ACKNOWLEDGEMENT

There could not have been a better plate form than this for me to express my deep routed feeling for all those who, in some way or the other, patronized the cause of my paper compilation on and pavet my way to comprehend the fact in a better peropective. I would like to offer my sincere regards to respected

and ,without whose help this presentation would not have been posible.

CHOLECYSTITIS

Dr.K.K.SIJORIA Dr.PRAVEEN CHAUDHARY

RAVI RANJAN BAMS Final Prof.

CHOLECYSTITIS

DIRECTED BYDr. K.K.SIJORIA PRESENTED BYDr. PRAVEEN CHAUDHARY RAVI RANJAN BAMS Fina Prof.

CHOLECYSTITISCHOLECYSTITIS► Cholecystitis - Inflammation of GallbladderCholecystitis - Inflammation of Gallbladder

► PathogenesisPathogenesis: - Pathogenesis of acute cholecystitis can be converiently described by four factors.: - Pathogenesis of acute cholecystitis can be converiently described by four factors.► ► (1)Obstruction or stasis.(1)Obstruction or stasis.► (2)Chemical irritation.(2)Chemical irritation.► (3)Bacterial infection.(3)Bacterial infection.► (4)Pancreatic refluse.(4)Pancreatic refluse.

► (1) (1) Obstruction or StasisObstruction or Stasis: - Stones obstructing the cystic duct can be implicated in upto 80% of : - Stones obstructing the cystic duct can be implicated in upto 80% of acute cholecystitis Kinking of gallbladder or duct or pressure from anomalous vessel or from acute cholecystitis Kinking of gallbladder or duct or pressure from anomalous vessel or from adjacent structures may cause non-calculus abstruction.adjacent structures may cause non-calculus abstruction.

► Oedema or erosion coused by the stone may also cause obstruction of outlet of Oedema or erosion coused by the stone may also cause obstruction of outlet of gallbladder.Obstruction will cause stasis of bile leading to progressive conce of bite and chemical gallbladder.Obstruction will cause stasis of bile leading to progressive conce of bite and chemical irritation of the gallbladder wall.irritation of the gallbladder wall.

► ► (2) (2) Chemical irritationChemical irritation: - Such other factor may chemical irritation with caoncentration of bite : - Such other factor may chemical irritation with caoncentration of bite

or erosion of the mucosa by a stone. Such erosion give access of to bile salt into tissue planes.Bile or erosion of the mucosa by a stone. Such erosion give access of to bile salt into tissue planes.Bile salts are very toxic to cell and this cause destruction of cells and chemical cholecystits.salts are very toxic to cell and this cause destruction of cells and chemical cholecystits.

► Venous or lymphatic stasis may play a contributory role in chemical irritations. Stone obstructing Venous or lymphatic stasis may play a contributory role in chemical irritations. Stone obstructing the cystic duct also impaires venous return. This causes congestion of gallbladder. Such extrinsic the cystic duct also impaires venous return. This causes congestion of gallbladder. Such extrinsic pressure may interfere c blood supply of the gall bladder. This will make the gall ballader a prey to pressure may interfere c blood supply of the gall bladder. This will make the gall ballader a prey to chemical irritation by the conc. bilechemical irritation by the conc. bile

► (3) (3) Bacterial infectionBacterial infection: - In a small number of cases approximately 5 to 10% of all cases only : - In a small number of cases approximately 5 to 10% of all cases only bacterial infection may be incriminated as the initiating aetiologic agent. There is usually some bacterial infection may be incriminated as the initiating aetiologic agent. There is usually some comconitant severe infection or septicaemia. Bacteria may reach gallballader through blood comconitant severe infection or septicaemia. Bacteria may reach gallballader through blood lymphatics,bileduct or by direct invasion from neighbouring viscera.lymphatics,bileduct or by direct invasion from neighbouring viscera.

► The common organism are E – coil, streptococci, The common organism are E – coil, streptococci, Aerobactore,aerogenes,klebsiella,salmonella,clostridia and staphylococci.Aerobactore,aerogenes,klebsiella,salmonella,clostridia and staphylococci.

► (4) (4) Pancreatic refluxPancreatic reflux: - Experimentally injection of pancreatic enzymes exercises a : - Experimentally injection of pancreatic enzymes exercises a definite inflammatory response. Active lipases amylase and proteases have been identified in definite inflammatory response. Active lipases amylase and proteases have been identified in the bile in patients suffering from acute cholecystitis.the bile in patients suffering from acute cholecystitis.

► Since the pressure in the pancreatic duct is generally greater than of the billiary Since the pressure in the pancreatic duct is generally greater than of the billiary tract,presence of a common channel permits entry of pancreatic juice into the gall buladder.tract,presence of a common channel permits entry of pancreatic juice into the gall buladder.

