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Tamarah P. Cristobal, M.D.

 R.B.

 39 year old
 Female

 Filipino

 Single

 Roman Catholic

 Pasay City
 Abdominal Pain
 7 months prior to admission
 Abdominal pain located at the right upper quadrant,
aggravated by consumption of oily and fatty foods.
 Associated with a burning epigastric pain and acid reflux.
 No associated vomiting nor fever was noted
 Consulted a private physician and UTZ was done which
revealed a 1.5cm stone in her gallbladder
 She was advised to undergo an operation but the patient
did not comply
 She was prescribed with unrecalled medications to which
the patient did not comply as well.
 Two months prior to admission
 Recurrence of the above signs and symptoms.
 Consulted her private physician and another
ultrasound was done which revealed 1 1.4cm
stone in her gallbladder.
 She was again advised to have an operation but
the patient declined.
 No medications were given.
 One week prior to admission
 Recurrence of the same signs and symptoms.
 Consulted her private physician who again
advised her to have the stone surgically removed.
 Patient decided to finally comply so she set for
the date, hence this admission.

 The patient is a known Hypertensive for 6 years

 Highest BP of 150/100 and a Usual BP of 120/80
 Prescribed with Metoprolol 10mg OD as
maintenance but the patient is poorly compliant
 She is a non diabetic and a non asthmatic.
 No allergy to food nor drugs
 No other operations prior to this admission

 Maternal aunt is a known Diabetic.

 There are no other heredofamilial diseases
such as Hypertension, Asthma,
Cardiovascular diseases, Respiratory
Diseases, Kidney Diseases, nor cancer noted

 Semi conductor operator

 Non smoker

 Non alcoholic beverage drinker.

 Regular monthly period
 28 day cycle

 Lasts 3-5 days

 Consumes 3 pads per day

 Occasional dysmenorrhea noted

 Mefenamic Acid 500mg prn

 Single

 No coitus yet
 No pap smear done
 G0P0 (0-0-0-0)
 Patient is conscious, coherent, afebrile, and not in
cardiorespiratory distress
 Vital Signs:
BP: 130/90mmHg PR: 80 RR: 20 TEMP: 36.7C
 anicteric sclera, pink palpebral conjunctiva, no nasal discharge,
no tonsillopharyngeal congestion, no cervicolymphadenopathies
 symmetrical chest expansion, no retractions, clear breath sounds
 adynamic precordium, normal rate regular rhythm, PMI at the 5th
LICS, no murmurs
 Flat abdomen, normoactive bowel sounds, soft, + tenderness on
right upper quadrant, (+) Murphy’s sign, no organomegaly
 full and equal pulses, no edema, no cyanosis

 Located in the bed of the liver in line with that
organ's anatomic division into right and left
 It is a pear-shaped organ with an average
capacity of 50 mL
 Divided into four anatomic portions: the
fundus, the corpus or body, the infundibulum,
and the neck.
 Fundus is the rounded, blind end
 Normally extends beyond the liver's margin

