Theoretical question 94

ACUTE AND CHRONIC CHOLECYSTITIS. ETIOLOGY,

CLASSIFICATION, CLINIC, DIAGNOSTICS,
PRINCIPLES OF CONSERVATIVE AND OPERATIONAL
TREATMENT.
 ETIOLOGY OF ACUTE
In etiology of cholecystitis major factors considered are the following: infection, incoordination in passage of bile
and metabolic disturbance. All of them predetermine formation of calculus.

On bacteriological examination of secretions of gall-bladder colon bacillus, staphylococcus and enterococcus are
seen. Rarerly there is streptococcus and other microorganisms.

Risk factors for calculous cholecystitis mirror those for cholelithiasis and include the following: Increasing age,
Female sex, Pregnancy, Certain ethnic groups (eg, Native American Indians), Obesity or rapid weight loss, Drugs
(especially hormonal therapy in women)

Acalculous cholecystitis is related to conditions associated with biliary stasis, and include the following: Critical
illness, Major surgery or severe trauma/burns, Sepsis, Long-term total parenteral nutrition (TPN), Prolonged fasting

Other causes of acalculous cholecystitis include the following: Cardiac events, including myocardial infarction,
Sickle cell disease, Salmonella infections, Diabetes mellitus , Patients with AIDS who have cytomegalovirus,
cryptosporidiosis, or microsporidiosis

Patients who are immunocompromised are at an increased risk of developing cholecystitis from a number of
different infectious sources. Idiopathic cases also exist.

 CLASSIFICATION
calculous and acalculous

primary (arisen with complete health) or secondary “as a relapse or exacerbation of

disease at chronic relapsing cholecystitis”.

According to the character of morphological changes in the gallbladder, it cans

distinguish simple catarrhal cholecystitis; phlegmonous (phlegmonous-ulcerative)
cholecystitis; gangrenous cholecystitis; perforating cholecystitis; empyema of the
gallbladder.

Also distinguish uncomplicated acute cholecystitis; complicated acute cholecystitis

(peritonitis, cholangitis, hepatitis, obturative icterus, pancreatitis, paravesical
infiltrate, paravesical abscess).

 CLINICAL MANIFESTATIONS
1) Triad : RUQ pain, Fever, Leukocytosis

2) Gradually worsening colic: Started with

biliary colic (early stage: gallbladder expansion
-> late stage: peritoneal irritation)

3) nausea, anorexia (vomiting is rare)

4) Murphy’s sign: deep inspiration or cough

during subcostal palpation of RUQ -> pain
aggravation & inspiration arrest

In the early stages of the disease, jaundice is

rare

 CLINICAL MANIFESTATION (2)

Pain syndrome. Characteristic for it is severe pain in right hypochon- drium and epigastric area with radiation to right
supraclavicular area and right shoulder. If pain syndrome is strongly expressed and is cramp-like in character, it is named
hepatic colic.

Dyspepsia syndrome. Frequent symptoms which disturb a patient, are nausea, frequent vomiting, initially by gastric
contents, and later - by bile. Later feeling of fullness of abdomen, delay of emptying and gases often follow.

Examination. During examination in almost all patients slight icterus of sclera even with normal secretion of bile can be
observed. Tongue, as a rule, is white-grey in colour. Patients complain of dryness of mouth. In difficult cases the tongue
is usually dry, assessed by white stratification with a yellow spot in the center.

Increase of temperature of body is brief and insignificant (on the average to 37,2 С) but in catarrhal cholecystitis the
temperature is within the limits of 38 С at its destructive forms.

Tachycardia to a certain extent testifies the degree of intoxication. In the initial phase of disease the pulse, usually, is
relevant to the tempera ture, and with progress of the disease, especially with development of peritonitis, it becomes
rapid and low volume.

During palpation tenderness in the place of crossing of right costal margin with the external edge of direct muscle of
stomach can be observed (the Kehr's point). By superficial and deep palpation of right hypo-chondrium, as a rule,
tenderness, increased size of gall-bladder is exposed, that can be important as a symptom.

 DIAGNOSTICS
1) Medical history and physical examination are the most important

2) lab test : leukocytsis, lymphopenia and increased ESR, hyperbilirubinemia , increase AST,ALT

3) Abdominal ultrasound: gallstone found in 90 ~ 95%, gall-bladder can reveal the increase in
its sizes, bulge of walls, development of perivesical abscesses, presence or absence of sludge
and their sizes.

4) radionuclide biliary scan (HIDA, DISIDA): US is normal, but performed if clinical symptoms
are suspected

- In case of cholecystitis (due to obstruction of the cystic duct), no biliary shadow was observed

- Perform biliary scan after CCK administration to identify the cause of acalculous
cholecystopathy (simple pain, discomfort, etc., not cholecystitis)

PRINCIPLE OF CONSERVATIVE TREATMENT

Medical treatment (2-3 days before surgery)

1) Fasting, L-tube insertion

2) analgesics: meperidine, NSAIDs

3) Spasmolytics : sulfate of atropine, platyphyllin, papaverin, no-shparum, baralgin ->morphine is

contraindicated because it causes spasm of the sphincter of Oddi

4) Antibiotic therapy: In case of severe acute cholecystitis, when bacterial infection is suspected

• ureidopenicillin, ampicillin/sulbactam, cephalosporin

• DM, G (-) sepsis: Used in combination with Aminoglycosides

• Add metronidazole if gangrene/emphysema cholecystitis is suspected

PRINCIPLE OF SURGICAL TREATMENT

Indication to surgical treatment : All forms of acute calculous chole- cystitis, destructive and
complicated forms of noncalculous cholecystitis (except for infiltrative), and also acute
catarrhal cholecystitis for which conservative treatment was ineffective, are subjected to
surgical treatment ->Overhead-middle laparotomy is considered the best choice.

