acute cholecystitis
TRANSCRIPT
ACUTE CHOLECYSTITIS
Assistant professor : pechyonkin
Student: raza sarif
Group : 414 A
Inflammation of gall bladder is called ACUTE CHOLECYSTITIs
DEFINITION
• COMMON IN FERTILE
• FATTY
• ABOVE FORTY
• FEMALES lydia shum
INCIDENCE
· Obstruction
· Bacterial invasion
· Trauma and chemical irritation
· Pancreatic reflex
Etiology
Etiology
1 CALCULOUS
etiology
2ACALCULOUS Cholesterosis(strawberry gall
bladder) Cholesterol polyposis of gall
bladder Cholecystitis glandularis
proliferans Diverticulosis of gall bladder Typhoid of gall bladder
etiology
BACTERIAL INFECTION E-coli Klebsiella S.faecalis Salmonella Clostridia Anaerobes
classification
• On etiology: calculous,acalculous,emphysamatous
• On inflammation:simple,destructive
Emphysamatous
classification• On morphology:
catarhal,phlegmonous,gangrenous,gangrenous perforation
Clinical Findings Symptoms: 1. Abdominal pain
· Where· When· How
Abdominal pain
• SITE - RIGHT HYPOCHONDRIUM• TYPE - COLICKY• ONSET – SUDDEN• DURATION – MORE THAN 12 hrs • RADIATION BACK SHOULDER RIGHT HYPOCHONDRIUM LEFT HYPOCHONDRIUM
Symptoms:
· 2 gastrointestinal
· Nausea, bilious vomiting · Abdominal distension · Belching or flatulence
3. Fever
Acute cholecystitis in elderly and old patients is characterized by quickly developing intoxication syndrome
signs
• GENERAL TACHYCARDIA PYREXIA
From MMWR – Aug 2004
From MMWR – Aug 2004
• Local TENDERNESS - RT
HYPOCHONDRIUM RIGIDITY - RT HYPOCHONDRIUM MURPHY’S SIGN BOAS SIGN MASS
murphy’s sign
Boas sign
• An area of hyperasthesia between 9th and 11th rib posteriorly right side is a feature
Ortner sign
Kera sign
• Mussi sign• Shotkin blumber sign
· Elevated leukocyte count
· Elevated serum bilirubin
· Elevated amylase level
Laboratory findings
Instrumental investigation
• PLAIN X-RAY ABDOMEN
Radioopaque gall stone
• ULTRASONOGRAPHY Dilatation of billiary tree Stones Fluid
Common bile duct dialation
Intra hepatic duct dialation
Gall stone
GALL BLADDER RADIONUCLIDE SCAN
ORAL CHOLECYSTOGRAM
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP
HIDA SCAN
HIDA IS HEPATIC IMINODIACETIC ACID
due to edema of cystic duct HIDA
Does not enter in gall bladder hence nonvisualization of gall bladder is diagnostic of acute cholecystitis
Its imortance lies in diagnostic of acalculous cholecystitis
HIDA SCAN SHOWING NONVISUALIZATION OF GALL BLADDER
ERCP showing mirizzi syndrome
DIFFERENTIAL DIAGNOSIS
common ACUTE PANCREATITIS PERFORATED DUODENAL ULCER PERFORATED PEPTIC ULCER APPENDICITIS
RARE
ACUTE PYELONEPHRITIS
HEPATITIS
MYOCARDIAL INFARCTION
PNEUMONITIS
complication• EMPYEMA• PERFORATION PERITONITIS• ABSCESS• FISTULA• MUCOCELE• ACUTE PANCREATITIS• GALL STONE ILEUS• OBSTRUCTIVE JAUNDICE
Treatment
Nonsurgical or preoperative
management
· Intravenous fluids
· Nasogastric tube
· Broad spectrum antibiotics
• Naspgastric tube:
ryle’s tube admistration immediately continued 3 to 5 days.aspirating HCL decreases the secretion of bile.spasm of bladder may come down
intravenous fluid: in the beginning 5 % dexrose saline
may be started but subsquently fluid may be changed according to electrolyte balance of paitent
Analgesic +anticholinergic given to reduce spasm
Antibiotic
broad spectrum to cotrol inflammation.combination of ampicillin+clindamycin+ and aminoglycoside is good.
• Conservative treatment stopped and early cholecystectomy advised
1)pain and tenderness spread across the abdomen
2)gall bladder increases in size
3)Pulse rate continuse to rise
4)In very elderly patient
Surgical Treatment
1.Attack within 48-72 h of diagnosis
2.Deterioration in patient’s general condition
3.Complications are present
Perforation
Peritonitis
Acute obstructive suppurative cholangitis
Acute pancreatitis
Surgical methods
• Open cholecystectomy• Laparoscopic cholecystectomy
• Two method in cholecystectomy:
duct first method:
the cystic duct and artery are first dissected and divided
fundus first method: in which dissection is started
from fundus and gradually proceed toward cystic duct
Operative problems
1)CBD and right hepatic artery injury during the operation of fundus first method
2)Slipped of clip or ligature may lead to profuse bleeding
3)Biliary leakage from some unknown duct which may lead to syndrome known as waltman-walter syndrome
this syndrome is menifested by chest pain or upper abdominal pain,low BP,tachycardia.it mimics coronory thrombosis,pulmonary embolism.this condition is fatal so immediately reexplored the abdomen
Postoperative treatment
1)Drainage is removed after 48 hours or it may be kept for longer period
2)Gastric aspiration and IV fluid is continued until the peristalsis of intestine is come back
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