Galbadder disease 2 _ نوري حنون Flashcards
Cholecystitis causes
Calculous 85 – 95 %
Acalculous 5 – 15 %
what’s the most common organism that cause acute Cholecystitis ?
1-E.coli . 2- klebsiella
3-streptococcus faecalis
The most common bacteria isolated from bile in acute cholecystitis are E. coli, Klebsiella, and Enterococcus faecalis, thus antibiotic therapy should be directed against these organisms.
while the others are rare
4- bacteroid .
5- clostridia & typhoid (uncommon & serious).
Causes of acute cholecystitis
1-Stone in 90% impacted in Hartmann’s pouch or obstructing cystic duct .
2- Stasis
3- Pancreatic juice reflux 4 – CBD stone .
5- Bacteremia .
6 – Vascular effect of → D.M.
→ sickle
→ hypertension
→ collagen disease
cystic artery thrombosis → ischemia .
but the most common cases are the DM or sickler
Clinical features of acute cholecystitis
1- sudden onset .
2- 30 – 70 years & > 60 years 25% - 35% .
3- White caucasian > black people .
4- Heavy fatty meal .
5- Pain (colicky).
6- Nausea & vomitting .
7- Fever > 38̊ C . low grade
8- Boas’s sign .
Boas’s sign is hyperaesthesia (increased or altered sensitivity) below the right scapula can be a symptom in acute cholecystitis (inflammation of the gallbladder). It is one of many signs a medical provider may look for during an abdominal examination.
9- Jaundice ? is rare
10- Murphy sign .
Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive
11- Tenderness & rigidity .
12- Palpable tender mass .
DDx of the acute cholecystitis
1- Appendicitis . 2- Perforated peptic ulcer .
3- Acute Rt. Pyelonephritis 4- Liver abscess .
5- Rt. Lower lobar pneumonia. 6- Hepatitis
7- Pancreatitis 8- Herbes zoster .
9- *Myocardial infarction
but the main are pancreatitis. peptic ulcer disease.and MI
The sequelae of attack of the acute cholecystitis
1- Resolution ; disimpaction of the stone & drainage , slipping back of the stone.
2- Impacted stone persist → gangrene , mucocele , empyema .
3- Perforation .
4- Chronic .
Dx of the acute cholecystitis
1- ultrasound thick wall , dilateted with fluid
2- Radio isotop scan ( HIDA ) .
3- L.F.T.
4- WBC ___ leucocytosis .
Treatment of the acute cholecystitis ?
A- Conservative Rx followed by laparoscopic Cholecystectomy (after 6-8 weeks).
B- immeddate Laparoscopic Cholecystectomy .
conservative treatment of the acute cholecystitis ?
90% of cases the symptoms subside.
1- N.G. tube & *nil per mouth .
2- Antibiotics e.g.; cefazolin , Cefotaxim , gentamicin .
3- Analgesia & antispasmatic .
Cholecystoctomy done
→ Early 2 – 3 – 5 days .
→ Delayed ˃ 6 weeks
depend on the the pt status
when we do open surgery ?
rarely Open
-if laparoscopic is not accessible
-or in case of conversion
Conversion rate in acute cholecystitis more than in elective ( delayed ) but still conversion not failure of laparoscopic cholecystectomy
Conversion disorder is a mental condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation
Chronic cholycystitis
thickened , fibrosed and shrinkage gallbladder wall
Chronic cholycystitis symptoms
1- Pain : episodes of Rt. hypochondrial pain of varying severity & interval ( 3 – 12 hours) after .
less sever
2- Flatulent dyspepsia , fullness , belching , heartburn & distension .
3- nausea & vomiting
no fever no morphy sign no WBC or LFT
Dx of Chronic cholycystitis
1- ultrasound thick wall , shrinkage without fluid
2- Radio isotop scan ( HIDA ) .
3- L.F.T.
4- WBC ___ leucocytosis .
