Acute cholecystitis notes, Study Guides, Projects, Research of Medical Sciences

Download Acute cholecystitis notes and more Study Guides, Projects, Research Medical Sciences in PDF only on Docsity! GIT surgery acute cholecystitis 1 Biliary Passage * Gall Bladder * Ligamentum teres -_ Fundus Gall Zs Bladder [— Body Ze \4 } , Hepatic artery —— Neck Cystic duct Porta hepatis Right hepatic duct and artery Left hepatic duct and Artery Cystic a. - Accessory cystic arteries Common hepatic duct Inferior surface of liver Hepatic A. Common bile duct Gall Bladder Hartmann's pouch Cystic duct ILV.C. Opening to lesser sac 1° part of duodenum Gastro-duodenal a- 2™ part of duodenum Head of pancreas Common bile duct Empyema of gall bladder c. Gangrenous inflammation:(rare ). Persistence of obstruction — high pressure inside gall bladder — obstruction of blood supply in the wall or thrombosis of blood vessels — gangrene and perforation of the wall. Gangrenous cholecystitis d. Emphysematous cholecystitis. Rare, in diabetics due to infection with anerobic gas forming organism e.g colistridia. Emphysematous cholecystitis 2. Acute non-calcular cholecystitis :(Rare , 2%) e It is more dangerous than calcular cholecystitis . e This occur in ICU patient suffering from major burn, major trauma , sever shock or infection (eg. typhoid). ¢ Changes in the composition of bile or ischaemia of G.B , may be the cause. « The condition is very serious because it is unsuspected and diagnosis is delayed . e Ultrasound is diagnostic & treatment is urgent cholecystectomy. Gallstone blocking cystic duct Gallstones formin in gallbladder Stomach * Consequences and Complications: 1, With treatment , reso/ution in most cases , the stone dislodges and the obstruction is relieved with drainage of bile and gradual resolution of inflammation . 2. Chronicity is the commonest complications , with more stones formation and recurrent acute exacerbations. 3. Local spread of infection \eading to ascending cholangitis , cholangiohepatitis and descending pancreatitis. 4.Gangrene & Perforation :(rare ) + This usually leads to \ocalized peritonitis ( as a defensive mechanism the greater omentum , duodenum and colon adhere to the gall bladder ) or rarely ( 1 % ) generalized peritonitis . ¢The fundus is th most liable because it is the least vascular part of the G.B. «Less commonly perforation may occur at the neck due to pressure necrosis by an impacted stone. ¢ Gangrene of gall bladder is rare because it has numerous 10 b-Local: 1. Tenderness, rebound tenderness and rigidity in the right hypochondrium maximum at the tip of right 9". costal cartilage leading to difficult to palpte GB distention . 2.Limitation of abdominal mobility with respiration in the right hypochondrium. 3. A mass may be felt below the right costal margin in empyema or mucocele of G.B. (mention the characters of G.B. mass). It is difficult to palpate due to tenderness and rigidity . 4. Murphy's sign : A gentle pressure is applied just below the right costal margin then ask the pt, to take a deep breath ~ the pt. will catch her breath. Sonographic Murphy's sign is more accurate in the diagnosis . Wiemmicarenerlite Of eliciting Murphy’ eee saa 5 . Boas’ sign : An area of hyperaeshtesia between 9-11 ribs posterior on the right side ( below right scapula ). Boas sign 11 * Investigations: 1. Blood picture: Shows leucocytosis. 2. Liver function tests are usually normal or rarely serum billirubin may be raised. 3. Ultrasonography: (Most important & first investigation) * It Shows distended G.B., thick wall, micro abscesses & serosal oedema. * It shows 98 % of GB stones and 1/3 of bile duct stones . * Dilatation of CBD and intrahepatic biliary passage indicates stones in the CBD . e It is non-invasive, easy & inexpensive. 4. Plain x-ray : ( replaced by U/S & rarely done nowadays ) e It shows radio-opaque stones (10-20 %) . e Presence of air in the GB in emphysematous cholecystitis . 5. CT scan may be needed in doubtful cases . 6. HIDA scan : °°"Tc is given IV to be excreted rapidly by the liver to visualize the biliary passage . Non-visualization of GB IHBD 12 indicate obstruction of cystic duct and confirm the diagnosis of acute cholecystitis . * D.D : of pain in the right hypochondrium 1- Hepatobiliary diseases : Cholangitis Biliary colic Acute cholecystitis Pain pain in right hypochondriu Duration of pain usually less than 6 usually more than 6 hours Few days hours Fever no fever low grade fever high fever & rigor leucocytosis no leucocytosis Mild leucocytosis Severe leucocytosis jaundice no jaundice e Chronic cholecystitis usually no jaundice e Hepatitis and amoebic liver abscess 2- Acute pancreatitis Jaundice ( Charcot’s triade ) 15 , size of the mass , early manifestations of complications and ultrasound . eResult of conservative treatment: 1. In 90% of cases the acute attack subside — delayed or interval cholecystectomy after 6 weeks . 2. Rarely failure of conservative treatment or development of complications : a) In fit patient : urgent cholecystectomy . or b) In unfit patient : cholecystostomy ( the fundus of gall bladder is opened , remove of stones and drainage of gall bladder by a tube for one week ) followed after 6 weeks by elective cholecystectomy . Urgent cholecystectomy : After rapid pre-operative preparation ( within few hours ) , cholecystectomy should be done as emergency in the following patients : 1- Elderly diabetic ( high mortality & morbidity with time) 2- Pain and tenderness spread across the abdomen(Suggest perforation) 3- Deterioration of the general condition of the patient under conservative treatment . 4- Development of complications . 5- Acute non-calcular cholecystitis . 6- Doubtful diagnosis with deterioration of the general condition of the patient .  * There is conservative treatment in acute cholecystitis while in acute appendicitis there is no conservative treatment due to the followings 16 Acute cholecystitis Acute appendicitis 1-GB receive arterial supply from cystic artery and many blood vessels from the undersurface of the liver . 1- Appendix receive only single arterial supply only from appendicular artery and its tip receive an end branch from this artery . 2-Less virulent organism 2-Highly virulent organism 3-GB has thin wall dispensable with mild increase in its intra- luminal pressure . 2-Appendix has thick rigid wall indispensable with marked increase in its intra- luminal pressure . 4- Rare late perforation 4- Early common perforation Anatomy of the Gallbladder Cystic duct Enlargement of gall blade, tle ‘ducts and arteries bile duct Ascending branch of ileocolic artery leocolic artery Anterior and posterior cecal ‘branches of ileocolic artery Ileal branch of ileocolic artery Mesoappendix Appendicular artery Appendix