calculus, cholecystitis, gallbladder stone, jaundice,

1. DR BASHIR YUNUS
GENERAL SURGERY UNIT
PRESENTATION
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2. • INTRODUCTION
• DEFINITION
• EPIDEMIOLOGY
• RELEVANT ANATOMY
• AETIOLOGY
• PATHOGENESIS
• MANAGEMENT
• HISTORY
• PHYSICAL EXAMINATION
• INVESTIGATIONS
• TREATMENT
• COMPLICATIONS
• CONCLUSION
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3. Cholecystitis is the inflammation of the gall bladder.
Calculus cholecystitis results from obstruction by gall stone and is the
commonest cause of cholecystitis.
• EPIDEMIOLOGY
(Fat, Fair, Female, Fertile, at Fourty)
90% of patient with acute cholecystitis is associated with calculus
obstruction. Cholelithiasis is common in western countries. 10% of
adult white hours gall stones . 60% of patients are women. It afflicts
more than 20million Americans annually. Most are silent. Only 20%
develop acute cholecystitis
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Pear shape organ
that lie at the
underside of the liver
between the right
and left lobe
7.5-12cm long
Capacity about 25-
30ml
Cystic duct is 3cm in
length, 1-3mm in
diametre
CHD 2.5cm
CBD 7.5cm

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Should be identified
during
cholecystectomy to
avoid damage to
extrahepatic biliary
system

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8. • Three factors are important in the formation of gall stones
• Metabolic ; reduction of bile salt cholesterol ratio below 13:1 e.g
avitaminosis A or excessive gallbladder absorption in ifection
• Infection; streptococci, E.coli, salmonella, Cl. welchi
• Bile stasis; stasis enable gall stone to grow
• Types of stone;
• Cholesterol (20%)
• Pigment (5%)
• Mixed (75%)
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9. • Cholesterol stones:
• Obesity, age <50
• Estrogens: female, multiparity, OCPs
• Commer in western/ developed countries
• Terminal ileal resection or disease (Crohn’s Disease)
• Impaired gallbladder emptying: starvation, DM type 1
• Rapid weight loss: rapid cholesterol mobilization and biliary stasis
• Inborn error of bile salt metabolism
• hyperlipidemia
• Pigment stones :
• Commoner in Asia and Africa
• More in rural than urban area
• Chronic (contains calcium bilirubinate):
• Cirrhosis
• Chronic hemolysis
• Biliary stasis (strictures, dilation, biliary infection)

10. • When stone becomes impacted in the cystic duct the gall
bladder becomes inflamed(chemical and bacterial
inflammation). The mucous membrane is swollen and the wall
thickened. The event may now take several turns
the mucous membrane may become lifted away from the sides of the
stone wedged in the neck of the gall bladder, so that the muco-
purulent content of the bladder drain into the common bile duct. The
attack is then temporarily arrested.
Impaction may persist leading to empyema of the gall bladder.
May perforate (rare- due thickening of wall from recurrent cholecytitis,
seen diabetic and elderly)
Gangrene of the gall bladder- interference to blood supply
Empyema and inflammatory mass
Mirzzi syndrome
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11. stones
obstruction to
bile outflow
inflammation of gall bladder wall due to
phospholipases from the mucosa hydrolyzes biliary
lecithin to lysolecithin (toxic to the mucosa)
disrupt normal
protective
glycoprotein layer
exposed the mucosal
epithelium to the direct
detergent action of bile salts
Superimposed bactrial
infection
Distended gall
bladder
Prostaglandin
released
Mucosal and
mural
inflammation
Increase
intraluminal
pressure
Compromise
mucosal blood
flow

