Post on 14-Apr-2018
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Factors Contribute Inflammation
Mechanical inflammation: by increased intraluminal
pressure and distention with resulting ischemia of the
gall bladder mucosa and wall
Chemical inflammation: by release of lysolecithinand other local tissue factor
Bacterial inflammation: play a role in 50 to 85% of
patients E Choli, Klebsiella, Streptococcus,
Clostridium
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Persistent cystic duct obstruction
Pain lasts > 4 hours Usually fatty food ingestion 1 hr before pain
Biliary Colic
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Acute Cholecystitis
Early stages Edema and hyperemia
Later stages Adhesions, fibrosis, and necrosis
Courtesy of Netter
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Lanjutan komplikasi.
Limey (milk of calcium) bile and porcelain
gallbladder : calcium salts may be secreted into the
lumen of gallbladder in sufficient concentration and
diffuse, hazy opacification of bile or a layering ofplain abdominal roentgenography
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Mirrizzis syndrome: rare complication in
which a gallstone becomes impacted in the
cystic duct or neck of the gallbladder causing
compression of the CBD, resulting in CBD
obstruction and jaundice. Ultrasound shows
gallstone lying outside the hepatic duct
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Algorithm for the diagnosis of Acute cholecystitis
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Complications of Cholecystitis
Empyema and Hydrop Gangrene and Perforation
Fistula formation and Gall stones ileus
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Acute Cholecystitis2
Thickened gallbladder wall or edema
Pericholecystic Fluid Sonographic Murphys Sign
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Acute Cholecystitis
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Acute cholecystitis
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Contracted gb w/ wall thickening
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Management of Acute Cholecystitis
Supportive care with IVFs, bowel rest, & Abx
Almost half of patients have positive bile cultures
E. Coli is most common organism
Antibiotic choice: Ampicillin + Aminoglycoside
or 3rd generation cephalosporin
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Management cont.
No evidence exists showing a definite benefit
with use of antibiotics
NSAIDs may improve course of acute
cholecystitis6
SURGERY is the only definitive treatment
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Management cont.
1st open cholecystectomy: 1886 by Justus
Ohage
1st half of 20th Century: Supportive care
delayed open cholecystectomy
In 1970s mid-1980s: Open
cholecystectomy early in the treatment course
Golden 72 hours Rule
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Studies in early 1980s early surgery was
better than delayed surgery (using standard
open approach)14
Laparoscopic surgery developed in late 1980s
Complications from LC dependent on
laparoscopic skill of surgeon (major bleeding,
wound infection, bile leak, and biliary injury)
Was the benefit of early surgery by the open
approach true laparoscopically??
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Timing of Surgery
Early surgery = Within 72 hours of admission
or onset of symptoms
Delayed surgery = Supportive care only
followed by discharge and readmission in 6-12
weeks for surgery
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Chronic Cholecystitis
Chronic inflammation of the gallbladder wall which
is always associated with the presence of gallstones
and is thought to result from repeated bouts of
subacute or acute cholecystitis or from persistentmechanical irritation of the gallbladder wall by
gallstones
The presence of bacteria in the bile occurs in more
than one-quarter of patients with chronic cholecystitis
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Whos at Risk?
Immunosuppressed
Critically ill (trauma, burns, sepsis, vent)
CAD Diabetes
Cholesterol emboli
TPN Obstetric patients
Recent surgery
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Pathogens
Usual: Klebsiella, ecoli, enterococcus,
pseudomonas, bacteroides
Unusual: typhoid, campylobacter,leptospirosis, clostriudium, vibrio, Q fever,
dengue fever
Immunosuppressed: CMV, microsporidium,cryptosporidium, salmonella, candida
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Presentation
May be subtlevague RUQ pain (25%),
leukocytosis, fever
May rapidly progress to septic shock May also be similar to classic cholecystitis w/
positive Murphys sign
May become jaundiced
Mortality 10-50%
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To the lab
LFT abnormalities: +/- elevated TBili,
AlkPhos and aminotransferases
Blood cultures prior to antibiotics
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To the basement
Ultrasound (1st test of choice)
Absence of stones
Thickened GB wall >5mm
US Murphys sign
champagne bubble sign
Perforation +/- abcess formation (oops)
30-92% sensitive, >90% specific
HIDA scan: failure to opacify the gallbladder =positive
79% sensitive, 87% specific
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Normal HIDA scan
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Treatment
Blood cultures
Antibiotics
If untreated: Zosyn, Unasyn or Imipenam
If already on broad spectrum:
3rd generation ceph PLUS
Metronidazole OR Imipenam PLUS/MINUS Fluconazole
If known MRSA hx consider Vanc
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Cholelithiasis
Prevalence: 6-10 % men, 12-20 % women
Three types of stone:Mixed cholesterol 80 %
Pure cholesterol 10 %
Pigment 10 %
18-50% become symptomatic over 10-15 yr.
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Statistics
About 3 million adults in the U.S. have
gallstones
Elderly, diabetics, obese patients, debilitated
patients increased incidence of gallstones
90% of acute cholecystitis cases due to
gallstones
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Incidence of Biliary Tract
Disease Cholelithiasis affects > 15 million in U.S.
