Cholecystitis

Front 1

Focused history of Cholecystits

Back 1

Fever - more likely acute
Previous episodes- more likely stones
Post prandial pain- colic
Jaundice- indicating passing of stone to common bile duct

Front 2

Physical exam cholecystitis

Back 2

Murphys sign
Rectal Exam
Pedal/Edema Exam (CHF and engorgement of liver)

Front 3

Courvoisiers sign

Back 3

a non-tender, distended gallbladder (Courvoisier's sign) is a sign of obstruction of the common bile duct (CBD) by something other than gallstones, most commonly pancreatic cancer.

Front 4

Acute cholecystitis - Lab abnormalities

Back 4

classically associated with leukocytosis, elevated neutrophil count, and a left shift. Although many texts describe leukocytosis as a requisite diagnostic finding in patients with acute cholecystitis, this is not the case. While an elevated WBC count is typical, up to 32% of patients presenting with acute cholecystitis have a normal WBC count.(1)

Front 5

gallstone pancreatitis- WBC count

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WBC count may or may not be elevated and is thus not diagnostically specific, but a WBC count greater than 16,000 at presentation is one of Ranson's criteria and is established as a poor prognostic sign.

Front 6

Choledocholithiasis- bilirubin level

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initially causes a direct hyperbilirubinemia in 70-90% of patients

Front 7

long standing choledocholithiasis - bilirubin level

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In long standing obstruction, a mixed hyperbilirubinemia may result from two mechanisms: direct bilirubin in the circulation may break down into indirect bilirubin, and hepatocellular damage secondary to cholestasis may inhibit the liver's ability to conjugate bilirubin.

Front 8

The classic presentation of cholangitis consists of

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Charcot's triad of fever, jaundice and right upper quadrant pain. Overall approximately 60% of cholangitis patients exhibit jaundice while 88-100% have hyperbilirubinemia.

Front 9

Difference between alk phis in gallbladder vs stones

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those processes confined to the gallbladder do not cause biliary obstruction and are thus associated with infrequent and mild Alk. Phos. elevations while those processes caused by stones in the common bile duct are usually associated with Alk. Phos. elevations, which can be severe.

Front 10

Most patients with choledocholithiasis have a significant degree of

Back 10

Alk. Phos. elevation. The amount of elevation depends on the degree of obstruction present, but Alk. Phos. is often the first of the liver function tests to become abnormal. Elevations of greater than 2.5x normal have been shown to be predictive of choledocholithiasis in patients with known cholelithiasis.(1)

Front 11

Reynold's pentad

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charcot's triad, but adds hypotension and mental status changes. This addition refers to symptoms of sepsis from cholangitis (3). Although Reynold's pentad is seen in only 14% of patients with common duct stones (4), the inclusion of hypotension and mental status changes is an important reminder that cholangitis is a systemic disease that can frequently result in sepsis.

Front 12

Charcot's triad

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consisting of fever, right upper quadrant pain and jaundice and described patients suffering from cholangitis. In clinical practice, only 25% of patients with common duct stones exhibit all three symptoms (2).

Front 13

The cardinal ultrasonographic signs of acute cholecystitis

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gallstones in the gallbladder and often visualized impacted in the neck or cystic duct, gallbladder wall thickening (>3mm), and pericholecystic fluid.

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HIDA scan is also extremely sensitive (>90%) and specific (>90%) for

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acute cholecystitis
Filling of the gallbladder in less than 30 minutes is considered a normal result, while no filling after greater than 4 hours is strong evidence of acute cholecystitis.

Front 15

Ultrasound is more sensitive and specific than CT for diagnosing

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acute cholecystitis as CT scans can often miss gall stones

Front 16

HIDA scans can show that the cystic duct

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is obstructed, but this can occur in both acute and chronic cholecystits

Front 17

In which situation would an intraoperative cholangiogram be indicated?

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Scleral Icterus, T. Bili = 3.8, Gallstone Pancreatitis, (indicated when there is an obstruction in the common bile duct)

Front 18

The most commonly injured structure in a laparoscopic cholecystectomy is the

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Common bile duct injuries, though rare, are one of the most dreaded complications of laparoscopic cholecystectomies, as they require major reconstructive surgery. They occur most commonly in situations with significant inflammation of the gall bladder, such as with acute cholecystitis

Front 19

The cystic artery is a branch of which artery?

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Right Hepatic Artery

Front 20

The most common gross pathologic operative finding in acute cholecystitis that has been present for 4-5 days is

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Edema of the gall bladder wall will be the most common finding associated with acute cholecystitis. Perforation can be associated with acute cholecystitis, but not as frequently as wall edema; it is more common in the diabetic with acute cholecystitis.

Front 21

Hydrops of the gallbladder

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Hydrops is a non-inflammatory dilatation of the gall bladder and can be associated with chronic obstruction of the gall bladder outlet.

Front 22

four laparoscopic ports are used to perform a cholecystectomy

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the primary operating instrument is placed in the epigastric port
The mid-clavicular port is used to host the instrument that retracts the hilum of the gallbladder laterally
The anterior axillary port hosts the instrument that retracts the gallbladder over the liver,
At the end of the operation, the camera is switched to the epigastric port and the gallbladder is removed through the umbilical port

Front 23

In closing the holes used for the ports...

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only the skin is sutured closed in the epigastric, mid-clavicular and anterior axillary incisions. In the largest incision, the one used for the umbilical port, the fascia is also closed to prevent the formation of an incisional hernia.

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In 2-15% of cases, however, laparoscopic cholecystectomy is not technically feasible and must be converted to an open procedure- why would convert?

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Conversion to open cholecystectomy is usually necessitated by extensive abdominal adhesions or excessive inflammation of the gallbladder, both of which make dissection difficult

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Pre-operative risk factors for conversion to open cholecystectomy

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include male gender, age greater than sixty, a history of upper abdominal surgery, a thickened gallbladder wall, and the presence of acute cholecystitis

Front 26

what histopathological changes imply chronic cholecystitis

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inflammation, mucosal changes (thick), edema

Front 27

The most common source of bleeding after laparoscopic cholecystectomy

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is an arterial branch perforating the rectus muscle at a trocar site. This is more likely to present with hematoma and local pain than with systemic signs or symptoms of hypovolemia

Front 28

The most common site of wound infection in laparoscopic cholecystectomy

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umbilical trocar site

Front 29

Retained Stone Origin Stone Type Treatment?

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Primary Biliary Tree Pigmented ERCP w/ possible
Hepatojejunostomy
Secondary Gallbladder Cholesterol,Pigmented ERCP w/ sphincterotomy