Rx of Chronic cholycystitis
Cholecystectomy
Saint’s Triad of Chronic cholycystitis
Saint’s Triad is the association of hiatal hernia, gallbladder disease, and diverticulosis in patients with atypical abdominal symptoms.
1- Gall stone(s) .
2- diverticulosis .
3- Hiatus hernia .
It is important to find which one is the cause for dyspepsia
Hi divin gal
these pt will complain from after surgery with the same symptoms
Post cholecystoctomy complications
1- Bleeding .
2- Jaundice .
3- Adjacent organs injury.
4- Biliary leak → fistula ; due to : a) Slipped ligature
b) Accessory duct .
c) CBD. Injury or ischemia .
d) Mirizzi syndrome .
5- Post cholecystectomy syndrome.
Indications of cholecystoctomy
1- Symptomatic gall stones.
2- Asymptomatic gall stone as prophylactic cholecystectomy (controversial) as
a- malignency 0.3-3%
b- DM
c- sickle and thalasimia
d-morbid obsity
Post cholecyctomy syndrome mean
it’s 15 % when the surgery fail to relieve the symptoms
Post cholecyctomy syndrome causes
1- sain traid 2-pancrititsis 3- dudenal ulcer 4-CBD stone 5-CBD stricture 6-long cyctic duct lump 7-fibrosis in the sphinector of oddi
The sphincter of Oddi is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through ducts from the liver and pancreas into the first part of the small intestine (duodenum).
Stone of the bile duct
is ether primary or secondary
consequence of the bile duct stone
1- cholangitis
2-obstructive juaindice
symptoms of the Stone of the bile duct
1- jauindice either intermitant or persistant
2-colicky pain
3- fever and rigor
complication of the Stone of the bile duct
1- cholangitis
2- panceritis
3- billiary cirrhosis
DX of Stone of the bile duct
1- LFT
2- US fallowed by MRCP
3- ERCP
4-PTC
Treatment of Stone of the bile duct
1- ERCP & sphineterotomy .طريقه الناظور
2- Choledochotomy :طريقه الجراحه
means expolartion of the CBD
A- Supraduodenal choledochotomy stone removal and then T. tube or choledocho-duodenostomy .
B- Transduodenal sphineterotomy & stone extraction .
has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically.
Ascending (suppurative) cholangitis
Bacterial infection of biliary tree due to common bile duct stone
Charcot’s triad
For CHArcot's! Jaundice Pain Fever Seen in ascending cholangitis. -----------------------------------------------
c–color — yellow - Jaundice— seen in Cholangitis.
h— hot – fever
A–ache—pain
when we seen Charcot’s triad
ascending cholangitis.
Complications Ascending (suppurative) cholangitis
- gram negative septicemia → might lead to organ failure
- multiple liver abscesses .
Dx of Ascending (suppurative) cholangitis
L.F.T……………..obstructive picture
- ultrasound ….dilated bile ducts
- culture………. Isolation of an organism from blood on culture
treatment of Ascending (suppurative) cholangitis
1- Rehydration → I.V. Fluid .
2- Antibiotics → cephalosporin .
3- Drainage → ERCP (sphincterotomy) or PTC.
4- C.B.D stone removal …… ERCP
+ cause carcinoma of GB ?
90% cause stone more in female
1-stones 0.3-3%.
2- age 70
3- porcelan gall bladder
Porcelain gallbladder is a calcification of the gallbladder believed to be brought on by excessive gallstones, although the exact cause is not clear
types carcinoma of GB ?
1- scirrhous carcioma
2-adeno
3-sequemous
spread of carcinoma of GB ?
1- direct invasion to liver
2- lymphatic –hilar -celic
3-distant — uncommon
clinical feature of of carcinoma of GB ?
1- accidently 1%
2-presented like cholecyctitis
3- mass
4-jaundic
treatment of carcinoma of GB ?
Cholecystecctomy + excision of gall bladder liver bed + Hilar lymphadenectomy.
Prognosis :
Prognosis of carcinoma of GB ?
- Poor.
- 90% will die in one year .
- 2–5% is 5 year survival .
