Anatomy of gall bladder

Cholecystitis
• Related to inflammation within the gall
bladder

• Acute:
- Acute bacterial inflammation of the gall
bladder with or with out stones.
- Types :-
1. Calculous (obstructive, commonest)
- complication of cholelithiasis
2. Acalculous (non-obstructive)
 Acute cholecystitis
• Common organisms responsible:
1. E. Coli
2. Streptococci
3. Salmonella
4. Klebsiella
5. Others: Clostridium

~~bile stasis precipitates infection

• Pathogenesis (Calculous)

STONE / BILIAY SLUDGE

Obstruction of bile flow mucosal erosion

Stasis destruction of cells

by toxic bile salts

Bacterial proliferation release inflammatory

mediators (Pg I2 n E2)

Necrosis and perforation

• Acalculous cholecystitis
– Usually associated with major illness like
polytrauma, burns, major surgery
– Distension of gall bladder
– Features are like thrombosis, necrosis
and edema
 Symptoms
• Often have history of biliary colic
• 4 F : fat, forty, fertile, female
• severe constant epigastric or RUQ pain
• anorexia, nausea and vomiting are
common
• Low grade fever (except in clostridial
infection)
• If the stone moves to CBD, obstructive
jaundice and cholangitis may occur.
 Signs
• systemic signs – low grade fever (<38.5 ºC),
tachycardia
• Murphy’s sign +ve (sudden cessation of
inspiration with deep RUQ palpation)
• Boas’ sign (area of hyperasthesia bw 9th and
11th ribs posteriorly on the right side
• Guarding and rigidity @ upper abdomen
• Vague mass (consisting inflammed GB,
omentum, inflammatory exudates)
 Differential Diagnosis
1. perforated peptic ulcer
2. acute pancreatitis
3. hiatus hernia
4. right lower lobe pneumonia
5. myocardial infarction
6. appendicitis
 Investigations
• Full blood count
– WBC high

• Liver Function test

– mildly elevated bilirubin, ALP
– sometimes slight elevation AST, ALT

• X-Ray Abd
– view any gall stones (radio opaque)
– TRO perforated ulcer (air under diaphragm)
• U/S abdomen (Diagnostic test)
• Thicken gallbladder wall (>3mm)
• Pericholecystic fluid
• Distended gallbladder
• Present of gallstone / cystic duct stone
• Sonographic Murphy’s sign (pain on inspiration after
placement of USG probe over gallbladder)
 Principle of Treatment
Conservative followed by cholecystectomy
->90% subside

-4 principles:
a)NBM and intravenous fluids (hydrate the patient)
b)Analgesics
c)Antibiotics - Use broad spectrum as Ceferoxime
d)Antiemetics , if severe vomiting, NG suctioning
may be required
• Inflammation subsiding, NG tube removed,
fluids followed by a fat free diet

• lack of improvement with conservative

treatment ––> operate within 24-48 hours
(cholecystectomy)

• Subsequent management- monitoring of

vital signs and USG done to look for local
complications.
 Complication
1. Empyema
2. Perforation
3. Mucocele
4. Gallstone ileus
5. Gangrenous cholecystitis
6. Cholecystoenteric fistulas
Thank You