L31 cholecystitis students
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Cholecystitis
Lecture 31
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• Cholecystitis (Greek, -cholecyst, "gallbladder", combined with the suffix -itis, "inflammation") is inflammation of the gallbladder, which occurs most commonly due to obstruction of the cystic duct with gallstones (cholelithiasis).
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Classification
• Acute: calculous & acalculous• Chronic• Acute superimposed on chronic
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Acute Cholecystitis
• Acute calculous cholecystitis is an acute inflammation of the gallbladder, precipitated 90% of the time by obstruction of the neck or cystic duct.
• It is the primary complication of gallstones and the most common reason for emergency cholecystectomy.
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Aacalculous cholecystitis
• Cholecystitis without gallstones called acalculous cholecystitis may occur in severely ill patients and accounts for about 10% of patients with cholecystitis.
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Pathogenesis.
• Acute calculous cholecystitis results from
chemical irritation and inflammation of the obstructed gallbladder.
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• The action of mucosal phospholipases hydrolyzes luminal lecithins to toxic lysolecithins.
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• The normally protective glycoprotein mucus layer is disrupted, exposing the mucosal epithelium to the direct detergent action of bile salts.
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• Prostaglandins released within the wall of the distended gallbladder contribute to mucosal and mural inflammation.
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• Gallbladder dysmotility develops; distention and increased intraluminal pressure compromise blood flow to the mucosa.
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• Acute calculous cholecystitis frequently
develops in diabetic patients who have symptomatic gallstones.
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Pathogenesis
• Acute acalculous cholecystitis is thought to result from ischemia. The cystic artery is an end artery with essentially no collateral circulation.
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Risk factors for acute acalculous cholecystitis include:
(1) Sepsis with hypotension and multisystem organ failure;
(2) Immunosuppression; (3) Major trauma and burns; (4) Diabetes mellitus; and (5) Infections.
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Morphology.
In acute cholecystitis the gallbladder is usually enlarged and tense, and it may assume a bright red or blotchy, violaceous to green-black discoloration, imparted by subserosal hemorrhages.
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• The serosal covering is frequently layered by fibrin and, in severe cases, by a definite suppurative, coagulated exudate.
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Morphology
• In calculous cholecystitis, an obstructing stone is usually present in the neck of the gallbladder or the cystic duct.
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• The gallbladder lumen may contain one or more stones and is filled with a cloudy or turbid bile that may contain large amounts of fibrin, pus, and hemorrhage.
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• In mild cases the gallbladder wall is thickened, edematous, and hyperemic.
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• In more severe cases it is transformed into a green-black necrotic organ, termed
gangrenous cholecystitis, with small-to-large perforations.
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• The invasion of gas-forming organisms, notably clostridia and coliforms, may cause an acute “emphysematous” cholecystitis.
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Clinical Features. • An attack of acute cholecystitis begins with
progressive right upper quadrant or epigastric pain, frequently associated with mild fever, anorexia, tachycardia, sweating, nausea, and vomiting.
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• The pain may be referred pain that is felt in the right scapula rather than the right upper quadrant or epigastric region (Boas' sign).
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• It may also correlate with eating greasy, fatty, or fried foods.
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• The Murphy sign is specific, but not sensitive for cholecystitis.
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• Elderly patients and those with diabetes may have vague symptoms that may not include fever or localized tenderness.
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• More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as
• abscess formation, • perforation or • ascending cholangitis.
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• Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.
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• Clinical symptoms of acute acalculous cholecystitis tend to be more insidious, since symptoms are obscured by the underlying conditions precipitating the attacks.
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• As a result of either delay in diagnosis or the disease itself, the incidence of gangrene and perforation is much higher in acalculous than in calculous cholecystitis.
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Chronic Cholecystitis • Chronic cholecystitis may be a sequel to
repeated bouts of mild to severe acute cholecystitis,
• but in many instances it develops in the apparent absence of antecedent attacks.
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• Since it is associated with cholelithiasis in more than 90% of cases, the patient populations are the same as those for gallstones.
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• supersaturation of bile predisposes to both chronic inflammation and, in most instances, stone formation.
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• Unlike acute calculous cholecystitis, obstruction of gallbladder outflow is not a requisite.
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• , the symptoms of calculous chronic cholecystitis are biliary colic to indolent right upper quadrant pain and epigastric distress.
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Morphology.
• The morphologic changes in chronic cholecystitis are extremely variable and sometimes minimal.
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• The serosa is usually smooth and glistening but may be dulled by subserosal fibrosis.
• Dense fibrous adhesions
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• On sectioning, the wall is variably thickened, and has an opaque gray-white appearance.
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• In the uncomplicated case • the lumen contains fairly clear, green-yellow,
mucoid bile and usually stones. The mucosa itself is generally preserved.
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Microscopy
• In the mildest cases, only scattered lymphocytes, plasma cells, and macrophages are found in the mucosa and in the subserosal fibrous tissue.
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• In more advanced cases there is marked subepithelial and subserosal
fibrosis, accompanied by mononuclear cell infiltration.
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• Outpouchings of the mucosal epithelium through the wall
(Rokitansky-Aschoff sinuses) may be quite prominent.
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Acute superimposed on chroniccholecystitis
Superimposition of acute inflammatory changes implies acute exacerbation of an already chronically injured gallbladder.
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Porcelain gallbladder
• In rare instances extensive dystrophic
calcification within the gallbladder wall may yield a porcelain gallbladder, notable for a markedly increased incidence of associated cancer.
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• Xanthogranulomatous cholecystitis is also a rare condition in which the gallbladder has a
massively thickened wall, is shrunken, nodular, and chronically inflamed with foci of necrosis and hemorrhage.
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• Finally, an atrophic, chronically obstructed gallbladder may contain only clear secretions, a condition known as
hydrops of the gallbladder.
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Clinical Features.
• Usually characterized by recurrent attacks of either steady or colicky epigastric or right upper quadrant pain.
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• Nausea, vomiting, and intolerance for fatty foods are frequent accompaniments.
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