chronic cholecystitis Flashcards
definition
Chronic, polyetiological, inflammatory, non-calculus gallbladder associate wit dyskinesia of the bile tract & changes composition of bile (dyscholia). Duration : >6mths
etiology
- infectn: Gram –ve & +ve, E.coli, Strep, Staph, Enterococcus, mycoplasma, Fungi, Virus hepatitis, Parasites ( Ascaris, Lamblia)
- Duodenobiliary & duodenogastric reflux
- Allergic reaction
- GIT patho - gallstone in cystic duct, tumor of pancreas / liver, enteritis, pancreatitis / cholangitis
- ↓blood supply to GB
- Acute cholecystitis
- Gallbladder sludge
- Alcoholic
- trauma
Predisposing factors :
- obesity
- Pregnancy
- Chronic stress
- trigger fatty food
- Dysbacteriosis of intestine
- Immunodeficient
- Bile stasis
- Congenital, family history
- metabolic disease -diabetes,gout
- female, fertile, forties, fat, fair
pathogenesis
- Infectn
a. Enterogenic (intestine) / ascending - due to transient sepsis, reflux of sphincter Odi, disturbances in motor func of bowels
b. Hematogenic- frm infectn of URTI (pharyngitis, otitis, sinusitis, tonsillitis). Occur due to ↓ immunity & hypersensitivity to infectious agent causing allergy. Hyperergic agent ↑ permeability of blood vessels of GB & colonizes mucosa to cause inflamn
c. lymphogenic
- Bile stasis – GB stones formed due to hypokinesias in obese ppl, high levels of TG, VLDL, cholesterol in blood causes ↑ prodn in bile & causes prolonged stagnation in GB. As a result, protein coagulates, mineral precipitation & form stones
- Infectn+bile stasis
Infection → bile reflux→neuroendocrine disorders→hypotonia of GB →neurodystrophy of GB wall→ bile stasis→ Inflamn & thickening of GB wall→ cholecystitis
clinical picture
- Pain syndrome:
- Spastic pain in right hypochondrium radiate to R shoulder, clavicle, scapular, chest, back. 2-3 days
- Increase pain with deep breathing & emotional stress; heavy work; alcohol; spicy, hot or cold, fatty, gassy food, egg yolk. Pain disappear aft application of hot water bottle / spasmolytics - Dyspeptic syndrome
a. Gastric dyspepsia- nausea, vomiting, belching+bitter taste
b. Intestinal dyspepsia- Diarrhea+constipation, meteorism, jaundice - Inflammatory syndrome- weakness, malaise, restlessness, fever
- Neurotic syndrome – depression, anxiety, neurosis, with vegetative signs - vascular tone changes: disorder in GIT regulation,tachycardia
- Cardiac syndrome
a. Angina like pain - spastic pain in precordial region, irradiate to the L part, assoct wit arrhythmic syndrome (supraventricular fibrillation) & physical activity
b. Cardialgia- pain in the apex, indefinate duration, spontaneous charac, not assct wit physical activity - Mech. Jaundice- Yellow skin & eyes
- Dyskinetic syndrome
a. Hyperkinetic- acute spastic pain due to trigger factors, nausea,vomiting, acute periodic episodes due to spasm of isthmus, distension causes pain; relaxation by myolitics
b. Hypokinetic – Dull permanent pain w/o signs of inflamn due to stasis of bile, distension causes pain; need analgesics - Solaric plexus syndrome
- Asthenic syndrome- decreased appetite, weakness, decreased activity
- Allergic syndrome- skin itching
- rigid abd
- Murphy, Courvoiser, Kehr, grekov–ortner, Rashbar‘s, Kaikar‘s, Musy‘s signs
investigation
Ortner‘s, Kalk‘s, Ker‘s, Murphy‘s, Mussi-Georgievsky‘s, Razba‘s, Shotkin Blumberg‘s, & Kurvuasie‘s signs are positive If jaundice- yellow color of skin, painful palpation & muscle guarding on right side
Lab:
1. Blood analysis – L shift leucocytosis, ↑ESR, ↑α2 & γ-globulin, ↑fibrinogen, ↑bilirubin, if present liver prob: changes in ALT, AST
2. Bile aspiration frm duodenum, GB, & bile duct
Bile in GB - leucocytosis, mucus, cylinder epithelium, cholesterol crystals, pathological no of bact., spec. pigmented cells, changes in bile pigments, large volume.
3. liver function test
4. blood culture
Instrumental:
1. U/sound : thickening of GB wall >3cm
- Shape, size, stones, dislocation, deformation, ↓mobility, crystals of cholesterol, density of contents
2. X-ray: retrograde pancreato-cholangiography, percutaneous transhepatic cholangiography
- change of bile duct (widening of ducts, fragment of duct due to sclerosis narrowing)
- shadow of bladder is not seen, absence of GB
- stone seen if present
- functional disorder (emptying)
- CT
- Thermography
- Endoscopy if stones are in the papulla.
- Radioisotopic examination if cancer is suspected.
- hepatobiliary scintigraphy - imaging of liver, bile duct, gallbladder and upper part of small intestine
- laparoscopy
- fibroduodenoscopy
- cholecystography
treatment
- Diet N5. No triggering food. Including boiled and steamed food and increase protein
- Choleretics
- increase bile acid (true choleretics): cholagol, decholic, Alahol, Decharin, Oxaphenamide
- increase bile water component (Hydroretics): sodium salicylate Sodium salicylates, cholekinetics. - Cholekinetics
- ↑tone of GB, ↓ tone of bile tracts – Sarbite, Mannite, Xylite
- Relaxation of GB & bile tract- nitroglycerin, atropine ,euphylinne, platyphilline, spasmolytic - antibiotics
1st choice- ampicillin, erythromycin, lincomycin, rifampicin 2nd choice- Tetracycline 3rd choice- quinollones, cephalosporins, nitrofuran - Pain syndrome:
- Spasmolytics – Baralgin, Noshpa, Atropine, Papaverin, nitroglycerine
- Analgesics –Pramidol - Prevent stones formn- dehydrocholic acid - Cholagin
- Improve immunity – vit & anabolics
- Detoxification therapy - Ringer
- Etiologic: bacterial - antibiotics
- Pathogenetic: choleretics, cholekinetics
- anti-inflammatory drugs if inflammation present
- symptomatic – drug for dyspeptic syndrome
- dissolution of gallstone – methyl ter-butyl ether, bile acids, chenodeoxycholic acid
- Surgical treatment: Indicated in complications and obstruction by stone.
complications
- Rupture, gangrene of GB
- Sepsis
- Peritonitis, cholangitis, enterocolitis
- Malignization
- Stenosis of bile tract
- GIT bleeding
- Jaundice
- DM
- abscess
- Fistulas in the intestine, perforation
- Malabsorption of lipids leading to metabolic disorders
- Intestinal dyskinesia.
- empyema and hydrops
- gallstones ileus
- limely bile and porcelain gallbladder
