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DEFINITIONS The term cholecystitis refers to inflammation of the gallbladder.

Gallstones acute cholecystitis Acalculous cholecystitis. Chronic cholecystitis 2


INTRODUCTION 1.Acute cholecystitis predominantly occurs as a complication of gallstone disease and typically develops in patients with a history of symptomatic gallstones. 2. 6 to 11 percent of patients with symptomatic gallstones over a median follow-up of 7 to 11 years

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Acute cholecystitis Refers to a syndrome of

Right upper quadrant pain, Fever Leukocytosis 4


Acute Cholecystitis •Severe persistent pain •+/- Jaundice •Positive Murphy’s Sign

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Acute Cholecystitis • Distention and inflammation of the gallbladder • Obstruction of cystic duct ⇒ Chemical irritants in

the bile • Lysolecithin • Prostaglandins

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Acute Cholecystitis

• Persistent cystic duct obstruction • Pain lasts > 4 hours • Usually fatty food ingestion ≥ 1 hr before pain • ≠ Biliary Colic

3= Cleveland Clinic Journal of Med 7


Acute Cholecystitis • Early stages ⇒ Edema and hyperedemia • Later stages ⇒ Adhesions, fibrosis, and necrosis • Triangle of Calot visible in early stages Courtesy of Netter

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cholesterol stones pigment stones black pigment stones brown pigment stones

     

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10~20



0.3 0.02 50

  

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Anatomy :Calot's triangle

The triangle of Calot is bounded by the cystic duct, the common hepatic duct, and the inferior border of the liver. (From Gilchrist BF, Trunkey DD, Biliary Tract trauma. In Zuidema GD [ed]: Shackelford's surgery of the alimentary tract, 3rd ed. WB 11 Saunders, Philadelphia, 1991, pp 257.)


Acalculous cholecystitis Acute cholecystitis but is not associated with gallstones and usually occurs in critically ill patients 10 percent of cases of acute cholecystitis Associated with high morbidity and mortality rates 12


Chronic cholecystitis Chronic inflammatory cell infiltration of the gallbladder The result of mechanical irritation or recurrent attacks of acute cholecystitis leading to fibrosis and thickening of the gallbladder .

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Chronic cholecystitis Its presence does not correlate with symptoms since patients with extensive chronic inflammatory cell inflammation may have only minimal symptoms, and there is no evidence that chronic cholecystitis increases the risk for future morbidity

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PATHOGENESIS  Infection of bile within the biliary system probably

has a role in the development of cholecystitis not all patients with cholecystitis have infected bile.  Patients with gallstones, acute cholecystitis, and hydropic gallbladder had similar rates of positive cultures in the gallbladder and common bile duct, ranging from 22 to 46 percent.  The main species isolated were Escherichia coli, Enterococcus, Klebsiella, and Enterobacter. 15


 Histologic changes: mild edema and acute

inflammation to necrosis and gangrene.  Prolonged impaction of a stone in the cystic duct

can lead to a distended gallbladder that is filled with colorless, mucoid fluid. This condition, known as a mucocele with white bile (hydrops)

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CLINICAL MANIFESTATIONS  The clinical manifestations of acute cholecystitis

include 1. Prolonged (more than four to six hours), steady, severe right upper quadrant or epigastric pain, 2. Fever, 3. Abdominal guarding, 4. Positive Murphy's sign 5. Leukocytosis. 17


CLINICAL MANIFESTATIONS  History —

1.Complain of abdominal pain, most commonly in the right upper quadrant or epigastrium. 2. May radiate to the right shoulder or back 3. Include fever, nausea, vomiting, and anorexia. 4. Often a history of fatty food ingestion one hour or more before the initial onset of pain. 18


CLINICAL MANIFESTATIONS  Physical examination —

1. usually ill appearing, febrile, and tachycardic 2. Frequently will have a positive Murphy's sign 3. abdominal crepitus (emphysematous cholecystitis), 4. bowel obstruction (gallstone ileus).

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CLINICAL MANIFESTATIONS  Laboratory evaluation —

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1. Leukocytosis 2. Total bilirubin and alkaline phosphatase Cholangitis, hepatitis, choledocholithiasis, or Mirizzi syndrome (a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct 3. Amylase, along with hyperbilirubinemia and jaundice may be due to the passage of small stones, sludge, or pus.


