gall bladder prof dr tharwat s. kandiel assist. prof. of general surgery
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Gall BladderProf Dr Tharwat S. Kandiel
Assist. Prof. Of General SurgeryGastro-intestinal Surgical Center
Dr. Tharwat S Kandiel
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Anatomy
The gallbladder (or cholecyst, sometimes gall bladder) is a pear-shaped organ that stores about 50 mL of bile (or "gall") until the body needs it for digestion.
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Anatomy
The gallbladder is about 7-10 cm long in humans and appears dark green because of its contents (bile), rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.
The cystic duct leads from the gallbladder and joins with the common hepatic duct to form the common bile duct.
The common bile duct then joins with the pancreatic duct, and enters the duodenum through the hepatopancreatic ampulla at the major duodenal papilla.
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Anatomy
ArteryCystic artery
VeinCystic vein
NerveCeliac ganglia, vagus
PrecursorForegut
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Histology
The layers of the gallbladder are as follows: The gallbladder has a simple columnar epithelial
lining characterized by recesses called Aschoff's recesses (lacunae of Luschka) , which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue.
Beneath the connective tissue is a wall of smooth muscle that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
There is essentially no submucosa.
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Function
The gallbladder stores about 50 mL of bile , which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.
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Anomalies
The gallbladder may be absent = 0.075% The gallbladder and cystic duct may be absence. the gallbladder is irregular in form or constricted
across its middle; more rarely, it is partially divided in a longitudinal direction.
two distinct gallbladders, each having a cystic duct that joined the hepatic duct. (0.026%), The cystic duct may itself be doubled
The gallbladder has been found on the left side (to the left of the ligamentum teres) in subjects in whom there was no general tranposition of the thoracic and abdominal viscera.
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The gallbladder may be intrahepatic or beneath the left lobe. Ectopic sites include retrohepatic positions, or in the anterior abdominal wall or falciform ligament, they may be suprahepatic or transversely position, floating, or retroperitoneal. They may be in the midline anterior epigastric above the left lobe or suprahepatic above the right hepatic lobe.
Dr. Tharwat S Kandiel
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Dr. Tharwat S Kandiel
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Choledochal cyst
Choledochal cysts are congenital anomalies of the bile ducts. They consist of cystic dilatations of the extrahepatic biliary tree, intrahepatic biliary radicles, or both.
Douglas is credited with the first clinical report in a 17-year-old girl who presented with intermittent abdominal pain, jaundice, fever, and a palpable abdominal mass.
Pathophysiology: The pathogenesis of choledochal cysts is most likely multifactorial. A congenital etiology, A congenital predisposition to acquiring the disease
under the right conditions.
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The vast majority of patients with choledochal cysts have an anomalous junction of the common bile duct with the pancreatic duct (anomalous pancreatobiliary junction [APBJ]). An APBJ is characterized when the pancreatic duct enters the common bile duct 1 cm or more proximal to where the common bile duct reaches the ampulla of Vater.
APBJs in more than 90% of patients with choledochal cysts.
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The APBJ allows pancreatic secretions and enzymes to reflux into the common bile duct. In the relatively alkaline conditions found in the common bile duct, pancreatic pro-enzymes can become activated. This results in inflammation and weakening of the bile duct wall. Severe damage may result in complete denuding of the common bile duct mucosa.
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From a congenital standpoint, defects in epithelialization and recanalization of the developing bile ducts during organogenesis and congenital weakness of the duct wall have also been implicated. The result is formation of a choledochal cyst.
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Anatomy of Choledochal cyst
based on the Todani classification published in 1977.
Type I choledochal cysts most common ; 80-90% of the lesions. Type I cysts are dilatations of the entire common
hepatic and common bile ducts or segments of each. They can be saccular or fusiform in configuration.
Type II choledochal cysts isolated protrusions or diverticula that project from the
common bile duct wall. They may be sessile or may be connected to the common bile duct by a narrow stalk.
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Type III choledochal cysts are found in the intraduodenal portion of the common bile duct. Another term used for these cysts is choledochocele.
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Type IVA cysts are characterized by multiple dilatations of the intrahepatic and extrahepatic biliary tree. Most frequently, a large solitary cyst of the extrahepatic duct is accompanied by multiple cysts of the intrahepatic ducts. Type IVB choledochal cysts consist of multiple dilatations that involve only the extrahepatic bile duct.
