Cholecystitis

Normal Abnormal This is when the gallbladder becomes infected. It is associated with gallstones more than 90% of the time. When gallstones become impacted in the bile ducts, infection occurs behind the impaction.

Often starts after a large fatty meal Sudden, steady pain in the middle or right upper abdomen omiting !e"er

#allstones Ischemia $blood supply decrease to gallbladder% Infections in persons with AIDS

&'amination( ). Tenderness in right upper abdomen *. #allbladder can be felt in some cases +. ,ellow s-in or eyes may occur

.aboratory !indings( ). &le"ated white blood cell count 2. &le"ated total Bilirubin le"el 3. &le"ated Alkaline phosphatase 4. Amylase may be moderately ele"ated

Imaging

1. X !ays may who gall stones

2. /I01 scan $special X !ay test for obstructed gallstones% 3. "ltrasoun# may show gallstones or thic-ened gallbladder wall

2owel rest $no food or drin-% Intra"enous fluid3feeding Intra"enous broad4spectrum antibiotics 5ain medications $0emerol usually best% Surgical remo"al of the gallbladder *4+ days after cholecystitis for most patients Immediate surgical gallbladder remo"al if gangrene has occurred

6ntreated gangrene in the gallbladder may occur. This is a se"ere infection with destruction of tissue. 0iabetics and the elderly are at highest ris-. Cholan$itis 44 infection that occurs in common bile duct outside the gallbladder

See- immediate emergency medical treatment.

5erforated ulcer 5ancreatitis Appen#icitis .i"er Abscess /epatitis %neumonia $in right lung% #allstones

Acute Cholecystitis
7holecystitis is inflammation of the $allbla##er, a small pear4shaped organ in the upper right area of the abdomen. The gallbladder holds bile produced by the li"er. The bile is released into the small intestine where it aids in digestion, especially the absorption of fats. If the gallbladder is remo"ed, that function is performed directly by the li"er. In many cases of acute cholecystitis, $allstones $solid lumps formed by substances found in the gallbladder% bloc- the bile #ucts $tubes that allow bile to pass from the gallbladder into the small intestine%. 2ile builds up and can push on the walls of the gallbladder, causing inflammation. Other causes of acute cholecystitis include infection, trauma, diabetes or bloc-age of the bile ducts due to a tumor.

Symptoms
Symptoms of acute cholecystitis include

Intense& su##en pain in the upper ri$ht part o' the ab#omen !ecurrent& pain'ul attacks 'or se(eral hours a'ter meals %ain that can )orsen )ith #eep breaths an# that e*ten#s to the lo)er part o' the ri$ht shoul#er bla#e Shortness o' breath #ue to pain )hen inhalin$ Nausea +omitin$ Sti'' ab#ominal muscles& especially on the ri$ht si#e Sli$ht 'e(er Chills ,aun#ice -yello)in$ o' the skin an# eyes.&perio#ically billirubinaemia especially in the mornin$ - in #upine potition the stone mo(e to the neck o' the $allbla##er )ich may cause collic bilier a'ter eatin$ 'atty 'oo# . Ab#ominal bloatin$

Dia$nosis
2ecause the symptoms of acute cholecystitis can resemble symptoms of other illnesses, it is sometimes difficult to diagnose. If a doctor suspects acute cholecystitis after a careful physical e'amination, he or she may perform some of the following tests(

1bdominal ultrasound / use o' hi$h 're0uency soun# )a(es to create an ima$e o' internal or$ans /epatobiliary scintigraphy / an ima$in$ techni0ue use# to see the li(er& bile #ucts& $allbla##er an# upper part o' the small intestine 7holangiography / in1ection o' #ye into the bile #ucts so the $allbla##er an# #ucts can be seen on X rays 7omputed tomography scan $7T scan% / an ima$in$ proce#ure that uses a combination o' X rays an# computer technolo$y to pro#uce ima$es o' the internal or$ans

2reatment
Treatment for acute cholecystitis usually in"ol"es hospitali8ation. The patient is not allowed to eat or drin-, and li9uids are gi"en through an intra"enous $I % line. If an infection is suspected, antibiotics may be gi"en. :ost patients who ha"e acute cholecystitis ha"e their gallbladder remo"ed, either immediately after diagnosis or after the patient has impro"ed. This procedure, called a cholecystectomy, can be performed using a laparoscope $a tube inserted through small incisions% or by con"entional surgery. Source 3 American 4e#ical Association.

5re"ious ;elated 1rticles

Cholecystectomy !emo(al o' the 5allbla##er %eptic "lcers In$uinal 6ernia 4illennium In$uinal 6ernia Chronic Diarrhea Detectin$ Appen#icitis in 7our Chil#ren "lcerati(e Colitis Irritable Bo)el Syn#rome In'lammatory Bo)el Disease -IBD. an# +accines Bo)el Control %roblems

Cholelithiasis can be seen on a cholangiogram. Radio-opaque dye is used to enhance the x-ray. Multiple stones are present in the gallbladder (PTCA).

Gallbladder removal

Normal anatomy

The gallbladder is located in the abdomen on the right side underneath the li!er. The gallbladder stores bile produced by the li!er and deli!ers it to the "irst part o" the small intestine (duodenum) #here it aids in the digestion o" "at. The cystic and common bile ducts connect the gallbladder to the duodenum-bile passes through these ducts "rom the gallbladder to the duodenum.

