1. Cholecystitis Dr. Shashi Shekhar MS, PhD Associate Professor Dept. of General Surgery Dar Al Uloom University, Riyadh, KSA.

2. Biliary Tract Made up of: Intra hepatic ducts Exta hepatic ducts Gallbladder Common Bile Duct

3. The Gallbladder The gallbladder concentrates and stores bile. Bile: Secreted by the liver Contains cholesterol, bile pigments and phospholipids Flows from the liver, through the hepatic ducts, into the gallbladder Exits the gallbladder via the cystic duct Flows from the cystic duct into the common bile duct, into the small intestine In the small intestine, aids digestion by breaking down fatty foods and fat-soluble vitamins

4. Cholecystitis Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Abdominal wall Gallbladder

5. Signs and Symptoms. Complaints of indigestion after eating high fat foods. Localized pain in the right-upper quadrant epigastric region. Anorexia, nausea, vomiting and flatulence. Increased heart and respiratory rate – causing patient to become diaphoretic which in turn makes them think they are having a heart attack.

6. Signs and Symptoms. Low grade fever. Elevated leukocyte count. Mild jaundice. Stools that contain fat – steatorrhea. Clay colored stools caused by a lack of bile in the intestinal tract. Urine may be dark amber- to tea-colored.

7. Acute Acalculous Cholecystitis Presence of an inflamed gallbladder in the absence of an obstructed cystic or common bile duct Typically occurs in the setting of a critically ill patient (eg, severe burns, multiple traumas, lengthy postoperative care, prolonged intensive care) Accounts for 5% of cholecystectomies Aetiology is thought to have ischemic basis, and gangrenous gallbladder may result Increased rate of complications and mortality An uncommon subtype known as acute emphysematous cholecystitis generally is caused by infection with clostridial organisms and occlusion of the cystic artery associated with atherosclerotic vascular disease and, often, diabetes.

8. Acute Calculous Cholecystitis Inflammation of the gallbladder that develops in the setting of an obstructed cystic or bile duct Most patients have complete remission within 1-4 days. 25-30% of patients either require surgery or develop some complication Perforation occurs in 10-15% of cases.

9. Acute Calculous Cholecystitis Symptoms Right upper quadrant pain – continuous, longer duration Signs Fever, Local peritonism. Murphy’s sign 2 fingers on RUQ, ask patient to breathe in. Positive if pain and arrest of inspiration Investigations Bloods – U&E, FBC, LFT, Amylase, CRP Ultrasound of abdomen Thickened gallbladder wall, pericholecystic fluid and stones OGD (Oesophagogastroduodenoscopy) Treatment Nil by mouth Analgesia Intravenous antibiotics Cholecystectomy

10. Stages of Acute Cholecystitis. - Gallbladder has a grayish appearance & is edematous. -There is an obstruction of the cystic duct and the gallbladder begins to swell. - It no longer has the "robin egg blue" appearance of a normal gallbladder. - As acute cholecystitis progresses, the gallbladder begins to become necrotic and gets a speckled appearance as the wall begins to die. - Gallbladder undergoes gangrenous change and the wall becomes very dark green or black. - This is the stage when perforation occurs.

11. Empyema / Mucocoele Empyema refers to a gallbladder filled with pus due to acute cholecystitis Mucocele refers to an overdistended gallbladder filled with mucoid or clear and watery content.

