eMentorSurgery

Dear students, This is only for your revision and NOT A FULL TEXT.

Cholelithiasis and Cholecystitis

¨Presence of gallstones in the gallbladder.

¨Spectrum rangesfrom asymptomatic, colic, cholangitis, choledocholithiasis, cholecystitis

¨Colic is atemporary blockage, cholecystitis is inflammation from obstruction of CBD or cysticduct, cholangitis is infection of the biliary tree.

Pathophysiology

¨Three types ofstones, cholesterol, pigment, mixed.

¨Formation ofeach types is caused by crystallization of bile.

¨Cholesterol stones most common.(in western countries)

.Mixed type of stones are common in Asian countries.

¨Bile consists oflethicin, bile acids, phospholipids in a fine balance.

¨Impairedmotility can predispose to stones.

Causes ¨Cholecystitis isoften caused by cholelithiasis (the presence of choleliths, or gallstones,in the gallbladder), with choleliths most commonly blocking the cystic ductdirectly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms,predominantly E.coli and Bacteroides species

Pathophysiology

¨Sludge iscrystals without stones. It may be a first step in stones, or be independent ofit.

¨Pigment stones(15%) are from calcium bilirubinate. Diseases that increase RBC destructionwill cause these. Also in cirrhotic patients, parasitic infestations.

Pathology of Cholecystitis

The gallbladder's wall becomes inflamed. Extreme cases may result innecrosis and rupture. Inflammation often spreads to its outer covering, thusirritating surrounding structures such as the diaphragm and bowel.

Less commonly, in debilitated and trauma patients, the gallbladder maybecome inflamed and infected in the absence of cholelithiasis, and is known asacute acalculous cholecystitis.

Stones in the gallbladder may cause obstruction and the accompanying acuteattack. The patient might develop a chronic, low-level inflammation which leadsto a chronic cholecystitis, where the gallbladder is fibrotic and calcified.

Sex

¨More common in women. Etiology may be secondary to variations in estrogen causing increasedcholesterol secretion, and progesterone causing bile stasis.

¨Pregnant women more likely to have symptoms.

¨Women withmultiple pregnancies at higher risk

¨Oral contraceptives, estrogen replacementtx.

Age

¨It is uncommon for children to have gallstones. If they do, its more likely that they havecongenital anomalies, biliary anomalies, or hemolytic pigment stones.

¨Incidence of GS increases with age 1-3% per year.

History

¨3 clinicalstages 

asymptomatic,

symptomatic, and

with complications (cholecystitis, cholangitis,CBD stones).

¨Most (60-80%)are asymptomatic

¨A history ofepigastric pain with radiation to shoulder may suggest it.

¨A detailedhistory of pattern and characteristics of symptoms as well as US make thediagnosis.

History

¨Most patientsdevelop symptoms before complications.

¨Indigestion,bloating, fatty food intolerance occur in similar frequencies in patientswithout gallstones, and are not cured with cholecystectomy.

History

¨Best definitionof colic is pain that is severe in epigastrium or RUQ that last 1-5 hrs, oftenwaking patient at night.

¨In classic casespain is in the RUQ, however visceral pain and GB wall distension may be only inthe epigastric area.

¨Once peritoneumirritated, localizes to RUQ. Small stones more symptomatic.

Physical           

¨Vital signs and physical findings in asymptomatic cholelithiasis are completely normal.

¨Fever,tachycardia, hypotension, alert you to more serious infections, includingcholangitis, cholecystitis.

¨Murphy’s sign

Cholecystitis usually presents as a pain in the right upperquadrant. This is usually a constant, severe pain. During the initial stages,the pain may be felt in an area totally separate from the site of pathology,known as referred pain. In cholecystitis the referred pain may occur in theright scapula region.

This may also present with the above mentioned pain after eating greasy orfatty foods such as pastries, pies, and fried foods.

This is usually accompanied by a low-grade fever, diarrhea, vomiting, nauseaand granulocytosis. The gallbladder may be tender and distended.

More severe symptoms such as high fever, shock and jaundiceindicate the development of complications such as abscess formation,perforation or ascending cholangitis. Another complication, gallstoneileus, occurs if the gallbladder perforates and forms a fistula with thenearby small bowel, leading to symptoms of intestinal obstruction.

Chronic cholecystitis manifests with non-specific symptoms such as nausea,vague abdominal pain, belching, and diarrhea.

