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:
Inflammation of the gallbladder in the presence of gallstones.
 *  Calculus Cholecystitis.
 * It is classical to subdivide further :
 * Acute Calculus Cholecystis.
 * Chronic Calculus Cholecystis.

Inflammation of the gallbladder in the absence of gallstones. Give rise to clinical picture similar to calculus cholecystitis.
 *  Acalculous 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:
<ul> <li> Ultrasonography will confirm the diagnosis. </li> </ul>

Chronic calculus cholecystitis:
<font color="#800000">Clinical features: <ul> <li>Right Hypochondrial pain.<ul> <li> Radiation to between the shoulder blades is frequent and it may associated with nausea and vomiting. Fatty foods often precipitate it. </li> <li> During an attack, tenderness in the hypochondrium is present. </li> <li> Murphy's sign may be (+). </li> <li> The temperature and white blood count are elevated. </li> <li> Flatulent dyspepsia: </li> </ul> </li> </ul> <font color="#800000">Diagnosis: <ul> <li> Ultrasonography is usually the only investigation needed to show gallstones. </li> <li> A bile duct &gt;8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation. </li> </ul>

Acute Acalculous Cholecystitis:

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

<font color="#FF0000"> 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.