Topic 4. Acute cholecystitis and complications PDF

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TOPIC 4. ACUTE CHOLECYSTITIS AND ITS COMPLICATIONS.Acute cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. It is one of the most commonly encountered surgical disorders and on freak occupy second pl...

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TOPIC 4. ACUTE CHOLECYSTITIS AND ITS COMPLICATIONS. Acute cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. It is one of the most commonly encountered surgical disorders and on freak occupy second place after appendicitis, amount 10% all urgent diseases. Mortality among patients remains high, level 6-8%, and in elderly patients and senile age – 15-20%.

Fig. 1. The gallbladder and bile ducts anatomy Anatomy. The gallbladder, a pear-shaped reservoir 5 to 12 cm in length, lies in a fossa on the lower surface of the liver. Four parts of the gallbladder are described: the fundus, the body, the infundibulum, and the neck. In addition, a Hartmann's pouch often develops as a pathological feature in the neck and infundibulum of the gallbladder in the presence of gallstones. Various congenital abnormalities have been described, including double, bilobed, and intrahepatic gallbladder, and congenital absence. The occasional presence of a long mesentery is of significance since it may allow torsion. The gallbladder drains by the cystic duct to the junction of the common hepatic duct and common bile duct. The wall of the cystic duct contains muscle fibres that form the sphincter of Lutkens, while the mucosa of the cystic duct forms crescentic folds known as the spiral valve of Heister Classification of cholecystitis (by AA Shalimov et al., 1993): I. Chronic cholecystitis (calculous, acalculous) 1. Primary chronic cholecystitis is called cholecystitis, which has appeared without onset of the acute attack. Chronic recurrent cholecystitis when in the anamnesis there is (are) one and more onsets 2. Chronic recurrent uncomplicated cholecystitis. 3. Chronic recurrent cholecystitis complicated by: 

impaired patency of the bile ducts;

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septic cholangitis; obliterating cholangitis; pancreatitis; hepatitis and biliary cirrhosis of the liver; mucocele of G.B; sclerosis of the gallbladder; chronic abscess; chronic empyema of the gallbladder; internal fistula.

II. Acute cholecystitis (calculous, acalculous) 1. Simple (catarrhal, infiltrative, ulcerative). 2. Abscess 3. Gangrenous. 4. Perforated. 5. Complicated:       

biliary peritonitis; paracystic infiltrate; paracystic abscess; with obstructive jaundice; abscess of liver; septic cholangitis; acute pancreatitis. GALL STONE DISEASE (CHOLELITHIASIS)

Cholelithiasis involves the presence of gallstones, which are concretions that form in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct (CBD).

Fig. 2. Gallstones.

Aetiology 1. Metabolic causes. Cholesterol is produced from the liver which gives rise to bile acids. Normal ratio of bile acids : cholesterol is 25 : 1. This ratio is necessary to maintain the cholesterol in liquid form by forming micelles. When the ratio drops down to 13 : 1; this is called 'critical ratio', at which the cholesterol gets precipitated. Risk factors:     

Female sex Obesity Maturity onset diabetes Diet: High animal fat Age > 40 years

The phrase "fair, female, fat, and fertile" summarizes the major risk factors for development of gallstones. Although gallstones and cholecystitis are more common in women, men with gallstones are more likely to develop cholecystitis (and more severe cholecystitis) than women with gallstones 2. Infection. It is the most common cause responsible for a gall stone in 80% of patients. Sources of infection are tonsils, tooth, bowel, etc. Organisms such as E. coil, Proteus, anaerobic organisms, streptococci, etc., through the blood stream reach the gall and bile salts get precipitated. Over a period of many years, this results in a mixed stone. They are usually multiple and occur in an infected bile. 3. Bile stasis. Obesity, pregnancy, hypercholesterolaemia and following vagotomy. They are prone for mixed stones as a result of bile stasis. 4. Haemolytic anaemia. E.g. hereditary spherocytosis, sickle cell anaemia, etc. Because the bilirubin production is increased. Since the production is more, they cannot conjugate with glucuronic acid which is produced at normal levels. Such unconjugated bilirubin combines with the calcium and is excreted in the biliary tree resulting in calcium bilirubinate stones—pigment stones —not only in the gall bladder, also in the entire ductal system. 5. Saint's triad. 1. Gall stones (can occur along with the other 2 conditions mentioned below). 2. Diverticulosis of colon. 3. Hiatus hernia. 6. Parasites. In oriental countries, Clonorchis sinensis (Chinese liver fluke) infestations can cause stone in biliary tree. Ascaris lumbricoides in the biliary tree may produce stones in India. Types of gall stones 1. Cholesterol stones. Constitutes about 10% of the gall stones. Occur in patients with increased cholesterol levels. Fatty women are commonly affected. It is single, solitary, occurs in aseptic bile. Sometimes they can be multiple. Probably, due to bile stasis. 2. Pigment stones They are found in 5 to 10% of patients. They are calcium bilirubinate stones. Commonly occur due to haemolysis. Hence, they are black, multiple, small, irregular concretions or sludge particles. 3. Mixed stones They constitute about 80% of gall stones. They contain alternating layers of cholesterol and pigment with epithelial debris or vegetations, from infective organisms. They are multiple, small faceted by mutual pressure.

