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Acute cholecystitis

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Acute cholecystitis

  2. 2. CHOLELITHIASIS • Most common biliary pathology • it is estimated that gallstones are present in 10- 15% of the adult population in the USA • they are asymptomatic in the majority (>80%) • in the UK the prevalence of gallstones at the time of death is estimated to be 17% and may be increasing • Approximately 1-2% of asymptomatic patients will develop symptoms requiring cholecystectomy per year, making cholecystectomy one of the most common operations performed by general surgeons
  3. 3. Aetiology • 3 main types: • cholesterol (80% in USA) • pigment (80% in Asia) • mixed stones – 51-99% pure cholesterol – admixture of calcium salts, bile acids, bile pigments and phospholipids
  4. 4. • Cholesterol which is insoluble in water is secreted from the canalicular membrane in phospholipid vesicles. • Whether cholesterol remains in solution depends on – the concentration of phospholipids and bile acids in bile and – the type of phospholipids and the bile acid
  5. 5. • Micelles formed by the phospholipid hold cholesterol in a stable thermodynamic state • when bile is supersaturated with cholesterol or bile acid concentrations are low, unstable unilamellar phospholipid vesicles form from which cholesterol crystals nucleate and stones may form.
  6. 6. Factors associated with gallstone formation Impaired gall bladder function Emptying Absorption Excretion Supersaturated bile Age Diet- high calorie Obesity Genetics Sex Cholesterol Glycoprotein Infection Mucus Absorption/ Enterohepatic circulation of bile acids Cholestyramine Deoxycholate (increase the secretion of cholesterol and supersaturate the bile, increasing lithogenicity of bile) Faecal enteric flora Ileal resection Bowel transit time
  7. 7. • Nucleation of cholesterol monohydrate crystals from multilamellar vesicles is a crucial step in gallstone formation • abnormal emptying of the gall bladder may promote the aggregation of nucleated cholesterol crystals, hence removing gallstones without removing the gall bladder inevitably leads to gallstone recurrence.
  8. 8. Pigment stones • Name used for stones with <30% cholesterol • there are two types: • black – black stones are largely composed of an insoluble bilirubin pigment polymer mixed by calcium phosphate and calcium bicarbonate – 20-30% of stones are black – incidence rises with age – accompany haemolysis, usually hereditary spherocytosis or sickle cell disease, haemoglobinopathies – patients with cirrhosis and biliary stasis have a higher incidence of pigmented stones
  9. 9. • brown – contain calcium bilirubinate – calcium palmitate – calcium stearate – cholesterol • rare in gallbladder • form in the bile duct and related to bile stasis and infected bile
  10. 10. • Stone formation is related to the deconjugation of bilirubin diglucuronide by bacterial beta- glucuronidase. • Insoluble unconjugated bilirubinate precipitates • Brown pigment stones are also associated with the presence of foreign bodies within the bile ducts such as endoprosthesis (stents), E coli or parasites such as Clonorchis sinensis and Ascaris lumbricoides
  11. 11. Clinical presentation • Right upper quadrant pain • Epigastric pain • radiate to back • colicky or dull and constant • others: – dyspepsia – flatulence – food intolerance – particularly to fats
  12. 12. • altered bowel frequency • Biliary colic is typically present in 10-25% of patient • described as a severe right upper quadrant pain that ebbs and flows associated with nausea and vomiting. • Pain may radiate to the chest • the pain is usually severe and may last for minutes or even several hours
  13. 13. • Frequently, the pain starts during the night, waking the patient. • Minor episodes of the same discomfort may occur intermittently during the day • Dyspeptic symptoms may coexist and be worse after such an attack. • As the pain resolves, the patient is able to eat and drink again, often only to suffer further episodes of this nature over a period of a few weeks and then no more trouble for some months • Jaundice may result if a stone migrates from the gallbladder and obstructs the common bile duct. Rarely, a gallstone can lead to bowel obstructions
  14. 14. Natural History Asymptomatic 1-2% per year 0.2% per year Acute cholecystitis Biliary colic 5% per year symptoms Chronic cholecystitis Gall bladder carcinoma 0.08% symptomatic patients Bile duct stone Pancreatitis Cholangitis Jaundice
