general surgery knmu acute cholecystitis lecture

8/18/2019 General Surgery KNMU Acute Cholecystitis Lecture

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Kharkov National Medical University

Department of Surgery No.

Course: 4th general medicine

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Date: #$%""%#$"&

'opic: (cute Cholecystitis

ACUTE CHOLECYSTITIS

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(cute cholecysitis is in)ammation of the gall*ladder that causes severe a*dominalpain. +t is usually a complication of cholelithiasis that involves the gall*ladder ,ithvarious degrees of severity.

-hysiology of the gall*ladder: 'he gall*ladder stores and concentrates *ile. ile )o, is controlled *y hepatic

secretory pressure the tone of Sphincter of /ddi gall*ladder contraction and therate of gall*ladder )uid a*sorption.

'he gall*ladder also releases *ile in to the common hepatic duct.

(natomy of gall*ladder:0undus or tipCorpus+nfundi*ulum called 1artmann2s pouchNeckCystic duct 3#4 cm long5

iliary tract

'he iliary tract includes the intrahepatic *ile duct the e6trahepatic *iel dut thegall*ladder and the sphincter of /ddi.

+ntrahepatic *ile duct:ile canaliculiSegmental *ile duct7o*al *ile duct8ight or left hepatic duct

96trahepatic *ile duct:7eft and right hepatic *ile ductCommon hepatic duct ductus hepaticus communis

Common *ile duct ductus choleduchusCystic duct of gall*ladderSphincter of /ddi

Classication of acute cholecystitis

Types of acute cholecystitis:acute calculous cholecystitis ;$;&<acute acalculous cholecystitis

Forms of acute cholecystitis:Simple or catarrhal-helgmonous!angrenous-erforated

(cute calculous cholecystitis

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involves a gallstone= is a complication of cholelithiasis.the gallstone *locks the path,ay from the gall*ladder to the cystic duct leadingultimately to in)ammation of the gall*ladder.o*struction of cystic duct increase intraluminal pressure in the gall*ladder.is associated ,ith arterial dilation and entesive venous lling

(cute acalculous cholecystitis ((Cis in)ammation of the gall*ladder ,ithout stone formationis associated ,ith arterial occlusion and minimal or no vneous lling . 'he criticalfactor in acute acalculous cholecystis is gall*ladder ischemia or reperfusion in>ury.*ile stasis due to volume depletion is also a factor in ((C 3lysophospholipid choline+ *ile can cause local in>ury of the gall*ladder ,all%mucosa= other *ile componentslike glucuronidase can induce ((C

Clinical picture of acute cholecystitis

• Sudden pain in the rugiht upper ?uadrant 38U@5

N: sudden pain is also in *iliary colic *ut the onset of the pain in *iliary colicis foodrelated.-ain in acute cholecystitis is not connected ,ith meals and *egins as a dullpoorly localiAed pai in the midepigastrium.

• 'enderness and n rigidity of 8U@

• Nausea vomiting

Signs of acute cholecystitis in acute calculous and acalculous cholecystitis

• Murphy2s sign B press the right upper ?uadrant region ,hile the patient is

inspiring deeply. Murphy2s sign is positive ,hen patient stops *reathingduring inspiration *ecause your pressing caused pain.

• Ker2s sign ker2s point is ,here the right lateral edge of the rectus a*dominismuscle meets the right costal arch. Ker2s point is the pro>ection of thegall*ladder. Ker2s sign is positive if pain is felt *y the patient ,hen youpercuss Ker2s point.

• /rtner2s sign is positive ,hen pain is felt if you strikKer2s point ,ith edge ofthe palm.

• De Mussy!eorgievsky2s sign or the phrenic sign pressing the clavicular

edge of the sternocleidomastoid muscle causes pain in the right upper?uadrant.

• oas sign area of hyperesthesia *et,een ;th and ""th ri* posteriorly on the

right side

7a*oratory investigationsCC leukocytois "#$$$"&$$$ cellsCheck liver function serum *iliru*in serum alkaline phosphatase and serumamylase

+nstrumental methods


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US to demonstrate gallstonesC' to sho, thickening of the gall*ladder ,all.

Management

Conservative treatment:

(dmit the ptient to the hospitalDiet+v hydrationSystemic anti*ioticsMonitor the patient/ther drugs ie spasmolytics anithistamines *ut do not give pain killers. +f you dogive pain killers you ,on2t *e a*le to tell ,hen the in)ammation spreads ;painintensies5 and you ,on2t kno, ,hen to use surgical treatment.

Surgical treatment/pen or laparoscopic cholecystectomy/pen cholecystectomy: usually a midline incision is used= is of # types antegrade

and retrogradeSurgery s contraindicated in carcinoma choledocholithiasis *iliary stenosis severa*dominal infection pregnancy

DiEerential diagnosis(ppendicitisCholangitisCholelithiasisDiverticulitis!astroenteriritishepatitis

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general surgery knmu acute cholecystitis lecture

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