ACUTE CHOLECYSTITIS

MS, MAIS, FICS(USA), FMAS, Dipl. In Laproscopic surgery, Fellow in Robotic & Lap. Colo-Rectal Surgery(korea univ.) CONSULTANT GEN. SURGEON LAPROSCOPIST & COLOPROCTOLOGIST

DR DILIP S.RAJPAL

HON SURGEON NOVA MEDICAL CENTRE HON SURGEON GODREJ MEMORIAL HOSPITAL HON. ASS PROF GRANT MED. COLLEGE HON.SURGEON JJ. HOSPITAL EX-ASST. PROF L.T.M.GEN. HOSPITAL

ANATOMY OF GIT
FOREGUT MIDGUT HINDGUT

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

PATHOPHYSIOLOGY
OBSTRUCTION STASIS DISTENTION INCREASE IN INTRALUMINAL PRESSURE STIMULATION OF INFLAMATORY MEDIATORS COMMENSALS BECOME VIRULENT INFECTION
CONSULTANT

GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJPAL

VISCERAL PAIN
DULL, CRAMPY OR ACHING PAIN. GEOMETRIC FORCES SUCH AS DISTENTION, STRETCHING, TRACTION, CONTRACTION & CERTAIN CHEMICALS GIVE RISE TO PAIN. ALWAYS FELT IN MIDLINE.

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP S.RAJ

DEFINITION
Inflammation of gall bladder is called ACUTE CHOLECYSTITIS .

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

INCIDENCE
COMMON IN FERTILE FATTY ABOVE FORTY FEMALES

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

AETIOLOGY
1 CALCULOUS Obstruct cystic duct 2 ACALCULOUS Cholesterosis(strawberry gall bladder) Cholesterol polyposis of gall bladder Cholecystitis glandularis proliferans Diverticulosis of gall bladder Typhoid of gall bladder
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

 BACTERIAL INFECTION

E-coli Klebsiella S.faecalis Salmonella Clostridia Anaerobes

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

 SEVERE ILLNESS
Ileus Sepsis Severe burns/injuries Starvation Multiple blood transfusions

CARCINOMA
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

INFLAMMATION LOCALIZATION Ileus Movement of omentum Loops of intestine RESOLUTION EMPYEMA MUCOCELE PERFORATION GENERALIZED PERITONITIS LOCAL ABSCESS FISTULA

PATHOLOGY

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

CLINICAL FEATURES
PAIN
SITE - RIGHT HYPOCHONDRIUM TYPE - COLICKY ONSET SUDDEN
BACK SHOULDER RIGHT HYPOCHONDRIUM LEFT HYPOCHONDRIUM

DURATION MORE THAN 12 hrs

RADIATION

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

PRECIPITATING FACTORS Fatty Food Movement Breathing RELIEVING FACTORS Analgesics FEVER NAUSEA/VOMITING DISTENTION/CONSTIPATION JAUNDICE

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

SIGNS
TACHYCARDIA PYREXIA

GENERAL LOCAL

TENDERNESS - RT HYPOCHONDRIUM RIGIDITY - RT HYPOCHONDRIUM MURPHYS SIGN MASS

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

INVESTIGATIONS
BLOOD COMPLETE PICTURE LEUCOCYTOSIS URINE BILIRUBIN PLAIN X-RAY ABDOMEN Radioopaque gall stones

ULTRASONOGRAPHY
Dilatation of billiary tree Stones Fluid

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

GALL BLADDER RADIONUCLIDE SCAN ORAL CHOLECYSTOGRAM PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

ABDOMINAL ULTRASOUND SHOWING GALL STONES DR DILIP S.RAJP

DIFFERENTIAL DIAGNOSIS
COMMON ACUTE PANCREATITIS PERFORATED DUODENAL ULCER PERFORATED PEPTIC ULCER APPENDICITIS

RARE ACUTE PYELONEPHRITIS HEPATITIS MYOCARDIAL INFARCTION PNEUMONITIS C ONSULTANT GEN. SURGEON
LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

COMPLICATIONS
EMPYEMA PERFORATION PERITONITIS ABSCESS FISTULA MUCOCELE ACUTE PANCREATITIS GALL STONE ILEUS OBSTRUCTIVE JAUNDICE
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Definitions
Symptomatic Wax/waning postprandial epigastric/RUQ cholelithiasis pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT Acute cholecystitis Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, WBC, LFT, +Murphys = inspiratory arrest

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Chronic cholecystitis -Recurrent bouts of colic/acute choly leading to chronic GB wall inflamm/fibrosis. No fever/WBC. Acalculous cholecystitis -GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Choledocho-lithiasis -Gallstone in the common bile duct (primary means originated there, secondary = from GB) Cholangitis -Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 1
46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now. No prior episodes Minimal RUQ tenderness, no Murphys WBC 8, LFT normal RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid Diagnosis: ?
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 1
denotes gallstones

denotes the acoustic shadow due to absence of reflected sound waves behind the gallstone