Complications of gallstones: 1) Silent stones. This is usually a single, silent, cholesterol stone which is symptomless. They are accidentally discovered, may be by an ultrasound or plain X-ray abdomen. This stone rarely causes obstructive jaundice. 2) Flatulent dyspepsia. If an obese woman (Female, Flatulent, Forties, Fertile, Fatty) complains of gaseous distention, intolerance to fatty food and discomfort in the abdomen, heartburn, belching, she probably has gall stones. These patients need cholecystectomy. 3) Gall stone colic. It usually occurs at night wherein a stone tends to block the cystic duct. It is a severe colicky upper abdominal pain felt in the right hypochondrium, may shoot to the back or between shoulder blades. The pain lasts for a few hours. The pain is due to spasm of gall bladder. It is associated with vomiting due to reflex pylorospasm. There is tenderness in the right hypochondrium. ACUTE CHOLECYSTITIS Definition: Acute bacterial inflammation of the gall bladder with or without stone. Types 1. Calculous — with gallstones, obstructive cholecystitis. It is the commonest variety. 2. Acalculous — without stones, non-obstructive cholecystitis. It is uncommon, seen in patients who recover from head injury, burns, major surgery, diabetic patients, etc. Etiology 1. Majority of the cases of calculous cholecystitis are due to organisms such as E. coli, streptococci, Salmonella, Klebsiella, etc. 2. Typhoid fever can also cause "Typhoid Cholecystitis' around 2nd week of infection. 3. Clostridial infection of the gall bladder produces acute cholecystitis with toxaemia. 4. Bile stasis precipitates infection. Risk factors for acalculous cholecystitis include diabetes, human immunodeficiency virus (HIV) infection, vascular disease, total parenteral nutrition, prolonged fasting, or being an intensive care unit (ICU) patient. Children are more likely than adults to have acalculous gallstones. If stones exist, they are more likely pigmented stones from hemolytic diseases (eg, sickle cell diseases, spherocytosis, glucose-6-phosphate dehydrogenase [G-6-PD] deficiency) or chronic diseases (eg, total parenteral nutrition, burns, trauma). Pathology 1. Inflammation: Entire gall bladder is inflamed, swollen and is friable. Inflammatory exudate surrounding the gall bladder when it collects under the diaphragm, results in pain radiating to the right shoulder (C3,4) due to phrenic nerve irritation. 2. Extensive ulcerations of gall bladder may result in perforation of gall bladder with biliary peritonitis and carries a very high mortality rate.

3. If the obstruction is complete—gall bladder is converted into mucocoele or pyocoele (empyema). Empyema of the gall bladder can occur with high grade fever and chills and rigors and can even cause septicaemia. 4. Gangrene of gall bladder can occur if the blood vessels get thrombosed. All these features are more in an obstructive variety. Perforation can occur when the stone is impacted in the Hartmann's pouch. Clinical features. A fatty, fertile, female is the typical victim who presents with severe upper abdominal pain. Symptoms of biliary colic. Typical gallbladder colic generally includes 1-5 hours of constant pain, most commonly in the epigastrium or right upper quadrant. Peritoneal irritation by direct contact with the gallbladder localizes the pain to the right upper quadrant. The pain is severe, dull or boring, constant (not colicky), and may radiate to the right scapular region or back. Patients tend to move around to seek relief from the pain. The onset of pain develops hours after a meal, occurs frequently at night, and awakens the patient from sleep. Associated symptoms include nausea, vomiting, pleuritic pain, and fever. Symptoms of cholecystitis. Persistence of biliary obstruction leads to cholecystitis and persistent right upper quadrant pain. The character of the pain is similar to gallbladder colic, except that it is prolonged and lasts hours (usually >6 h) or days. Nausea, vomiting, and low-grade fever are associated more commonly with cholecystitis. Up to 70% of patients with cholecystitis report having experienced similar episodes in the past that spontaneously resolved. Symptoms of cholelithiasis. Most gallstones (60-80%) are asymptomatic at a given time. Smaller stones are more likely to be symptomatic than larger ones. However, almost all patients develop symptoms before complications, such as steady pain in the right hypochondrium or epigastrium, nausea, vomiting, and fever. An acute attack often is precipitated by a large or fatty meal. Local symptoms 1. Murphy’s sign. The patient can’t do a deep breath with the pressure in the Kerr’s point (Kerr’s point is located on the bisector of the triangle which is formed by the right costal arch and m. rectus abdominis). 2. Mussei-Georgievsky’s sign. Increased pain with the pressure of m. sternocleidomastoidei. 3. Ortner’s sign. Increased pain with a tapping movement in the right costal arch. 4. Leichovitsky’s sign. Increased pain with the pressure on the xiphoid process (because of the inflammation of lymph node). 5. Boas’s sign. Painful paravertebral points in the right side at the level of 8,9,10 of intercostals space. 6. Upper abdominal guarding and rigidity are present. 7. A vague mass consisting of inflamed gall bladder,omentum, inflammatory exudate can be felt sometimes. Diagnosis Plain X-ray abdomen erect position. Tasks:

a) Gall stones can be demonstrated in 10% of the patients, as radio-opaque shadows in the right hypochondrium. b) To rule out other causes, such as perforated peptic ulcer. The advantages of abdominal radiographs include their readily availability and low cost. However, abdominal radiographs have low sensitivity and specificity in evaluating biliary system pathology, but they can be helpful in excluding other abdominal pathology such as renal colic, bowel obstruction, perforation. Between 10% and 30% of stones have a ring of calcium and, therefore, are radiopaque. A porcelain gallbladder also may be observed on plain films. Emphysematous cholecystitis, cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation may show air in the biliary tree. Air in the gallbladder wall indicates emphysematous cholecystitis due to gas-forming organisms such as clostridial species and Escherichia coli.

Fig. 3. Abdominal X-ray. Gallstones in gallbladder. Ultrasonography. Ultrasonography is 90-95% sensitive for cholecystitis and has a 78-80% specificity. For simple cholelithiasis, it is 98% sensitive and specific. Tasks: a) To demonstrate stones, which cast posterior acoustic shadow. b) It can demonstrate inflamed, thickened organ, in cases of acalculous cholecystitis Findings include gallstones or sludge and one or more of the following conditions:   

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Gallbladder wall thickening (>2-4 mm) - False-positive wall thickening found in hypoalbuminemia, ascites, congestive heart failure, and carcinoma Gallbladder distention (diameter >4 cm, length >10 cm) Pericholecystic fluid from perforation or exudate - May be seen as a hypoechoic or anechoic region seen along the anterior surface of the gallbladder within the hepatic parenchyma Air in the gallbladder wall (indicating gangrenous cholecystitis) Ultrasonographic Murphy sign (86-92% sensitive, 35% specific) - pain when the probe is pushed directly on the gallbladder (not related to breathing).

Additional findings in the presence or absence of gallstones may include a dilated common bile duct or dilated intrahepatic ducts of the biliary tree, which indicate common bile duct stones. In the absence of stones, a solitary stone may be lodged in the common bile duct, a location that is difficult to visualize ultrasonographically.

Fig. 4. Ultrasonography. Gallstones in gallbladder. Laboratory tests are not always reliable, but the following findings may be diagnostically useful:       

Leukocytosis with a left shift may be observed Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct (CBD) obstruction Bilirubin and alkaline phosphatase assays may reveal evidence of CBD obstruction Amylase/lipase assays are used to assess for pancreatitis; amylase may also be mildly elevated in cholecystitis Alkaline phosphatase level may be elevated (25% of patients with cholecystitis) Urinalysis is used to rule out pyelonephritis and renal calculi All females of childbearing age should undergo pregnancy testing

Other instrumental method of diagnosis:       

Ct scan Scintigraphy (hida scan) hepatobiliary 2,6-dimethyl-iminodiacetic acid Gall bladder radionuclide scan Oral cholecystogram Percutaneous transhepatic cholangiography (PTC) Intraoperative cholangiography Endoscopic retrograde cholangiopancreatography (ERCP)

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Laproscopy Magnetic resonance cholangiopancreatography (MRCP)

Fig. 5. MRCP

Fig. 6. ERCP

Treatment (conservative). Majority of the cases are managed by conservative treatment 1. Admission to the hospital. 2. Aspiration with Ryle's tube: Aspirating HC1 decreases the stimulus to the secretion of bile. Spasm of gall bladder may come down.