  15. 15. Complications of Gallstones • Biliary colic • Acute cholecystitis • Chronic cholecystitis • Mucocoele • Empyema of the gall bladder • Perforation • Biliary obstruction • Acute cholangitis • Acute pancreatitis • Intestinal obstruction • (gallstone ileus)
  16. 16. Complications • Acute cholecystitis: • due to obstruction of the neck of gallbladder or cystic duct by a stone resulting in a chemical inflammatory reaction. Bacteria are cultured from the bile in approximately 1/2 of patients with gallstones and unrelieved obstruction in the presence of this infected bile may produce an empyema • Boas' sign :hyperaesthesia below the right scapula in cholecystitis
  17. 17. • The thickened gallbladder becomes intensely inflamed, edematous and occasionally gangrenous • the fundus of the distended, inflamed gallbladder may perforate giving rise to localised abscess formation and occasionally to biliary peritonitis • the commo organism implicated in inflammation of the gallbladder are E coli, Klebsiella aerogenes and Strep faecalis • Staphylococci, clostridia and salmonella are occasionally
  18. 18. Chronic cholecystitis • Repeated bouts of biliary colic or acute cholecystitis culminate in fibrosis, contraction of the gallbladder nd chronic inflammatory change my be present i the absence of gallstones, as is the case in the gallbladders of typhoid carriers • the incidence of carcinoma of the gallbladder is increased in patients with longstanding gallstones
  19. 19. Mucocoele • a mucocoele develops when the outlet of the gallbladder ceomes obstructed in the absence of infection • the imprisoned bile is absorbed, but clear mucus contiues to be secreted into the distended gallbladder.
  20. 20. Choledocholithiasis • when gallstones enter the common bile duct, they may pass spontaneously or give rise to obstructive jaundice, cholangitis or acute pancreatitis • Gallstone pancreatitis most ommonly occurs when a small stone becomes temporarily arrested at the ampulla of vater
  21. 21. Gallstone ileus • A large gallstone becomes impacted inthe intestine • stones large enough to block gut generally gain access by eroding through the wall of the gallbladder into the duodenum
  22. 22. Biliary colic • transient obstruction of GB from an impacted stone • Severe gripping pain after meals an in the evening whihc is maximal in the epigastrium and right hypochondrium with radiation to th back • Despite being continuous the pain may wax and wane in intensity over several hours, vomiting and retching are common. Resolution occurs when the stone falls back into the gallbladder lumen or passes onwards into the CBD • The patient the obstruction does not resolve an patient develops acute cholecystitis
  23. 23. Differential diagnosis of cholecystitis • Common – Appendicitis – Perforated peptic ulcer – Acute pancreatitis • uncommon – Acute pyelonephritis – Myocardial infarction – Pneumonia- right lower lobe • Ultrasound scan aids diagnosis • Uncertain diagnosis- do CT scan
  24. 24. Diagnosis • A diagnosis of gallstone disease is based on the history and physical examination with confirmatory radiological studies such as transabdominal U/S and radionuclide scans • In the acute phase, the patient may have right upper quadrant tenderness that is exacerbated during inspiration by the examiner's right subcostal palpation
  25. 25. • A positive Murphy's sign may suggests acute inflammation and may be associated with a leucocytosis and moderately elevated liver function tests. • A mass may be palpable as the omentum walls off an inflamed gallbladder. Fortunately in the majority of cases process is limited by the stone slipping back into the body of the gallbladder one contents of the gallbladder escaping by way of the cystic duct. • This achieves adequate drainage of the gall bladder and enables the inflammation to resolve
  26. 26. • If resolution does not occur, an empyema of the gall bladder may result. • The wall may become necrotic and perforate with tthe development of localised peritonitis • The abscess may then perforate into the peritoneal cavity with a septic peritonitis- however, this is uncommon because gallbladder is usually localised by omentum around the perforation
  27. 27. • A palpable non tender gall bladder (courvoisier sign) - more sinister diagnosis • Results from a distal common duct obstruction secondary to a peripancreatic malignancy • Rarely a non tender palpable gall bladder results from complete obstruction of the cystic duct with reabsorption of the intraluminal bile salts and secretion of uninfected mucus secreted by the epithelium, leading to a mucocoele of the gall bladder.