Type V choledochal cysts are defined by dilatation of the intrahepatic biliary radicles. Often, numerous cysts are present with interposed strictures that predispose the patient to intrahepatic stone formation, obstruction, and cholangitis. The cysts are typically found in both hepatic lobes. Occasionally, unilobar disease is found and most frequently involves the left lobe.
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The patient may present at any age with1. Obstructive jaundice
2. Cholangitis and
3. Abd signs, with RUQ swelling in some cases It is a premalignant condition Diagnosis by US and MRI Radical excision of the cyst is the treatment
of choice with Roux – en –Y reconstruction
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Gall stones
Gall stones are the most common abdominal reason for admission to hospital in developed countries and account for an important part of healthcare expenditure. Around 5.5 million people have gall stones in the United Kingdom, and over 50 000 cholecystectomies are performed each year.
Normal bile consists of 70% bile salts (mainly cholic and chenodeoxycholic acids), 22% phospholipids (lecithin), 4% cholesterol, 3% proteins, and 0.3% bilirubin.
There are two major types of gallstones, which seem to form due to distinctly different pathogenetic mechanisms.
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Cholesterol Stones
About 90% of gallstones are of this type. These stones can be either; almost pure cholesterol {Cholesterol stones}
or mixtures of cholesterol and other substances{ cholesterol predominant (mixed) stones}.
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The key event leading to formation and progression of cholesterol stones is precipitation of cholesterol in bile.
Unesterified cholesterol is virtually insoluble in aqueous solutions and is kept in solution in bile largely by virtue of the detergent-like effect of bile salts.
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Imbalance lead to stone formation
Hyper-secretion of cholesterol into bile due to obesity, acute high calorie intake, chronic polyunsaturated fat diet, contraceptive
steroids or pregnancy, diabetes mellitus and certain forms of familial hypercholesterolemia.
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Hypo-secretion of bile salts due to impaired bile salt synthesis and abnormal intestinal loss of bile salts (e.g. recirculation
failure due to ileal disease). Impaired gallbladder function with incomplete
emptying or stasis. seen in late pregnancy with oral contraceptive use, in patients on total parenteral nutrition and due to unknown causes, perhaps associated with
neuro-endocrine dysfunction.
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There are clearly important genetic determinants for cholesterol stone formation. For example, the prevelance of the disease in descendents of Chilean, Indians and in American Indians is extraordinarily high and not accounted for by environment.
There is also an important sex bias in development of stones - the prevelance in adult females is two to three times that seen in males
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•Age >40 years
Bile salt loss (ileal disease or resection)
Female sex (twice risk in men)Diabetes mellitus
Genetic or ethnic variationCystic fibrosis
High fat, low fibre dietAntihyperlipidaemic drugs(clofibrate)
ObesityGallbladder dysmotility
Pregnancy (risk increases with number of pregnancies)
Prolonged fasting
HyperlipidaemiaTotal parenteral nutrition
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Pigment Stones
Roughly 10% of gallstones are pigment stones
composed of large quantities of bile pigments, along with lesser amounts of cholesterol and
calcium salts. Black pigment stones
consist of 70% calcium bilirubinate and are more common in patients with haemolytic diseases (sickle cell anaemia, hereditary spherocytosis, thalassaemia) and cirrhosis.
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Brown pigment stones (accounting for <5% of stones) They form as a result of stasis and infection within the
biliary system, usually in the presence of Escherichia coli and Klebsiella spp, which produce β glucuronidase that converts soluble conjugated bilirubin back to the insoluble unconjugated state leading to the formation of soft, earthy, brown stones.
Ascaris lumbricoides and Opisthorchis senensis have both been implicated in the formation of these stones, which are common in South East Asia.
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sEffects and complications of Gall StonesIn the GB: Silent stones Chronic cholecystitis Acute cholecystitis Gangrene Perforation Empeyma Mucocele carcinoma
In the bile ducts: Obstructive jaundice Cholangitis Acute pancreatitis
In the intestine: Acute intestinal
obstruction (Gall stone ileus)
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Cholecystitis
Definition Cholecystitis refers to a painful inflammation of the
gallbladder's wall. The disorder can occur a single time (acute), or can recur multiple times (chronic).
Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Ninety percent of cases involve stones in the cystic duct (ie, calculous cholecystitis), with the other 10% representing acalculous cholecystitis. Although bile cultures are positive for bacteria in 50-75% of cases, bacterial proliferation may be a result of cholecystitis and not the precipitating factor.
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Causes
Risk factors for calculous cholecystitis mirror those for cholelithiasis and include the following:
Female sex Certain ethnic groups (Race) Obesity or rapid weight loss Drugs (especially hormonal therapy in women) Pregnancy Increasing age
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Acalculous cholecystitis is related to conditions associated with biliary stasis, to include the following: Critical illness Major surgery or severe trauma/burns Sepsis Long-term TPN Prolonged fasting
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Other causes of acalculous cholecystitis include the following: Cardiac events, including myocardial infarction Sickle cell disease Salmonella infections Diabetes mellitus Patients with AIDS with cytomegalovirus,
cryptosporidiosis, or microsporidiosis
Idiopathic cases exist.
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History
Typical gallbladder colic is 1-5 hours of constant pain, most commonly in the epigastrium or right upper quadrant. Pain may radiate to the right scapular region or back. Peritoneal irritation by direct contact with the gallbladder localizes the pain to the right upper quadrant. Pain is severe, dull or boring, and constant (not colicky). Patients tend to move around to seek relief from the pain. Onset of pain develops hours after a meal, occurs frequently at night, and awakens the patient from sleep.
Associated symptoms include nausea, vomiting, pleuritic pain, and fever.
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Indigestion, belching, bloating, and fatty food intolerance are thought to be typical symptoms of gallstones; however, these symptoms are just as common in people without gallstones and frequently are not cured by cholecystectomy.
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Most gallstones (60-80%) are asymptomatic at a given time. Smaller stones are more likely to be symptomatic than larger ones. Almost all patients develop symptoms prior to complications.
Symptoms of cholecystitis are steady pain in the right hypochondrium or epigastrium, nausea, vomiting, and fever. Acute attack often is precipitated by a large or fatty meal.
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Physical
Vital signs parallel the degree of illness. Patients with cholangitis are more likely to have fever, tachycardia, and/or hypotension. Patients with gallbladder colic have relatively normal vital signs.
Patients with cholecystitis are usually more ill appearing than simple biliary colic patients, and they usually lie still on the examination table since any movement may aggravate any peritoneal signs.
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Abdominal examination; Epigastric or RUQ tenderness and abdominal
guarding. The Murphy sign (an inspiratory pause on
palpation of the right upper quadrant) can be found on abdominal examination.
Positive Murphy sign was extremely sensitive (97%) and predictive (PPV, 93%) for cholecystitis. However, in elderly patients, this sensitivity may be decreased.
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peritoneal signs should be taken seriously. Most uncomplicated cholecystitis does not have peritoneal signs; thus, search for complications (eg, perforation, gangrene) or other sources of pain.
Gallbladder gangrene can be a complication in up to 20% of cases of cholecystitis and is usually in diabetics, elderly, or immunocompromised persons.
A palpable fullness in the RUQ may be appreciated in 20% of cases.
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As in all patients with abdominal pain, perform a complete physical examination, including rectal and pelvic examinations in women.
In elderly patients and those with diabetes, occult cholecystitis or cholangitis may be the source of fever, sepsis, or mental status changes.
Jaundice is unusual in the early stages of acute cholecystitis and may be found in fewer than 20% of patients.
A very high bilirubin =think for common bile duct and pancreatic region disease.
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Abdominal Aortic AneurysmAcute Mesenteric IschemiaAmebic Hepatic AbscessesAppendicitisBiliary ColicBiliary DiseaseCholangiocarcinomaCholangitisCholedocholithiasisCholelithiasisGallbladder CancerGallbladder MucoceleGallbladder Tumors
Gastric Ulcers Gastritis, Acute Gastroesophageal Reflux Disease Hepatitis, Viral Myocardial Infarction Nephrolithiasis Pancreatitis, Acute Peptic Ulcer Disease Pneumonia, Bacterial Pregnancy and Urolithiasis Pyelonephritis, Acute Renal Disease and Pregnancy Renal Vein Thrombosis
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Lab Studies
Labs with cholelithiasis and gallbladder colic should be completely normal.
Because biliary obstruction is limited to the gallbladder in uncomplicated cholecystitis, elevation in the serum total bilirubin and alkaline phosphatase concentrations may not be present.