3. Antispasmodics: Injection nospani 2,0 ml; papaverini 2,0 ml; promedoli 1,0 ml; with injection atropine 1 ml to relieve spasm of sphincter of Oddi. 4. Antibiotics: Broad spectrum are given against gram +ve, gram -ve and anaerobic organisms. 5. Detoxication I.V. fluids (reosorbilakt 200 ml, glucosae 5%- 400 ml + acidi ascorbinici 10%-10 ml, albumini 10% or 20%-100 ml). 6. Patient is kept on nil orally for 2-3 days and during this time I.V. fluids are given. After 2-3 days pain comes down, signs disappear, (tenderness) and abdomen is soft. Ryle's tube is removed followed later by soft diet. Indications to surgical treatment Urgent operative treatment during first 1-2 hour, when you recognize any complications: а) bile peritonitis; b) purulent cholangitis; c) gangrenous cholecystitis; diagnostic laparoscopy. Emergency – ineffective conservative treatment for 48 hours. Delayed - through 8-10 days after reduction of acute inflammatory process, after detailed checkup. Planned - 1-3 months after reduction of acute inflammation.

Fig. 7. Open cholecystectomy (from the neck)

Open cholecystectomy. Incision - right paramedian, or right subcostal incision (Kocher's incision). Examine all abdominal organs, including gallbladder. Isolate the gallbladder area with packs. Aspirate the gallbladder if it greatly distended, thru fundus via trocar & cannula attached to a suction apparatus. Grasp the neck of gallbladder with sponge-holding forceps. Display the junction of cystic, common hepatic & bile ducts via dissection, & identify cystic artery & its relation to common hepatic duct. Cholangiography is performed, to confirm the anatomy of biliary tree, & to check for stones in main ducts. Ligate the cystic duct, & then divide it. Dissect the gallbladder from its bed, from below & upwards, dividing the peritoneum on gallbladder. Secure hemostasis, & close the abdominal wall. Drainage is not-mandatory; if used, it should be a 3 mm closed suction, drain.

Fig. 8. Open cholecystectomy (from the bottom) Laparoscopic cholecystectomy. It has become the most popular method of choice today. 90% of gall bladders can be removed through a laparoscope. Some principles and procedure of laparoscopic cholecystectomy. Contraindications 1. Very badly contracted, fibrosed gall bladder. 2. Stones in C.B.D. 3. Adhesions of abdominal cavity (after previous operations)

Fig. 9. Laparoscopic cholecystectomy 1 cm long incision is made below the umbilicus, through which a pneumoperitoneum is maintained by CO2 insufflation. Following this, a laparoscope is introduced and a camera is attached. Under vision, 3 small 1/2 cm incisions are made in epigastrium and in the right hypochondrium. These are used for suction, instrumentation, cauterisation, etc. Cystic duct and cystic artery are clipped and gall bladder is removed by gall bladder holding forceps and is brought outside through the umbilical port. Bleeding from liver is controlled by lasers/cautery. Procedure is done under general anaesthesia. Advantages: 1. 2. 3. 4.

Hospital stay is 2-3 days, recovery is very fast. Pain is minimal. Hence, mobilization of the patient is much better and easy. It gives an acceptable and better cosmetic result. Complications like adhesions and incisional hernia are rare.

Intraoperative methods of diagnosis Visual inspection and palpation of the bile ducts. Normally, the width of Cystic duct (CD) is 1-2 mm, common bile duct (CBD) is - 4-8 mm, 4-6 mm is the hepatic duct. Dilatation of common bile duct (CBD) to 9 mm or more is a sign of billary hypertension. The distal segment of the CD and CBD are palpated to determine the small stones, formation of bile stasis, as well as thickness, density and tonus of walls of CBD. Cholangiomanometry: The method is based on measuring the pressure in the biliary tract. It helps to determine the functional state of the sphincter apparatus of the distal part of bile duct

and the extent of its ability. (Normal pressure is 100-160 mm Hg). Pressure of 200 mm Hg and more, indicates the presence of obstacles to bile outflow. Debitometry (debitocholangiometry). This method is based on the fact that through the hole of ampulla of vater on giving a certain pressure will occur a certain amount of liquid. The unit of constant pressure is taken 300 mm Hg, which corresponds to the secretory pressure of the liver. Because of the graded-debitometr vessel (a cylindrical syringe of volume 50-100 ml), situated at a height of 300 mm above the bile duct, through a rubber tube connected to a cannula saline is introduced into the stump of cystic duct. In normal patency of distal end of duct after 1 min from debitometry arrives 20-30 ml/min. Debit below 20 ml/min indicates to suspect the presence of obstruction of outflow of bile and requires further cholangiography, flow rate below 15 ml / min indicates a violation of the outflow, which requires correction. Intraoperative cholangiography (CG) – X-Ray method for studying the bile ducts. It allows to determine the anatomical relationship between parts of billary-excreting system, to identify the nature of the organic changes of the bile ducts (stones, the level and extent of the strictures, infiltrative processes, etc.). In CG we use any water-soluble iodine X-Ray substance at a concentration of 30-35%, which, in the amount of 20 ml are ...