  28. 28. Investigations • Blood tests: neutrophilia in acute cholecystitis or its complications. • Elevated serum bilirubin or alkaline phosphatase may signify the presence of common duct stones • Prothrombin time should be measured if there was presence of jaundice
  29. 29. • Plain Xray • 15% contain calcium • Gas seen in biliary tree if there is a fistula between the biliary tract and the gut as in gallstone ileus or following endoscopic sphincterotomy • Ultrasound • permits inspection of the gallbladder, its wall and its contents • demonstrates dilation of the ultrasonic wave and are throuwn into prominence by the acoustic shadow they produce. • Does not depend on hepatic excretion of contrast, it can be used in both jaundicedd and non jaundiced patients, and therefore has supplanted oral cholecystography
  30. 30. Cholangiography • IV cholangiography replacee by MRCP which is increasingly to assess the biliary tree non invasively whereas ERCP is reserved for removing common bile duct stones by endoscopic sphincterotomy • Complications occur in up to 7% of patients and may include cholangitis, bleeding and acute pancreatitis
  31. 31. Management • Admit patient • Monitor • Analgesics • IV fluids • Broad spectrum antibiotics eg cephalosporin • NPO and pass NG tube only if patient is vomiting • Majority of patients settle within few days on this regimen • Failure to settle suggests presence of empyema
  32. 32. • Some surgeons delay operation for 2-3 months after the attack in the expectation that the acute inflammatory reaction will have resolved by then but most now prefer to perform cholecystectomy during the same admission and within 72hours of onset of attack. • Provided the operation is carried out by an experienced surgeon and under antibiotic cover the early cholecystectomy is not associated with a increased incidence of complications
  33. 33. • Duration of illness and hospitalisation is reduced, and further attacks of acute cholecystitis during the waiting period for elective surery are averted • it shouldd be noted that this a planned procedure carrioed out after appropriate investigation (U/S) and with all facilities, on a scheduled list
  34. 34. • Laparoscopic cholecystectomy is more difficult to perform in the acute setting but is the method preferreed by most surgeons • If surrounding inflammation makes identification of the relevant anatomical structures difficult drainage of the gallbladder with removal of stones (cholecystectomy) may be performed as an interim measures.Elective cholecystectomy is usually performe approximately 2 months later.
  35. 35. CHRONIC CHOLECYSTITIS • Chronic cholecystitis is most common cause of symp tomatic gallbladder disease. • the patient gives history of recurrent flatulence, fatty food intolerance, right upper quadrant pain • pain worse after food, feeling of distension and heartburn • DDx: duodenal ulcer, hiatus hernia, MI, chronic pancreatitis and gastrointestinal neoplasia. • Symptoms for mucocoele are the same as those for chronic cholecystitis but a nontender piriform swelling may be palpable in the right hypochondrium. there is little systemic upset and no pyrexia
  36. 36. CHOLEDOCHOLITHIASIS • Stones may be present in the common bile duct of some 5-10% of patients with gallstones • there is little muscle in the wall of the bile uct • and pain is not a symptoms unless the stone impedes flow through the sphincter of Oddi • the vast majority of stones in the common bile duct originate in the gallbladder. • Primary duct stones are really rare
  37. 37. • Impaction of a stone at the sphincter obstructs the flow of bile producing jaundice, pale stools and dark urine • Obstruction commonly persists for several days but may clear spontaneously as a result of either passage of the stone or of its disimpaction • Small stones may pass through the common bile duct with no symptoms • In longstanding obstruction the bile ducts become markely dilated and the diameter of the CBD may exceed its upper limit of 7mm. • Diameter greater than 10mm is usually strongly suggestive of stone or tumour
  38. 38. • A totally obstructed duct system becomes dilled with clear white bile as back pressure on the hepatocytes prevents clearance of bilirubin and mucus secretion is increased • Infected of an obstructed biliary tract causes cholangitis, which is characterised by attacks of pain, pyrexia and jaundice (Charcot) frequentl ass/w rigors • Long standing biliary obstruction--- secondary biliary cirrhosis
  39. 39. Treatment • Observe patients with asymptomatic gallstones with cholecystectomy only performed for those patients who develop symptoms or complications of their gallstones • However prophylactic cholecystectomy should be considered in diabetic patients, those with congenital haemolytic anemia and those due to undergo bariatic surgery for morbid obesity as these groups are at increased risk of complications from gallstones
  40. 40. Treatment • for patients with biliary colic or cholecystitis, cholecystectomy is the treatment of choic in the absence of medical contraindications • the timing of surgery in acute cholecystitis remains controversial. • many units favour early intervention, whereas others suggest that a delayed approach is preferable.
