1. Acute cholecystitis and its complications
Лекция №2

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

3. 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%

4. 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.

5. 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.

6. 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.

7. 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

8. 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

9. 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

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

11. 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

12. 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%

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

14. Localisation of the pain in acute cholecystitis

15. 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

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

17. 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

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

19. Gall bladder
Concrement

20. Laparoscopic picture of acute cholecystitis
Gangrenous cholecystitis

21. 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

22. RPChG

23. Percutaneus transhepatic cholecystostomy and cholangiography

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

25. Treatment of the acute cholecystitis
Conservative
Antispasmodics
Antibiotics
Infusion
Detoxication
Symptoms

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

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

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

29. Laparoscopic cholecystectomy29

30. Laparoscopic cholecystectomy

31. Instruments for mini access cholecystectomy

32. Open cholecystectomy Cholecystectomy from the bottom
Cholecystectomy from the cervix 32

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

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

35. PCCHCSRS (ЧЧХЦСPC) by method Рig
tail

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

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

38. Treatment tactics in acute cholecystitis
Perforation, peritonitis
Acute obturated cholecystitis
Combination of choledocholitiasis with mechanical jaundice
Open operation
Conservative therapy till 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

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

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

41. 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

42. 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

43. Extrahepatic duct stricture

44. Cholecystostomy

45. Endoscopic retrograde papillosphincterotomy

46. Retrograde papilosphincterotomy
Under
After

47. Third day after EPST

48. Types of retrograde papillosphincterotomy
Limited papillosphincterotomy
Subtotal or total papillosphincterotomy
Papillotomy

49. baskets of Dormia

50. Removal with help of the Fogarty’s probe

51. Removing stones with a loop

52. Dilatation of the terminal part of choledoch with his stricture

53. Percutaneous transhepatic cholangiography and holangiostomy

54. Ways to drain the bile ducts (external and internal)

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

56. Choledochoduodenostomy
By Yurash
By Flerken
By Finsterer 56

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

58. Choledochal drainage ways
Keru
Vishnevsiy
Xolsted
Kerte 58

59. 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.