Surgical Procedures/Abdominal Surgery/Cholecystitis

Cholecystitis

Introduction:

• It is an inflammation of gall bladder.
• Almost always occurs in association with gallstone.
• It is one of the most common indications for abdominal surgery.
• Its epidemiologic disturbance closely parallels to gallstone.

Types of Cholecystitis:

• Calculus Cholecystitis.

            Inflammation of the gallbladder in the presence of gallstones.

• It is classical to subdivide further:
  • Acute Calculus Cholecystis.
  • Chronic Calculus Cholecystis.

• Acalculous Cholecystitis.

            Inflammation of the gallbladder in the absence of gallstones.
            Give rise to clinical picture similar to calculus cholecystitis.

• It is classical to subdivide further:
  • Acute Acalculous Cholecystitis.
  • Chronic Acalculous Cholecystitis.

Acute Calculus Cholecystitis:

• Precipitated 90% of the time by gallstone obstruction of the:
  • Neck of the gallbladder.
    • Gallstone impacted in Hartmann's pouch.
  • Cystic duct.
• Caused by Bile infections:
  • E.coli.
  • Klebsiella sp.
  • Streptococcus faecalis (Keighley).
  • Strict anaerobes, e.g. Bacteroides sp.
  • Gas forming organisms, e.g. clostridia.
  • Typhoid infection.

• It is the primary complication of gallstones.
• One of the most common reasons for emergency cholecystectomy.

Sequel of Acute Cholecystitis attack:

• When a certain degree of distension of the gall bladder has been reached, the mucous membrane tends to be lifted away from the sides of the stone and, as a consequence, the stone may slip back into the body of the gallbladder, and any mucoid (from a mucocele) or mucopurulent contents of the gallbladder escape by way of the cystic duct.
•  Less frequently, the impaction persists and an empyema (pyocele) of the gallbladder results.
•  On rare occasions, the distended, inflamed gallbladder perforates.

Clinical features of acute calculus cholecystitis:

• The onset is sudden.
• Pain is located in mainly in the right hypochondrium.

Diagnosis of Acute Calculus Cholecystitis:

• Ultrasonography will confirm the diagnosis.

Chronic calculus cholecystitis:

Clinical features:

• Right Hypochondrial pain.
  • Radiation to between the shoulder blades is frequent and it may associated with nausea and vomiting. Fatty foods often precipitate it.
  • During an attack, tenderness in the hypochondrium is present.
  • Murphy's sign may be (+).
  • The temperature and white blood count are elevated.
  • Flatulent dyspepsia:

Diagnosis:

• Ultrasonography is usually the only investigation needed to show gallstones.
• A bile duct >8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation.

Acute Acalculous Cholecystitis:

• Particularly seen in patients recovering from:
  • Major surgery.
  • Trauma.
  • Burns.

NB!    In these patients the diagnosis is often missed and the mortality rate is 20 %.

• Diagnosis:
  • Oral cholecystography is more useful than Ultrasonography in those presenting with chronic symptoms.
  • Radioisotope scanning for presenting with acute symptoms.
  • Cholesterol crystals in duodenal aspirate may also help.

Treatment:

Treatment of choice:

• Laparoscopic cholecystectomy.
• Open cholecystectomy.
• Percutaneous transhepatic placement of a cholecystostomy tube.