► PATHOLOGYPATHOLOGY: - The gallbladder is usually enlarged two to three times. It becomes bright red : - The gallbladder is usually enlarged two to three times. It becomes bright red or violet to green black in colour. The serosa is cargested,may br covered with a fibrinous or violet to green black in colour. The serosa is cargested,may br covered with a fibrinous exudates ande may have areas of gangrene or necrosis. The wall of gallbladder becomes exudates ande may have areas of gangrene or necrosis. The wall of gallbladder becomes oedematous and thickened. The obstructing stone may be roticed to be impacted in the oedematous and thickened. The obstructing stone may be roticed to be impacted in the infundibulum or the cystic duct. Bloody bile or pus may be found within the lumen. The infundibulum or the cystic duct. Bloody bile or pus may be found within the lumen. The mueosa may show sloughing in a few places. When the content exudates is virtually pure mueosa may show sloughing in a few places. When the content exudates is virtually pure pus,the condition is could empyema of the gallbladder. Cystic duct obstruction is essential for pus,the condition is could empyema of the gallbladder. Cystic duct obstruction is essential for development of empyema. Gall stone are usually present upto 80% of cases. Often a fine development of empyema. Gall stone are usually present upto 80% of cases. Often a fine sandy gravel is mined with the biliary contents. The gallbladder wall may be thickended upto sandy gravel is mined with the biliary contents. The gallbladder wall may be thickended upto 10 times the normal. Oedema fluid exudates and haemorrhage will flow from the cut surface. 10 times the normal. Oedema fluid exudates and haemorrhage will flow from the cut surface. The mucasa is hyperaemic and may show necrotic surface in sevese case. This condition is The mucasa is hyperaemic and may show necrotic surface in sevese case. This condition is called gangrenous cholecystitis. Certain areas of ischaemia may be noticed due to thrombosis called gangrenous cholecystitis. Certain areas of ischaemia may be noticed due to thrombosis of the small arteries. Perfrotion through the site of ischaenic gangrene may give rise to Biliary of the small arteries. Perfrotion through the site of ischaenic gangrene may give rise to Biliary peritonitis.peritonitis.

► What is common is that the omentum and surrounding vircera and parietal peritoneum will What is common is that the omentum and surrounding vircera and parietal peritoneum will adhere and confine the area resulting lacalised pericholecystic adscess. Rarely the adhere and confine the area resulting lacalised pericholecystic adscess. Rarely the gangrenous area of the gallbladeer becomes adherent to the wall of the duodenum or the gangrenous area of the gallbladeer becomes adherent to the wall of the duodenum or the small intestine. n such case perforation through this gangrenous area may cause a small intestine. n such case perforation through this gangrenous area may cause a cholecystoenteric fistula (internal fistrula). Gall stone may pass through such fistula into the cholecystoenteric fistula (internal fistrula). Gall stone may pass through such fistula into the small intestine. It the stone is sufficiently large it may be impacted at the distal part of the small intestine. It the stone is sufficiently large it may be impacted at the distal part of the ileum near ileocaecal value causing intestinal obstruction. This is known as gallstone ileus. ileum near ileocaecal value causing intestinal obstruction. This is known as gallstone ileus.

► CLINICAL FEATURESCLINICAL FEATURES:- :- ► SymptomsSymptoms:- :- ► Majority attacks of acute cholecystits occur in patients who give past history of chronic Majority attacks of acute cholecystits occur in patients who give past history of chronic

cholecystits and cholelithiasis. Acute cholecystitis occurs in any age but the hightes incidence is cholecystits and cholelithiasis. Acute cholecystitis occurs in any age but the hightes incidence is between 4th and 5th decades. The onset is usually sudden. Often it follows a heavy,fatty meal. between 4th and 5th decades. The onset is usually sudden. Often it follows a heavy,fatty meal. This is due to vigorous attempts of the gallbladder to empty its contents. Scute cholecystitis This is due to vigorous attempts of the gallbladder to empty its contents. Scute cholecystitis presents as an acute abdominal emergency. Agonising pain is complained of in the presents as an acute abdominal emergency. Agonising pain is complained of in the

► Rt. upper quadrant of the abdomen. Rt. upper quadrant of the abdomen. ► Pain refer to inferior angle of Rt. scapula.Pain refer to inferior angle of Rt. scapula.► or to the Rt. shoulder.or to the Rt. shoulder.► Nausea & vomiting.Nausea & vomiting.► Signs:- Signs:-

(1)Pyrexia (1)Pyrexia (2)Jaundice(2)Jaundice (3)Tenderness in Rt. upper quadrant(3)Tenderness in Rt. upper quadrant

► (1) (1) Pyrexia Pyrexia: - It is a regular feature of acute cholecystitis. It may be absent only in the elderly : - It is a regular feature of acute cholecystitis. It may be absent only in the elderly and in patient who take steroids or nonsteroidal anty – influmatory drugs.and in patient who take steroids or nonsteroidal anty – influmatory drugs.

