Acute cholecystitis and its complications Лекция №2

Actually of problem explanted with prevalence of gall stone disease, determinate at the republic of industrial development, where 12% man and 25 % woman have gallstone disease and they are reason for important cropped of acute cholecistites and it’s complication

Frequency complication and fatal outcomes № Authors Frequency complication and fatal outcome Year 1. Аripov U.A.  25,8% 7,0% 1993 2. Каrimov Sh.I. 27,4% 6,9% 1998 3. Talman R.Y. 26,4% 6,3% 1999 4. Borodach V.А. 17,4% 0,9% 2008 5. Sotnochehko B.А. 22,4% 1,0% 2009 6. Gostishev V.К. 33,4% 0,8% 2010 7. Sandakov P.Ia. - 0,5% 2011 8.  Kuznetstov N.А. 27,3% 0,7%

Development the researches of acute cholecystites On the began develop of surgery by bile duct depended with ending XIX c. Till this time was solitary experience of surgical manipulation on the gall bladder. in 1618 y. surgeon from England, Fabricus opened of gall bladder and remove two stones to patient who 70 years old. Bobbs on the first was establish fistula to patient with emphiem of bladder in 1867 y. Blodgett Rosenbach u Sims cholecistostomy was performed in 1878 y. In Russian studying develop of surgery of bile duct depended with scientists, as Federov S.P., Martinov A.V., Dobrotvorskiy V.I. and in the Europe Kehr Korte (German), Doyen Gosset (France), Mayo Robson (England) In Uzbekistan was performed difficult research investigation and improve surgical miniinvazive treatment of acute cholecistites and it’s complication under the chef academic Karimov Sh.I.

Anatomy of Gall bladder 1 —- ductus hepaticus sinister; 2 — ductus hepaticus dexter; 3 — ductus hepaticus communis; 4 — ductus cysticus; 5 — ductus choledochus; 6 — ductus pancreaticus; 7 — duodenum; 8 — collum vesicae felleae; 9 — corpus vesicae felleae; 10 — fundus vesicae felleae.

TOPOGRAPHY of the CONTENTS CONTAINED IN HEPATODUODENAL LIGAMENT . 1 — ductus hepaticus communis; 2 — ramus sinister a. hep. propriae; 3 — ramus dexter a. hep. propriae; 4 — a. hepatica propria; 5 — a. gastrica dextra; 6 — a. hepatica communis; 7 — ventriculus; 8 — duodenum; 9 — a. gastroduodenalis; 10 — v. portae; 11 — ductus choledochus; 12 — ductus cysticus; 13 — vesica fellea.

Classification of acute cholecystitis (Fedorov S.P. 1934) I. Acute cholecystitis with primary outcome a) recovery, and b) a primary water-cooled, and c) a secondary inflammatory dropsy. II. Chronic recurrent uncomplicated cholecystitis III. Complicated recurrent cholecystitis. a) purulent b) in ulcerative) gangrenous g) empyema IV. Sclerosis bladder V. Actinomycosis bubble VI. Tuberculosis VII. Inflammation of the bile ducts. 1) subacute, 2) acute, 3) suppurative cholangitis 7

Classification of acute cholecystitis Etiology: A) acalculous B) calculous. According to the degree of inflammation. a) Simple b) Destructive The morphological features a) catarrhal b) abscess a) gangrenous e) gangrenosum-ruptured. Complications of acute cholecystitis - Perforation of the gallbladder and peritonitis, - Suppurative cholangitis, - Mirizzi’s syndrome, - Fistulas biliodigistivnye, - Choledocholithiasis, - Jaundice, - Acute pancreatitis, - Hepatic failure. 8

Complication of acute cholecystitis Peritoneal form - Flegmonous cholecystitis - Gangrenous cholecystitis - Acute empyema of the gallbladder - Ruptured cholecystitis Obstructive form - Obstructive cholecystitis (Obstruction of the cystic duct, gallbladder hydrops bladder) Obstruction of bile duct (choledocholithiasis, stenosis of a large duodenal papilla, pancreatitis) 9

Ethio pathogenesis of acute cholecystitis Hypertension (stones, a block from outside) Infection Cystic artery thrombosis Injury Secondary inflammation 10

Pathogenesis of acute cholecystitis Оbturation of neck and duct of gallbladder Pressure of the bile in gall bladder ( 700 mm.Hg.) Developing of the infectious process in gall bladder Local or diffuse peritonitis developing of the stasis in blood vessels Destruction of the wall of the gall bladder

Role of infectius causes in acute cholecystitis Esherichia coli Streptococcus faecalis Klebsiella Bacteroides Clostridia First stroke – till 48 hours sterile, after 72 hours - infection Correlation positive and negative results of microbiological researches: First stroke – 1:2 Recurrent– 4:1 Purulent complications 9-20% sepsis – 3-10%

Morfological changes in gall bladder - Catharal cholecystitis - Flegmonous cholecystitis - Gangrenous cholecystitis - Acute empyema Perforative cholecystitis (perivesical infiltration, Perivesical abscess, Local peritonitis, diffuse peritonitis)

