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ACUTE CHOLECYSTITIS

Acute cholecystitis is inflammation


of gall-bladder.

BILIARY ANATOMY

Anatomy: vascular supply

ETIOLOGY AND PATHOGENESIS

infection
discoordination passage of bile
metabolic disturbance

CLASSIFICATION
I. Acute calculous cholecystitis
II. Acute non-calculous cholecystitis
1. Catarrhal.
2. Phlegmonous.
3. Gangrenous.
4. Perforated.
5. Complicated:
a) Hydropsy;
b) Empyema;
c) Pancreatitis;
d) Jaundice;
e) Hepatitis;
f) Cholangitis;
g) Infiltrate;
h) Abscess;
i) hepato-renal insufficiency;
j) Peritonitis.

Classifying the Biliary Stone


Patient
Asymptomatic
Cholelithiasis

Incidental Finding on Sonogram

Acute Cholecystitis

Cholelithiasis on Sonogram, clinical Cholecystitis


diagnosis or Positive Pipida Scan

Symptomatic
Cholelithiasis

Positive Sonogram, normal Liver Function Tests

Cholelithiasis with
Suspected
Choledocholithiasis

Abnormal Liver Function Tests (Serum Transaminases


elevation or Bilirubin >3.0, gallstone pancreatitis)

Cholelithiasis with
Choledocholithiasis

CBD Stone on Sonogram, MR Cholangiography or


Jaundice

Cholelithiasis with
Resolving Gallstone
Pancreatitis

Pancreatitis on Sonogram, CT or MER


Cholangiography or clinically, Documented High
Serum Amylase and Lipase - WITH - Decreasing
Serum Pancreatic Enzymes after initial attack

Identifying Biliary Stone Patients

1) History and Physical Examination,


2) Liver Function Studies,
3) Sonographic Findings.

BILE STONES

BILE STONES

The pathological
sequences during
a bout of
uncomplicated
cholecystitis

Sequence of
pathological
processes with
local inflammation
around a
gallbladder

Sequence of
pathological
processes.
Formation of an
empyema or
mucocele of the
gallbladder

Sequence of
pathological
processes leading
to perforation of
the gallbladder

Sequence of
pathological
processes
localising a
perforation of the
gallbladder

Symptoms and clinical signs


Pain syndrome. Characteristic for it is great acute
pain in right hypochondrium and epigastric area with an
irradiation in right supraclavicular area and right shoulder.
If pain syndrome has the strongly expressed character, it is
named hepatic colic.
Dyspepsic syndrome. Frequent symptoms which
disturb a patient, are nausea, frequent vomitting, at first by
gastric maintenance, and later with bile. Afterwards
feelings of swelling of stomach, delay of emptying and
gases.

Symptoms and clinical signs


Murphy's symptoms is a delay of breathing during
palpation of gall-bladder on inhalation.
Kehr's symptom is strengthening of pain at
pressure on the area of gall-bladder, especially on deep
inhalation.
Ortner's symptom painfulness at the easy
pushing on right costal arc by the edge of palm.
Mussy's symptom painfulness at palpation
between the legs (above a collar-bone) of right nodding
muscle.
Blumberg's signs are the increases of painfulness
at the rapid taking away of fingers by which a front
abdominal wall is pressed on. This symptom is not
pathognomic for cholecystitis but matters very much in
diagnostics of peritonitis.

Complications
Hydropsy (mucocele) of gall-bladder is its aseptic
inflammation, that arises up as a result of blockade of cystic
duct by concrement or mucus. The bile from a bubble is
sucked in, and on replacement transparent exudation
accumulates in its formation. During palpation increased and
unpainfully gall-bladder is marked in patients.
Empyema of gall-bladder is unliquidated in time
hydropsy, that at repeated infection is transformed in a new
form. Gall-bladder in such patients is palpated as a dense,
moderately painful formation, however, the symptoms of
irritation of peritoneum, as a rule, are absent. The high
temperature of body is periodically observed. In blood high
leucocytosis with the shift of formula of blood to the left is
present.

Complications
Biliary pancreatitis. Worsening of the patients
condition, appearance of pain, frequent vomitting, signs of
cardio-vascular insufficiency, high amylasuria, presence of
infiltrate in epigastric area and positive Voskresensky's and
Mayo-Robson's symptoms are its basic signs.
An icterus arises up at violation of passage of bile in
duodenum as a result of obturation of choledochus by
concrement, by putty or through the edema of head of
pancreas. Thus icterus sclera, bilirubinemia, dark urine and
light unpainted excrement arise.
Cholangitis. The Sharko triad is characteristic for the
patient with this pathology. Next to pain syndrome and
icterus, the temperature of body rises to 3839 0, there is a
fever, high leucocytosis and decline of sizes of functional
tests of liver is observed.

DIAGNOSTIC PROGRAM
1. Anamnesis and physical methods of
inspection.
2. Survey sciagraphy of organs of abdominal
cavity.
3. Sonography.
4. General analysis of blood and urine.
5. Diastase urines.
6. Biochemical blood test (bilirubin, amylase,
alanine aminotransferase, asparaginase,
alkaline phosphatase, creatinine).
7. Coagulogram.

Tactics and choice of treatment method

1. Bed rest.
2. Hunger of 13 days, than diet 5 by Peuzner.
3. Desintoxication therapy (neohemodes, reopolyglucine).
4. Spasmolytics ( platyphyllin, no-shparum, baralgin).
5. Antibacterial therapy:
6. Inhibitors of protease (contrical, trasilol, gordox).
7. Desensitizing preparation (dimedrole, pipolphen, tavegile).
8. Vitamins (, 1, 6, 12 vitamins).

Indication To Surgical Treatment

All forms of acute calculous cholecystitis


Destructive and complicated forms of
noncalculous cholecystitis
Acute catarrhal cholecystitis, conservative
treatment of which was uneffective

Methods of Operative Treatment

Cholecystectomy from the neck


(retrograde)
Cholecystectomy from the bottom
(antegrade)
Laparoscopic cholecystectomy

CHOLECYSTECTOMY

OPERATING ROOM SET-UP

OPERATING ROOM SET-UP

Equipment

STEP 1: Exposing the Cystic


Duct and Artery

STEP 2: Dissecting the Cystic


Duct and Artery

STEP 3: Routine Intra-operative


Cholangiogram

STEP 4: Transecting the Cystic


Duct and Artery

STEP 5: Dissecting the Body of


the Gallbladder

CHOLECYSTECTOMY

Complications

Complications

INTRA-OPERATIVE
EXAMINATION
Sonography
Cholangiography
Cholangioscopy

INTRA-OPERATIVE
SONOGRAPHY

INTRA-OPERATIVE
SONOGRAPHY

The Intra-operative
Cholangiography

The Intra-operative
Cholangiogram

The Intra-operative
Cholangiogram

The Intra-operative Cholangiogram

The Intra-operative
Cholangiogram

The Intra-operative
Choledochoscopy

The Choledochoscopy

Retrieving the CBD Stones

CBD Stones