► ►

► (2) (2) JaundiceJaundice: - It is present only 10% of cases and is usually mild. This is : - It is present only 10% of cases and is usually mild. This is ► accompanied by cholangitis. Jaundice may be due toentry of bile pigments accompanied by cholangitis. Jaundice may be due toentry of bile pigments

into the circulation through the damaged gallbladder mucosa. into the circulation through the damaged gallbladder mucosa. Jaundice may also occur from choledochal sphincter spasm induced by the Jaundice may also occur from choledochal sphincter spasm induced by the adjacent inflammatory process. Concomitant choledocholithiasis may also adjacent inflammatory process. Concomitant choledocholithiasis may also be the cause. be the cause.

► (3) (3) Tenderness in the Rt. upper quadrant Tenderness in the Rt. upper quadrant :- Tenderness in the Rt. upper quadrant is a :- Tenderness in the Rt. upper quadrant is a reliable finding. In about ½ of the patients there may be rigidity. Rebound tenderness may also reliable finding. In about ½ of the patients there may be rigidity. Rebound tenderness may also be present when the parietal peritoneum is inflamed. Murphy’s sign, though often present,may be present when the parietal peritoneum is inflamed. Murphy’s sign, though often present,may not be solely relied upon. During deep palpation of the Rt. upper quadrant,the patient is asked not be solely relied upon. During deep palpation of the Rt. upper quadrant,the patient is asked to take deep breath in and out. Patient complains of acute pain during deep inspiration with to take deep breath in and out. Patient complains of acute pain during deep inspiration with inspiratory arrest when tender inflamed inspiratory arrest when tender inflamed

► gallbladder cornes down and touch the palpating fingers.gallbladder cornes down and touch the palpating fingers.

► Boass signBoass sign:- It present,isdiagnostic of acute cholecystitis. This is an area of :- It present,isdiagnostic of acute cholecystitis. This is an area of Hyperasesthesia between the 9th and 11th ribs pasteriorly on the right side.Hyperasesthesia between the 9th and 11th ribs pasteriorly on the right side.

► SPECIAL INVESTIGATIONSPECIAL INVESTIGATION

► (1) (1) BloodBlood :- Leucocytosis presents in 8.5% of cases with high polymorphonuclear count. :- Leucocytosis presents in 8.5% of cases with high polymorphonuclear count. There may be elevation of serum bilirubin and serum amylase (in 1/3 of cases). Serum There may be elevation of serum bilirubin and serum amylase (in 1/3 of cases). Serum amylase may be as high as 1000 somogyi units in acute cholecystitis.amylase may be as high as 1000 somogyi units in acute cholecystitis.

► (2) (2) E.C.G.E.C.G.:- Should be down in all patients above 40 years of age.:- Should be down in all patients above 40 years of age.

► (3) (3) Straight X-rayStraight X-ray:- Of the abdomen in supine and in erect posture and an upright :- Of the abdomen in supine and in erect posture and an upright chest X-Ray study are essential. Only 15% of gallstones are radio-opaque. Upright chest chest X-Ray study are essential. Only 15% of gallstones are radio-opaque. Upright chest X-Ray is performed to exclude other condition of acute abdomen. It may be indicate X-Ray is performed to exclude other condition of acute abdomen. It may be indicate cholecystoentric fistula.cholecystoentric fistula.

► (4) (4) CholecystographyCholecystography ;- There is no place of oral cholecytography. Intravenous ;- There is no place of oral cholecytography. Intravenous cholangiography may be performed,but its place is gradually taken over by cholangiography may be performed,but its place is gradually taken over by cholescintigraphy and ultrasonography.cholescintigraphy and ultrasonography.

► (5) (5) CholescintigraphyCholescintigraphy ;- This is performed C a derivative of 99m technetium-iminediacetic ;- This is performed C a derivative of 99m technetium-iminediacetic acid (technetium-IDA scan). This is only specific test for acute cholecystitis. After intravenous acid (technetium-IDA scan). This is only specific test for acute cholecystitis. After intravenous injection that contrast material is excerted by the liver into the biliary ductal system even in injection that contrast material is excerted by the liver into the biliary ductal system even in prescence of hyperbilirubinaemia. Normally the scan outlines the liver and extrahepatic biliary prescence of hyperbilirubinaemia. Normally the scan outlines the liver and extrahepatic biliary system including the gallbladder. In acute cholecystitis the gallbladder is not seen in the scan as system including the gallbladder. In acute cholecystitis the gallbladder is not seen in the scan as the gallbladder outlet or the cystic duct is obstructed. This test becomes positive in almost all the gallbladder outlet or the cystic duct is obstructed. This test becomes positive in almost all patients who are actually suffering from acute cholecystitis. Obstruction of the common bile duct patients who are actually suffering from acute cholecystitis. Obstruction of the common bile duct or hepatic duct is also detectable by this scan but these are more clearly visualized by PTC or or hepatic duct is also detectable by this scan but these are more clearly visualized by PTC or ERCP. ERCP.

► (6) (6) UltrasonographyUltrasonography:- It can detect calculi within the gallbladder as also right upper :- It can detect calculi within the gallbladder as also right upper quadrant mass and enlargechent of the bile duct and pancreas. One may perform routine quadrant mass and enlargechent of the bile duct and pancreas. One may perform routine ultrasonography in acute cholecystitis to confirm presence of allstones.ultrasonography in acute cholecystitis to confirm presence of allstones.

► DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS:-:-

► It must be differentiated from other acute abdominal condition e.g. perfosated or penetrating It must be differentiated from other acute abdominal condition e.g. perfosated or penetrating peptic ulcer,acute pancreatitis,acute pyelonephritis,gallbladder colic and hepatitisand coronary peptic ulcer,acute pancreatitis,acute pyelonephritis,gallbladder colic and hepatitisand coronary thrombosis.thrombosis.

► COMPLICATIONCOMPLICATION :- :-

► (1)Perforation(1)Perforation► (2)Pericholecystic abscess(2)Pericholecystic abscess► (3)Internal fistula(3)Internal fistula

► TreatmentTreatment: - Though conflicting opinions exist as to whether immediate cholecystectony : - Though conflicting opinions exist as to whether immediate cholecystectony should be performed or not in case of acute cholecystitis,yet majority of surgeons in this region should be performed or not in case of acute cholecystitis,yet majority of surgeons in this region favour conservative treatment followes by elective cholecystectomy at an interval of 6 weeks to3 favour conservative treatment followes by elective cholecystectomy at an interval of 6 weeks to3 months. The believers of this treatment explain thatmonths. The believers of this treatment explain that

► (1)Most case of acute cholecystitis subside on conservative management without significant (1)Most case of acute cholecystitis subside on conservative management without significant complication.complication.

► (2) Acute inflammatory changes obscure the anatomy and leads to technical errors if the (2) Acute inflammatory changes obscure the anatomy and leads to technical errors if the operation is performed eassly without conservative treatment.operation is performed eassly without conservative treatment.

► (3) In early stage these is vascular congestion and vigorous inflammation and surgery (3) In early stage these is vascular congestion and vigorous inflammation and surgery may be injurious by spreading infection.may be injurious by spreading infection.

► (4 )Many of the patients with this discase may have associated diseases which should be (4 )Many of the patients with this discase may have associated diseases which should be excluded and be treated before one ventures for cholecystectomy.excluded and be treated before one ventures for cholecystectomy.

► CONSERVATIVE MANAGEMENTCONSERVATIVE MANAGEMENT aims at creating a situation of functional rest for the aims at creating a situation of functional rest for the gallbladder and upper gastrointestinal tract and relaxing spasm of sphincter of oddi. This gallbladder and upper gastrointestinal tract and relaxing spasm of sphincter of oddi. This can be achieved by – can be achieved by –

► (1) Nothing is given by mouth. Nasogastric qspiration should be started immediately and (1) Nothing is given by mouth. Nasogastric qspiration should be started immediately and should be continued for at least 3 to 5 days. Intravenous fluid adrninstration should be should be continued for at least 3 to 5 days. Intravenous fluid adrninstration should be started in the beginning 5 % dextrose saline may be startes,but subsequently fluids should started in the beginning 5 % dextrose saline may be startes,but subsequently fluids should be changed according to the electrolyte balance of the patient.Monitosing of haemodynamic be changed according to the electrolyte balance of the patient.Monitosing of haemodynamic parameters and usinary output should influence fluid administration.parameters and usinary output should influence fluid administration.

► (2) Anticholinergic drug should be given to reduce gastric and pancreatic (2) Anticholinergic drug should be given to reduce gastric and pancreatic secretion. secretion. This will also relax the sphincter of addi.This will also relax the sphincter of addi.

► (3) Analgesics should be given to combat pain.Morphin and pethidine should be avoided as (3) Analgesics should be given to combat pain.Morphin and pethidine should be avoided as both these drugs cause spasm of sphincter of oddi. Though pethidine has gat relaxant effect both these drugs cause spasm of sphincter of oddi. Though pethidine has gat relaxant effect on the smooth muscles of the G.I. tract,yet it dose cause spasm of sphincter of oddi small on the smooth muscles of the G.I. tract,yet it dose cause spasm of sphincter of oddi small amounts of amounts of DemerolDemerol may be used. may be used.