Gallbladder removal

Indication

$allbladder surgery is done to treat gallbladder disease. $allbladder disease is commonly caused by the "ormation o" gallstones in the gallbladder (cholelithiasis). $allstones can a""ect di""erent locations. 1. 2. 3. Obstruction of the cystic duct leading to severe abdominal pain (biliary colic). Infection or inflammation of the gallbladder (cholecystitis). Bloc age of the biliary ducts leading to the duodenum (biliary obstruction).

%n each case the gallbladder is o"ten remo!ed (cholecystectomy). %ncision

Most gallbladder surgery today is done using laparoscopic surgical techniques in #hich narro# instruments including a camera are introduced into the abdomen through small puncture holes. %" the procedure is expected to be straight"or#ard laparoscopic

cholecystectomy may be used. A laparoscopic camera is inserted into the abdomen near the umbilicus (na!el). %nstruments are inserted through & more small puncture holes. The gallbladder is "ound the !essels and tubes are cut and the gallbladder is remo!ed. Procedure

%" the gallbladder is extremely in"lamed in"ected or has large gallstones the abdominal approach (open cholecystectomy) is recommended. A small incision is made 'ust belo# the rib cage on the right side o" the abdomen. The li!er is mo!ed to expose the gallbladder. The !essels and tubes (cystic duct and artery) to and "rom the gallbladder are cut and the gallbladder is remo!ed. The tube (common bile duct) that drains the digesti!e "luid (bile) "rom the li!er to the small intestine (duodenum) is examined "or bloc(ages or stones. A small "lat tube may be le"t in "or se!eral days to drain out "luids i" there is in"lammation or in"ection. A"tercare

Most patients #ho undergo laparoscopic cholecystectomy can go home the day o" surgery or the next day and resume a normal diet and acti!ities immediately. Most patients #ho undergo open cholecystectomy require )-* days o" hospitali+ation are able to resume a

normal diet a"ter one #ee( and normal acti!ates a"ter ,-- #ee(s.

!holelithiasis" cholecystitis" and related disorders

!ontents
1. 2. 3. &. (. *. ,. -. /. #ead boo e$cerpt !holecystitis% Introduction !holecystitis !auses !holecystitis 'reatments )atest treatments Ne+s !linical trials .iagnosis of !holecystitis !holecystitis Overvie+

10. 1ore boo e$cerpts for !holecystitis

!holelithiasis" cholecystitis" and related disorders% 2$cerpt from 3andboo of .iseases

.iseases o" the gallbladder and biliary tract are common typically pain"ul conditions that usually require surgery and may be li"e-threatening. They/re commonly associated #ith deposition o" calculi and in"lammation. (0ee Common sites of calculus formation.)

%n most cases gallbladder and bile duct diseases occur during middle age. 1et#een ages &2 and )2 they/re six times more common in #omen but the incidence in men and #omen becomes equal a"ter age )2. A"ter that incidence rises #ith each succeeding decade.

!auses
The origin and "requency o" gallbladder and biliary tract disease !ary #ith the particular disorder.

!holelithiasis
The presence o" stones or calculi (gallstones) in the gallbladder results "rom changes in bile components. $allstones are made o" cholesterol calcium bilirubinate or a mixture o" cholesterol and bilirubin pigment. They arise during periods o" sluggishness in the gallbladder resulting "rom pregnancy use o" oral contracepti!es diabetes mellitus Crohn/s disease cirrhosis o" the li!er pancreatitis obesity and rapid #eight loss.

Cholelithiasis is the "i"th leading cause o" hospitali+ation among adults and accounts "or 324 o" all gallbladder and duct diseases. The prognosis is usually good #ith treatment unless in"ection occurs in #hich case the prognosis depends on the in"ection/s se!erity and response to antibiotics.

!holecystitis
Cholecystitis an acute or chronic in"lammation o" the gallbladder is usually associated #ith a gallstone impacted in the cystic duct5 the in"lammation de!elops behind the obstruction. Cholecystitis accounts "or 624 to &)4 o" all patients requiring gallbladder surgery.

The acute "orm is most common during middle age5 the chronic "orm among elderly people. The prognosis is good #ith treatment.

Biliary cirrhosis
Primary biliary cirrhosis is a chronic progressi!e disease o" the li!er characteri+ed by autoimmune destruction o" the intrahepatic bile ducts and cholestasis. This condition usually leads to obstructi!e 'aundice and pruritus and in!ol!es the portal and periportal spaces o" the li!er. %t a""ects #omen bet#een the ages o" ,2 and -2 nine times more o"ten than men. The prognosis is poor #ithout li!er transplantation.

!holangitis

An in"ection o" the bile duct cholangitis is commonly associated #ith choledocholithiasis and may "ollo# percutaneous transhepatic cholangiography. Predisposing "actors include bacterial or metabolic alteration o" bile acids. 7idespread in"lammation may cause "ibrosis and stenosis o" the common bile duct. The prognosis "or this rare condition is poor #ithout stenting or surgery.

!holedocholithiasis
8ne out o" e!ery 62 patients #ith gallstones de!elops choledocholithiasis or gallstones in the common bile duct (sometimes called common duct stones). This occurs #hen stones passed out o" the gallbladder lodge in the hepatic and common bile ducts and obstruct the "lo# o" bile into the duodenum. The prognosis is good unless in"ection occurs.