DIAGNOSIS  Presenting with right upper quadrant or

epigastric pain, fever leukocytosis. Positive Murphy's sign  Confirmation of the diagnosis sonographic Murphy‘s sign Gallbladder wall thickening or edema, Cholescintigraphy 21


Murphy's sign  Patients with acute cholecystitis frequently have

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a positive "Murphy's sign". To check for a Murphy's sign, the patient is asked to inspire deeply while the examiner palpates the area of the gallbladder fossa just beneath the liver edge. Deep inspiration causes the gallbladder to descend toward and press against the examining fingers, which in patients with acute cholecystitis commonly leads to increased discomfort and the patient catching his or her breath.  In one study, using cholescintigraphy as the gold standard, the sensitivity and specificity of a positive Murphy's sign were 97 and 48 percent, respectively . However, the sensitivity may be diminished in the elderly


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Imaging studies  Ultrasonography is usually the first test obtained

and can often establish the diagnosis.  Nuclear cholescintigraphy may be useful in cases

in which the diagnosis remains uncertain after ultrasonography

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Ultrasonography  sonographic features include:  â—?Gallbladder wall thickening (greater than 4 to 5

mm) or edema (double wall sign).  â—?A "sonographic Murphy's sign".

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Acute Cholecystitis

• Thickened gallbladder wall or edema • Pericholecystic Fluid • Sonographic Murphy’s Sign

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Acute Cholecystitis

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Cholescintigraphy (HIDA scan)  Cholescintigraphy using 99mTc-hepatic

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iminodiacetic acid (generically referred to as a HIDA scan) is indicated if the diagnosis remains uncertain following ultrasonography. Technetium labeled hepatic iminodiacetic acid (HIDA) is injected intravenously and is then taken up selectively by hepatocytes and excreted into bile  The HIDA scan is also useful for demonstrating patency of the common bile duct and ampulla. Normally, visualization of contrast within the common bile duct, gallbladder, and small bowel occurs within 30 to 60 minutes .  The test is positive if the gallbladder does not visualize.


Morphine cholescintigraphy  A modified version of the HIDA scan has been

described in which patients are given intravenous morphineduring the examination. Morphine increases sphincter of Oddi pressure, thereby causing a more favorable pressure gradient for the radioactive tracer to enter the cystic duct. This modification is thought to be particularly useful in critically ill patients, in whom standard HIDA scanning may be associated with false positive results. However, the test has not been well standardized and has not gained wide acceptance. 30


Magnetic resonance cholangiography Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive technique for evaluating the intrahepatic and extrahepatic bile ducts  MRCP was superior to ultrasound for detecting stones in the cystic duct (sensitivity 100 versus 14 percent)  However, MRCP may be appropriate if there is concern that the patient may have a stone in the common bile duct. 

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Computed tomography  Abdominal computed tomography (CT) is usually

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unnecessary in the diagnosis of acute cholecystitis, although it can easily demonstrate gallbladder wall edema associated with acute cholecystitis.  CT findings include pericholecystic stranding and fluid, and high-attenuation bile .  However, CT may fail to detect gallstones because many stones are isodense with bile.  CT can be useful when complications of acute cholecystitis (such as emphysematous cholecystitis or gallbladder perforation) are suspected or when other diagnoses are being considered.


DIFFERENTIAL DIAGNOSIS  Biliary colic :usually caused by the gallbladder

contracting in response to a fatty meal, pressing a stone against the gallbladder outlet or cystic duct opening.  The pain is entirely visceral in origin, without true gallbladder wall inflammation, so peritoneal signs are absent.  Patients with biliary colic are afebrile with normal laboratory studies. As the gallbladder relaxes, the stones often fall back from the cystic duct. 33


 A variety of other conditions can give rise to symptoms in the

           

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upper abdomen, which may be confused with biliary colic or acute cholecystitis. These include: ●Acute pancreatitis. ●Appendicitis. ●Acute hepatitis. ●Peptic ulcer disease. ●Nonulcer dyspepsia. ●Irritable bowel disease. ●Functional gallbladder disorder. ●Sphincter of Oddi dysfunction. ●Diseases of the right kidney. ●Right-sided pneumonia. SLE ●Fitz-Hugh-Curtis syndrome (perihepatitis caused by gonococcal infection). Right upper quadrant pain with fever and even a possible positive Murphy's sign in patients at high risk for sexually transmitted diseases should raise this possibility. The HIDA scan is usually negative, but pericholecystic fluid may be confused with acute cholecystitis


COMPLICATIONS  The most common complication is the development of

gallbladder gangrene (up to 20 percent of cases)  Gangrene — Gangrenous cholecystitis is the most common complication of cholecystitis, particularly in older patients, patients with diabetes, or those who delay seeking therapy . The presence of a sepsis-like picture in addition to the other symptoms of cholecystitis suggests the diagnosis  Perforation — Perforation of the gallbladder usually occurs after the development of gangrene. It is often localized, resulting in a pericholecystic abscess). Less commonly, perforation is free into the peritoneum, leading 35 to generalized peritonitis. Such cases are associated with a high mortality rate.