► (4) Antibiotic should be started immediately to control inflammantory procers. Broad (4) Antibiotic should be started immediately to control inflammantory procers. Broad spectrum antibiotics are usually preferred.The broadest coverage may be achieved by the spectrum antibiotics are usually preferred.The broadest coverage may be achieved by the gmbination of Ampiciline,Clindanycin,and Aminoglycoside. But the last antibiotic is known gmbination of Ampiciline,Clindanycin,and Aminoglycoside. But the last antibiotic is known for its toxicity. Therefore administration of second generation cephalosposine is often for its toxicity. Therefore administration of second generation cephalosposine is often parctised by many surgeous. Simple chloramphenical also has a broad converage on parctised by many surgeous. Simple chloramphenical also has a broad converage on organisim of acute cholecystitis. Butblood examination should be performed regularly when organisim of acute cholecystitis. Butblood examination should be performed regularly when this drug is used. Antibiotic should be initiated as soon as the diagnosis is made. When the this drug is used. Antibiotic should be initiated as soon as the diagnosis is made. When the temperature,pulse and other physical sign show that the inflanation is temperature,pulse and other physical sign show that the inflanation is subsides,conservative treatment is continued on the 3rd day suppository is given to empty subsides,conservative treatment is continued on the 3rd day suppository is given to empty the bowel. Once the bowel is moved,tenderness is greatly reduced and there is the bowel. Once the bowel is moved,tenderness is greatly reduced and there is dissapearnce of mass in the gallbladder region,gastric aspiration tube may be removed and dissapearnce of mass in the gallbladder region,gastric aspiration tube may be removed and fluids may be given by mouth gradually the I.V. dsup is removed. After 5 days soft fat free fluids may be given by mouth gradually the I.V. dsup is removed. After 5 days soft fat free diet is given and gradually within a few days normal fat free diet can be recommended. An diet is given and gradually within a few days normal fat free diet can be recommended. An oral cholecystoram is advised 3 weeks later. Cholecystectomy is advised 8 to 10 weeks after oral cholecystoram is advised 3 weeks later. Cholecystectomy is advised 8 to 10 weeks after the acute symptoms have subsided.the acute symptoms have subsided.

► CONSERVATIVE TREATMENT IS STOPPED AND EARLY CHOLECYSTECTOMY IS CONSERVATIVE TREATMENT IS STOPPED AND EARLY CHOLECYSTECTOMY IS ADVISED:-ADVISED:-

► (1)If pain and tenderness spread across the abdomen.(1)If pain and tenderness spread across the abdomen.► (2)Gallbladder lump becomes obvious and increases in size along with increase in (2)Gallbladder lump becomes obvious and increases in size along with increase in

muscle rigidity and rebound tenderness.muscle rigidity and rebound tenderness.► (3)It pulse rate continues to rise along with fever inspite of best conservative (3)It pulse rate continues to rise along with fever inspite of best conservative

managementmanagement► (4)In the very ill and elderly patients who are not responding to conservative (4)In the very ill and elderly patients who are not responding to conservative

management as expected.management as expected.

► In these patients cholecystectomy is the operation of choice.In these patients cholecystectomy is the operation of choice.

► Conservative treatment is not advised – Conservative treatment is not advised –

► (1)When the diagnosis is in dout and condition like acute high retrocaecal affendicitis (1)When the diagnosis is in dout and condition like acute high retrocaecal affendicitis and peptic perforation have not been excluded.and peptic perforation have not been excluded.

► (2)In case of typhoid cholecystitis due to frequency of perforation in these cases.(2)In case of typhoid cholecystitis due to frequency of perforation in these cases.

► CholecystectomyCholecystectomy :- :- ► ► The step of this operation performed in case of acute cholecystitis is more or less similar The step of this operation performed in case of acute cholecystitis is more or less similar

to the elective cholecystectomy and cholecystectomy performed for chronic cholecystitis to the elective cholecystectomy and cholecystectomy performed for chronic cholecystitis and cholelithiasis. Only paint is that one must be very careful to identify the junction of and cholelithiasis. Only paint is that one must be very careful to identify the junction of cystic duct and common bile duct as inflammation that there is very possibility to injure cystic duct and common bile duct as inflammation that there is very possibility to injure the ductal system and the neighbouring structures. There will be mose bleeding in acute the ductal system and the neighbouring structures. There will be mose bleeding in acute cholecystitis and this will make the operation mose problematical. Indications for cholecystitis and this will make the operation mose problematical. Indications for exploration of the common bile duct are the same as those during elective exploration of the common bile duct are the same as those during elective choleoystectomy.choleoystectomy.

► CholecystectomyCholecystectomy :- :-

► The gallbladder Is segregated from other abdominal viscera by hot moist packs. A wide-bore The gallbladder Is segregated from other abdominal viscera by hot moist packs. A wide-bore needle with a sysinge is pushed though the founds of the gallbladder to aspirate some bile needle with a sysinge is pushed though the founds of the gallbladder to aspirate some bile from it. Two pairs of tissue forceps are applied on each side of the needle and they are lifted from it. Two pairs of tissue forceps are applied on each side of the needle and they are lifted up. The needle is withdrown and immediate incision is made through the punetuse of the up. The needle is withdrown and immediate incision is made through the punetuse of the needle. The remaining contents are evacuated including small stones, the neek of the needle. The remaining contents are evacuated including small stones, the neek of the gallbladder and cystic duct are carefully palpated. Any calculi there are milked towards the gallbladder and cystic duct are carefully palpated. Any calculi there are milked towards the gallbladder. In case of a stone is firmly impacted at the neek of the cystic duct there may be gallbladder. In case of a stone is firmly impacted at the neek of the cystic duct there may be risk of infecting severe trauma to dislodge this stone. In this case the surgeon should be risk of infecting severe trauma to dislodge this stone. In this case the surgeon should be content with simple drainage to relieve the patient of the fulminating infection. Inflamntary content with simple drainage to relieve the patient of the fulminating infection. Inflamntary oedena will be sulosided later on to loosen the stone,so that it may caome out thourgh the oedena will be sulosided later on to loosen the stone,so that it may caome out thourgh the drainage opening or down the duct into the bowel. The importancer of removal of the drainage opening or down the duct into the bowel. The importancer of removal of the stones cannot be over emphasized,as this will cause gallbladder symptoms after removal of stones cannot be over emphasized,as this will cause gallbladder symptoms after removal of cholecystectony tube if a stone is impacted within the infundibulum or cystic duct. A rubber cholecystectony tube if a stone is impacted within the infundibulum or cystic duct. A rubber tube about half on inch in diameter is introduced into the gallbladder through the incision tube about half on inch in diameter is introduced into the gallbladder through the incision around the duct is performed by a pusse-string suture. The tube is brought out through a around the duct is performed by a pusse-string suture. The tube is brought out through a seprate stab incision below the right castal margin. A drainage is also provided.seprate stab incision below the right castal margin. A drainage is also provided.