!holesterolosis
Cholesterol polyps or cholesterol crystal deposits in the gallbladder/s submucosa may result "rom bile secretions containing high concentrations o" cholesterol and insu""icient bile salts. The polyps may be locali+ed or may spec(le the entire gallbladder. Cholesterolosis the most common pseudotumor isn/t related to #idespread in"lammation o" the mucosa or lining o" the gallbladder. The prognosis is good #ith surgery.

4allstone ileus
$allstone ileus results "rom a gallstone lodging in the terminal ileum. %t/s more common in elderly people. The prognosis is good #ith surgery.

5ostcholecystectomy syndrome
Postcholecystectomy syndrome commonly results "rom retained or recurrent common bile duct stones spasm o" the sphincter o" 8ddi "unctional bo#el disorder technical errors or mista(en diagnoses. %t occurs in 64 to )4 o" all patients #hose gallbladders ha!e been surgically remo!ed and may produce right upper quadrant abdominal pain biliary colic "atty "ood intolerance dyspepsia and indigestion. The prognosis is good #ith selected radiologic procedures endoscopic procedures or surgery.

!omplications

9ach disorder produces its o#n set o" complications. Cholelithiasis may lead to any o" the disorders associated #ith gallstone "ormation: cholangitis cholecystitis choledocholithiasis or gallstone ileus.

Cholecystitis can progress to gallbladder complications such as empyema hydrops or mucocele or gangrene. $angrene may lead to per"oration resulting in peritonitis "istula "ormation pancreatitis limy bile and porcelain gallbladder. 8ther complications include chronic cholecystitis and cholangitis.

Choledocholithiasis may lead to cholangitis obstructi!e 'aundice pancreatitis and secondary biliary cirrhosis. Cholangitis especially in the suppurati!e "orm may progress to septic shoc( and death. $allstone ileus may cause bo#el obstruction #hich can lead to intestinal per"oration peritonitis septicemia secondary in"ection and septic shoc(.

6igns and symptoms

Although gallbladder disease may produce no symptoms acute cholelithiasis acute cholecystitis choledocholithiasis and cholesterolosis all produce the symptoms o" a classic gallbladder attac(. 0uch attac(s commonly "ollo# meals rich in "ats or may occur at night suddenly a#a(ening the patient.

A gallbladder attac( may begin #ith acute abdominal pain in the right upper quadrant that may radiate to the bac( bet#een the shoulders or to the "ront o" the chest. The pain may be so se!ere that the patient see(s emergency care.

8ther signs and symptoms include recurring "at intolerance biliary colic belching "latulence indigestion diaphoresis nausea !omiting chills lo#-grade "e!er 'aundice (i" a stone obstructs the common bile duct) and clay-colored stool (#ith choledocholithiasis).

0igns and symptoms o" cholangitis include a rise in eosinophils 'aundice abdominal pain high "e!er and chills. 1iliary cirrhosis may produce 'aundice related itching #ea(ness "atigue slight #eight loss and abdominal pain. $allstone ileus produces signs and symptoms o" small-bo#el obstruction ;nausea !omiting abdominal distention and absent bo#el sounds i" the bo#el is completely obstructed. %ts most telling sign is intermittent recurrence o" colic(y pain o!er se!eral days.

.iagnosis
<ltrasonography and =-rays detect gallstones. 0peci"ic procedures include the "ollo#ing: Ultrasonography re"lects stones in the gallbladder #ith 3-4 accuracy. Percutaneous transhepatic cholangiography allo#s imaging under "luoroscopic control to help distinguish bet#een gallbladder or bile duct disease and cancer o" the pancreatic head in patients #ith 'aundice. Endoscopic retrograde cholangiopancreatography !isuali+es the biliary tree a"ter insertion o" an endoscope do#n the esophagus into the duodenum cannulation o" the common bile and pancreatic ducts and in'ection o" contrast medium. Hepatobiliary iminodiacetic acid analogue scan o" the gallbladder helps detect obstruction o" the cystic duct. Computed tomography scan, although not routinely used helps distinguish bet#een obstructi!e and nonobstructi!e 'aundice. Plain abdominal X-rays identi"y calci"ied but not cholesterol stones #ith 6)4 accuracy. Oral cholecystography sho#s stones in the gallbladder and biliary duct obstruction. 9le!ated icteric index and ele!ated total bilirubin urine bilirubin and al(aline phosphatase le!els support the diagnosis. 7hite blood cell count is slightly ele!ated during a cholecystitis attac(. .i""erential diagnosis is essential because gallbladder disease can mimic other diseases (myocardial in"arction angina pancreatitis pancreatic head cancer pneumonia peptic ulcer hiatal hernia esophagitis and gastritis). 0erum amylase le!els help distinguish gallbladder disease "rom pancreatitis. 7ith suspected heart disease cardiac en+yme testsand an electrocardiogram should precede gallbladder and upper $% diagnostic tests.

'reatment
0urgery usually electi!e is the treatment o" choice "or gallbladder and bile duct diseases. 0urgery may include open or laparoscopic cholecystectomy cholecystectomy #ith operati!e cholangiography and possibly exploration o" the common bile duct.

8ther treatment includes a lo#-"at diet to pre!ent attac(s and !itamin > "or itching 'aundice and bleeding tendencies resulting "rom !itamin > de"iciency. Treatment during an acute attac( may include insertion o" a nasogastric tube and an %.?. line and possibly administration o" an antibiotic.

A nonsurgical treatment "or choledocholithiasis in!ol!es insertion o" a "lexible catheter "ormed around a biliary tube (T tube) through a sinus tract into the common bile duct. $uided by "luoroscopy the catheter is directed to#ard the stone. A .ormia bas(et is threaded through the catheter opened t#irled to entrap the stone closed and #ithdra#n.