12. Empyema / Mucocoele Symptoms Right upper quadrant pain – continuous, longer duration Signs Fever, Local peritonism. Murphy’s sign 2 fingers on RUQ, ask patient to breathe in. Positive if pain and arrest of inspiration Investigations Bloods – U&E, FBC, LFT, Amylase, CRP Ultrasound of abdomen Thickened gallbladder wall, distended gallbladder, pericholecystic fluid, stones Treatment Nil by mouth Analgesia Intravenous antibiotics Cholecystectomy

13. Obstructive Jaundice Blockage of the biliary tree by gallstones Symptoms Pain, Jaundice, dark urine, pale stools Signs Jaundice. Investigations Bloods – U&E, FBC, LFT, Amylase, CRP, Hepatitis screen, Coagulation screen Ultrasound of abdomen Treatment Endoscopic Retrograde CholangioPancreatogram

14. Ascending Cholangitis Obstruction of biliary tree with bile duct infection Symptoms Unwell, pain, jaundice, dark urine, pale stools Charcot triad (ie, fever, right upper quadrant pain, jaundice) occurs in only 20-70% of cases Signs Sepsis (Fever, tachycardia, low BP), Jaundice. Investigations Bloods – U&E, FBC, LFT, Amylase, CRP, Coagulation screen Ultrasound of abdomen Treatment Intravenous antibiotics Endoscopic Retrograde CholangioPancreatogram

15. Acute Pancreatitis Acute inflammation of pancreas and other retroperitoneal tissues. Symptoms Severe central abdominal pain radiating to back, vomiting Signs Variable – None to Sepsis (Fever, tachycardia, low BP), Jaundice, acute abdomen Investigations Bloods – U&E, FBC, LFT, Amylase, CRP Ultrasound of abdomen MRCP CT Pancreas Treatment Supportive Endoscopic Retrograde CholangioPancreatogram

16. Gallstone ileus Obstruction of the small bowel by a large gallstone A stone ulcerates through the gallbladder into the duodenum and causes obstruction at the terminal ileum Symptoms Small bowel obstruction (vomiting, abdominal pain, distension, nil pr) Signs Abdominal distension, obstructive bowel sounds. Investigations Bloods – U&E, FBC, LFT, Amylase, CRP, Hepatitis screen, Coagulation screen Plain film of abdomen – Air in CBD, small bowel fluid levels and stone Treatment Laparotomy and removal of stone from small bowel.

17. Diagnostics. Fecal studies. Serum bilirubin tests. Ultrasound of the gallbladder.

18. Diagnostics. HIDA scan - imaging test used to examine the gallbladder and the ducts leading into and out of the gallbladder - also referred to as cholescintigraphy. Oral cholecystogram - the patient takes iodine-containing tablets by mouth - iodine is absorbed from the intestine into the bloodstream - removed from the blood by the liver and excreted by the liver into the bile – it is concentrated in the gallbladder - outlines the gallstones that are radiolucent (x-rays pass through them). Operative cholangiography – common bile duct is directly injected with radiopaque dye.

19. Medical Management. Lithotripsy for patients with only a FEW stones. If the attack of cholelithiasis is mild – bed rest is prescribed. patient is placed on NPO to allow GI tract and gallbladder to rest. an NG tube is placed on low suction. fluids are given IV in order to replace lost fluids from NG tube suction.

20. Medical Management.  If stones are present in the common bile duct, an endoscopic sphincterotomy must be performed to remove them BEFORE a cholecystectomy is done.  A number of various instruments are inserted through the endoscope in order to "cut" or stretch the sphincter.  Once this is done, additional instruments are passed that enable the removal of stones and the stretching of narrowed regions of the ducts.  Drains (stents) can also be used to prevent a narrowed area from rapidly returning to its previously narrowed state.

21. Surgical Management. Cholecystectomy or Laparoscopic Cholecystectomy – removal of the gallbladder. This is the treatment of choice. The gallbladder along with the cystic duct, vein and artery are ligated.

22. Cholecystectomy Laparoscopic cholecystectomy standard of care Timing Early vs interval operation Patient consent Conversion to open procedure 10% Bleeding Bile duct injury Damage to other organs

23. Mirizzi Syndrome Refers to common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct Estimated to occur in 0.7-1.4% of all cholecystectomies Often not recognized preoperatively, which can lead to significant morbidity and biliary injury, particularly with laparoscopic surgery.