This document summarizes cholecystitis, or inflammation of the gallbladder. It discusses the various causes of cholecystitis including gallstones, tumors, infections, and decreased blood flow. It also outlines the different types of cholecystitis, symptoms, diagnosis, treatment options including conservative management, surgery, and percutaneous drainage procedures. Key points covered include the signs and symptoms of acute vs chronic cholecystitis, investigations like ultrasound and HIDA scan, indications for early cholecystectomy, and endoscopic and surgical treatment approaches.

1. CHOLECYSTITIS
SATURDAY SURGICAL UNIT
PRESENTATION BY DR.PHANEENDRA
HOU-DR.RAM SIR
AP-DR.DMP SIR

2.  Inflammation of gallbladder
 Most commonly associated with gallstones

3. CAUSES
 Gallstones
 Tumours
 Chemical irritants
 Bile duct block due to kinking or scarring
 Infections- viral or bacterial
 Decreased blood flow to the GB due any
severe illness

4. TYPES
ACALCULUS
 Without evidence of gallstone
or cystic duct obstuction
 Cholesterosis (strawberry GB)
 Cholesterol
polyposis(pseudopolyps)
 Cholecystitis glandularis
proliferans
 GB diverticulosis
 Bacterial invasion
 Pancreatic reflux
 Typhoid of GB
CALCULUS
 With evidence of
gallstones 80% are of
cholesterol type.

5.  Acalculous cholecystitis is common in chronically icu admitted
patients
 Conditions and management leading to cholestasis
 Prolonged NBM
 Prolonged fasting
 Patients on prolonged TPN

6. Cholesterol laden macrophages aggregation in
mucosa (strawberry gall bladder)
Cholesterol polyps of GB

7. Emphysematous cholecystitis
Emphysematous cholecystitis(clostridial cholecystitis)
Acute infection caused by gas forming
Surgical emergency

8. Cholecystitis glandularis proliferans
 Circumscribed diffuse thickening of wall of chronically inflamed GB
 Excessive proliferation and invasion of wall by epithelium
 Formation of crypts(Rokitansky aschoff sinuses) which dilate to form cysts may
be referred as adenomatous polyp, cystadenoma, cholesterol cyst papilloma,
 Adenomyoma

9. GB Diverticulosis

10. Bacteria causing cholecystitis
 E-coli
 Klebsiella
 S.fecalis
 Salmonella
 Clostridia anaerobes (clostridium welchii) causes
emphysematous cholecystitis

11. ACUTE
 Sudden inflammation of GB causing
marked abdominal pain often with nausea
vomiting and fever

12. CHRONIC
 Low intensity inflammation of GB that lasts a
long time
 May be caused by repeated attacks of
cholecystitis
 Symptoms include only mild intermittent
abdominal pain or no symptoms at all
 Damage to the walls of GB leads to thickened and
scarred GB which ultimately shrink and looses the
ability to store and release bile

13. PATHOGENESIS
 Gallstone obstruct the bile flow
 Irritation and raised pressure of GB due to build
up of bile
 Inflammation and distension of GB causing
oedema of GB (bacterial and chemical)
 Blood flow compromise causing cholecystitis

14. CLINICAL MANIFESTATIONS
 Severe pain in right upper quadrant
 Spreading to right shoulder or back
 Nausea
 Vomiting
 Fever
 Jaundice and clay coloured stool may occur if
CBD gets blocked

15. CLINICAL SIGNS

16. CLINICAL SIGNS

17. Staging based on morphology
 Catarrhal- Involving only mucosa
 Phlegmonous- Inflamation penetrating deeper layers
 Gangrenous
 Gangrenous perforation

18. COMPLICATED CHOLECYSTITIS
 Empyema
 Mucocele
 Pancreatitis
 Icterus
 Hepatitis
 Cholangitis
 Peritonitis

19. COMPLICATIONS OF ACUTE CALCULOUS
CHOLECYSTITIS
 Perforation
 Usually in the fundus or in neck causing peritonitis
 Can cause cholecystoduodenal, cholecystointestinal or
 Cholecystobiliary fistula
 Pericholecystic abscess
 Fistula
 Gall stone ileus (Riggler’s triad)
 Gall stone pancreatitis
 Obstruction of cbd
 Empyema GB
 Ascending cholangitis
 Septicemia
 Emphysematous GB
 Gangrenous GB

20. TOKYO GUIDELINES

21. DIAGNOSIS AND EVALUATION
 USG-highlights any gallstones and may show the
condition of the GB
 BLOOD INVESTIGATIONS- high wbc count: raised crp
and esr indicates inflamation
 LFT- raised bilurubin
 Raised s-amylase
 CT SCAN- may reveal signs of cholecystitis
 Hepatobiliary iminodiacetic acid scan (HIDA)- creates
pictures of liver GB biliary tract and small intestine: The
HIDA scan should be done when usg is not
diagnostic and when there is clinical signs of acute
cholecystitis

22.  Per cutaneous Transhepatic Cholecystography (PTC)
 ERCP
 MRCP

23. USG
 Sensitive 85% specificity 95%
 Inexpensive and reliable
 What to look for in usg….?
 GallStone
 Pericholecystic fluid (exudative in acute cholecystitis)
 GB wall thickening
 Sonographic murphy’s sign

24. HIDA SCAN

25.  Non visualisation of GB on HIDA scan with in 1 hour along with
clinical signs is diagnostic of acute cholecystitis (without clinical
signs-cystic duct obstruction)
 Non visualisation of intestine points towards cbd obstruction
 Its importance lies in diagnosing acalculos cholecystitis

26. DIFFERENTIAL DIAGNOSIS
Common
 Acute pancreatitis
 Perforated duodenal/gastric
peptic ulcer
 Appendicitis
Rare
 Pyelonephritis
 Hepatitis
 MI
 Pneumonitis

27. Treatment (conservative approach)
 NBM: To rest the GB
 Ryle’s tube insertion and aspiration of gastric acid
decreases the secretion of bile and spasm of bladder may
come down
 Fat free diet
 Antibiotics to treat infection
 Analgesics

28. Indications for stopping conservative
management and early cholecystectomy
 Pain and tenderness dot decreasing and spreading
 Incresing gb size
 Increasing pulse
 Geriatric patient
 Another attack with in 48-72 hours of diagnosis

29. SURGICAL APPROACH
 ERCP WITH STONE REMOVAL/STENTING
 EMERGENCY CHOLECYSTECTOMY
 INTERVAL CHOLECYSTECTOMY LAPAROSCOPIC
SOS OPEN
 PERCUTANEOUS CHOLECYSTOSTOMY
 OPEN CHOLECYSTOSTOMY
 ENDOSCOPIC US GUIDED
CHOLECYSTODUODENOSTOMY

30. INDICATIONS OF EMERGENCY
CHOLECYSTECTOMY
 Empyema GB- High grade fever with chills, leucocytosis
 Signs of local complications- PeriGB collection, Sub hepatic local
collection
 Failure of medical management
 Emphysematous cholecystitis
 Perforation
 Peritonitis
 Acute pancreatitis
 Obstructive suppurative cholangitis

31. Indications for percutaneous drainage
 Seldom a first line mx
 Patients too ill to tolerate alternate procedures
 Poor surgical candidates
 Unexplained sepsis in terminally ill patients
 Access to or drainage of biliary tree following failed ercp

32. Percutaneous cholecystostomy
 Schematic representation
 Fluoroscopy image

33.  Relatively less complications and less painful
 Indicated in patients where even
percutaneous cholecystostomy is not
suitable
 Endoscopic ultrasound guided
cholecystoduodenostomy

34. THANK YOU