Cholecystitis

Question 1

What is cholelithiasis ?

Answer 1

It is formation of calculus in biliary tracts including gallbladder

Question 2

Etiology of Cholelithiasis

Answer 2

• eating of fat food and meat
• obesity, sedentary life-style
• inflammation of biliary tracts and gallbladder
• elderly age
• pregnancy
• diseases of GIT(colitis, duodenitis, duodenostasis, hepatitis, gastric or duodenal ulcer, pancreatitis etc

Question 3

Pathogenesis of Cholelithiasis

Answer 3

Due to participation of bile acids in enterohepatic circulation or disbalance between concentration of phospotides and cholesterol in bile , it results in precipitation of crystals of cholesterol from the oversaturated bile which then shape a nucleus and form a stone
Pigmentary stones consist of unsolvable precipitates of Calcium and bilirubin(bilirubinate calcium)
Brown pigmented stones may consist of bilirubinate calcium, mild and are rarely formed

There are stages in Pathogenesis
1. Preclinical stage
- disorders in metabolism of cholesterol, bile acids,phospholipids
-
2.Clinical stage
a.physico-chemical stage- impairment of colloid stability of bile, inflammation
b.stage of formation of microliths-agglomeration of particles and formation of microliths, inflammation,dyskinesia
c.Stage of microlithiasis and complications-agglomeration of microliths into macroliths,inflammation,dyskinesia
d.stage of complications-stage of obstruction and dilation of bile ducts

Question 4

Classification of Cholelithiasis and Cholecystitis

Answer 4

For Cholelithiasis;
Cholelithiasis noncomplicated by infection 
-biliary colic
-valvular calculus of choledoch 
-impacted calculus of choledoch 

Cholelithiasis complicated by infection

• catarrhal cholecystitis
• phlegmpnous cholecystitis
• gangrenous cholecystitis
• perforated cholecystitis

Acalculous acute cholecystitis

• catarrhal
• phlegmonous
• gangrenous
• perforated
• enzymatic

Complications of cholecystitis

• cholangitis
• sepsis
• peritonitis
• pancreatitis
• hepatitis

Biliary dyskinesia

• hypomotor
• hyper motor

Question 5

Clinical picture of Cholelithiasis and Acute Cholecystitis

Answer 5

Cholelithiasis
-acute pain in right hypochondrion or epigastric region with irradiation to right scapula
The attack is often caused by calculus in the cystic duct, if the stone goes back the pain stops
-the pain arises after a meal, onset is acute
- incase of impacted stone of common bile duct (especially the terminal part) mechanical jaundice occurs
Incase of valvular calculus it can appear and disappear
There is urobilin in urine, feces which become dark, the number of conjugated bilirubin decreases in blood
During and after the attack, attacks of biliary colics and jaundice are common for mechanical jaundice incase of obturation of choledoch by a calculous
If there is a tumor of pancreatic head, or large duodenal papillae there is no pain, jaundice occurs in healthy organism and does not disappear
Covoisers syndrome ( jaundice and enlarged painless gallbladder, light colored feces is seen in these patients

Acute cholecystitis
-abrupt pain in right hypochondrion and it can be permanent
-nausea ABs vomiting without relief
-temperature rise( in destructive forms it reaches 38-40degrees celcius
-chills
-tongue dryness
-rapid augmentation of weakness
1/3 of the patients have jaundice is not always a consequence of calcolous obturation of the common bile duct
The common bile duct can be pressed by inflammatory infiltrate narrowing of the duct can be to mucous edema.
Clinical presentation of acute cholecystitis depends on the type of inflammation
Enlarged gallbladder can be revealed incase of relaxed abdomen but muscular tension of abdominal wall (incase of destructive forms) does not always allow to palpate the gallbladder
If there is purulent type enlarged liver can be seen

There is positive
Otners symptom- pain on percussion of right costal margin
Kehrs symptom-sharp pain on placement of the wrist in the right hypochondrion during inhalation
Muccis symptom- on Palpation there is tenderness between peduncles of the right sternocleidomastoid muscle)

On labs they are used for acute cholecystitis. Acute cholecystitis is a rule accompanied by high left shifted leukocytosis(up to 15-30x10^9/l), lymphopenia, decrease of monocytes, increase ESR
In CBC blood tests on bilirubin, CRP, amylase, lipase to reveal the degree of involvement of pancreas(accompanying pancreatitis)

Incase of gangrenous cholecystitis in the right hypochondrium there can be decrease of pain, tension of abdominal muscles, especially in elderly people can be light or absent at all within large augmentation of intoxication symptoms
Within augmentation of the inflammatory process and then biliary transduction through the wall of gallbladder the symptom of peritoneal irritation becomes positive
In this case it’s a serious case for surgeon about peritonitis development and necessity for surgical treatment especially if the symptom is observed not only in the right hypochondrion but along lateral canal.

Question 6

Diagnostic methods

Answer 6

Diagnosis of lesions of extrahepatic biliary ducts before the operation is made by;

• US highly -effecient contemporary method. If there are calculi in the gallbladder efficiency of diagnosis is 98-100% . The method also allows evaluating the thickness of gallbladder wall, size of biliary ducts
• Radiographic contrast study of biliary ducts
  a. Plain radiography of abdomen allows to reveal calcified calculi of biliary ducts and pancreas ,