< Surgical Procedures < Abdominal Surgery

Cholecystitis

Introduction:

• It is an inflammation of gall bladder.
• Almost always occurs in association with gallstone.
• It is one of the most common indications for abdominal surgery.
• Its epidemiologic disturbance closely parallels to gallstone.

Types of Cholecystitis:

  • Calculus Cholecystitis.

            Inflammation of the gallbladder in the presence of gallstones.

  • It is classical to subdivide further:
    • Acute Calculus Cholecystis.
    • Chronic Calculus Cholecystis.


  • Acalculous Cholecystitis.

            Inflammation of the gallbladder in the absence of gallstones.
            Give rise to clinical picture similar to calculus cholecystitis.

  • It is classical to subdivide further:
    • Acute Acalculous Cholecystitis.
    • Chronic Acalculous Cholecystitis.

Acute Calculus Cholecystitis:

  • Precipitated 90% of the time by gallstone obstruction of the:
    • Neck of the gallbladder.
      • Gallstone impacted in Hartmann's pouch.
    • Cystic duct.
  • Caused by Bile infections:
    • E.coli.
    • Klebsiella sp.
    • Streptococcus faecalis (Keighley).
    • Strict anaerobes, e.g. Bacteroides sp.
    • Gas forming organisms, e.g. clostridia.
    • Typhoid infection.
  • It is the primary complication of gallstones.
  • One of the most common reasons for emergency cholecystectomy.


Sequel of Acute Cholecystitis attack:

  • When a certain degree of distension of the gall bladder has been reached, the mucous membrane tends to be lifted away from the sides of the stone and, as a consequence, the stone may slip back into the body of the gallbladder, and any mucoid (from a mucocele) or mucopurulent contents of the gallbladder escape by way of the cystic duct.
  •  Less frequently, the impaction persists and an empyema (pyocele) of the gallbladder results.
  •  On rare occasions, the distended, inflamed gallbladder perforates.

    • Clinical features of acute calculus cholecystitis:

  • The onset is sudden.
  • Pain is located in mainly in the right hypochondrium.

    • Diagnosis of Acute Calculus Cholecystitis:

    • Ultrasonography will confirm the diagnosis.

    Chronic calculus cholecystitis:

    Clinical features:

    • Right Hypochondrial pain.
      • Radiation to between the shoulder blades is frequent and it may associated with nausea and vomiting. Fatty foods often precipitate it.
      • During an attack, tenderness in the hypochondrium is present.
      • Murphy's sign may be (+).
      • The temperature and white blood count are elevated.
      • Flatulent dyspepsia:

    Diagnosis:

    • Ultrasonography is usually the only investigation needed to show gallstones.
    • A bile duct >8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation.

    Acute Acalculous Cholecystitis:

    • Particularly seen in patients recovering from:
      • Major surgery.
      • Trauma.
      • Burns.

    NB!    In these patients the diagnosis is often missed and the mortality rate is 20 %.

    • Diagnosis:
      • Oral cholecystography is more useful than Ultrasonography in those presenting with chronic symptoms.
      • Radioisotope scanning for presenting with acute symptoms.
      • Cholesterol crystals in duodenal aspirate may also help.

    Treatment:

    Treatment of choice:

    • Laparoscopic cholecystectomy.
    • Open cholecystectomy.
    • Percutaneous transhepatic placement of a cholecystostomy tube.
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