The presence of bacteria in the bile occurs in >25% of patients
with chronic cholecystitis.
Chronic Cholecystitis

4. EPIDEMIOLOGY
 Gallstone disease is the most common cause of biliary
obstruction.
 Women are much more likely to develop gallstones than men.
 Gallbladder cancer is also more common in females than in
males.
‘5Fs’ mnemonic
 Is a reminder to students that patients with upper abdominal
pain and who conform to a profile of 'fair, fat, female, fertile
and forty' are likely to have cholelithiasis.

5. PATHOPHYSIOLOGY & AETIOLOGY
CALCULOUS CHOLECYSTITIS
Cholecystitis is associated with gallstones in over 90% of cases.
Gallstones are divided into two major types:
Cholesterol stones Pigment stones
- Composed 1o of Ca- bilirubinate
- They contain <20% cholesterol
- Classified into “black” and
“brown” types
- Account for > 90% of all gallstones in
Western industrialized countries.
- Usually contain >50% cholesterol
monohydrate + an admixture of Ca salts,
bile pigments, proteins, & fatty acids

5. PATHOPHYSIOLOGY & AETIOLOGY (Contd…)
PREDISPOSING FACTORS FOR GALLSTONE FORMATION
1. CHOLESTEROL GALLSTONE FORMATION
CHOLELITHIASIS

PREDISPOSING FACTORS FOR GALLSTONE FORMATION
2. PIGMENT GALLSTONE FORMATION
CHOLELITHIASIS

ACALCULOUS CHOLECYSTITIS
Should be considered when;
 Unexplained fever or right upper quadrant pain occurs within 2–4 weeks
of major surgery or in a critically ill patient who has had no oral intake
for a prolonged period;
 Multi-organ failure is often present.
 Acute cholecystitis may also be caused by
 Infectious agents eg, cytomegalovirus, cryptosporidiosis, microsporidiosis in patients with AIDS
 Vasculitis eg, polyarteritis nodosa, Henoch-Schönlein purpura.

6. CLINICAL FEATURES
 Biliary colic - most specific and x-tic symptom of gallstone disease
The resultant visceral pain is;
 X-tically severe steady [constant] ache or fullness in epigastrium/RUQ of abd
 Often long-lasting pain
 May persist with severe intensity for 30 min to 5 h, subsiding gradually or rapidly
 Frequent radiation to the interscapular area, right scapula, or shoulder.
 May be precipitated by
 Eating a fatty meal,
 A large meal following a period of prolonged fasting, or by eating a normal meal;
 Frequently nocturnal, occurring within a few hours of retiring.
 Nausea and vomiting, Fever or chills (rigors), Jaundice

6. CLINICAL FEATURES (Contd…..)
Physical examination findings
 Right upper quadrant abdominal tenderness
 Is almost always present, often with a Murphy sign
 Is usually associated with muscle guarding and rebound
tenderness.
 A palpable gallbladder is present in about 15% of cases.
 However, a painless palpable gall bladder in a jaundiced patient
is highly suggestive of malignant obstruction. (Courvoisier law).

7. DIAGNOSIS
ADEQUATE INTERVIEW
PHYSICAL EXAMINATION
INVESTIGATIONS

Laboratory Findings
 Leucocytosis
 Bilirubinemia even in absence of bile duct obstruction
may be seen
 Serum aminotransferase and alkaline phosphatase often
elevated
 Serum amylase may also be moderately elevated.
7. DIAGNOSIS (Contd…)

Imaging
 Plain abdominal films of the may show radiopaque gallstones in 15% of
cases.
 99mTc hepatobiliary imaging also known as the hepatic iminodiacetic
acid
 Demonstrates an obstructed cystic duct, which is the cause of acute cholecystitis
in most patients.
 CT may show complications of acute cholecystitis, such as perforation
or gangrene

Imaging (Contd….)
RUQ abdominal USS often performed first,
 May show gallstones (67% sensitivity, 82% specificity in acute
cholecystitis
 Findings suggestive of acute cholecystitis are;
 gallbladder wall thickening,
 pericholecystic fluid,
 A sonographic Murphy sign.

ULTRASOUND
• Cholelithiasis
ERCP
• Normal biliary tract
ERC
• Choledocholithiasis
ERCP
• Scleroing cholangitis
Examples of ultrasound and radiologic studies of the biliary tract.