1) Early cholecystectomy (TOC): Perform surgery quickly when the patient's condition is stable

2) Emergency cholecystectomy: immediate operation in case of complications such as

emphysema cholecystitis, abscess, perforation, twist, etc.

3) Delayed cholecystectomy: When immediate surgery is difficult due to poor general

condition of the patient or when the diagnosis is not clear

-> After ENGBD, EUS-guided cholecystostomy or PTGBD, cholecystectomy if symptoms

improve

 CHRONIC CHOLECYSTITIS
Inflammation of gall-bladder, that gained prolonged chronic character, is considered
chronic cholecystitis.

Etiology : Everything mentioned above about etiology and pathogenesis of acute

cholecystitis to a certain extent is responsible for chronic cholecystitis, but with the
proper amendments, related to expression and duration of inflammatory process,
degree of violation of passage of bile and individual features of patient. Chronic
cholecystitis is calculous. Its non-calculous forms are met infrequently. Salmonella is
considered to be a leading cause of special clinical form of non- calculous chronic
cholecystitis.

 CLASSIFICATIONS
Chronic cholecystitis is divided into:

1) chronic calculous.

2) chronic non-calculous.

-Primary cholecystitis is that, which arises without the previous acute attack,

-recurrent - when in history there is one or more attacks

-complicated - if the chronic cholecystitis is associated with: violation of patency of

biliary ducts; septic cholangitis; obliterating cholangitis; hydropsy of gall-bladder;
pancreatitis; hepatitis; sclerosis of gall-bladder; 8)paravesicular chronic abscess;
internal fistula.

 CLINICAL MANIFESTATIONS
Dull, aching pain is considered the main symptom of chronic cholecystitis in right
hypochondrium, that radiates to right subclavian area, shoulder-blade or shoulder. Belt-like
character of pain testifies the involvement of the pancreas. Violation of diet causes, usually,
increase of pain and can provoke the attack of acute cholecystitis.

Dyspeptic syndrome. Feeling of fullness, feeling of swelling in right hypochondrium, distension

of abdomen after the intake of meal, bitter taste in the mouth, belching, nausea, vomiting,
which brings some relief, heartburn and violation of emptying, are the frequent signs of this
syndrome (delay, more frequent diarrhea). It is important to pay special attention to these
symptoms, because they can be the first signs of disease of chronic cholecystitis.

On examination skin and sclera there is often slight icterus. Prolonged history, in a thin,
exhausted patient, rather yellowish colour of the person should lead to the suspicion of the
possibility of cirrhosis of liver, and when there is increase of temperature of body - one should
think about acute attack of the disease or presence of cholangitis. Sometimes in these patients
it is possible to expose brown spots in right hypochondrium -aquired by application of hot-
water bottle. Activity of patients often cause pain in the right hypochondrium.

 DIAGNOSTICS (1)
1. History and physical examination.

2. Survey rontgenoscopy of organs of abdominal cavity.

3. Peroral and intravenous cholangiography.

4. Sonography.

5. General analysis of blood and urine.

6. Analysisofurinefordiastasis.

7. Biochemicalbloodtest(bilirubin,amylase,hepatictests).

8. Coagulogram.

9. Duodenal intubation. 10. Endoscopy.

 DIAGNOSTICS (2)
Sonography examination reveals the size of gall-bladder, thickness of its walls, presence or
absence of calculus and their sizes.

Rontgenoscopy survey of right hypochondrium in 10 % of patients exposes roentgenopaque

calculus of salts of calcium.

With contrast peroral or intravenous cholecystogram is confirms: the multiple defects of filling
of gall-bladder due to calculus. Special attention is to be paid to the state of ducts. Dilatation of
general bile duct to the diameter larger than 10 mm specifies the violation of passage of bile
and requires correction during operation. Negative cholecystogram (when a gall-bladder is
filled) is suggests of blockade of cystic duct.

By duodenal intubation the inflammatory changes are exposed in bile from duodenum (portion
A), from gall-bladder (portion B) and from hepatic passings (the С portion). Absence of the bile
"B" grounds suspects impossibility of cystic duct or violation of function of gallbladder.

PRINCIPLE OF CONSERVATIVE TREATMENT

- choleic preparations (alohol, holagol, holenzyme, holosas, olimetyn);

- cholekinetics (sulfate of magnesium, cholecystokinin, pituitrin);

- spasmolytics (sulfate of atropine, platyphyllin, methacin, amino-phylline);

- duodenal intubation;

- antibacterial preparations (during acute attacks).

PRINCIPLE OF OPERATIVE TREATMENT

Operative treatment must provide deletion of hearth of inflammatory process

(cholecystectomy), and in case of violation of passage of bile by the ducts it is
repaired. It is nessesary to remember, that earlier the operation is performed, the
better are the immediate and late results of surgery.
THANK YOU