6pecial considerations

 1e"ore surgery teach the patient to deep breathe cough expectorate and per"orm leg exercises that are necessary a"ter surgery. Also teach splinting repositioning and ambulation techniques. 9xplain the perioperati!e procedures to help ease the patient/s anxiety and ensure his cooperation.

A"ter surgery monitor !ital signs "or indications o" bleeding in"ection or atelectasis.

%" a T tube is surgically placed maintain tube patency and secure placement. Measure and record bile drainage daily (&22 to @22 ml is normal).

%" your patient #ill be discharged #ith a T tube teach him ho# to per"orm dressing changes and routine s(in care.

Patients #ho ha!e had a laparoscopic cholecystectomy may be discharged the same day or #ithin ,A hours a"ter surgery. These patients should ha!e minimal pain be able to tolerate a regular diet #ithin &, hours a"ter surgery and be able to return to normal acti!ity #ithin a #ee(.

9ncourage the patient to per"orm deep-breathing and leg exercises e!ery hour. The patient should ambulate a"ter surgery. Pro!ide antiembolism stoc(ings to support leg muscles and promote !enous blood "lo# to pre!ent stasis and clot "ormation.

Assess the location duration and character o" any pain. Administer an analgesic as needed to relie!e pain.

At discharge (usually the day o" surgery or 6 to & days a"ter#ard) teach the patient that "ood restrictions are unnecessary unless he has an intolerance to a speci"ic "ood or some underlying condition (such as diabetes atherosclerosis or obesity) that requires such restriction.

5ictures

Boo 6ource .etails

Boo 'itle% Bandboo( o" .iseases 7uthor(s)% 0pringhouse 8ear of 5ublication% &22@ !opyright .etails% Bandboo( o" .iseases Copyright C &22@ Dippincott 7illiams E 7il(ins.

Cholecystitis ($all bladder)

Cholecystitis !ommon pathogens

Possible therapeutic alternati!es

Ampicillin-sulbactam 1.(93g ivpb :*h or 'icarcillin9clavulanic acid 3.1g ivpb :*h or 5iperacillin9ta;obactam 3.3,(g ivpb :*h or <5iperacillin 3 to & grams I=5B :*h >?9 1etronida;ole (00mg ivpb :*9-h@ or <Ampicillin 2g ivpb :*h > gentamicin > 1etronida;ole (00mg ivpb :*h@ or < @rd generation cephalosporin > !lindamycin or 1etronida;ole @ !efotetan 192 gm I= :12h or !efo$itin 192 gm I= :*h Penicillin allergic: <A+treonam 192g ivpb :*9-h > !lindamycin F

Images
7holecystitis

cholecystectomy

4e#ical 8ncyclope#ia3 Cholecystectomy 6ome 9 :ibrary 9 6ealth 9 4e#ical 8ncyclope#ia 4ore about Cholecystectomy3 %urpose %recautions %reparation A'tercare !isks !esources De'inition A cholecystectomy is the sur$ical remo(al o' the $allbla##er. 2he t)o basic types o' this proce#ure are open

cholecystectomy an# the laparoscopic approach. It is estimate# that the laparoscopic proce#ure is currently use# 'or appro*imately ;<= o' cases. Description 2he laparoscopic cholecystectomy in(ol(es the insertion o' a lon$ narro) cylin#rical tube )ith a camera on the en#& throu$h an appro*imately 1 cm incision in the ab#omen& )hich allo)s (isuali>ation o' the internal or$ans an# pro1ection o' this ima$e onto a (i#eo monitor. 2hree smaller incisions allo) 'or insertion o' other instruments to per'orm the sur$ical proce#ure. A laser may be use# 'or the incision an# cautery -burnin$ un)ante# tissue to stop blee#in$.& in )hich case the proce#ure may be calle# laser laparoscopic cholecystectomy. In a con(entional or open cholecystectomy& the $allbla##er is remo(e# throu$h a sur$ical incision hi$h in the ri$ht ab#omen& 1ust beneath the ribs. A #rain may be inserte# to pre(ent accumulation o' 'lui# at the sur$ical site. / ?athleen D. @ri$ht& !N

Sur$ery 8ncyclope#ia3 Cholecystectomy

Who 5erforms the 5rocedure and Where Is It 5erformed< 7holecystectomy, including the laparoscopic approach, is usually performed by a general surgeon who has completed a fi"e4year residency training program in all components of $eneral sur$ery and in particular proper techni9ues in"ol"ing the use of the laparoscope. If surgery is being considered, it is a good idea to find out how many laparoscopic cholecystectomies the surgeon performs on a yearly basis. .aparoscopic cholecystectomies are often performed in the speciali8ed department of a general hospital, but they are also performed in speciali8ed gastrointestinal clinics or institutes for gastrointestinal disorders. =uestions to 1s- the 0octor What are my alternati"es< Is surgery the answer for me< 7an you recommend a surgeon who performs the laparoscopic procedure< If surgery is appropriate for me, what are the ne't steps< /ow many times ha"e you performed open or laparoscopic cholecystectomy< 1re you a board4certified surgeon< What type of outcomes ha"e you had< What are the most common side effects or complications< What should I do to prepare for surgery< What should I e'pect following the surgery<