An elevated WBC is expected but not reliable. Only 61% of patients with cholecystitis had a WBC greater than 11,000. A WBC greater than 15,000 may indicate perforation or gangrene.
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Mild elevation of amylase up to 3 times normal may be found in cholecystitis, especially when gangrene is present.
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are not expected to be elevated unless sepsis or underlying cirrhosis is present. Coagulation profiles are helpful if the patient needs operative intervention.
For febrile patients, send 2 sets of blood cultures to attempt to isolate the organism.
Although expected to be normal, urinalysis is essential in the workup of patients with abdominal pain to exclude pyelonephritis and renal calculi.
Conduct a pregnancy test for women of childbearing age.
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Imaging Studies
Ultrasound and nuclear medicine studies are the best imaging studies for the diagnosis of both cholecystitis and cholelithiasis. Plain radiography, CT scans, and endoscopic retrograde cholangiopancreatography (ERCP) are diagnostic adjuncts.
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Abd. radiographs (Plain X-Ray)
Adominal radiographs have low sensitivity and specificity in evaluating biliary system pathology, but
They can be helpful in excluding other abdominal pathology such as renal colic, bowel obstruction, perforation. Between 10 and 30% of stones have a ring of calcium and, therefore, are radiopaque. A porcelain gallbladder also may be observed on plain films.
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Emphysematous cholecystitis, cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation may show air in the biliary tree. Air in the gallbladder wall indicates emphysematous cholecystitis due to gas-forming organisms such as clostridial species and Escherichia coli.
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Computed tomography scan CT scan is recommended only for the evaluation of abdominal
pain if the diagnosis is uncertain. CT scan can demonstrate gallbladder wall edema, pericholecystic stranding and fluid, and high-attenuation bile.
Advantages: For complications of cholecystitis and cholangitis, gallbladder perforation, pericholecystic fluid, and intrahepatic ductal dilation, CT scan may be adequate. CT scan provides better information of the surrounding structures than sonogram and HIDA. CT scan is also noninvasive.
Disadvantages: CT scan misses 20% of gallstones because the stones may be of the same radiographic density as bile. CT scan is also more expensive and takes longer since the patient usually has to drink oral contrast. Also, given the radiation dose, it may not be ideal in the pregnant patient.
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Ultrasound
An ultrasound is the most common test used for the diagnosis of biliary colic and acute cholecystitis. It is 90-95% sensitive for cholecystitis and 78-80% specific. For simple cholelithiasis, it is 98% sensitive and specific.
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sFindings include gallstones or sludge and one or more of the following conditions
Gallbladder wall thickening (>2-4 mm) - False-positive wall thickening found in hypoalbuminemia, ascites, congestive heart failure, and carcinoma
Gallbladder distention (diameter >4 cm, length >10 cm)
Pericholecystic fluid from perforation or exudate
Air in the gallbladder wall (indicating gangrenous cholecystitis)
Sonographic Murphy sign (86-92% sensitive, 35% specific), pain when the probe is pushed directly on the gallbladder (not related to breathing)
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Some sonographers recommend the diagnosis of cholecystitis if both a sonographic Murphy sign and gallstones (without evidence of other pathology) are present.
Additional findings in the presence or absence of gallstones: Dilated common bile duct or dilated intrahepatic ducts of the biliary tree indicate common bile duct stones. In the absence of stones, a solitary stone may be lodged in the common bile duct, a location difficult to visualize sonographically.
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Advantages of sonography include the following: Images other structures (eg, aorta, pancreas, liver) Identifies complications (eg, perforation, empyema,
abscess) Rapidly performed at the bedside No radiation (important in pregnancy)
Disadvantages of sonography include the following: Operator dependent and patient dependent Inability to image the cystic duct Decreased sensitivity for common bile duct stones
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Biliary scintigraphy (HIDA, diisopropyl iminodiacetic acid [DISIDA]), nuclear medicine studies Sonography or nuclear medicine testing is the test of
choice for cholecystitis. HIDA scans have sensitivity (94%) and specificity (65-85%) for acute cholecystitis. They are sensitive (65%) and specific (6%) for chronic cholecystitis. Oral cholecystography is not practical for the ED.
HIDA and DISIDA scans are functional studies of the gallbladder. Technetium-labeled analogues of iminodiacetic acid (IDA) or diisopropyl IDA-DISIDA are administered intravenously (IV) and secreted by hepatocytes into bile, enabling visualization of the liver and biliary tree.