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Symptomatic cholelithiasis

aka biliary colic The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes Pain usually lasts 1-5 hrs, rarely > 24hrs Ultrasound reveals evidence at the crime scene of the likely etiology: gallstones Exam, WBC, and LFT normal in this case Treatment: Laparoscopic C ONSULTANT GEN. SURGEON cholecystectomy DR DILIP S.RAJP LAPROSC OPIST & COLOPROCTOLOGIST

Spectrum of Gallstone Disease

Cholelithiasis

Symptomatic cholelithiasis can be a herald to:

an attack of acute cholecystitis or ongoing chronic cholecystitis

Asymptomatic Symptomatic cholelithiasis cholelithiasis

Chronic calculous cholecystitis

Acute calculous cholecystitis

May also resolve

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 2
Same case, except pt has had multiple prior attacks of similar RUQ pain No fever or WBC Ultrasound reveals gallstones, thickened GB wall, no pericholecystic fluid Diagnosis: ? C ONSULTANT GEN. SURGEON

LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Chronic calculous cholecystitis

Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones Overtime, leads to scarring/wall thickening Treatment: laparoscopic cholecystectomy
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 3
Same pt, now > 24hrs of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever Exam: Palpable, tender gallbladder, guarding, +Murphys = inspiratory arrest WBC 13, Mild LFT U/S: gallstones, wall thickening (>4mm), GB distension, pericholecystic fluid, sonographic Murphys sign (very specific) Diagnosis: ?
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 3
Curved arrow
Two small stones at GB neck

Straight arrow
Thickened GB wall

pericholecystic fluid = dark lining outside the wall

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 3

denotes the GB wall thickening denotes the fluid around the GB GB also appears distended

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Acute calculous cholecystitis

Persistent cystic duct obstruction leads to GB distension, wall inflammation &edema Can lead to:empyema, gangrene, rupture Pain usu. persists >24hrs & a/w N/V/Fever Palpable/tender or even visible RUQ mass Nuclear HIDA scan shows nonfiling of GB
If U/S non-diagnostic, obtain HIDA

Tx: NPO, IVF, Abx (GNR & enterococcus) DR DILIP S.RAJP Sg: Cholecystectomy usu within 48hrs

Case 4
87yo M critically ill, on long-term TPN w RUQ pain, fever, WBC Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones Diagnosis: ?

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Acute acalculous cholecystitis

In 5-10% of cases of acute cholecystitis Seen in critically ill pts or prolonged TPN More likely to progress to gangrene, empyema, perforation due to ischemia Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin Tx: Emergent cholecystectomy usu open If pt is too sick, perc cholecystostomy tube and interval cholecystectomy later C ONSULTANT GEN. SURGEON DR DILIP S.RAJP onOPIST & COLOPROCTOLOGIST LAPROSC

Complications of acute cholecystitis

Empyema of gallbladder Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever

Emphysematous More commonly in men and diabetics. cholecystitis Severe RUQ pain, generalized sepsis.

Imaging shows air in GB wall or lumen Occurs in 10% of acute choly, usually becomes a contained abscess in RUQ Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)

Perforated gallbladder

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 5
46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers Known history of cholelithiasis Exam: unremarkable WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg Ultrasound: Gallstones, CBD stone, dilated CBD > 1cm Diagnosis: ?
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Choledocholithiasis
Can present similarly to cholelithiasis, except with the addition of jaundice DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain Tx: Endoscopic retrograde cholangiopancreatography (ERCP)
Stone extraction and sphincterotomy

Interval cholecystectomy after recovery from ERCP

C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 6
46yo F p/w fever, RUQ pain, jaundice (Charcots triad) If also altered mental status and signs of shock = Raynauds pentad VS tachycardic, hypotensive ABCs, Resuscitate
2 large bore IV, Foley, Continuous monitor 1-2L fluid bolus, repeat until resuscitated

Diagnosis: ?
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Cholangitis
Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures Charcots triad seen in 70% of pts May lead to life-threatening sepsis and septic shock (Raynauds pentad) Tx: NPO, IVF, IV Abx Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC) Used to require emergency laparotomy
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Case 7
46yo F p/w persistent epigastric & back pain Known history of symptomatic gallstones No EtOH abuse Exam: Tender epigastrum Amylase 2000, ALT 150 Ultrasound: Gallstones Diagnosis: ?
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP

Gallstone pancreatitis
35% of acute pancr 2ndary to stones Pathophysiology
Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone

ALT > 150 (3-fold elevation) has 95% PPV for diagnosing gallstone pancreatitis Tx: ABC, resuscitate, NPO/IVF, analgesic Once pancreatitis resolving, ERCP w stone extraction/sphincterotomy Cholecystectomy before hosp discharge

Take Home Points

As always, ABC & Resuscitate before Dx Understanding the definitions is key Is this acute cholecystitis? (fever, WBC, tender on exam with positive Murphys) Or simply cholelithiasis vs ongoing chronic cholecystitis? (no fever/WBC) Is patient sick or toxic-appearing, to suspect empyema, gangrene or even perforation? Elicit h/o jaundice, acholic stools, tea-colored urine Rule out cholangitis, because this will kill the patient unless dx & tx early
C ONSULTANT GEN. SURGEON LAPROSC OPIST & COLOPROCTOLOGIST

DR DILIP S.RAJP