# Surgical Procedures/Abdominal Surgery/Cholecystitis

Cholecystitis

## Introduction:

* It is an inflammation of gall bladder.
* Almost always occurs in association with gallstone. • It is one of the most common indications for abdominal surgery. • Its epidemiologic disturbance closely parallels to gallstone.

## Types of Cholecystitis:

* Calculus Cholecystitis.
Inflammation of the gallbladder in the presence of gallstones.
* It is classical to subdivide further:
** Acute Calculus Cholecystis.
** Chronic Calculus Cholecystis.
* Acalculous Cholecystitis.
Inflammation of the gallbladder in the absence of gallstones.  Give rise to clinical picture similar to calculus cholecystitis.
* It is classical to subdivide further:
** Acute Acalculous Cholecystitis.
** Chronic Acalculous Cholecystitis.

## Acute Calculus Cholecystitis:

* Precipitated 90% of the time by gallstone obstruction of the:
** Neck of the gallbladder.
*** Gallstone impacted in Hartmann's pouch.
** Cystic duct.
* Caused by Bile infections:
** E.coli.
** Klebsiella sp.
** Streptococcus faecalis (Keighley).
** Strict anaerobes, e.g. Bacteroides sp.
** Gas forming organisms, e.g. clostridia.
** Typhoid infection.
* It is the primary complication of gallstones.
* One of the most common reasons for emergency cholecystectomy.

## Sequel of Acute Cholecystitis attack:

* When a certain degree of distension of the gall bladder has been reached, the mucous membrane tends to be lifted away from the sides of the stone and, as a consequence, the stone may slip back into the body of the gallbladder, and any mucoid (from a mucocele) or mucopurulent contents of the gallbladder escape by way of the cystic duct.
* Less frequently, the impaction persists and an empyema (pyocele) of the gallbladder results.
* On rare occasions, the distended, inflamed gallbladder perforates.

## Clinical features of acute calculus cholecystitis:

* The onset is sudden.
* Pain is located in mainly in the right hypochondrium.

## Diagnosis of Acute Calculus Cholecystitis:

* Ultrasonography will confirm the diagnosis.

## Chronic calculus cholecystitis:

Clinical features:
* Right Hypochondrial pain.
** Radiation to between the shoulder blades is frequent and it may associated with nausea and vomiting. Fatty foods often precipitate it.
** During an attack, tenderness in the hypochondrium is present.
** Murphy's sign may be (+).
** The temperature and white blood count are elevated.
** Flatulent dyspepsia:
Diagnosis:
* Ultrasonography is usually the only investigation needed to show gallstones.
* A bile duct >8mm is size requires investigation by endoscopic cholangiography to determine the cause of the dilatation.

## Acute Acalculous Cholecystitis:

* Particularly seen in patients recovering from:
** Major surgery.
** Trauma.
** Burns.
NB! In these patients the diagnosis is often missed and the mortality rate is 20 %.
* Diagnosis:
** Oral cholecystography is more useful than Ultrasonography in those presenting with chronic symptoms.
** Radioisotope scanning for presenting with acute symptoms.
** Cholesterol crystals in duodenal aspirate may also help.

## Treatment:

Treatment of choice:
* Laparoscopic cholecystectomy.
* Open cholecystectomy.
* Percutaneous transhepatic placement of a cholecystostomy tube.