Causes( Incidences )

¨Fair, fat,female, fertile of course.

¨High fat diet

¨Obesity

¨Rapid weightloss, TPN, Ileal disease, NPO.

¨Increases with age, alcoholism.

¨Diabetics have more complications.

¨Hemolytics

Diagnosis of CholecystitisCholecystitis is usually diagnosed by a history of the above symptoms, aswell examination findings:(

fever (usually l+/-

Murphy's sign

Ortner's sign .

Boas' sign -

¨Ultrasound canassist in the differential.Differentials

Differential diagnosis of Acute cholecystitisThis should be suspected whenever there is acute right upper quadrant orepigastric pain, other possible causes include:

Perforated peptic ulcer

Acute peptic ulcer exacerbation

Amoebic liver abscess

Acute amoebic liver

colitis

Acute pancreatitis

Acute intestinal obstruction

Renal colic

Acute retro-colic appendicitis

Chronic cholecystitis:(

. Liverfunction tests will likely show increases across all enzymes (AST, ALT, ALP,GGT) with raised bilirubin. As with choledocholithiasis, diagnosis is confirmedusing cholangiopancreatography.

D.Ds

¨AAA

¨Appendicitis

¨Cholangitis,cholelithiasis

¨Diverticulitis

¨Gastroenteritis,hepatitis

¨IBD, MI,SBO

¨Pancreatitis,renal colic, pneumonia

Workup

Investigations

BloodLaboratory values may be notable for an elevated alkaline phosphatase, possibly an elevated bilirubin(although this may indicate choledocholithiasis), and possibly an elevationof the WBC count. CRP (C-reactive protein

RadiologySonographyis a sensitive and specific modality for diagnosis of acute cholecystitis;adjusted sensitivity and specificity for diagnosis of acute cholecystitis are88% and 80%, respectively. The 2 major diagnostic criteria are cholelithiasisand sonographic Murphy's sign. Minor criteria include gallbladderwall thickening greater than 4 mm, pericholecystic fluid, and gallbladderdilatation.

The reported sensitivity and specificity of CT scan findings are in the range of90-95%. CT is more sensitive than ultrasonography in the depiction ofpericholecystic inflammatory response and in localizing pericholecysticabscesses, pericholecystic gas, and calculi outside the lumenof the gallbladder. CT cannot see noncalcified gallbladder calculi, and cannotassess for a Murphy's sign.

Hepatobiliary scintigraphywith technetium-99mDISIDA (bilirubin)analog is also sensitive and accurate for diagnosis of chronic and acute cholecystitis.It can also assess the ability of the gall bladder to expel bile (gall bladderejection fraction), and low gall bladder ejection fraction has been linked tochronic cholecystitis. However, since most patients with right upper quadrantpain do not have cholecystitis, primary evaluation is usually accomplished witha modality that can diagnose other causes, as well.

¨Labs with asymptomatic cholelithiasis and biliary colic should all be normal.

¨WBC, elevatedLFTS may be helpful in diagnosis of acute cholecystitis, but normal values do not rule it out.

¨Study by Singeret al examined utility of labs with chole diagnosed with HIDA, and showed nodifference in WBC, AST,ALT Bili, and Alk Phos, in patients diagnosed and thosewithout.

Workup

¨Elevated WBC is expectedbut not reliable.

¨ALT, AST, APmore suggestive of CBD stones

¨Amylase elevation may be GS pancreatitis.

Imaging Studies

¨US and Hidabest. Plain x-rays, CT scans ERCP are adjuncts.

¨X-rays: 15%stones are radiopaque, porcelain GB may be seen. Air in biliary tree,emphysematous GB wall.

¨CT: forcomplications, ductal dilatation, surrounding organs. Misses 20% of GS. Get ifdiagnosis uncertain.

CT Scan

Plain Films

Imaging

¨Ultrasound is95% sensitive for stones, 80% specific for cholecystitis. It is 98% sensitiveand specific for simple stones.

¨Wall thickening(4mm) false positives!

¨Distension

¨Pericholecysticfluid, sonographic Murphy’s.

¨DilatedCBD(7-8mm).

Imaging

¨Hida scandocuments cystic duct patency.

¨94% sensitive,85% specific

¨GB should bevisualized in 30 min.

¨If GB visualizedlater it may point to chronic cholecystitis.

¨CBD obstructionappears as non visualization of small intestine.

¨False positives,high bilirubin.