► Postoperative treatmentPostoperative treatment: - : -

► The tube is connected with a receptacle at the bed side. The tube is taken off after 7 to 10 The tube is connected with a receptacle at the bed side. The tube is taken off after 7 to 10 days. The fistula close spontaneously within a few weeks unless. There is any obstruction in days. The fistula close spontaneously within a few weeks unless. There is any obstruction in the common bile duct. Cholangiography through the tube prior to its removal will identify the common bile duct. Cholangiography through the tube prior to its removal will identify retained stones,which can be extracted under fluoroscopic guidance.retained stones,which can be extracted under fluoroscopic guidance.

► Chronic CholecystitisChronic Cholecystitis

► It is of two type – It is of two type –

► (1)Follows an episode of acute cholecystitis and is known as (1)Follows an episode of acute cholecystitis and is known as secondary chronic cholecystitis secondary chronic cholecystitis ► (2)It occurs primarily without antecedent acute cholecystitis and is known as (2)It occurs primarily without antecedent acute cholecystitis and is known as primary primary

chronic cholecystitischronic cholecystitis..

► PathologyPathology: - : -

► The external surface of the gallbladder no longer has an appearance of The external surface of the gallbladder no longer has an appearance of thinnes,but it become opaque and yellow due to accumulation of subserous thinnes,but it become opaque and yellow due to accumulation of subserous fat. The gallbladder may be dilated or contracted depending on the relating fat. The gallbladder may be dilated or contracted depending on the relating balance of abstruction and inflammantion of obstruction occurs before the balance of abstruction and inflammantion of obstruction occurs before the chronic inflammatory changes have had time to produce thickening,the chronic inflammatory changes have had time to produce thickening,the gallbladder may be dilated and relatively thin walled otherwise the gallbladder gallbladder may be dilated and relatively thin walled otherwise the gallbladder is contracted and its wall is thickened. After opening the gallbladder,trhe is contracted and its wall is thickened. After opening the gallbladder,trhe lumen usually contains fairly clear,greenish – yellow muceid bile stones are lumen usually contains fairly clear,greenish – yellow muceid bile stones are present 90% of cases. The mucosa may show usually mucosal folds or present 90% of cases. The mucosa may show usually mucosal folds or flattening of the mucosal flods with thinning and atrophy of the mucosa due to flattening of the mucosal flods with thinning and atrophy of the mucosa due to obstruction.obstruction.

► CLINICAL FEATURESCLINICAL FEATURES:-:-

► Ctironic cholecystitis is vague and insidious to start with. It usually manifests Ctironic cholecystitis is vague and insidious to start with. It usually manifests itself by intolerance to fatty food,bleching,postcibal epigastric itself by intolerance to fatty food,bleching,postcibal epigastric distension,nousea and vomiting.Recurrent attacks of pain in the right upper distension,nousea and vomiting.Recurrent attacks of pain in the right upper guardant or epigastric region are common complaint. Pain usually follows guardant or epigastric region are common complaint. Pain usually follows meals. There may be discomfort and not typical pain. Nausea and vomiting meals. There may be discomfort and not typical pain. Nausea and vomiting may occur during the pain and often itself induced in an attemptto get relief of may occur during the pain and often itself induced in an attemptto get relief of pain. The discomfort may persist for several days or only a few hours. There pain. The discomfort may persist for several days or only a few hours. There may be vasiable intervals between the attacks lasting for a month to several may be vasiable intervals between the attacks lasting for a month to several years. Sometimes the pain may be colicky in nature (gallbladder colic) which years. Sometimes the pain may be colicky in nature (gallbladder colic) which result from the temporary obstruction of the gallbladder outlet by a stone in result from the temporary obstruction of the gallbladder outlet by a stone in the cystic duct or the infundibulun. Pain aftera large meal is explained by the cystic duct or the infundibulun. Pain aftera large meal is explained by gallbladder contraction induced by cholecystokinin against fixed obstruction. gallbladder contraction induced by cholecystokinin against fixed obstruction. The pain persists so long as the contraction remains and is relieved when the The pain persists so long as the contraction remains and is relieved when the gallbladder relaxes. Gallbladder pain characteristically radiates to the back to gallbladder relaxes. Gallbladder pain characteristically radiates to the back to inferior angle of the right scapula or inter-scapulor region or to the Rt. inferior angle of the right scapula or inter-scapulor region or to the Rt. shoulder. shoulder.