 It may be unusually kinked and present the

appearance of a “phrygian cap.”
 It contains most of the smooth muscle of the
 Corpus or body, which is the major storage
area and contains most of the elastic tissue.
 The body tapers into the neck, which is
funnel-shaped and connects with the cystic
 The neck usually follows a gentle curve, the
convexity of which may be distended into a
dilatation known as the infundibulum, or
Hartmann's pouch.
 The wall of the gallbladder is made up of
smooth muscle and fibrous tissue
 Lumen is lined with a high columnar
epithelium that contains cholesterol and fat
 The mucus secreted into the gallbladder
originates in the tubular alveolar glands in the
globular cells of the mucosa lining the
infundibulum and neck.
 The gallbladder is supplied by the cystic artery,
which normally originates from the right hepatic
artery behind the cystic duct.
 It is approximately 2 mm in diameter and courses
above the cystic duct for a variable distance, until it
passes down the peritoneal surface of the
gallbladder and branches.
 Venous return is carried through small veins, which
enter directly into the liver from the gallbladder, and
a large cystic vein, which carries blood back to the
right portal vein.
 Lymph flows directly from the gallbladder to
the liver and drains into several nodes along
the surface of the portal vein.
 The nerves of the gallbladder arise from the
celiac plexus and lie along the hepatic artery
 Motor nerves are made up of vagus fibers
mixed with postganglionic fibers from the
celiac ganglion.
 The preganglionic sympathetic level is at T8
and T9
 Sensory supply is provided by fibers in the
sympathetic nerves coursing to the celiac
plexus through the posterior root ganglion at
T8 and T9 on the right side.
 The gallbladder is connected with the common duct system via
the cystic duct, which joins the common hepatic duct at an acute
 The segment of the cystic duct adjacent to the gallbladder bears
a variable number of mucosal folds that have been referred to as
the “valves of Heister” but do not have any valvular function.
 Immediately behind the cystic duct resides the right branch of the
hepatic artery.
 The length of the cystic duct is highly variable, though the
average is around 4 cm.
 Variations of the cystic duct and its point of union with the
common hepatic duct are surgically important.
 The cystic duct may run parallel to the common
hepatic duct and actually be adherent to it. I
 It may be extremely long and unite with the hepatic
duct at the duodenum.
 It may be absent or very short and have a high
(cephalad) union with the hepatic duct, in some
cases joining the right hepatic duct instead.
 The cystic duct may spiral anteriorly or posteriorly in
relation to the common hepatic duct and join it on
the left side.
 Understanding the
 The Gallbladder is a small, pear-
shaped organ in the abdomen.
Its job is to store and release
bile, a fluid made by the liver.
Bile helps break down fats in the
food you eat. Normally, bile
moves smoothly through the
digestive system. But if stones
form in the gallbladder, they can
block the release of bile. This
can cause pain and lead to
serious complications.
 Your liver makes bile.
Most of the bile is sent
through a network of
ducts to the duodenum
(first part of the small
intestine). A small
amount of bile is also
sent to the gallbladder
for storage.
 The gallbladder
stores some bile. The
concentrates the bile by
removing the water.
When bile is needed to
digest fats, hormones
(chemical messengers)
signal the gallbladder to
squeeze bile out
through the cystic duct.
 Bile is sent to the
duodenum. The bile
moves through the
common bile duct to
the duodenum. There,
it mixes with food. The
pancreas adds other
digestive juices.
Digestion continues in
the small intestine
When Gallstones Form
 Most gallbladder problems are caused by
gallstones. These form when substances in the bile
crystallize and become solid. In some cases, the
stones don't cause any symptoms. In others, they
irritate the wall of the gallbladder. Most serious
problems occur if the stones move into nearby ducts
and cause blockages. This stops the flow of bile
and can lead to pain, nausea, and infection.
Jaundice ( a buildup of bile chemical in the blood)
can also occur. Symptoms include yellowing of the
skin and eyes, dark urine, and itching.
obstruction of the neck of the gallbladder or cystic duct caused by stones
impacted in Hartmann's pouch

Direct pressure of the calculus on the mucosa

ischemia, necrosis, and ulceration with

swelling, edema, and impairment of venous return.

increase and extend the intensity of the inflammation.

 Vascular effects of collagen disease
 Terminal states of hypertensive vascular
 Thrombosis of the main cystic artery

 Acute cholecystitis in which the gallbladder is

devoid of stones is known as acalculous
 Can occur at any age
 But the greatest incidence
is between the fourth and
eighth decades
 Patients over the age of
sixty comprise between
one- quarter and one-third
of the group
 Caucasians are afflicted
more frequently than blacks
 Women more than men.
 The onset of acute symptoms is frequently related
to a vigorous attempt of the gallbladder to empty its
contents, usually after a heavy, fatty, or fried meal.
 Moderate to severe pain is experienced in the right
upper quadrant and epigastrium and may radiate to
the back in the region of the angle of the scapula or
in the interscapular area.
 The patient is often febrile, and vomiting may be
severe. Tenderness, usually along the right costal
margin, often associated with rebound tenderness
and spasm, is characteristic.
 The gallbladder may be palpable, or a
palpable mass in the region may be the result
of omentum wrapped around the gallbladder.
 Mild icterus may be present and may be
caused by calculi within the ampulla and
edema encroaching on the common duct.
 Perforationor penetration of peptic ulcer
 Appendicitis

 Pancreatitis

 Hepatitis

 Myocardial ischemia or infarction

 Pneumonia

 Pleurisy

 Herpes zoster involving an intercostal nerve.