  41. 41. Conservative treatment followed by cholecystectomy • In more than 90% of cases, the symptoms of acute cholecystitis subside with conservative measures. Non operative treatment is based on four principles.
  42. 42. 1.Nil per mouth and IV fluid administration 2.Administration of analgesics 3.Administration of antibiotics: as the cystic duct is blocked in most instances, the concentration of antibiotics in the serum is more important than its concentration in bile. Cephazolin, Cefuroxime, Gentamicin
  43. 43. • Subsequent management: when the temperature, pulse and other physical signs show that the inflammation is subsiding, oral fluids are reinstated followed by regular diet. Ultrasonography is performed to ensure that no local complications have developed, that the bile duct is of a normal size and that no stones are contained in the bile duct • Cholecystectomy may be performed on the next available list or the patient may be allowed home to return later when the inflammation has completely resolved
  44. 44. When to abandon conservative treatment? • Conservative treatment must be abandon if the pain and tenderness; depending on the status of the patient, operative intervention and cholecystectomy should be performe • If the patient has serious comorbid conditions a percutaneous cholecystectomy can be performed under ultrasound control, which will rapidly relieve symptoms. A subsequent cholecystectomy is usually required
  45. 45. Routine early operation • As noted above, some surgeons advocate urgent operation as a routine measure in cases of acute cholecystitis. • Provided that the operation is undertaken within 5-7 days of the onset of the attack, the surgeon is experienced and excellent operating facilities are available, good results are achieved.
  46. 46. • Nevertheless, the conversion rate in laparoscopic cholecystectomy is five times higher in acute than in elective surgery • If an early operation is not indicated, one should wait approximately 6 weeks for the inflammation to subside before preceding to operate
  47. 47. Cholesterosis • aka strawberry gallbladder • mucosa of gallbladder infiltrated with lipid and cholesterol • affects middle aged and elderly patients of both sexes • cholesterol stones found in half • mucosa brick red and speckled with bright yello nodules • Management: as for chronic cholecystitis
  48. 48. Adenomyomatosis • Mucosal diverticulosis - Rokitansky Aschoff sinuses • particularly addect the fundus and penetrate the muscular layers to the serosa • Muscular hypertrophy and inflammatory cell infiltrates are present • the diagnosis may be made on careful imaging but is often only made following cholecystectomy as the gallbladder normally contains stones.
  49. 49. Acute acalculous cholecystitis • Few patients with acute cholecystitis have acalculous inflammation • Major surgery • bacteria • trauma • pancreatitis • complication of parenteral nutrition • Best diagnosedd using a nuclear imaging hepatobiliary iminodiacetic acid scan • the inflammatory reaction in the gallbladder wall may be intense and severe, leding to gangrene and perforation • in ill patients, percutaneous drainage (cholecystostomy) under ultrasound guidance may be considered, but urgent cholecystectomy is often advisable.