7an you refer me to one of your patients who has had this procedure< What diagnostic procedures are performed to determine if I re9uire surgery< Will I need to see another specialist for the diagnostic procedures< 0efinition 1 cholecystectomy is the surgical remo"al of the $allbla##er. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach. It is estimated that the laparoscopic procedure is currently used for appro'imately >0% of cases. 5urpose 1 cholecystectomy is performed to treat cholelithiasis and cholecystitis. In cholelithiasis, $allstones of "arying shapes and si8es form from the solid components of bile. The presence of these stones, often referred to as gallbladder disease, may produce symptoms of e*cruciatin$ right upper ab#ominal pain radiating to the right shoulder. The gallbladder may become the site of acute infection and in'lammation, resulting in symptoms of upper right abdominal pain, nausea, and "omiting. This condition is referred to as cholecystitis. The surgical remo"al of the gallbladder can pro"ide relief of these symptoms. 7holecystectomy is used to treat both acute and chronic cholecystitis when there are significant pain symptoms. The typical composition of gallstones is predominately cholesterol, or a compound called calcium bilirubinate. 7holelithiasis :ost patients with cholelithiasis ha"e no significant physical symptoms. 1ppro'imately >0% of gallstones do not cause significant #iscom'ort. 5atients who de"elop biliary colic generally do ha"e some symptoms. When gallstones obstruct the cystic #uct, intermittent, e'treme, crampin$ pain typically de"elops in the right upper 0ua#rant of the abdomen. This pain generally occurs at night and can last from a few minutes to se"eral hours. 1n acute attac- of cholecystitis is often associated with the consumption of a large, high4fat meal. The medical management of gallstones depends to a great degree on the presentation of the patient. 5atients with no symptoms generally do not re9uire any medical treatment. The best treatment for patients with symptoms is usually surgery. :aparoscopic cholecystectomy is typically preferred o"er the open surgical approach because of the decreased reco"ery period. 5atients who are not good candidates for either type of surgery can obtain some symptom relief with drugs, especially oral bile salts. 7holecystitis 7holecystitis is an inflammation of the gallbladder, both acute and chronic, that results after the de"elopment of gallstones in some indi"iduals. The most common symptoms and physical findings associated with cholecystitis include( pain and tenderness in the upper right 9uadrant of the abdomen nausea "omiting

In a laparoscopic cholecystectomy, four small incisions are made in the abdomen $1%. The abdomen is filled with carbon #io*i#e, and the surgeon "iews internal structures with a "ideo monitor $2%. The gallbladder is located and cut with laparoscopic scissors $7%. It is then remo"ed through an incision $0%. $Illustration by ##S Inc.% fe"er ?aundice history of pain after eating large, high4fat meals 0emographics O"erall, cholelithasis is found in about *0,000,000 1mericans. 1n o"erwhelming ma?ority of these indi"iduals do not e"er de"elop symptoms. O"erall, about @00,000 to A00,000 $*B+%% are treated with cholecystectomies e"ery year. Typically, the incidence of cholelithasis increases with age. The greatest incidence occurs in indi"iduals between the ages of C0 and A0 years. The following groups are at an increased ris- for de"eloping choleliathiasis( pregnant women female se' family history of gallstones obesity certain types of intestinal disease age greater than C0 years oral contracepti(e use diabetes mellitus estrogen replacement therapy

rapid weight loss O"erall, patients with cholelathiasis ha"e about a *0% chance of de"eloping biliary colic $the e'tremely painful complication that usually re9uires surgery% o"er a *04 year period. 1cute cholecystitis de"elops most commonly in women between the ages of C0 and A0 years. Some ethnic groups such as Dati"e 1mericans ha"e a dramatically higher incidence of cholecystitis. 0escription The laparoscopic cholecystectomy in"ol"es the insertion of a long, narrow cylindrical tube with a camera on the end, through an appro'imately 0.C in $) cm% incision in the abdomen, which allows "isuali8ation of the internal organs and pro?ection of this image onto a "ideo monitor. Three smaller incisions allow for insertion of other instruments to perform the surgical procedure. 1 laser may be used for the incision and cautery $burning un)ante# tissue to stop bleeding%, in which case the procedure may be called laser laparoscopic cholecystectomy. In a con"entional or open cholecystectomy, the gallbladder is remo"ed through a surgical incision high in the right abdomen, ?ust beneath the ribs. 1 drain may be inserted to pre"ent accumulation of fluid at the surgical site. 0iagnosis35reparation The initial diagnosis of acute cholecystitis is based on the following symptoms( constant, #ull upper right 9uadrant abdominal pain fe"er chills nausea "omiting pain aggra"ated by mo"ing or coughing :ost patients ha"e ele"ated leu-ocyte $white blood cells% le"els. .eu-ocyte le"els are determined using laboratory analysis of blood samples. Traditional ' rays are not particularly useful in diagnosing cholecystitis. 6ltrasonography of the gallbladder usually pro"ides e"idence of gallstones, if they are present. 6ltrasonography can also help identify inflammation of the gallbladder. Duclear imaging may also be used. This type of imaging cannot identify gallstones, but it can pro"ide e"idence of obstruction of the cystic and common bile #ucts. 7holelithiasis is initially diagnosed based on the following signs and symptoms( history of biliary colic or ?aundice nausea "omiting sudden onset of e'treme pain in the upper right 9uadrant of the abdomen fe"er chills .aboratory blood analysis often finds e"idence of ele"ated bilirubin, al-aline phosphatase, or aminotransferase le"els. 6ltrasonography, computed tomo$raphy $7T% scanning, and ra#ionucli#e ima$in$ are able to detect the impaired functioning of bile flow and of the bile ducts. 1s with any surgical procedure, the patient will be re9uired to sign a consent form after the procedure is e'plained thoroughly. !ood and fluids will be prohibited after midnight before the procedure. &nemas may be ordered to clean out the bo)el. If nausea or "omiting are present, a suction tube to empty the stomach may be used, and for laparoscopic procedures, a urinary drainage catheter will also be used to decrease the ris- of accidental puncture of the stomach or bla##er with insertion of the trocar $a sharp, pointed instrument%. 1ftercare