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Normal scans are characterized by normal visualization of gallbladder in 30 minutes.
With cystic duct obstruction (cholecystitis), the HIDA scan shows nonvisualization (ie, considered positive) of the gallbladder at 60 minutes and uptake in the intestine as the bile is excreted directly into the duodenum.
Obstruction of the common bile duct causes nonvisualization of the small intestine.
The rim sign is increased tracer adjacent to the gallbladder at 60 minutes and suggests gangrenous cholecystitis.
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Advantages of HIDA/DISIDA scans include the following: Assessment of function Normal-appearing gallbladder (by ultrasound);
obstructed cystic duct abnormal on DISIDA scan but not ultrasound.
Simultaneous assessment of bile ducts Disadvantages of HIDA/DISIDA scans include the
following: High bilirubin (>4.4 mg/dL) possibly decreases
sensitivity Recent eating or fasting for 24 hours also possibly
affects study No imaging of other structures in the area
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Other Tests: Endoscopic retrograde
cholangiopancreatography (ERCP) ERCP provides both endoscopic and
radiographic visualization of the biliary tract. It can be diagnostic and therapeutic by direct removal of common bile duct stones.
Magnetic Resonance cholangiopancreatography (MRCP)
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sTREATMENT; Conservative treatment followed by cholecystectomy
Symptoms of acute cholecystitis subside with conservative treatment in 90 % of cases
Four principles1. Naso-gastric suction & IV fluid
2. analgesics
3. Antibiotics (broad spectrum effective against Gm –ve aerobes)
4. Subsequent management ( if inflame. Subside→ oral fluids → fat free diet)
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Cholecystectomy on the next available list or after 4-6 wks
Conservative treatment is not advised if there is:1. Uncertain diagnosis
2. The possibility of high retrocecal appendix or
3. Perforated DU cannot be excluded Conservative treatment must be abandoned if pain
and tenderness increased →percutaneous cholecystostomy → subsequent cholecystectomy
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sTREATMENT; Routine early operations
Indications:1. Within 24 hrs of the onset of the attack
2. Experienced surgeons
3. Excellent operating facilities cholecystectomy can be done either by
open or laparoscopic approaches
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Acalcuolous cholecystitis
Some patients have non-specific inflammation of the GB , wherease other have one of the Cholecystoses
Diagnosis either by oral cholecystography ( chronic cases) or by isotopic scanning (acute cases)
Cholesterol crystal in the duod. aspirate may help diagnosis
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Acute acalcuolous cholecystitis is seen more frequently in:
Critical illness Major surgery or severe trauma/burns Sepsis Long-term TPN Prolonged fasting
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The Cholecystoses
Not uncommon conditions affecting the GB where there is chronin inflamm. Changes with hyperplasia of of all tissue elemnts
Cholesterosis (Strawberry GB) Submucous aggregations of
cholesterol crystals and cholesterol esters (yellow seeds) in the red mucosa
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Cholesterol polyposis of the GB These are either cholesterol polyposis or
adenomatous changes
Cholecystitis glandularis proliferans (polyp, adenomyomatosis and intramural diverticuolosis)
MM polyps- fleshy and granuolomatous All layer of GB may be thickened Sometimes incomplete septums forms Intraparietal mixed calculi may be present
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Diverticuolosis of the GB Usually manifest as black pigment stones impacted in
the out-pouchings of the lacunae of Luschka
Typhoid GB S. Typhi or occasionally S Typhimurium can infect the
GB leading to acute cholecystitis and more commonly chronic cholecystitis
The patient being typhoid carrier excreting the bacteria in the bils
Gall stones may be present
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GB cancer Rare ( common in certain area as India where it reaches 9% of
biliary tract disease Found in less than 1% of GB operations In over 90 % of cases gall stones are present
Presentations Age= 70s Sex= female (F-M= 5-1)
Pathology Scirrhous, but may be squamous cell & mixed squamous
adenocarcinoma Spread= direct, lymphatics and veins
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Clinical P Either extensive mass in the liver during
investigations for jaundice or At cholecystectomy at the time the histology is
received
Treatment Those diagnosed at cholecystectomy and confined to
the mucosa have a good prognosis (add wide excision & LN clearance or not ??)
Large T reaching serosa= chemoradiotherapy Median survival 1 year
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