 The hemogram usually demonstrates leukocytosis
with a shift to the left.
 Radiographs of the chest and abdomen are
indicated to rule out pneumonia.
 A radiopaque calculus is noted in less than 20
percent of cases.
 The serum bilirubin level may determine the
presence of common duct obstruction. Although an
elevated amylase level is generally regarded as
evidence of acute pancreatitis, levels as high as
1000 Somogyi units have been associated with
acute cholecystitis uncomplicated by pancreatitis.
 To rule out myocardial ischemia, an
electrocardiogram should be performed on
any patient over the age of forty-five being
considered for surgical treatment.
 An ultrasonogram may demonstrate calculi
and/or a thickened wall of the gallbladder and
is the diagnostic procedure of choice.

 There have been conflicting opinions on the
management of acute cholecystitis, particularly on
the optimal time for surgical intervention.
 For the purposes of discussion, early operation is
defined as one performed within 72 h after the onset
of symptoms;
 intermediate operation is one carried out between
72 h and the cessation of clinical manifestations;
 Delayed operation permits the acute inflammatory
process to subside; and
 scheduled elective surgery is performed after an
interval of 6 weeks to 3 months.
 Most surgeons now favor early operation, i.e.,
with 24 to 48 h.
 The mortality rate for emergent
cholecystectomy ranges from 0 to 5 percent.
 In the majority of cases, laparoscopic
cholecystectomy is successful, but the
incidence of conversion to open
cholecystectomy is greater in this group of
patients when compared to those without
acute inflammation.
 Accomplishes decompression and drainage of the
distended, hydropic, or purulent gallbladder
 It is particularly applicable if the patient's general
condition is such that it precludes prolonged
anesthesia, since the operation may be performed
under local anesthesia
 It is also performed in cases in which marked
inflammatory reaction obscures the anatomic
relation of critical structures
 Cholecystostomy may be a definitive procedure,
particularly if a postoperative tube cholangiogram is

 Theapplication of minimally invasive surgical

techniques to removal of the gallbladder has
emerged as the preferred way of treating
symptomatic gallstone disease. Although a
subcostal incision is avoided, these
operations should be viewed with the same
respect for surgical principles as are the open
 A harmless gas
inflates the abdomen.
The gas lifts the
abdominal wall away
from the internal
organs. This lets your
surgeon have a clear
view of the gallbladder
through the
 A cholangiogram catheter
may be inserted. The
catheter is a thin tube used
to inject a special dye into
the bile duct. Once the dye
has been injected, an x-ray
is taken of the duct. This
helps show whether any
stones have moved from
the gallbladder into the duct.
 Small clips close off the
bile duct and blood
vessels. The clips help
prevent bleeding and bile
leaks. Once the clips are in
place, the gallbladder is
detached from the liver.
The clips are made of metal
(titanium) or plastic that
does not harm the body.
They are left in place.
 The gallbladder is lifted
for removal. The neck of
the gallbladder is raised
through an incision. The
contents of the gallbladder,
including any stones, may
be removed. The
gallbladder is then carefully
lifted out through the
incision. Bile will now flow
directly from the liver into
the small intestine.
 If Open Surgery is Needed Your
doctor may decide during surgery to
switch from a laparoscopic to an
open approach. This does NOT
mean something has gone wrong.
Instead, it is done when your doctor
feels it is safer to remove the
gallbladder through a larger
incision. If you have open surgery,
the same methods are used to close
off the ducts and blood vessels.
The main difference is that you will
have a larger incision in your
abdomen. Having open surgery
also means a longer hospital stay
and recovery period after the