COMPLICATIONS  Cholecystoenteric fistula — A cholecystoenteric fistula

may result from perforation of the gallbladder directly into the duodenum or jejunum. Fistula formation is more often due to long standing pressure necrosis from stones than to acute cholecystitis .  Gallstone ileus — Passage of a gallstone through a cholecystoenteric fistula may lead to the development of mechanical bowel obstruction, usually in the terminal ileum (gallstone ileus) 36


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Management of Acute Cholecystitis • Supportive care with IVFs, bowel rest, & Abx • Almost half of patients have positive bile

cultures • E. Coli is most common organism

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Management of Acute Cholecystitis • Antibiotic choice: Ampicillin + Aminoglycoside

or 3rd generation cephalosporin • No evidence exists showing a definite benefit with use of antibiotics • NSAIDs may improve course of acute

cholecystitis • SURGERY is the only definitive treatment • “Golden 72 hours” Rule 39


Surgery for Calculous Biliary Disease Laparoscopic Cholecystectomy

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Indications for Open Cholecystectomy 1. Poor pulmonary or cardiac reserve 2. Suspected or known gallbladder cancer 3. Cirrhosis and portal hypertension 4. Third-trimester pregnancy 5. Combined procedure

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LC vs OC and timing of surgery • LC compared with OC has decreased pain

and disability without an increase in morbidity or mortality • LC is more cost-effective • Outcome of LC influenced by expertise of surgeon

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LC vs OC and timing of surgery • ASA scale useful but difficult to classify all

patients • Percutaneous cholecystostomy(PTGBD) useful alternative in ASA IV, V patients BUT 50% still require surgery • Conversion from laparoscopic to open cholecystectomy should not be viewed as a complication • Conversion must occur if anatomy is obscured or excessive bleeding occurs 48


LC vs OC and timing of surgery • Increased chance of gangrene of the gallbladder

after 72 hrs • Elderly, diabetics, obese patients, and debilitated

patients can safely undergo laparoscopic cholecystectomy for acute cholecystitis • Should be performed within 72 hrs of admission • If > 72 hours since admission, then evidence

supports attempted lap chole with a low threshold for conversion to an open procedure 49


Biliary Injury & Laparoscopic Cholecystectomy

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Causes of Biliary Injury in LC  Failure to properly occl. the cystic duct  Injury to the ducts in the liver bed caused by

entering a plane too deep to the gallbladder  Cautery Misuse – thermal necrosisductal tissue loss  Pulling forcefully up on the gallbladder when clipping the cystic duct  tenting injury to the junction of the CBD & common hepatic duct

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Biliary Injuries During Cholecystectomy (CCY)

 Reviews revealed the incidence of biliary injury

during open CCY to be 0.1-0.3%  1995 – Strasberg’s study which incl. more than 124,000 laparoscopic cholecystectomies (LC) reported in the literature found the incidence of major bile duct injury to be 0.5%.

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 52 180 (1) : 101-25.


Strasberg & Soper classificaiton of bile duct injuries  Type A – bile leak from minor



  

duct still in continuity w/ the CBD…cystic duct or liver bed Type B – occlusion of part of the biliary tree; ex. Result of an injury to an aberrant right hepatic duct. Type C – leak from duct NOT in communication w/ CBD Type D – lateral injury to extrahepatic bile duct Type E – circumferential injury

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Choledocholithotomy + T-tube drainage

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Natural orifice transluminal endoscopic surgery (NOTES)

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PTGBD 57


cholecystostomy 58


Take home information  â—?Acute cholecystitis refers to a syndrome of right

upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation and is usually related to gallstone disease.  â—?Patients with acute cholecystitis typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium. The pain may radiate to the right shoulder or back. Characteristically, acute cholecystitis pain is prolonged (more than four to six hours), steady, and severe. Associated complaints may include nausea, vomiting, and anorexia. 59


Take home information â—? Positive Murphy's sign supports the diagnosis. However, history, physical examination, and laboratory test findings are not sufficient to make the diagnosis. Confirmation of the diagnosis requires demonstration of gallbladder wall thickening or edema, a sonographic Murphy's sign, or failure of the gallbladder to fill during cholescintigraphy

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Take home information  â—?Acute cholecystitis must be distinguished from the more

benign condition of biliary colic, which presents with the same type of pain. Most patients who develop acute cholecystitis have had previous attacks of biliary colic. The following features may help to distinguish an attack of biliary colic from acute cholecystitis.  •The pain of biliary colic typically reaches a crescendo and then resolves completely. Pain resolution occurs when the gallbladder relaxes, permitting stones to fall back from the cystic duct. An episode of right upper quadrant pain lasting for more than four to six hours should raise suspicion for acute cholecystitis.  •Patients with biliary colic do not have signs of peritonitis 61 on examination and have normal laboratory tests.


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