ACUTE CHOLECYSTITIS

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ACUTE CHOLECYSTITIS
Acute cholecystitis is inflammation of
gall-bladder.
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BILIARY ANATOMY
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Anatomy vascular supply
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ETIOLOGY AND PATHOGENESIS

• infection
• discoordination passage of bile
• metabolic disturbance

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CLASSIFICATION
I. Acute calculous cholecystitis II. Acute
non-calculous cholecystitis 1. Catarrhal. 2.
Phlegmonous. 3. Gangrenous. 4. Perforated. 5.
Complicated a) Hydropsy b) Empyema c)
Pancreatitis d) Jaundice e) Hepatitis f)
Cholangitis g) Infiltrate h) Abscess i)
hepato-renal insufficiency j) Peritonitis.
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Classifying the Biliary Stone Patient
Asymptomatic Cholelithiasis Incidental Finding on Sonogram
Acute Cholecystitis Cholelithiasis on Sonogram, clinical Cholecystitis diagnosis or Positive Pipida Scan
Symptomatic Cholelithiasis Positive Sonogram, normal Liver Function Tests
Cholelithiasis with Suspected Choledocholithiasis Abnormal Liver Function Tests (Serum Transaminases elevation or Bilirubin gt3.0, gallstone pancreatitis)
Cholelithiasis with Choledocholithiasis CBD Stone on Sonogram, MR Cholangiography or Jaundice
Cholelithiasis with Resolving Gallstone Pancreatitis Pancreatitis on Sonogram, CT or MER Cholangiography or clinically, Documented High Serum Amylase and Lipase - WITH - Decreasing Serum Pancreatic Enzymes after initial attack
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Identifying Biliary Stone Patients

• 1) History and Physical Examination,
• 2) Liver Function Studies,
• 3) Sonographic Findings.

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BILE STONES
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BILE STONES
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The pathological sequences during a bout of
uncomplicated cholecystitis
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Sequence of pathological processes with local
inflammation around a gallbladder
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Sequence of pathological processes. Formation of
an empyema or mucocele of the gallbladder
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Sequence of pathological processes leading to
perforation of the gallbladder
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Sequence of pathological processes localising a
perforation of the gallbladder
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Symptoms and clinical signs
Pain syndrome. Characteristic for it is great
acute pain in right hypochondrium and epigastric
area with an irradiation in right supraclavicular
area and right shoulder. If pain syndrome has the
strongly expressed character, it is named hepatic
colic. Dyspepsic syndrome. Frequent symptoms
which disturb a patient, are nausea, frequent
vomitting, at first by gastric maintenance, and
later with bile. Afterwards feelings of
swelling of stomach, delay of emptying and gases.
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Symptoms and clinical signs
Murphy's symptoms is a delay of breathing during
palpation of gall-bladder on inhalation. Kehr's
symptom is strengthening of pain at pressure on
the area of gall-bladder, especially on deep
inhalation. Ortner's symptom painfulness at
the easy pushing on right costal arc by the edge
of palm. Mussy's symptom painfulness at
palpation between the legs (above a collar-bone)
of right nodding muscle. Blumberg's signs are
the increases of painfulness at the rapid taking
away of fingers by which a front abdominal wall
is pressed on. This symptom is not pathognomic
for cholecystitis but matters very much in
diagnostics of peritonitis.
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Hydropsy (mucocele) of gall-bladder is its
aseptic inflammation, that arises up as a result
of blockade of cystic duct by concrement or
mucus. The bile from a bubble is sucked in, and
on replacement transparent exudation accumulates
in its formation. During palpation increased and
unpainfully gall-bladder is marked in
patients. Empyema of gall-bladder is
unliquidated in time hydropsy, that at repeated
infection is transformed in a new form.
Gall-bladder in such patients is palpated as a
dense, moderately painful formation, however, the
symptoms of irritation of peritoneum, as a rule,
are absent. The high temperature of body is
periodically observed. In blood high leucocytosis
with the shift of formula of blood to the left is
present.
Complications
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Biliary pancreatitis. Worsening of the patients
condition, appearance of pain, frequent
vomitting, signs of cardio-vascular
insufficiency, high amylasuria, presence of
infiltrate in epigastric area and positive
Voskresensky's and Mayo-Robson's symptoms are its
basic signs.An icterus arises up at violation of
passage of bile in duodenum as a result of
obturation of choledochus by concrement, by putty
or through the edema of head of pancreas. Thus
icterus sclera, bilirubinemia, dark urine and
light unpainted excrement arise. Cholangitis.
The Sharko triad is characteristic for the
patient with this pathology. Next to pain
syndrome and icterus, the temperature of body
rises to 3839 0?, there is a fever, high
leucocytosis and decline of sizes of functional
tests of liver is observed.
Complications
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DIAGNOSTIC PROGRAM
1. Anamnesis and physical methods of
inspection. 2. Survey sciagraphy of organs of
abdominal cavity. 3. Sonography. 4. General
analysis of blood and urine. 5. Diastase
urines. 6. Biochemical blood test (bilirubin,
amylase, alanine aminotransferase, asparaginase,
alkaline phosphatase, creatinine). 7. Coagulogram.
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Tactics and choice of treatment method
1. Bed rest. 2. Hunger of 13 days, than diet ?
5 by Peuzner. 3. Desintoxication therapy
(neohemodes, reopolyglucine). 4. Spasmolytics (
platyphyllin, no-shparum, baralgin). 5.
Antibacterial therapy 6. Inhibitors of protease
(contrical, trasilol, gordox). 7. Desensitizing
preparation (dimedrole, pipolphen, tavegile). 8.
Vitamins (?, ?1, ?6, ?12 vitamins).
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Indication To Surgical Treatment

• All forms of acute calculous cholecystitis
• Destructive and complicated forms of
  noncalculous cholecystitis
• Acute catarrhal cholecystitis, conservative
  treatment of which was uneffective

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Methods of Operative Treatment

• Cholecystectomy from the neck (retrograde)
• Cholecystectomy from the bottom (antegrade)
• Laparoscopic cholecystectomy

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CHOLECYSTECTOMY
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OPERATING ROOM SET-UP
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OPERATING ROOM SET-UP
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Equipment
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STEP 1 Exposing the Cystic Duct and Artery
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STEP 2 Dissecting the Cystic Duct and Artery
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STEP 3 Routine Intra-operative Cholangiogram
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STEP 4 Transecting the Cystic Duct and Artery
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STEP 5 Dissecting the Body of the Gallbladder
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CHOLECYSTECTOMY
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Complications
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Complications
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INTRA-OPERATIVE EXAMINATION

• Sonography Cholangiography Cholangioscopy

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INTRA-OPERATIVE SONOGRAPHY
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INTRA-OPERATIVE SONOGRAPHY
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The Intra-operative Cholangiography
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The Intra-operative Cholangiogram
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The Intra-operative Cholangiogram
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The Intra-operative Cholangiogram
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The Intra-operative Cholangiogram
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The Intra-operative Choledochoscopy
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The Choledochoscopy
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Retrieving the CBD Stones
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CBD Stones