Localisation of the pain in acute cholecystitis

Clinic of acute cholecystitis Subjective symptoms Pain in right hypochondrium Irradiation of pain Nausea and belching Bitterness and dryness in the mouth Heartburn Vomiting Relationship of pain with food intake Abdominal distention Objective evidence Enlarged gallbladder Tension of the abdominal wall Symptoms: Murphy, Musso, Grekov-Ortner, Reflex angina Temperature rise Leukocytosis Elevated ESR 15

Instrumental diagnostics Noninvasive Ultrasonography X-ray Computed tomography Magnetic resonance imaging Invasive Cholangiography Laparoscopy

stones in the bladder neck Thick walls and a pair of vesicular exudate Ultrasonography stones in the bladder neck Thick walls and a pair of vesicular exudate

Complications of the acute cholecystitis A pair of vesicular infiltration A pair of vesicular abscess

Gall bladder Concrement

Laparoscopic picture of acute cholecystitis Gangrenous cholecystitis

Indications for ERPChG Icteritiousness or signs of cholangitis in anamnesis Increasing bilirubin and transaminases Pancreatitis in anamnesis Expansion ductus choledochus more than 8 mm Small stones in gall bladder and dilation diameter of bile ducts

RPChG

Percutaneus transhepatic cholecystostomy and cholangiography

Conservative treatment Perforation, peritonitis Active-waiting tactic Conservative treatment Perforation, peritonitis Acute cholecystitis Negative dynamics Emergency operation Positive dynamic Delayed operation Elective operation

Treatment of the acute cholecystitis Conservative Antispasmodics Antibiotics Infusion Detoxication Symptoms

Signs of inefficient conservative therapy Increasing or serving pain syndrome; Leucocytosis, increasing ESR; Increasing or serving body high temperature; Sonography inefficiency of conservativ therapy

Sonography signs inefficiency conservative tharepy Increasing of perivesical fluid Non homogen content Doubling wall of GB enlargement of sizes of GB

Treatment of the acute cholecystitis Operational Laparoscopic cholecystectomy Open cholecystectomy Cholecystostomy Papillae sphincterotomy Endo biliary intervention 28

Laparoscopic cholecystectomy 29

Laparoscopic cholecystectomy

Instruments for mini access cholecystectomy

Open cholecystectomy Cholecystectomy from the bottom Cholecystectomy from the cervix 32

Types of cholecystostomy Laparoscopic PTChS under X-ray PTChS under sonography with mini laparotomy

Treatment methods in patients with high operational risk 1 stage PTChS, drainig and sanation of GB 2 stage Cholecystectomy Мucoclasia Cholecystostomy

PCCHCSRS (ЧЧХЦСPC) by method Рig tail

With antiseptic, physiotherapeutical method Sanation of GB With antiseptic, physiotherapeutical method

Coagulational obstruction and mucoclasia of the GB Before coagulational obstruction After coagulational obstruction After mucoclasia

Treatment tactics in acute cholecystitis Perforation, peritonitis Acute obturated cholecystitis Combination of choledocholitiasis with mechanical jaundice Open operation Conservative therapy till 12-24 hours PTCH Relief of status In none-cupied LCE Relief of high risk groups assault In case of ineffectiveness Continue of conservative therapy LCE PTCH LCE LCE after 4-6 weeks Group of high risk In impossiblity LCE after 6-8 weeks In impossibility sanation of choledochus In cases of impossibility In necessary cases LCE after 6 weeks PTCH Open surgeric manipulations Открытые оперативные вмешательства Decompensation states Mucoplasia

Complications of the acute cholecystitis Perforation and biliary peritonitis, Suppurative cholangitis Mirizzi’s syndrome, Biliodigestiv fistula, Choledocholithiasis, Jaundice, Acute pancreatitis Hepatic failure.

Application of the drainages in biliar peritonitis Drainig of the abdominal cavity Intestinal decompression

Choledocholithiasis. Obstructive jaundice Choledocholithyasis – is the localization of the concrements in extra- and intrahepatic bile ducts, appears more frequently as a result of migration of the concrements from the gall bladder at the calculous cholecystitis

Mirizzi’s syndrome 1 type– the concrement, wedging to the neck of gall bladder, Hartman’s pocket or bladder’s duct, compresses the common bile duct from the outside 2 type- development of the bedsore with the formation of the cholecystocholedochial fistula

Extrahepatic duct stricture

Cholecystostomy

Endoscopic retrograde papillosphincterotomy

Retrograde papilosphincterotomy Under After

Third day after EPST

Types of retrograde papillosphincterotomy Limited papillosphincterotomy Subtotal or total papillosphincterotomy Papillotomy

baskets of Dormia

Removal with help of the Fogarty’s probe

Removing stones with a loop

Dilatation of the terminal part of choledoch with his stricture

Percutaneous transhepatic cholangiography and holangiostomy

Ways to drain the bile ducts (external and internal)

The way of dosed decompression to 5-6 hours decompression on 35-40 mm hyd. pole.

Choledochoduodenostomy By Yurash By Flerken By Finsterer 56

Surgeries for choledochal stricture Method Geynico-Miculich Resection with anastomosis "end - the end" 57

Choledochal drainage ways Keru Vishnevsiy Xolsted Kerte 58

Responsibility of PhGP: PhGP must have concepts about clinical characters of acute cholecistites and it’s complication To explain complication of gallstone disease whom have GSD Feature shepherd clinical instrumental investigation To sent of patient to the surgical stationary. Shepherd rehabilitation after surgical treatment.