► PHYSICAL SIGNPHYSICAL SIGN:-:-

► Right upper quadsant tenderness or epigastric tenderness can only be elicited during Right upper quadsant tenderness or epigastric tenderness can only be elicited during attacks. There is no muscle guarding or rebound tenderness. The gallbladder is also not attacks. There is no muscle guarding or rebound tenderness. The gallbladder is also not palpable. It Jaundice is present it is due to choledocholithiasis rather than anything else. palpable. It Jaundice is present it is due to choledocholithiasis rather than anything else. Musphy’s sign may be positive.Musphy’s sign may be positive.

► SPECIAL INVESTIGATION:-SPECIAL INVESTIGATION:-

► (1)Examination of blood does not reveal any specific piture.(1)Examination of blood does not reveal any specific piture.► (2)Oral cholecystography shows non-visualisation of gallbladder and is quite diagnostic. It (2)Oral cholecystography shows non-visualisation of gallbladder and is quite diagnostic. It

the Liver function is alright and the serum bilirubin level is normal this is dependable the Liver function is alright and the serum bilirubin level is normal this is dependable diagnostic due diagnostic due

► (3)Ultrasonagraphy(3)Ultrasonagraphy

► DIFFERNTIAL DIAGNOSISDIFFERNTIAL DIAGNOSIS:-:-

► Of chronic cholecystitis include pepticulcer,pancreatitis,oesophageal hiatus Of chronic cholecystitis include pepticulcer,pancreatitis,oesophageal hiatus hernia,appendicitis,right pyelonephritc,myocardial infraction,pleuritis,arthritic changes in the hernia,appendicitis,right pyelonephritc,myocardial infraction,pleuritis,arthritic changes in the thoracic spine causing upper quadrant and hepatitis. thoracic spine causing upper quadrant and hepatitis.

► TREATMENTTREATMENT :- :-

► Cholecystectomy is the right upper treatment for cholecystitis and cholelithiasis. If the Cholecystectomy is the right upper treatment for cholecystitis and cholelithiasis. If the patient present with biliary coilc conservative treatment should be started immediatelypatient present with biliary coilc conservative treatment should be started immediately

► CHOLECYSTECTOMYCHOLECYSTECTOMY

► These patients are likely to have some disturbances of liver function. So glucose drink – These patients are likely to have some disturbances of liver function. So glucose drink – 150 gm daily for 3 days should be given by mouth before operation. In cases where oral 150 gm daily for 3 days should be given by mouth before operation. In cases where oral intake is not allowed 5% glucose my be given intravenousy. Broad spectrum antibiotics intake is not allowed 5% glucose my be given intravenousy. Broad spectrum antibiotics should be started before operation,as cholangitis may be associated with these should be started before operation,as cholangitis may be associated with these conditions. An oral cholecystogram should be done any time before the operation. When conditions. An oral cholecystogram should be done any time before the operation. When the patient given history of jaundice with acute pain and fever (Charcot’s triad) during the patient given history of jaundice with acute pain and fever (Charcot’s triad) during the present illness the surgon can ask for I. V. Cholangiography.the present illness the surgon can ask for I. V. Cholangiography.

► TechniqueTechnique: - After preliminary exploration and tking the decision that gallbladder has : - After preliminary exploration and tking the decision that gallbladder has to be removed the surgeon will noe proceed to perform cholesystectomy. One wet mop to be removed the surgeon will noe proceed to perform cholesystectomy. One wet mop is placed displace downwards the duodenum,the transverse colon and coils of small is placed displace downwards the duodenum,the transverse colon and coils of small intestine and another wet mop is placed slighty to the left of the common bile duct to intestine and another wet mop is placed slighty to the left of the common bile duct to displace the stomach to the lrft. These two mops are held by the assistant. Now the displace the stomach to the lrft. These two mops are held by the assistant. Now the inferior surface of the right lobe of the liver is retracted upwords by a Deaver’s retractor. inferior surface of the right lobe of the liver is retracted upwords by a Deaver’s retractor. The whole of the gallbladder,common bile duct and cystic duct are now well exposed.The whole of the gallbladder,common bile duct and cystic duct are now well exposed.