%ostoperati(e care for the patient who has had an open cholecystectomy, as with those who ha"e had any ma?or surgery, in"ol"es monitoring of blood pressure, pulse, respiration, and temperature. 2reathing tends to be shallow because of the effect of anesthesia, and the patientEs reluctance to breathe deeply due to the pain caused by the pro'imity of the incision to the muscles used for respiration. The patient is shown how to support the operati"e site when breathing deeply and cou$hin$ and is gi"en pain medication as necessary. !luid inta-e and output is measured, and the operati"e site is obser"ed for color and amount of wound drainage. !luids are gi"en intra(enously for *CBC> hours, until the patientEs diet is gradually ad"anced as bowel acti"ity resumes. The patient is generally encouraged to wal- eight hours after surgery and discharged from the hospital within three to fi"e days, with return to wor- appro'imately four to si' wee-s after the procedure. 7are recei"ed immediately after laparoscopic cholecystectomy is similar to that of any patient undergoing surgery with $eneral anesthesia. 1 uni9ue postoperati(e pain may be e'perienced in the right shoulder related to pressure from carbon #io*i#e used in the laparoscopic tubes. This pain may be relie"ed by lying down on the left side with right -nee and thi$h drawn up to the chest. Wal-ing will also help increase the bodyEs reabsorption of the gas. The patient is usually discharged the day after surgery and allowed to shower on the second postoperati"e day. The patient is ad"ised to gradually resume normal acti"ities o"er a three4day period, while a"oiding hea"y lifting for about )0 days. ;is-s 5otential problems associated with open cholecystectomy include respiratory problems related to location of the incision, wound infection, or abscess formation. 5ossible complications of laparoscopic cholecystectomy include accidental puncture of the bowel or bladder and uncontrolle# bleeding. Incomplete reabsorption of the carbon dio'ide gas could irritate the muscles used in respiration and cause respiratory distress. While most patients with acute cholecystitis respond well to the laparoscopic techni9ue, about @B*0% of these patients re9uire a con"ersion to the open techni9ue because of complications. Dormal ;esults The prognosis for cholecystitis and cholelithaisis patients who recei"e cholecystectomy is generally good. O"erall, cholecystectomy relie"es symptoms in about 9@% of cases. :orbidity and :ortality ;ates The complication rate is less than 0.@% with open cholecystectomy and about )% with laparoscopic cholecystectomy. The primary complication with the open techni9ue is infection, whereas bile leak and hemorrha$e are the most common complications associated with the laparoscopic techni9ue. The o"erall mortality rate associated with cholecystectomy is less than )%. /owe"er, the rate of mortality in the elderly is higher. In a small minority of cases, symptoms will persist in patients who recei"e cholecystectomy. This has been named the post4cholecystectomy syndrome and usually results from functional bowel disorder, errors in diagnosis, technical errors, o"erloo-ed common bile #uct stones, recurrence of common bile duct stones, or the spasm of a structure called the sphincter o' A##i. 1lternati"es 1cute cholecystitis usually impro"es following conser"ati"e therapy in most patients. This conser"ati"e therapy in"ol"es the withholding of oral feedings, the use of intra"enous feedings, and the administration of antibiotics and anal$esics. This is only a short4term alternati"e in hospitali8ed patients. :ost of these patients should recei"e cholecystectomy within a few days to pre"ent recurrent attac-s. In the short4term, patients often recei"e narcotic anal$esics such as meperi#ine to

relie"e the intense pain associated with this condition. 5atients who ha"e e"idence of gallbladder per'oration or $an$rene need to ha"e an immediate cholecystectomy. In patients with cholelithasis who are deemed un'it for surgery, alternati"e treatments are sometimes effecti"e. These indi"iduals often ha"e symptom impro"ement after lifestyle changes and medical therapy. .ifestyle changes include dietary a"oidance of foods high in polyunsaturated fats and gradual weight loss in obese indi"iduals. :edical therapy includes the administration of oral bile salts. 5atients with three or fewer gallstones of cholesterol composition and with a gallstone diameter less than 0.A in $)@ mm% are more li-ely to recei"e medical therapy and ha"e positi"e results. The primary re9uirements for recei"ing medical therapy include the presence of a functioning gallbladder and the absence of calci'ication on computed tomography $7T% scans. Other non4surgical alternati"es include using a sol(ent to dissol"e the stones and using sound wa"es to brea-up small stones. 1 ma?or #ra)back to medical therapy is the high recurrence rate of stones in those treated. ;esources 2oo-s F7holecystitis,F and FF7holelithiasis.F In !erriEs 7linical 1d"isor, edited by !red !. !erri. St. .ouis( :osby, *00). 7urrent Surgical 0iagnosis G Treatment. Dew ,or-( :c#raw4/ill, *00+. FThe 0igesti"e System.F 7onnEs 7urrent Therapy. 5hiladelphia( W.2. Saunders, *00). F0iseases of the .i"er, #allbladder, and 2ile 0ucts.F In 7ecilTe'tboo- of :edicine, edited by .ee #oldman, and H. 7laude 2ennett. 5hiladelphia( W.2. Saunders, *000. F.i"er, 2iliary Tract, G 5ancreas.F In 7urrent :edical 0iagnosis G Treatment. Dew ,or-( :c#raw4/ill, *00+. Schwart8, Seymour I. $ed.% 5rinciples of Surgery. Dew ,or-( :c#raw4/ill, )999. I :ar- :itchell +eterinary Dictionary3 cholecystectomy Top 6ome J :ibrary J Animal :i'e J +eterinary Dictionary &'cision of the gallbladder. @ikipe#ia3 7holecystectomy Top 6ome J :ibrary J 4iscellaneous J @ikipe#ia This article needs additional citations for (eri'ication. 5lease help impro(e this article by adding reliable re'erences. 6nsourced material may be challen$e# and remo(e#. $:arch *00>%

