1. ACUTE CHOLECYSTITIS
Assistant professor :
pechyonkin
Student: raza sarif
Group : 414 A

2. DEFINITION
Inflammation of gall bladder is
called ACUTE CHOLECYSTITIs

4. INCIDENCE
• COMMON IN FERTILE
• FATTY
• ABOVE FORTY
• FEMALES
lydia shum

5. Etiology
Obstruction
Bacterial invasion
Trauma and chemical irritation
Pancreatic reflex

6. Etiology
1 CALCULOUS

7. etiology
2 ACALCULOUS
 Cholesterosis(strawberry gall
bladder)
 Cholesterol polyposis of gall bladder
 Cholecystitis glandularis proliferans
 Diverticulosis of gall bladder
 Typhoid of gall bladder

8. etiology
BACTERIAL INFECTION
 E-coli
 Klebsiella
 S.faecalis
 Salmonella
 Clostridia Anaerobes


9. classification
• On etiology:
calculous,acalculous,emphysamatous
• On inflammation:simple,destructive
Emphysamatous

10. classification
• On morphology:
catarhal,phlegmonous,gangrenous,gan
grenous perforation

11. Clinical Findings
Symptoms:
1. Abdominal pain
Where
When
How

12. Abdominal pain
• SITE - RIGHT HYPOCHONDRIUM
• TYPE - COLICKY
• ONSET – SUDDEN
• DURATION – MORE THAN 12 hrs
• RADIATION
 BACK
 SHOULDER
 RIGHT HYPOCHONDRIUM
 LEFT HYPOCHONDRIUM

13. Symptoms:
2 gastrointestinal
Nausea, bilious vomiting
Abdominal distension
Belching or flatulence
3. Fever

14. Acute cholecystitis in
elderly and old patients
is characterized by
quickly developing
intoxication syndrome

15. signs
• GENERAL
 TACHYCARDIA
 PYREXIA
From MMWR –
Aug 2004

16. • Local
 TENDERNESS - RT




HYPOCHONDRIUM
RIGIDITY - RT HYPOCHONDRIUM
MURPHY’S SIGN
BOAS SIGN
MASS
From MMWR –
Aug 2004

17. murphy’s sign

18. Boas sign
• An area of hyperasthesia between 9th
and 11th rib posteriorly right side is a
feature

19. Ortner sign

20. Kera sign

21. • Mussi sign
• Shotkin blumber sign

22. Laboratory findings
Elevated leukocyte count
Elevated serum bilirubin
Elevated amylase level

23. Instrumental investigation
• PLAIN X-RAY ABDOMEN
Radioopaque gall stone

24. • ULTRASONOGRAPHY
 Dilatation of billiary tree
 Stones
 Fluid

25. Common bile duct dialation

26. Intra hepatic duct dialation

27. Gall stone

30. GALL BLADDER RADIONUCLIDE SCAN
ORAL CHOLECYSTOGRAM
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTC)
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP

31. 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

32. HIDA SCAN SHOWING NONVISUALIZATION OF GALL BLADDER

33. ERCP showing mirizzi
syndrome

34. DIFFERENTIAL DIAGNOSIS
common




ACUTE PANCREATITIS
PERFORATED DUODENAL ULCER
PERFORATED PEPTIC ULCER
APPENDICITIS

35. RARE
ACUTE PYELONEPHRITIS
HEPATITIS
MYOCARDIAL INFARCTION
PNEUMONITIS

36. complication
•
•

•
•
•
•
•
•
EMPYEMA
PERFORATION
PERITONITIS
ABSCESS
FISTULA
MUCOCELE
ACUTE PANCREATITIS
GALL STONE ILEUS
OBSTRUCTIVE JAUNDICE

37. Treatment
Nonsurgical or preoperative
management
Intravenous fluids
Nasogastric tube
Broad spectrum antibiotics

38. • 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

39. Antibiotic
broad spectrum to cotrol
inflammation.combination of
ampicillin+clindamycin+ and
aminoglycoside is good.

40. • 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

41. 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

42. Surgical methods
• Open cholecystectomy
• Laparoscopic cholecystectomy

43. • 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

44. 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

45. 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

46. 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

47. THANK U
СПAСИБO