¨ERCP isdiagnostic and therapeutic.

¨Providesradiographic and endoscopic visualization of biliary tree.

¨Do when CBD dilated and elevated LFTs.

¨Complications include bleeding, perforation, pancreatitis, cholangitis.

Emergency Department Care

¨Suspect GB colicin patients with RUQ pain of less than 4-6h duration radiating to back.

¨Consider acutecholecystits in those with longer duration of pain, with or without fever.Elderly and diabetics do not tolerate delay in diagnosis and can proceed tosepsis.

Emergency Department Care

Therapy

X-Ray during laparoscopic cholecystectomy

For most patients, in most centres, the definitive treatment is surgicalremoval of the gallbladder. Supportive measures are instituted in the meantimeand to prepare the patient for surgery. These measures include fluidresuscitation and antibiotics. Antibiotic regimens usually consist of abroad spectrum antibiotic such as piperacillin-tazobactam (Zosyn), ampicillin-sulbactam (Unasyn), ticarcillin-clavulanate(Timentin), or a cephalosporin (e.g.ceftriaxone)and an antibacterial with good coverage (fluoroquinolonesuch as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole.For penicillin allergic patients, aztreonam andclindamycinmay be used.

Gallbladder removal, cholecystectomy, can be accomplished via open surgeryor a laparoscopicprocedure. Laparoscopic procedures can have less morbidity anda shorter recovery stay. Open procedures are usually done if complications havedeveloped or the patient has had prior surgery to the area, making laparoscopicsurgery technically difficult. A laparoscopic procedure may also be 'converted'to an open procedure during the operation if the surgeon feels that furtherattempts at laparoscopic removal might harm the patient. Open procedure mayalso be done if the surgeon does not know how to perform a laparoscopiccholecystectomy.

In cases of severe inflammation, shock, or if the patienthas higher risk for general anesthesia (required for cholecystectomy),the managing physician may elect to have an interventional radiologist insert a percutaneousdrainage catheter into the gallbladder ('percutaneous cholecystostomytube') and treat the patient with antibiotics until the acute inflammationresolves. A cholecystectomy may then be warranted if thepatient's condition improves.

¨In patients whoare unstable or in severe pain, consider a bedside US to exclude AAA and toassist in diagnosis of acute cholecystitis.

¨Replace volume with IVF, NPO, +/- NGT.

¨Administer paincontrol early. A courtesy call to surgery may give them time to examine withoutnarcotics.

Consults

¨Historicallycholecystits was operated on emergently which increased mortality.

¨Surgical consultis appropriate, and depending on the institution, either medicine or surgerymay admit the patients for care.

¨Get GI involvedearly if suspect CBD obstruction.

Medications

¨Anticholinergicssuch as Bentyl (dicyclomine hydrochloride)to decrease GB and biliary tree tone.(20mg IM q4-6).

¨Demerol 25-75mgIV/IM q3

¨Antiemetics(phenergan, compazine).

¨Antibiotics(Zosyn 3.375g IV q6) need to cover Ecoli(39%), Klebsiella(54%), Enterobacter(34%),enterococci, group D strep.

 Complications of cholecystitis

Perforation or rupture

Ascending cholangitis

Further Inpatient Care

¨Cholecystectomycan be performed after the first 24-48h or after the inflammation has subsided.Unstable patients may need more urgent interventions with ERCP, percutaneousdrainage, or cholecystectomy.

¨Lap chole veryeffective with few complications (4%). 5% convert to open. In acute setting upto 50% open.

Laparoscopic Cholecystectomy

Further Outpatient Care

¨Afebrile, normalVS

¨Minimal pain andtenderness.

¨No markedlyabnormal labs, normal CBD, no pericholecystic fluid.

¨No underlyingmedical problems.

¨Next dayfollow-up visit.

¨Discharge onoral antibiotics, pain meds.

Complications

¨Cholangitis,

sepsis

¨Pancreatitis

¨Perforation(10%)

¨GS ileus(mortality 20% as diagnosis difficult).

¨Hepatitis

¨Choledocholithiasis

Prognosis

¨Uncomplicatedcholecystitis as a low mortality.

¨Emphysematous GB mortality is 15%

¨Perforation ofGB occurs in 3-15% with up to 60% mortality.

¨Gangrenous GB25% mortality.

Complications of cholecystitis

bile leak ("biloma")

bile duct injury (about 5-7 out of 1000 operations.