CHOLECYSTITIS Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus

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CHOLECYSTITIS
Bernard M. Jaffe, M.D.
Professor of Surgery,
Emeritus
GALLBLADDER
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Major Function- Concentrate, Store Bile
Supplied by Cystic Artery
Off Right Hepatic Artery
Off Common Hepatic Artery
Off Celiac Trunk
Many Arterial Variations
Replaced Right Hepatic Takes Off From
Superior Mesenteric
DUCTS
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Right and Left Hepatic Ducts Join
↓
Common Hepatic Duct
Cystic Duct Comes Off
↓
Common Bile Duct
↓
Ampulla, Duodenum
GALLSTONES
• Autopsy Prevalence 11-36%
• Female:Male Ratio is 3:1
• First Degree Relatives Have Twice the
Rate
• Cholecystectomy One of Commonest
Operations
PREDISPOSING FACTORS
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Obesity
Pregnancy
Dietary Factors
Crohn’s Disease, Ileal Resection
Hemolytic Diseases
Gastric Surgery
GALLSTONE CONSTITUENTS
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Bilirubin
Bile Salts
Phospholipids
Cholesterol
Calcium
CHOLESTEROL STONES
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Most Common Type
Rarely Pure, >70% Cholesterol
Precipitation from Supersaturated Bile
Usually Multiple, Variable Sizes
Hard and Facetted to Irregular and Soft
Color White/Yellow to Brown/Black
Only 10% are Radio-opaque
PIGMENT STONES
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<20% Cholesterol
Dark Because of Calcium Bilirubinate
Usually Tiny to Small
Invariably Multiple
Two Types- Black Stones
Brown Stones
BLACK STONES
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Form ONLY in Gall Bladder
Secondary to Hematologic Diseases
Spherocytosis
Sickle Cell Disease
Thalassemia
Common in Cirrhosis
More Common in Asia
BROWN STONES
• Form in Gall Bladder AND Bile Ducts
• Small, Soft, Often Mushy
• Secondary to Bacterial Infection
Caused by Bile Stasis
• Bacterial Cell Walls Prominent in
Stones
• More Common in Asia
NATURAL HISTORY
• Most Are Asymptomatic
• Asymptomatic Stones Detected On
Evaluation For Other Illnesses
• Ultrasound
• CT
• Plain Abdominal X-Ray
• Laparotomy
• 2/3 Stay Asymptomatic >20 Years
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COMPLICATIONS
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Biliary Colic- Initial Symptom
Acute Cholecystitis
Choledocholithasis
Cholangitis
Biliary Pancreatitis
Cholecysto-Duodenal Fistula
Gall Bladder Carcinoma
CHOLECYSTECTOMY
• Indicated for Symptomatic Patients
• Rare Indications in Asymptomatic Ones
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Elderly Diabetics
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Before Transplantation
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Isolation From Medical Care
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Gallbladder Polyp (Controversial)
• Porcelain Gall Bladder Absolute
Indication
CHRONIC CHOLECYSTITIS
• Recurrent Attacks of Pain
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Frequently After a Meal (Fatty?)
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Radiates to Back and Shoulder
• Nausea and Vomiting
• Gall Bladder- Minor Inflammation to
Small, Shrunken With Fibrosis,
Adhesions
• Mucosa Becomes Atrophied
DIAGNOSIS
• Stones on Ultrasound
• Gall Bladder May Have Sludge
• Cholesterolosis- Strawberry Gall
Bladder
• Adenomyomatosis- Thick Wall
• Normal Ducts
• Cholecystectomy Cures >95%
ACUTE CHOLECYSTITIS
• Obstruction of Cystic Duct By Stone
• Gall Bladder Distention, Inflammation,
Edema
• Mucus Secretion- Hydrops, Milk of Bile
(Pearly White)
• 5-10% Progress to Ischemia, Necrosis
• Perforation Occurs in Body (Widest Part)
MANIFESTATIONS
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Biliary Colic → Lasting, Constant Pain
Anorexia, Nausea, Vomiting, Fever
Focal RUQ Tenderness, Guarding
Murphys’ Sign is Suggestive
Palpable Gall Bladder is Diagnostic
Normal LFTs, ?Minimal Bilirubin Elevation
White Blood Cell Count Often Elevated
DIAGNOSIS
• Ultrasound
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Stones
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Thickened Gall Bladder Wall
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Distended Gall Bladder
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Peri-Cholecystic Fluid
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Sonographic Murphy’s Sign
• If HIDA Scan Fills Gall Bladder- Precludes
Diagnosis
TREATMENT
• Antibiotics- Gram Negative and
Anaerobic Coverage
• Early laparoscopic Cholecystectomy
• Late Presentation >4-5 DaysAntibiotics Alone with Delayed
Cholecystectomy
• Very Ill, Elderly patients- Percutaneous
Cholecystostomy
LAP CHOLE
• Mortality 0.1%, Morbidity 0.3%
• Can Add Choledochotomy
• Conversion to Open in Acute Disease
Reasons for Conversion
• Inability to Visualize
Adhesions
• Duct Injury
Bleeding
• Abnormal Anatomy
CHOLEDOCHOLITHIASIS
• Primary Stones Form in Ducts
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Associated with Biliary Dysfunction,
Infection
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Brown Stones
• Secondary Stones Form in Gall Bladder
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Migrate to Common Bile Duct
• 6-12% Cholelithiasis Patients
• 20-25% in Patients >60
MANIFESTATIONS
• Symptomatic or Can Be Silent
• Colicky Pain, Nausea, Vomiting,
ICTERUS
• Stones Single or Multiple, Small or
Large
• Can Cause Common Duct Obstruction
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Cholangitis
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Biliary Pancreatitis
DIAGNOSIS
• Elevated Bilirubin, Alkaline Phosphatase,
Transaminases
• Ultrasound- Dilated Ducts
• Magnetic Resonance CholangiogramSensitivity 95%, Specificity 89%
• ERCP- Successful >90%, Morbidity <5%
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Therapeutic and Diagnostic
TREATMENT
• ERCP With Sphincterotomy
• Common Bile Duct Exploration
• Open or Laparoscopic
• T-Tube Left in Place
• Missed Stones Can Be Retrieved
Choledochoscope
CHOLANGITIS
• Ascending Infection Associated With Bile
Duct Obstruction
• Commonest Organisms
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E. coli
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Klebsiella
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Strep faecalis
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Bacteroides
• 5-10% Mortality
MANIFESTATIONS
• Charcot’s Triad
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Abdominal Pain
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Jaundice
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Fever
• Reynold’s Pentad
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Same Plus Septic Shock
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Mental Status Changes
TREATMENT
• Immediate Antibiotics, Resuscitation
• Duct Drainage (Cholangitis is Closed
Space Infection)
• ERCP With Sphincterotomy
• Percutaneous Transhepatic
Cholangiogram With Catheter
Placement
• Open Common Duct Exploration
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