:aparoscopic Cholecystectomy as seen throu$h laparoscope

K4;ay during .aparoscopic 7holecystectomy 7holecystectomy $pronounced B-lGsst-tGmi3, plural( cholecystectomies% is the surgical remo"al of the $allbla##er. It is the most common method for treating symptomatic $allstones. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more in"asi"e procedure, called open cholecystectomy. 1 cholecystectomy is performed when attempts to treat gallstones with ultrasound to shatter the stones $lithotripsy% or medications to dissol"e them ha"e not pro"ed feasible. 7ontents Lhi#eM 1 Apen sur$ery 2 :aparoscopic sur$ery 2.1 %roce#ural !isks an# Complications 2.2 Biopsy 3 :on$ 2erm %ro$nosis 4 !e'erences

Open surgery 1 traditional open cholecystectomy is a ma?or ab#ominal surgery in which the surgeon remo"es the gallbladder through a )04)> cm $C4N inch% incision. 5atients usually remain in the hospital o"ernight and may re9uire se"eral additional wee-s to reco"er at home. It ta-es a minimum of N to )@ days to complete the treatment. 1lthough, in some cases, he can ta-e as long as +0 days.Lcitation nee#e#M .aparoscopic surgery :aparoscopic cholecystectomy has now replaced open cholecystectomy as the first4 choice of treatment for $allstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. Sometimes, a laparoscopic cholecystectomy will be con"erted to an open cholecystectomy for technical reasons or safety.

1 6S Da"y general surgeon and an operating room nurse discuss proper procedures while performing a laparoscopic cholecystectomy surgery. :aparoscopic cholecystectomy re9uires se"eral small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes appro'imately @4)0 mm in diameter, through which surgical instruments and a "ideo camera are placed into the ab#ominal ca(ity. The camera illuminates the surgical field and sends a magnified image from inside the body to a "ideo monitor, gi"ing the surgeon a close4 up "iew of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports. To begin the operation, the patient is anestheti8ed and placed in the supine position on the operating table. 1 scalpel is used to ma-e a small incision at the umbilicus. 6sing either a eress needle or /asson techni9ue the abdominal ca"ity is entered. The surgeon inflates the abdominal ca"ity with carbon #io*i#e to create a wor-ing space. The camera is placed through the umbilical port and the abdominal ca"ity is inspected. 1dditional ports are placed inferior to the ribs at the epi$astric, mi#cla(icular, and anterior a*illary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to e'pose and open CalotCs 2rian$le $the area bound by the cystic artery, cystic #uct, and common hepatic #uct%. The triangle is gently dissected to clear the peritoneal co"ering and obtain a "iew of the underlying structures. The cystic #uct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the li"er bed and remo"ed through one of the ports. This type of surgery re9uires meticulous surgical s-ill, but in straightforward cases can be done in about an hour. ;ecently, this procedure is performed through a single incision in the patientEs umbilicus. This ad"anced techni9ue is called Single Incision laparoscopic Surgery or FSI.ST:F. 5rocedural ;is-s and 7omplications :aparoscopic cholecystectomy does not re9uire the abdominal muscles to be cut, resulting in less pain, 9uic-er healing, impro"ed cosmetic results, and fewer complications such as in'ection and a#hesions. :ost patients can be discharged on the same or following day as the surgery, and most patients can return to any type of occupation in about a wee-.

