Cholecystitis is defined as nonspecific inflammation of the gallbladder with or without cholelithiasis. Types: calculous and acalculous.

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1 Cholecystitis is defined as nonspecific inflammation of the gallbladder with or without cholelithiasis. Types: calculous and acalculous. Anatomy of the gallbladder The gallbladder, a pear-shaped reservoir 5 to 12 cm in length, lies in a fossa on the lower surface of the liver. There are four parts of the gallbladder: 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. Biliary tract. The gallbladder drains by the cystic duct to the junction with the common hepatic duct where form the 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 the spiral valve of Heister Pathophysiology Ninety percent of cases involve stones in the gallbladder (calculous cholecystitis), with the other 10% of cases representing acalculous cholecystitis. Acute calculous cholecystitis is caused by obstruction of the cystic duct, leading to distention of the gallbladder. As the gallbladder becomes distended, blood flow and lymphatic drainage are compromised, leading to mucosal ischemia and necrosis. Pathology 1. Inflammation: Entire gallbladder is inflamed. When inflammatory exudate surrounding the gallbladder collects under the diaphragm, results in pain radiating to the right shoulder due to phrenic nerve irritation.

2 2. Extensive ulcerations of gallbladder may result in perforation of gallbladder with biliary peritonitis and carries a very high mortality rate. 3. If the obstruction is complete gallbladder is converted into mucocoele or pyocoele (empyema). Empyema of the gallbladder can occur with high grade fever and chills and can even cause septicaemia. 4. Gangrene of gallbladder can occur if the blood vessels get thrombosed. Etiology Risk factors for calculous cholecystitis include the following: Female sex Obesity or rapid weight loss Drugs (especially hormonal therapy in women) Pregnancy Increasing age 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 Epidemiology 1. The incidence of cholecystitis increases with age. 2. Gallstones are 2-3 times more frequent in females than in males, resulting in a higher incidence of calculous cholecystitis in females.

3 3. Acalculous cholecystitis is observed more often in elderly men. CLASSIFICATION OF CHOLECYSTITIS (by AA Shalimov et al., 1993) I. Chronic cholecystitis (calculous, acalculous) 1. Primary chronic cholecystitis is call cholecystitis, which had appeared without onset of the acute attack. 2. Chronic recurrent uncomplicated cholecystitis. 3. Chronic recurrent complicated by: a) impaired patency of the bile ducts; b) septic cholangitis; c) obliterating cholangitis; d) pancreatitis; e) hepatitis and biliary cirrhosis of the liver; f) mucocele of the gallbladder; g) sclerosis of the gallbladder; h) chronic abscess; i) chronic empyema of the gallbladder; j) internal fistula. II. Acute cholecystitis (calculous, acalculous): 1. Simple (catarrhal, infiltrative, ulcerative). 2. Аbscess. 3. Gangrenous. 4. Perforated. 5. Complicated: a) biliary peritonitis; b) paracystic infiltrate; c) paracystic abscess; d) with obstructive jaundice; e) abscess of liver; f) septic cholangitis; g) acute pancreatitis. History The most common presenting symptom of acute cholecystitis is upper abdominal pain. Signs of peritoneal irritation may be present, and in some patients, the pain may radiate to the right shoulder or scapula. Frequently, the pain begins in the epigastric region and then localizes to the right upper quadrant (RUQ). Although

4 the pain may initially be described as colicky, it becomes constant in virtually all cases. Nausea and vomiting are generally present, and patients may report fever. Most patients with acute cholecystitis describe a history of biliary pain. Some patients may have documented gallstones. Acalculous biliary colic also occurs, most commonly in young to middle-aged females. The presentation is almost identical to calculous biliary colic with the exception of reference range laboratory values and no findings of cholelithiasis on ultrasound. Cholecystitis is differentiated from biliary colic by the persistence of constant severe pain for more than 6 hours. Patients with acalculous cholecystitis may present similarly to patients with calculous cholecystitis, but acalculous cholecystitis frequently occurs suddenly in severely ill patients without a prior history of biliary colic. Physical Examination The physical examination may reveal fever, tachycardia, and tenderness in the RUQ or the epigastric region. A palpable gallbladder or fullness of the RUQ is present in 30-40% of cases. Jaundice may be noted in approximately 15% of patients. 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 in 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 5. Boas s sign. Painful paravertebral points in the right side at the level of 8,9,10 of intercostals space. Differential Diagnoses Abdominal Aortic Aneurysm Acute Gastritis Acute Mesenteric Ischemia Acute Pyelonephritis Appendicitis Biliary Colic Biliary Disease Cholangiocarcinoma Cholangitis Gallbladder Cancer Gallbladder Mucocele Gallbladder Tumors Gallstones (Cholelithiasis) Peptic Ulcer Disease

6 Laboratory Tests Leukocytosis with a left shift may be observed in cholecystitis. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct obstruction. Bilirubin and alkaline phosphatase assays are used to evaluate for common bile duct obstruction. Amylase/lipase assays are used to evaluate for the presence of pancreatitis. Amylase may also be elevated mildly in cholecystitis. Radiography Gallstones may be visualized on noncontrast radiography in 10-15% of cases. This finding only indicates cholelithiasis, with or without active cholecystitis. Ultrasonography Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific. Ultrasonographic findings that are suggestive of acute cholecystitis include the following: pericholecystic fluid, gallbladder wall thickening greater than 4 mm, dilatation of billiary tree, and sonographic Murphy sign. The presence of gallstones also helps to confirm the diagnosis. Ultrasonography is performed best following a fast of at least 8 hours because gallstones are visualized best in a distended bile-filled gallbladder. Computed Tomography Scanning and Magnetic Resonance Imaging