► There are two principal methods,which can be adopted to remove the gallbladder. One is There are two principal methods,which can be adopted to remove the gallbladder. One is the `duct first method, i.e. the cystic duct and the artery are dissected first and the `duct first method, i.e. the cystic duct and the artery are dissected first and divided,after which the gallbladder is removed. Another method is `fundus first `method, divided,after which the gallbladder is removed. Another method is `fundus first `method, in which the dissection is started from the fundus of the gallbladder and gradullay in which the dissection is started from the fundus of the gallbladder and gradullay proceeded towards the cystic duct which is divided last of all. But the first method is proceeded towards the cystic duct which is divided last of all. But the first method is popular because of the fact that there is less chance of injury to the common bile duct or popular because of the fact that there is less chance of injury to the common bile duct or to the right hepatic artery as the dissection of the junction of the cystic duct and to the right hepatic artery as the dissection of the junction of the cystic duct and common bile duct is done first before soiling of the part with exudates,haemorrhage or common bile duct is done first before soiling of the part with exudates,haemorrhage or biliary leakagebiliary leakage..

► THE `DUCT FIRST METHODTHE `DUCT FIRST METHOD- If the gallbladder is very much distended to prevent a - If the gallbladder is very much distended to prevent a good dissection at its neck and cystic duct,it is better to aspirate the gallbladder first and good dissection at its neck and cystic duct,it is better to aspirate the gallbladder first and then tro clamp the aspirating point so as to prevent biliary leakage. a sponge holding then tro clamp the aspirating point so as to prevent biliary leakage. a sponge holding forceps is applied to the infundibulum of the gallbladder and is used to retract the forceps is applied to the infundibulum of the gallbladder and is used to retract the gallbladder to the right so that the cystic duct is made taut. The junction of the cystic gallbladder to the right so that the cystic duct is made taut. The junction of the cystic and the common bile duct is now displayed by snipping the overlying peritoneum and and the common bile duct is now displayed by snipping the overlying peritoneum and then by gauze dissection with lahey’s forceps. If a stone is felt at the cystic duct it is then by gauze dissection with lahey’s forceps. If a stone is felt at the cystic duct it is milked towards the gallbladder. If the stone remains impacted,the ston is removed milked towards the gallbladder. If the stone remains impacted,the ston is removed though a small nick on the cystic duct. The dissection at the junction of the though a small nick on the cystic duct. The dissection at the junction of the cystic,common hepatic and common bile duct must be very clear. These three ducts cystic,common hepatic and common bile duct must be very clear. These three ducts should be shown to the assistants so that not only the surgeon but also the assistants should be shown to the assistants so that not only the surgeon but also the assistants are satisfied with the exposure. This step is very important and the way to prevent are satisfied with the exposure. This step is very important and the way to prevent damage to the common bile duct,common hepatic duct and the right hapetic artery. damage to the common bile duct,common hepatic duct and the right hapetic artery. Moynihan’s cholecysectomy forceps is passed deep to the cystic duct to bring no 2 Moynihan’s cholecysectomy forceps is passed deep to the cystic duct to bring no 2 chromic catgut or silk. The ligature is now divided to make two stands of ligature. One chromic catgut or silk. The ligature is now divided to make two stands of ligature. One strand is tightened on the cystic duct about 1 cm distal to its junction with the common strand is tightened on the cystic duct about 1 cm distal to its junction with the common bile duct. The other strand is tightened on the cystic duct at its junction with the bile duct. The other strand is tightened on the cystic duct at its junction with the common bile duct. common bile duct.

►

► FUNDUS FIRST METHOD FUNDUS FIRST METHOD

► This method is only applied when dissection at the region of the junction of the cystic This method is only applied when dissection at the region of the junction of the cystic duct,common hepatic duct and common bile duct becomes difficult due to lots of duct,common hepatic duct and common bile duct becomes difficult due to lots of adhesions and inflammatory exudates .This operation or the gallbladder is commenced adhesions and inflammatory exudates .This operation or the gallbladder is commenced from the funds. The peritoneal sheath is divided with scissors on each side of the from the funds. The peritoneal sheath is divided with scissors on each side of the gallbladder. When the gallbladder is completely freed the liver,the cystic duct and the gallbladder. When the gallbladder is completely freed the liver,the cystic duct and the artery are defined as much as practicable.These are divided between ligatures. The artery are defined as much as practicable.These are divided between ligatures. The danger remains of injuring the common bile duct and the right hepatic artery.danger remains of injuring the common bile duct and the right hepatic artery.

► POSTOPERATIVE TERATMENTPOSTOPERATIVE TERATMENT

► The drain is removed after 48 hours. It may be kept for longer period ,if the discharge The drain is removed after 48 hours. It may be kept for longer period ,if the discharge continues. Nasogastric aspiration and intravenous fluid administration are continued continues. Nasogastric aspiration and intravenous fluid administration are continued until the peristalsis of the intestine comes back and the patient passes flatus. At this until the peristalsis of the intestine comes back and the patient passes flatus. At this time aspiration and fluid administration are stopped and liquid diet is gradually allowed time aspiration and fluid administration are stopped and liquid diet is gradually allowed by mouth. Next semi-solid and fat free solid diet are gradually givenby mouth. Next semi-solid and fat free solid diet are gradually given