1n uncommon but potentially serious complication is in?ury to the common bile #uct, which connects the gallbladder and li"er. 1n in?ured bile duct can lea- bile and cause a painful and potentially dangerous infection. :any cases of minor in?ury to the common bile duct can be managed non4surgically. :a?or in?ury to the bile duct, howe"er, is a "ery serious problem and may re9uire correcti"e surgery. This surgery should be performed by an e'perienced biliary surgeon.D1E Ab#ominal peritoneal a#hesions, gangrenous gallbladders, and other problems that obscure "ision are disco"ered during about @% of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe remo"al of the gallbladder. A#hesions and gangrene, of course, can be 9uite serious, but con"erting to open surgery does not e9uate to a complication. 1 7onsensus 0e"elopment 7onference panel, con"ened by the National Institutes o' 6ealth in September )99*, endorsed laparoscopic cholecystectomy as a safe and effecti"e surgical treatment for gallbladder remo"al, e9ual in efficacy to the traditional open surgery. The panel noted, howe"er, that laparoscopic cholecystectomy should be performed only by e'perienced surgeons and only on patients who ha"e symptoms of gallstones. In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, e'perience, s-ill, and ?udgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be de"eloped for training and granting credentials in laparoscopic sur$ery, determining competence, and monitoring 9uality. 1ccording to the panel, efforts should continue toward de"eloping a nonin(asi(e approach to gallstone treatment that will not only eliminate e'isting stones, but also pre"ent their formation or recurrence. One common complication of cholecystectomy is inad"ertent in?ury to an anomalous bile duct -nown as Ducts o' :uschka, occurring in ++% of the population. It is non4 problematic until the gall bladder is remo"ed, and the tiny supra"esicular ducts may be incompletely cauteri8ed or remain unobser"ed, leading to biliary lea- post operati"ely. The patient will de"elop biliary peritonitis within @ to N days following surgery, and will re9uire a temporary biliary stent. It is important that the clinician recogni8e the possibility of bile peritonitis early and confirm diagnosis "ia /I01 scan to lower morbidity rate. 1ggressi"e pain management and antibiotic therapy should be initiated as soon as diagnosed. 2iopsy 1fter remo"al, the gall bladder should be sent for biopsy $pathological e'amination% to confirm the diagnosis and loo- for an incidental cancer. If cancer is present, a reoperation to remo"e part of li"er and lymph nodes will be re9uired in most cases. D2E .ong4Term 5rognosis 2ile is crucial to fat digestion, and after remo"al of a gallbladder, normal digestion can be ad"ersely affected. 2ile is still produced by the li"er, but rather than being stored in a reser"oir which releases large 9uantities when needed, bile is released in a continuous, slow tric-le into the intestine. Thus, when eating a meal that is high in fat content, there may not be an ade9uate amount of bile in the intestine to properly handle the normal absorption process. 0octors may prescribe medications to control the a"ailability of bile salts. 1s many as twenty percent of patients de"elop chronic diarrhea. The cause is unclear and the condition may last for many years. D3E 1 significant proportion of the population, up to C0%, de"elop a condition called postcholecystectomy syn#rome, or 57S.D4E Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen. The cause is uncertain. ;eferences

F Oapoor O. 2ile duct in?ury repair B When< What< Who< EHournal of /25 SurgeryE *00NP )C( CNA49. F Oapoor O. Incidental gall bladder cancer. E1merican Hournal of #astroenterologyE *00)P 9A( A*N4A*9. F Chronic #iarrhea3 A concern a'ter $allbla##er remo(alG 4ayoClinic.com F F%ostcholecystectomy syn#romeF. Web:0. http3BB))).)ebm#.comBh) popupB%ostcholecystectomy syn#rome. ;etrie"ed *00N40>4*@. (QdQe Di$esti(e system sur$ical an# other proce#ures $ICD H C4 +3 C*4@C% S5s38sopha$ Sialo$raphy R 8sopha$ectomy us 5astrostomy $%ercutaneous en#oscopic $astrostomy% R 5astrectomy $Billroth I, Billroth II, !ou* en 7% R Bariatric sur$ery $5astric bypass sur$ery, A#1ustable $astric ban#, Slee(e $astrectomy, +ertical ban#e# $astroplasty sur$ery% R 5astroenterostomy R 6ill repair R Nissen 'un#oplication R 5astrope*y 8n#oscopy( 8sopha$o$astro#uo#enoscopy 6pper gastrointestinal series

"ppe r 5I Stomach tract

Imaging

Di$esti(e tract

Bariatric sur$ery $Duo#enal s)itch, ,e1unoileal Small bypass% R ,e1unostomy R Ileostomy R %artial ileal bo)el bypass sur$ery :ar$e Colectomy R Colostomy R Appen#icectomy R bo)el 6artmannCs operation !ectu :o)er anterior resection R Ab#ominoperineal :o)e m resection r 5I tract Anal sphincterotomy R :ateral internal Anus sphincterotomy 8n#oscopy( Colonoscopy $+irtual% R %roctoscopy R Si$moi#oscopy R 8nteroscopy R Capsule en#oscopy Imaging 2ransrectal ultrasono$raphy R 8nteroclysis R Small bo)el 'ollo) throu$h R Ab#ominal ultrasono$raphy R :o)er $astrointestinal series 6epatectomy R :i(er transplantation R Arti'icial e*tracorporeal li(er support $:i(er #ialysis, Bioarti'icial li(er #e(ices%

Accessory

:i(er

Cholan$io$raphy $8n#oscopic retro$ra#e cholan$iopancreato$raphy, %ercutaneous 5allbla##e transhepatic cholan$io$raphy, 4a$netic resonance r, bile #uct cholan$iopancreato$raphy% R 7holecystectomy R Cholecysto$raphy R 6IDA scan %ancreatectomy R %ancreatico#uo#enectomy R %ancreas %ancreas transplantation R %uesto) proce#ure R IreyCs proce#ure %eritoneu %aracentesis R Intraperitoneal in1ection Ab#ominopel m (ic 6ernia 6erniorrhaphy R 4ac8)enCs operation Other .aparotomy

#i$esti(e system na"s( anat o' tract,$lan#s,perit,#iaphra$m3physio3#e(, noncon$en3con$en3con$en o' #J)3neoplasia, symptomsJsi$ns3eponymous, proc This entry is from Wi-ipedia, the leading user4contributed encyclopedia. It may not ha"e been re"iewed by professional editors $see 'ull #isclaimer% 0onate to Wi-imedia