 Perforated peptic ulcer,
 Acute pancreatitis,
 Appendicitis in a high-lying
appendix,
 Perforated colonic carcinoma
 Diverticulum of the hepatic flexure,
 Liver abscess, hepatitis,
 Pneumonia with pleurisy on the
right side,
 Myocardial ischemia.
Differential diagnosis
The disorders most likely to be confused with acute cholecystitis are;

8. TREATMENT
Surgical Therapy
A recommendation for cholecystectomy based on:
1. the presence of symptoms that are frequent enough or severe enough
to interfere with the patient’s general routine;
2. The presence of a prior complication of gallstone disease.
3. The presence of an underlying condition predisposing the patient to
increased risk of gallstone complications.

8. TREATMENT (Contd….)
Surgical Therapy (Contd….)
 Very large gallstones (>3 cm in diameter) and harboring gallstones in
a congenitally anomalous gallbladder might also be considered for
prophylactic cholecystectomy.
 Urgent (emergency) cholecystectomy or cholecystostomy is probably
appropriate when a complication of acute cholecystitis such as
perforation is suspected or confirmed
 Early elective cholecystectomy ideally within 48–72 h after diagnosis in
uncomplicated acute cholecystitis should undergo,.

Medical therapy : Gallstone dissolution & supportive RX
 In carefully selected patients with a functioning gallbladder and with
radiolucent stones <10 mm in diameter, complete dissolution can be
achieved in ~50% of patients within 6 months to 2 years.
 The dose of UDCA should be 10–15 mg/kg per day.
 Pigment stones are not responsive to UDCA therapy.
 Patients with cholesterol gallstone disease who develop recurrent
choledocholithiasis after cholecystectomy should be on long-term
treatment with UDCA

Medical Therapy….(Contd…)
 Oral intake is eliminated, nasogastric suction & intravenous
alimentation may be indicated,
 DeH2O and electrolyte abnormalities are repaired.
 Analgesia.
 Meperidine or NSAIDs e.g. ketoralac , or opioids, such as morphine
and hydromorphone.
 Intravenous antibiotic therapy is usually indicated.
 Effective antibiotics include piperacillin plus tazobactam,
ceftriaxone plus metronidazole, levofloxacin plus metronidazole.

9. COMPLICATIONS
A. GANGRENE AND PERFORATION
B. EMPHYSEMATOUS CHOLECYSTITIS
C. EMPYEMA AND HYDROPS
D. FISTULA FORMATION AND GALLSTONE
ILEUS
E. LIMEY (MILK OF CALCIUM) BILE AND
PORCELAIN GALLBLADDER
F. “STRAWBERRY GALLBLADDER,”
CHOLESTEROLOSIS
G. ADENOMYOMATOSIS
H. MIRIZZI SYNDROME
I. XANTHOGRANULOMATOUS
CHOLECYSTITIS
J. CARCINOMA OF THE GALLBLADDER
K. PANCREATITIS

Postcholecystectomy Complications
 Early complications following cholecystectomy include
 Atelectasis and other pulmonary disorders,
 Abscess formation (often subphrenic),
 External or internal hemorrhage,
 Biliary-enteric fistula, and bile leaks.
 Jaundice
 may indicate absorption of bile from an intraabdominal collection
following a biliary leak or mechanical obstruction of the CBD by retained
calculi, intraductal blood clots, or extrinsic compression.
9. COMPLICATIONS (Contd….)

Postcholecystectomy Complications (Contd….)
 Most common cause of persistent postcholecystectomy symptoms is
an overlooked symptomatic non-biliary disorder e.g.,
 Reflux esophagitis
 Peptic ulceration,
 Pancreatitis, or most often IBS.
9. COMPLICATIONS (Contd….)

PRE-CHOLECYSTECTOMY SYNDROMES
 In a small group of patients (mostly women) with biliary pain,
conventional radiographic studies of the upper gastrointestinal tract and
gallbladder—including cholangiography—are unremarkable.
 Emptying of the gallbladder may be markedly reduced on gallbladder
scintigraphy following injection of cholecystokinin; Cholecystectomy may
be curative in such cases.
 Histologic examntion of the resected gallbladder may show chronic
cholecystitis or microlithiasis.
10. PRE- & POSTCHOLECYSTECTOMY SYNDROMES

POSTCHOLECYSTECTOMY SYNDROMES
In a small percentage of patients, a disorder of the extra-hepatic
bile ducts may result in persistent symptomatology. These so-
called post-cholecystectomy syndromes may be due to
 Biliary strictures,
 Retained biliary calculi,
 Cystic duct stump syndrome,
 Stenosis or dyskinesia of the SOD,
 Bile salt–induced diarrhea or
Gastritis.
10. PRE- & POSTCHOLECYSTECTOMY SYNDROMES (Contd….)

