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Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus

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Presentation on theme: "Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus"— Presentation transcript:

1 Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus
CHOLECYSTITIS Bernard M. Jaffe, M.D. Professor of Surgery, Emeritus

2 GALLBLADDER Major Function- Concentrate, Store Bile
Supplied by Cystic Artery Off Right Hepatic Artery Off Common Hepatic Artery Off Celiac Trunk Many Arterial Variations Replaced Right Hepatic Takes Off From Superior Mesenteric

3 DUCTS Right and Left Hepatic Ducts Join ↓ Common Hepatic Duct
Cystic Duct Comes Off Common Bile Duct Ampulla, Duodenum

4 GALLSTONES Autopsy Prevalence 11-36% Female:Male Ratio is 3:1
First Degree Relatives Have Twice the Rate Cholecystectomy One of Commonest Operations

5 PREDISPOSING FACTORS Obesity Pregnancy Dietary Factors
Crohn’s Disease, Ileal Resection Hemolytic Diseases Gastric Surgery

Bilirubin Bile Salts Phospholipids Cholesterol Calcium

7 CHOLESTEROL STONES Most Common Type Rarely Pure, >70% Cholesterol
Precipitation from Supersaturated Bile Usually Multiple, Variable Sizes Hard and Facetted to Irregular and Soft Color White/Yellow to Brown/Black Only 10% are Radio-opaque

8 PIGMENT STONES <20% Cholesterol
Dark Because of Calcium Bilirubinate Usually Tiny to Small Invariably Multiple Two Types- Black Stones Brown Stones

9 BLACK STONES Form ONLY in Gall Bladder
Secondary to Hematologic Diseases Spherocytosis Sickle Cell Disease Thalassemia Common in Cirrhosis More Common in Asia

10 BROWN STONES Form in Gall Bladder AND Bile Ducts
Small, Soft, Often Mushy Secondary to Bacterial Infection Caused by Bile Stasis Bacterial Cell Walls Prominent in Stones More Common in Asia

11 NATURAL HISTORY Most Are Asymptomatic
Asymptomatic Stones Detected On Evaluation For Other Illnesses Ultrasound CT Plain Abdominal X-Ray Laparotomy 2/3 Stay Asymptomatic >20 Years

12 COMPLICATIONS Biliary Colic- Initial Symptom Acute Cholecystitis
Choledocholithasis Cholangitis Biliary Pancreatitis Cholecysto-Duodenal Fistula Gall Bladder Carcinoma

13 CHOLECYSTECTOMY Indicated for Symptomatic Patients
Rare Indications in Asymptomatic Ones Elderly Diabetics Before Transplantation Isolation From Medical Care Gallbladder Polyp (Controversial) Porcelain Gall Bladder Absolute Indication

Recurrent Attacks of Pain Frequently After a Meal (Fatty?) Radiates to Back and Shoulder Nausea and Vomiting Gall Bladder- Minor Inflammation to Small, Shrunken With Fibrosis, Adhesions Mucosa Becomes Atrophied

15 DIAGNOSIS Stones on Ultrasound Gall Bladder May Have Sludge
Cholesterolosis- Strawberry Gall Bladder Adenomyomatosis- Thick Wall Normal Ducts Cholecystectomy Cures >95%

16 ACUTE CHOLECYSTITIS Obstruction of Cystic Duct By Stone
Gall Bladder Distention, Inflammation, Edema Mucus Secretion- Hydrops, Milk of Bile (Pearly White) 5-10% Progress to Ischemia, Necrosis Perforation Occurs in Body (Widest Part)

17 MANIFESTATIONS Biliary Colic → Lasting, Constant Pain
Anorexia, Nausea, Vomiting, Fever Focal RUQ Tenderness, Guarding Murphys’ Sign is Suggestive Palpable Gall Bladder is Diagnostic Normal LFTs, ?Minimal Bilirubin Elevation White Blood Cell Count Often Elevated

18 DIAGNOSIS Ultrasound Stones Thickened Gall Bladder Wall
Distended Gall Bladder Peri-Cholecystic Fluid Sonographic Murphy’s Sign If HIDA Scan Fills Gall Bladder- Precludes Diagnosis

19 TREATMENT Antibiotics- Gram Negative and Anaerobic Coverage
Early laparoscopic Cholecystectomy Late Presentation >4-5 Days- Antibiotics Alone with Delayed Cholecystectomy Very Ill, Elderly patients- Percutaneous Cholecystostomy

20 LAP CHOLE Mortality 0.1%, Morbidity 0.3% Can Add Choledochotomy
Conversion to Open in Acute Disease Reasons for Conversion Inability to Visualize Adhesions Duct Injury Bleeding Abnormal Anatomy

21 CHOLEDOCHOLITHIASIS Primary Stones Form in Ducts
Associated with Biliary Dysfunction, Infection Brown Stones Secondary Stones Form in Gall Bladder Migrate to Common Bile Duct 6-12% Cholelithiasis Patients 20-25% in Patients >60

22 MANIFESTATIONS Symptomatic or Can Be Silent
Colicky Pain, Nausea, Vomiting, ICTERUS Stones Single or Multiple, Small or Large Can Cause Common Duct Obstruction Cholangitis Biliary Pancreatitis

23 DIAGNOSIS Elevated Bilirubin, Alkaline Phosphatase, Transaminases
Ultrasound- Dilated Ducts Magnetic Resonance Cholangiogram- Sensitivity 95%, Specificity 89% ERCP- Successful >90%, Morbidity <5% Therapeutic and Diagnostic

24 TREATMENT ERCP With Sphincterotomy Common Bile Duct Exploration
Open or Laparoscopic T-Tube Left in Place Missed Stones Can Be Retrieved Choledochoscope

25 CHOLANGITIS Ascending Infection Associated With Bile Duct Obstruction
Commonest Organisms E. coli Klebsiella Strep faecalis Bacteroides 5-10% Mortality

26 MANIFESTATIONS Charcot’s Triad Abdominal Pain Jaundice Fever
Reynold’s Pentad Same Plus Septic Shock Mental Status Changes

27 TREATMENT Immediate Antibiotics, Resuscitation
Duct Drainage (Cholangitis is Closed Space Infection) ERCP With Sphincterotomy Percutaneous Transhepatic Cholangiogram With Catheter Placement Open Common Duct Exploration

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