Contributes to 6-10,000 deaths annually
>500,000 cholecystectomies per year Annual cost of surgery > $3 billion
Majority of gallstones clinically silent
18-50 % become symptomatic over 10-15yr
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Cholesterol Stones
Compromised primary of cholesterol (generally
>60%) and mucin, calcium salts of bilirubin,
phosphate, carbonate and palmitate, and small
amounts of various other substances
Some stones contain less than 60% cholesterol buthave the morphologic and microstructural features of
typical cholesterol stones mixed stones
Risk factors: aging, female gender, obesity,
pregnancy, rapid weight loss, native american
ethnicity
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Pigment stones
Compromised mostly of pigment and calcium salts
Two types of pigment stones: black, brown
Black pigment stones: black colored, compromised
primarily of calcium bilirubinate and other pigment,
mucin, calcium salts of phosphate and carbonate, andsmall amounts of various other substances
exclusively in gall bladder
The major known associated conditions are: old age,
cirrhosis, hemolysis, possibly total parenteralnutrition
Brown pigment stones: brown colored, compromised
primarily of calcium bilirubinate, cholesterol, calcium
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. palmitate, and small amounts of various
other substances mostly in bile ducts
Predisposing condition: stasis and/or infection
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Processes of Gallstone Formation
Cholesterol Gall Stones: supersaturation on bile
with cholesterol, increase in gallbladder mucin, and
gall bladder stasis are the factors that play a role
Black pigment: precipitation of calcium salts and
pigment is the major patophysiologic event. Failureto maintain calcium ions in solution is considered
important, resulting in the precipitation of calsium
bilirubinate, phosphate, and carbonate
Brown pigment: precipitation of calcium bilirubinateand calcium salts of fatty acids are the major
pathophisiologic events. Biliary stasis and bacteria
in bile are important for stone formation
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Pathology
Obstruction Intraluminal
Extraluminal
Intramural
Infection Host
Sufficient inoculum
Stasis
Symptoms Pain, Jaundice, fever
Constitutional; nausea, vomiting, weight loss, anorexia
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Abdominal pain
Biliary colic Misnomer, constant RUQ
Visceral
Precipitated by any food or spontaneous
Pain due to obstruction (neck, duct)
Resolve spontaneously
Acute Cholecystitis RUQ
visceral Positive Murphys
Fever, WCC
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Risk Factors
Age Time dependent, typical 40, decrease in conversion of cholesterol
to bile salts
Gender F:M, 3:!, oestrogen decrease cholesterol uptake by liver
Race High: Hispanics, whites. Low: Black Africans
Genetics Family history
Obesity Increased activity of HMG reductase lead to increased cholesterol
synthesis
Crohns Decreased ileal resorption of bile salts
TPN GB stasis,
WT loss Low calorie, high protein diet, bypass surgery
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Scanning Considerations: Cholelithiasis
Ultrasonography: accuracy 90-95 %
Liver as acoustic window
Location: inferior hepatic surface, medial and
anterior to kidney, lateral and anterior to vena
cava 15 % of gall stones are radiopaque on plain
abdominal X-rays
CT scanning: provide more extensiveinformation than ultrasonography, but its
sensitivity is lower
ERCP: endoscopic retrograde cholangio
pancreatography: detects stones in bile ducts
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Natural History
Asymptomatic gallstones: the majority of
patients are asymptomatic and remainasymptomatic after decades of follow up
Billiary pain: arise from transient obstruction of
the cystic duct by stones or sludge Location is in the right upper quadrant or epigastrium
May range from mild to severe
Duration 15-30 minutes up to 3-4 hours
The interval between episodes varies from daily toonce every months or even longer
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Large stone with shadowing
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Many small stones
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Cholelitiasis multiple
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Layer of gravel with shadowing
Therapy: elective treatment
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Therapy: elective treatment
Bile salts (ursodeoxycholic acid or chenodeoxy cholic
acid) In patients who are at high risk for surgical
The cystic duct must be patent and the stones radiolucent
The complete dissolution rate for all patients is only 20-
30%. The highest success rates (60-70%) are in patientswith stones < 5 mm
Ursodeoxyc: agent of choice, chenodeoxy is rarely used
because of side effects
ESWL (extracorporeal shock wave litotripsy): forsingle stones < 20 mm in diameter
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Choledocholithiasis
Predictive tests
Pre operative
Bilirubin and Alk. phosphatase
Jaundice, pancreatitis Cholangitis
CBD stones on US
Operative
Dilated CBD Palpable stone
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Cholangitis
Stone in distal CBD
Bacteria in bile in 50% - 70%
Charcot Triad
Fever, jaundice, pain
Progress to septic shock
Treatment
Supportive, antibiotics Endoscopic decompression of biliary system
Surgery
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Medical treatment
Oral Dissolution Early 1970
Chenodeoxycholic acid
Treatment needed for 12 months
Cholesterol stones less than 10mm
Contact Dissolution
Methyl tertbutyl ether (organic solvent)
Pump directly into gallbladder
Cholesterol stones dissolve within hours
Technically feasible
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Medical treatment
Extracorporeal shock wave lithotripsy Mid 1980
Advantages Noninvasive
Reduced morbidity and mortality Which stones
Non calcified, less than 30mm
Complications Biliary colic, pancreatitis, haemobilia
Success rate 90% early
Recurrence 15%
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Post-cholecystectomy syndrome
40% of patients
Presentation Biliary colic
Gas bloating 40%
Abdominal pain
Dyspepsia
Causes
Misdiagnosis
Reflux, ulcer, diverticulosis, hepatitis, IBS
Management Further evaluation
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Choledocholithiasis
CBD stones
Primary
Migrated from GB
Retained Other diseases
Benign biliary stricture, scleorsing cholangitis
Incidence Not known, up to 15% have stones during
surgery
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Choledocholithiasis
Predictive tests
Pre operative
Bilirubin and Alk. phosphatase
Jaundice, pancreatitis Cholangitis
CBD stones on US
Operative
Dilated CBD Palpable stone
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CBD
CBD internal
diameter is < 4 mm
in 98% of normal
individuals
Cystic duct 1.8 mm
diameter and 1-2 cmlong
CBD
Portal vein
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Alhamdulillahi robbil alamien