 The overall mortality rate of cholecystectomy is less than 0.2%
 Hepatobiliary tract surgery is a more formidable procedure in
older patients, in whom mortality rates are higher;
 Mortality rates are also higher in persons with diabetes
mellitus and cirrhosis.
 A successful surgical procedure in an appropriately selected
patient is reults in complete resolution of symptoms.
11. PROGNOSIS

11. PROGNOSIS (Contd….)
 Sixty to 80% of persons with asymptomatic gallstones remain
asymptomatic over follow-up periods of up to 25 years.
 The probability of developing symptoms within 5 years after diagnosis is
2–4% per year and decreases in the years thereafter to 1–2%.
 In diabetic patients with silent gallstones, the cumulative risk of death
due to gallstone disease while on expectant management is small, and
Prophylactic cholecystectomy is not warranted.

 Complications requiring cholecystectomy are much more common
in gallstone patients who have developed symptoms of biliary pain.
 Patients found to have gallstones at a young age are more likely to
develop symptoms from cholelithiasis than are patients >60 years
at the time of initial diagnosis.

When to Refer or Admit Patients
 When to Admit: All patients with acute cholecystitis should
be hospitalized.
 Patients with sphincter of Oddi dysfunction should be
referred for diagnostic procedures

Anomalies of the biliary tract are not uncommon
Abnormalities in number, size, and shape include;
CONGENITAL ANOMALIES
 Agenesis of the gallbladder,
 Duplications,
 Rudimentary or oversized
“giant” gallbladders, and
diverticula). body.
 Left-sided gallbladder,
 Intrahepatic gallbladder,
 Retrodisplacement of the GB
 “Floating” gallbladder.
Anomalies of position or suspension are not uncommon and include;
The latter condition predisposes to acute torsion, volvulus, or herniation
of the gallbladder.

Multiple Gallbladders Intrahepatic Gall bladder
CONGENITAL ANOMALIES (Contd….)

Disordered motility of the gallbladder can produce recurrent biliary pain in
patients without gallstones.
The surgical findings have included abnormalities such as chronic
cholecystitis, gallbladder muscle hypertrophy, and/or a markedly
narrowed cystic duct.
The following criteria can be used to identify patients with acalculous
cholecystopathy:
(1)Recurrent episodes of typical RUQ pain characteristic of biliary tract
pain,
(2) Abnormal CCK cholescintigraphy demonstrating a gallbladder
ejection fraction of <40%, and
(3) Infusion of CCK reproducing the patient’s pain.
ACALCULOUS CHOLECYSTOPATHY

A group of disorders of the gallbladder characterized by excessive
proliferation of normal tissue components.
Adenomyomatosis: x-terized by a benign proliferation of gallbladder surface
epithelium with gland-like formations, extramural sinuses, transverse
strictures, and/or fundal nodule (“adenoma” or “adenomyoma”) formation.
Cholesterolosis: x-terized by abnormal deposition of lipid, especially
cholesteryl esters, within macrophages in the lamina propria of the
gallbladder wall.
Polyps: Types of gallbladder polyps include cholesterol polyps,
adenomyomas, inflammatory polyps, and adenomas (rare).
THE HYPERPLASTIC CHOLECYSTOSES

 Occurs in approximately 2% of all people operated on for biliary tract
disease; 5th most common GI malignancy
 The course is usually one of rapid deterioration, with death occurring
within a few months.
CARCINOMA OF THE GALLBLADDER
Risk factors
 Cholelithiasis.
 Chronic gallbladder infection with Salmonella typhi,
 Adenomatous gallbladder polyps over 1 cm in diameter
 Mucosal calcification of the gallbladder (porcelain gallbladder),
 anomalous pancreaticobiliary ductal junction,
 High parity in women,
 aflatoxin exposure

Signs & Symptoms
 Progressive obstructive jaundice in advance disease.
 Pain in the RUQ with radiation into the back
 Anorexia and weight loss are common.
 Rarely, hematemesis or melena
 Fistula formation
Physical examination reveals
 Features of obstructive jaundice
 Courvoisier sign
 Hepatomegaly associated with liver tenderness.
 Ascites may occur with peritoneal implants.
 In young and fit patients, curative surgery for gallbladder carcinoma may be
attempted if the cancer is well localized.
CARCINOMA OF THE GALLBLADDER (Contd….)