12. • HISTORY
• Pain
• Epigastric
• Right hypochondrial
• Sudden onset
• Associated with fatty meals
• Nausea and vomiting
• Fever
• Jaundice +/-
• Transient
• Usually sets in 2nd or 3rd day of the illness
• Marked or persistent in choledocholithiasis
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13. • PHISICAL SIGNS
• Pyrexia
• Tenderness, rebound tenderness and guarding or rigidity are
found in the right hypochondrium.
• Omental phlegmon- mass gallbladder and omentum, at the
right hypochodrium, as pain subside. It may turn out to be an
empyema or carcinoma especially in the elderly.
• Positive Murphy’s sign
• Positive Boas sign; tenderness over the 9th- 11th right ribs
posteriorly
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14. • Abdominal Uss;
• Calculi cast acostic shadow (80-90%)
• Thickening wall mucosa
• Distended gall bladder with serosal oedema (halo sign)
• Pericystic collection of fluid
• Plain X-ray
• Opacity (10-20%)
• Gas seen in gall bladder or biliary passage ; suggests infection by
anaerobes or passage of stone into the duodenum
• Full blood count ; leucocytosis
• LFT; slight elevation of serum transaminase, elevataed
alkaline phosphatase, bilirubin
• Elevated serum amylase
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15. • The general accepted practice is non-operative
management in the acute phase followed by
cholecystectomy. (interval or delayed cholecystectomy
6 weeks after inflammation has subsided)
• Argument ;
• Majority of patients settle on conservative measures
• Dissection of inflammed area could lead to spread of infection
• With inflammation there is anatomical anomalies with risks of error
• Patient with high risk of perforation are frequently
identifiable(diabetic and aged)
However, in recent years, early operation is increasingly
offered. Following conservative measures, patient is
operated as elective in the next available operation list in
few days.
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16. • REST THE INFLAMMED GALLBLADDER
• NPO, N-G tube aspiration
• IV fluids
• Anticholinergic drugs; propantheline 15mg i.m 8hourly or atropine
0.6mg i.m 8hourly for more rapid action
• SEDATION + analgesia
• Pethidine 100mg i.m
• NSAID suppresses pain from tension within the biliary system
• ANTIBIOTICS
• Broad spectrum and bactericidal. Third generation
cephalosporines are agent of choice
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17. 1. Signs of incipient perforation; temperature and pulse
not improving in 24-36hours. Pain and tenderness
persist across the abdomen.
2. Spreading gangrene of the gallbladder with redness and
oedema of the overlying skin
3. Presence of inflammatory mass in the right
hypochondrium
4. Mucocele
5. Detection of gas in the extrabiliary system
6. Detection of intestinal obstruction
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18. • Cholecystectomy
The gall bladder and cystic duct are removed by
transection and dissection of the cystic duct close to the
common bile duct
Types; Open or laparoscopic
Principles;
• Adequate exposure
• Exclude concomitant pathology of neighboring structures-
preliminary laparotomy
• Defining anatomy
• Adequate hemostasis
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19. Newer, fewer post op complication, shorter hospital stay
Absolute contraindications
• I. Sepsis including cholangitis
• 2. Diffuse peritonitis
• 3. Bleeding diathesis.
Relative contraindications
• I. Previous upper abdominal surgery
• 2. Acute cholecystitis
• 3. Choledocholithiasis
• 4. Gallstone pancreatitis
• 5. Co-existent carcinoma, diverticular and
• inflammatory bowel disease
• 6. Cirrhosis
• 7. Significant anaesthetic risks
• 8. Minor bleeding disorder (eg. aspirin intake)
• 9. Pregnancy
• 10. Obesity.
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20. • Unclear anatomy
• No tissue plane
• Uncontrollable bleeding
• Accidental damage
• Equipment failure
• Lack of progress
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21. • Cholecystostomy
The fundus of the gall bladder is opened and stone
removed with a forceps self retaining catheter place and
exteriorised via a separate wound. Elective
cholecystectomy the performed in 3-6 weeks
• Unfit – severely ill
• Elderly
• Empyema
• Persistent and progressive symptoms
. Better option as chances of injury to adjacent structures is higher
in emergency cholecystectomy
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22. • Iatrogenic bile duct injury
• Post op bile leak
• Haemorrhage
• Retained stone
• Post cholecystectomy syndrome
• Inadvertent bowel injury
• Subcutaneous emphysema
• Anaesthetic complication

23. • Acute appenditis
• Perforated peptic ulcer
• Acute pancreatitis
• Acute pyelonephritis
• Myocardial infarction
• Right lobar pneumonia
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24. • Overall reported mortality of acute cholecystitis is 2-3%
with much higher figures (10%) in patient over 70. This is
largely due to incidental cardiorespiratory disease and
complication.
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25. • Steven M. strasberg, MD; acute calculus cholecystitis. The
new England jornal of Medicine 2008; 358:2804-11
• E.A Badoe et al, “Principles and Practice of surgery including
pathology in the tropics” 4th edition, Assembly of God
Literature Center ltd, 2009
• Bailey and Love’s “Short Practice of Surgery” 26th edition
CRC press Taylor and Francis group. 2013
• www.slideshare .net
• www.wikepedia .org
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