Cholecystitis
АШУҮИС АУС 419-р хэсэг
Б.Энхмаа
Г.Удвал
А.Амгалан
Anatomy
Anatomy
Basicmedicalkey.com
Oddi`s sphincter , Ampulla of Vater
Anomaly of Gallbladder
Blood supply
https://teachmeanatomy.info/
Blood supply anomaly
https://www.semanticscholar.org cystic artery
Anomaly of Cystic artery
Anomaly of Cystic duct
www.coleraw.com
webmedmon.mn
Nerve supply of gallbladder
Physiology
• Bile function
• 1- Excretion of toxins and metabolite from liver
• 2- Absorption of nutrients from intestinal tract
Bile (500-1000ml\day)
• Bile salts (Cholic acid , Deoxycholic acid)
• Protein (Glycoprotein)
• Lipid (Phospholipid ,Cholesterol )
• Pigment
Gallbladder
• Hydrogen ion (ph)
• Mucin (Glycoprotein) *pronucleating
Bile salt physiology
Bile salt in digestion
Lipid metabolism in liver
• Pharmacologic inhibition of
IDOL could reduce plasma
LDL cholesterol by increasing
plasma LDL receptor density.
• IDOL (Inducible Degrader of
the LDL receptor)
Pigment (Billirubin)
Liver anatomy
Space of Disse
Ito cell
• Contains fat
• Fat soluble vitamins
Bile flow
• Neural , humoral
Parasympthatic activity
Hormone (Cholecystokinin *CCK ,Secretin)
Cholecystitis
• Calculus
• Acalculus
1. Risk factor (Age , Trauma , TPN , Diabetes , immunosupression)
• Tumor (Adenocarcinoma)
• Biliary Cyst
• Primary sclerosing cholangitis (PSC) – idiopathic usually associated with auto
immune
Cholelithiasis risk factors
• Genetic
1. Female gender
2. Pregnancy
3. Family history
• Enviromental factor
• Type 2 DM
• Dyslipidemia (low on HDL, High Triglycerides )
• Diet (High in fats , Low on fiber)
• Cirrhosis
• Long term fasting
• Rapid weight loss
Gallstone types
Stone forming process
• Cholestrerol
1. Hypersecretion of cholesterol (Hepatic metabolism)
2. Distorted balance between pronucleating (Crystallization promoting) –
antinucleating (Anti-Crystallization)
3. Loss of gallbladder muscular wall motility
4. Excessive sphincter contraction
• Pigment stone (More frequent in Asia)
1. RBC breakdown
2. Infection of biliary tract
Gallstone formation
Aftermath
• Stone \ non stone obstruction of Cystic duct
• Pressure on gallbladder
• Organ enlargement
• Wall thickens
• Blood supply decreases Obstruction of Oddi`s sphincter
• Exudate may form (Gallstone pancreatits)
• Infection
• Necrosis
• Gangrene
Diagnosis
• Clinical signs
• Laboratory
ALP elevated
Billirubin elevated
Transaminase elevated
WBC- Leukocytosis
• Ultrasonography
Sens-85% Spes-95%
• HIDA scan
• CT (Less sensitive and specific than US)
Symptoms
Asymphtomatic – 80%
The Charcot triad
•Fever
•Jaundice (Uncommon in acute cholongitis) *5mg\d< cutaneous jaundice
•Pain (Right upper quadrant)
The Reynold`s pentad
•Fever
•Jaundice (Uncommon in acute cholongitis)
•Pain (Right upper quadrant)
•Hypotension
•Change in mental status
Others
•Tachycardia , Shock, Mirizzi`s syndrome (Hartmanns pouch stone)
Pain
• Murphy`s sign positive (ddx of biliary colic)
• Epigastric \ Right upper quadrant
• After meal
Physical exam
• Ultrasonography of Acute cholecystitis
Pericholecystic fluid, Thickened gallbladder
wall
Differential Diagnosis
• Hepatitis
• GB cancer
• Pancreatitis
• Hepatic abscess
• Angina pectoris (MI)
• Gastric duodenal ulcer
• Right lower pneumonia
Complication of acute cholecystitis
• Ruptured cholecystitis
• Acute empyema of the gallbladder
• Gangrenous cholecystits
• Flegmonous cholecystits
• Obstruction of cystic duct
• Obstruction of bile duct
Treatment
• NPO
• IV (NaCl , Hartmann`s solution)
• IV (Antibiotic *emperal)
• IV (Narcotics)
• Surgery (Open , Laparoscopy )
• ERCP
Surgery treatment options
Laparoscopy
Thanks for your attention
References
• Sabiston textbook of surgery 20th edition
• Chapter 54 (Biliary system) page 1482-1509
• Osmosis.com (Ascending cholangitis)
• Emedecine.Medscape.com \Cholelithiasis
• Uspharmacist.com