Porcelain Gallbladder
CARCINOMA OF THE GALLBLADDER (Contd….)

13. REFERENCES
 Zhu, A. X., Hong, T. S., Hezel, A. F., & Kooby, D. A. (2010). Current management of gallbladder carcinoma.
Oncologist, 15(2), 168-181. https://doi.org/10.1634/theoncologist.2009-0302
 Netter, F. H. (2014). Atlas of human anatomy. Elsevier health sciences.
 Jennifer Lynn, B., & Peter F, E. (2019, Oct 16, 2019 ). Biliary obstruction. Medscape. Retrieved Jan 10, 2023
from https://emedicine.medscape.com/article/187001-overview#a6
 Papadakis, M., & Mc Phee, S. J. (2022). Carcinoma of the biliary tract. In Current medical diagnosis and
treatment (61 ed., pp. 1632-1634). USA: Mc Graw Hill.
 Bass, G., Gilani, S. N., & Walsh, T. N. (2013). Validating the 5fs mnemonic for cholelithiasis: Time to include
family history. Postgrad Med J, 89(1057), 638-641. https://doi.org/10.1136/postgradmedj-2012-131341
 Jameson, J. L., et al. (2018). Diseases of the gallbladder and bile ducts. In Harrison's principles of internal
medicine (20th ed., Vol. 1, pp. 2422-2430). McGraw-Hill Education.
 Brannen, E., Delaney, T., Pace, M., & Pingrey, C. (2019). Cholecystitis case study. THE OHIO STATE
UNIVERSITY. Retrieved 18 Feb, 2023 from https://u.osu.edu/cholecystitiscasestudyautum2019/patient-
case-presentation/

1.Which best describes the role of the gallbladder?
A. Similar to the appendix, the gallbladder has little known physiologic function. Because of this, it can be removed
without any consequence to the patient.
B. The gallbladder synthesizes bile. It also stores and secretes bile, a yellow-green substance needed to digest lipids.
C. The gallbladder makes cholecystokinin (CCK). CCK stimulates the Vagus nerve and facilitates movement of bile
through the intestines.
D. The gallbladder stores, concentrates, and secretes bile. Its structure allows for easy absorption of fluid and
electrolytes, leaving behind highly concentrated bile that is needed for fat digestion.
2. Which of the following is NOT considered a differential diagnosis for acute cholecystitis?
A. Acute pancreatitis B. Irritable bowel syndrome C. Peptic ulcer disease D. Appendicitis
3. Symptoms of gallbladder disease often resemble those of other GI diseases. Which group of
symptoms suggest cholecystitis?
A. Pain in the right lower quadrant, leukocytosis, low-grade fever
B. Pain in the right upper quadrant, low-grade fever, bloody stools
C. Pain in the right upper quadrant that radiates to the right shoulder or back, positive Murphy’s sign, bloody stools
D. Pain in the right upper quadrant that radiates to the right shoulder or back, positive Murphy’s sign, low-grade fever
14. QUIZ

4. G.B. is concerned about the need for additional medical workup. She asks, “Why do I need to have a
CT scan. Is there not a simple blood test that could confirm my diagnosis?” What is the most
appropriate way to respond to Mrs. G.B.’s question?
A. Blood tests are not appropriate in this situation given your symptoms.
B. Yes, that is a great suggestion. Thank you for being an advocate for yourself!
C. While some blood tests may be able to help with diagnosis, there is not a definitive blood test for
detecting cholecystitis. Imaging provided by a CT will enable a more accurate diagnosis because the
medical team can evaluate for the presence of gallbladder inflammation and stones which can help
differentiate from other possible causes of your symptoms.
D. We must do a CT scan, HIDA scan, and blood work to confirm your diagnosis.
5. G.B.’s family history reflects a maternal history of gallbladder disease. True or false: family history is
the ONLY risk factor for cholecystitis seen in G.B.’s case.
A. True, family history appears to be the only indication for G.B.’s condition.
B. False, she presents with additional risk factors for cholecystitis
12. QUIZ (Contd….)

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