7 The sensitivity and specificity of computed tomography (CT) scanning and magnetic resonance imaging (MRI) in predicting acute cholecystitis have been reported to be greater than 95%. Spiral CT scan and MRI have the advantage of being noninvasive. Findings suggestive of cholecystitis include wall thickening (>4 mm), pericholecystic fluid, subserosal edema (in the absence of ascites), intramural gas, and sloughed mucosa. CT scanning and MRI are also useful for viewing surrounding structures if the diagnosis is uncertain. Hepatobiliary Scintigraphy( HBS has been found to be up to 95% accurate in diagnosing acute cholecystitis. The reported sensitivities and specificities of biliary scintigraphy are in the range of % and 85-95%. In a typical study, the gallbladder, common bile duct, and small bowel fill within minutes. Endoscopic Retrograde Cholangiopancreatography ERCP may be useful for visualizing the anatomy in patients at high risk for gallstones if signs of common bile duct obstruction are present. Disadvantages of ERCP include the need for a skilled operator, high cost, and complications such as pancreatitis, which occurs in 3-5% of cases. Treatment

8 Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. Uncomplicated cases can often be treated on an outpatient basis; complicated cases may necessitate a surgical approach. In patients who are unstable, percutaneous transhepatic cholecystostomy drainage may be appropriate. Antibiotics may be given to manage infection. Definitive therapy involves cholecystectomy or placement of a drainage device. Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery. Conservative Treatment of Uncomplicated Cholecystitis Outpatient treatment may be appropriate for cases of uncomplicated cholecystitis. Criteria for outpatient treatment include the following: 1. Afebrile with stable vital signs. 2. No evidence of obstruction by laboratory values. 3. No evidence of common bile duct obstruction on ultrasonography. 4. No underlying medical problems, advanced age, pregnancy, or immunocompromised condition. 5. Reliable patient with transportation and easy access to a medical facility. Tactic of conservative treatment 1. Admission into a hospital. 2. Aspiration with Ryle's tube. 3. Antispasmodics. 4. Аdequate аnalgesia. 5. Broad spectrum antibiotics. 6. Deintoxication with іntravenous fluids. (intravenous hydration, correction of electrolyte abnormalities. 7. Тhe bowel must rest. The patient for 2-3 days does not take food orally, and during this time received intravenous fluids. After reducing pain after 2-3 days,

9 the symptoms disappear and the abdomen becomes soft. Raila tube removed. Later the patient adheres to a soft diet Indications to surgical treatment (А.А. Shalimov end all) 1. Urgent operative treatment must be in first 1-2 hour, when there are complications: a) bile peritonitis; b) purulent cholangitis; c) gangrenous cholecystitis. 2. Emergency when conservative treatment for 48 hours is ineffective. 3. Delayed - through 8-10 days after reduction of acute inflammatory process, after detailed checkup. 4. Planned - through 1-3 months after reduction of acute cholecystitis. Cholecystectomy Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis. Stages 1. 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. 2. Under vision, 3 small 0,5 cm incisions are made in epigastrium and in the right hypochondrium. They are used to enter manipulators (clamps, suction pump, coagulator). 3. Visualization and separate clipping of cystic duct and cystic artery. 4. Gallbladder removed from the abdominal cavity by holding it on a clamp through the umbilical port.

10 5. Bleeding at the site of the removal of the gallbladder from the liver is controlled by coagulation. 6. Drainage of the abdominal cavity through the hole for manipulator. Drainage performed to see what was evacuated from the abdominal cavity (blood or bile tell us about postoperative complications). 7. Suturing of wounds. For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic procedure to an open surgical procedure is approximately 5%. The conversion rate for emergency cholecystectomy where perforation or gangrene is present may be as high as 30%. Although laparoscopic cholecystectomy performed in pregnant women is considered safest during the second trimester. Contraindications to laparoscopic cholecystectomy include the following: High risk for general anesthesia. Morbid obesity. Signs of gallbladder perforation, such as abscess, peritonitis, or fistula. Giant gallstones or suspected malignancy. Stones in common bile duct. Adhesion illness. End-stage liver disease with portal hypertension and severe coagulopathy Septic shock from cholangitis Acute pancreatitis Opened cholecystectomy:

11 1. Cholecystectomy from the neck. 2. Cholecystectomy from the bottom. Stages: 1. Incision in right subcostal (Kocher's incision) or laparotomy. 2. Examination of all abdominal organs, including gallbladder. 3. Isolation of the gallbladder area. 4. Aspiration of the gallbladder if it greatly distended, thru fundus via trocar and cannula attached to a suction pumpю 5. Grasp the neck of gallbladder with clamp. 6. Visualized the cystic duct, common hepatic and common bile ducts, and identify cystic artery and its relation to common hepatic duct. 7. Ligate the cystic duct and artery. 8. Dissect the gallbladder from its bed, from below to upwards, dividing the peritoneum from gallbladder. 9. Hemostasis, draining and suturing of abdominal wall. Percutaneous Drainage For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy. Endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) allows visualization of the anatomy and can provide therapy by removing stones from the common bile duct. Endoscopic gallbladder drainage Endoscopic ultrasonographic guided biliary drainage may be used in the following clinical scenarios: Biliary obstruction and incomplete drainage with prior interventions

12 Previous failed bile duct cannulation during endoscopic retrograde cholangiopancreatography