The document discusses cholelithiasis (gallstones) and acute cholecystitis (inflammation of the gallbladder). It covers the prevalence and types of gallstones, risk factors, potential complications, clinical presentation, diagnosis and treatment options. For acute cholecystitis, conservative treatment with antibiotics and fluids is usually attempted first to resolve the inflammation before delayed cholecystectomy once symptoms subside.
Acute cholangitis is an infection of the bile ducts caused by obstruction and bacterial overgrowth. It presents with fever, jaundice, and right upper quadrant pain (Charcot's triad). Obstruction leads to increased pressure and bacterial growth in the bile ducts. Diagnosis involves blood tests, imaging like ultrasound or CT, and testing bile if drained. Treatment is antibiotics, hydration, and relieving obstruction endoscopically or surgically. Antibiotics are continued until obstruction is fully resolved to prevent recurrence.
This document provides information about jaundice and obstruction of the biliary tract. It begins with an overview of the causes of yellow discoloration of the skin and mucous membranes, which is caused by bilirubin accumulation. It then describes the breakdown of red blood cells and how bilirubin is processed and excreted. The document outlines various causes of obstructive jaundice including gallstones, strictures, tumors, and external compression. Investigation methods and treatment approaches for different biliary obstructions are also summarized.
This document discusses acute cholecystitis, which is inflammation of the gallbladder. It defines the condition and discusses its most common causes and risk factors. The main symptoms are abdominal pain in the right upper quadrant, nausea, vomiting, and fever. Diagnosis involves physical exam findings like Murphy's sign as well as imaging tests and bloodwork. Treatment involves intravenous fluids, antibiotics, and early cholecystectomy if symptoms worsen or complications arise. Both open and laparoscopic cholecystectomy are discussed as surgical treatment options.
The document provides tips for using a PowerPoint presentation on acute cholecystitis. It recommends:
1) Freely editing, modifying, and adding your name to slides.
2) Not worrying about number of slides, as half are blank except for titles.
3) Showing blank slides first to elicit student responses before presenting information.
4) Repeating this process of blank slide then information slide at the end for active learning.
5) Using this approach for self-study as well.
6) Checking notes for bibliography citations.
Acute calculous cholecystitis is caused by obstruction of the cystic duct by a gallstone. Symptoms include biliary colic, fever, and right upper quadrant pain. Ultrasound and hepatobiliary scintigraphy can diagnose thickened gallbladder walls and obstruction. Treatment involves early laparoscopic cholecystectomy for mild cases, or initial conservative treatment with antibiotics and potential percutaneous cholecystostomy for severe cases presenting with sepsis, with delayed cholecystectomy once the patient improves. Guidelines recommend early surgery for mild disease and initial medical management for severe acute cholecystitis.
This document discusses acute and chronic cholecystitis. Acute cholecystitis typically occurs due to gallstone impaction and results in inflammation of the gallbladder. Common symptoms include fever, right upper quadrant pain, and nausea. Diagnosis involves physical exam findings like Murphy's sign along with supportive lab and ultrasound results showing gallstones, thickened gallbladder walls, and pericholecystic fluid. Treatment involves antibiotics, pain medication, and cholecystectomy usually within 3 days. Chronic cholecystitis is due to long-standing gallstones or cholecystoses and results in a thickened, non-functioning gallbladder. Cholecystectomy is the treatment for chronic cholecystitis.
The document discusses acute cholangitis, including its pathogenesis, clinical manifestations, diagnostic criteria, severity assessment, imaging, and management. Regarding diagnostic criteria, it summarizes that Charcot's triad has low sensitivity for diagnosing acute cholangitis compared to the Tokyo Guidelines 2007 and 2013 criteria. It also notes that the Tokyo Guidelines 2007 criteria for severity assessment were insufficient and have been revised in subsequent guidelines to better distinguish mild from moderate cases in the initial diagnosis.
This document discusses disorders of the esophagus, including obstructive and vascular diseases. It describes the normal anatomy of the esophagus and its histology. Specific disorders covered include atresia, stenosis, achalasia, hiatal hernia, esophageal varices, and various types of esophagitis. Achalasia is characterized by incomplete relaxation of the lower esophageal sphincter. Esophageal varices occur due to portal hypertension, most commonly from cirrhosis of the liver. Various types of esophagitis discussed include those caused by reflux, chemicals, infections, and eosinophilic esophagitis.
This document discusses intestinal obstruction, including its definition, causes, clinical features, investigations and management. Intestinal obstruction occurs when bowel contents cannot pass through normally due to a mechanical or functional blockage. Clinical features depend on the location and cause of obstruction and may include pain, vomiting, distension and constipation.
Describes the concept of a surgical abdomen, acute abdominal pain, emergency intervention and approach to management, including the controversial use of analgesic and antibiotics in emergency room.
Cholecystitis is inflammation of the gallbladder that is usually caused by gallstones blocking the cystic duct. It presents with pain in the right upper abdomen that is initially intermittent but becomes constant and severe. Symptoms also include fever, nausea, vomiting, and diarrhea. Diagnosis is usually made based on symptoms and confirmed with ultrasound or CT scan showing gallbladder wall thickening and inflammation. Treatment involves antibiotics, pain medication, and fluid resuscitation to control symptoms prior to definitive treatment with laparoscopic surgery to remove the inflamed gallbladder.
This document provides an overview of acute appendicitis, including its embryology, anatomy, pathophysiology, clinical presentation, diagnosis, and management. It notes that appendicitis is most commonly caused by luminal obstruction and is the most frequent abdominal surgery. Clinical diagnosis involves abdominal pain shifting to the right lower quadrant along with nausea, anorexia, and tenderness. Imaging studies like ultrasound, CT, and MRI can help diagnose appendicitis and reduce negative appendectomy rates. Treatment involves antibiotic therapy for uncomplicated cases or appendectomy, which is most often performed laparoscopically.
Volvulus is a twisting of the intestine resulting in blood vessel compression and ischemia. There are three main types: midgut, cecal, and sigmoid volvulus. Risk factors include chronic constipation, abnormal intestinal contents, and congenital malrotation. Signs include abdominal distension, pain, vomiting, and rapid heart rate. Diagnostic tests include abdominal x-rays, blood work, barium enema, and CT scan. Treatment depends on the type but may include surgery, sigmoidoscopy, or monitoring for signs of ischemia. Complications can be dehydration, ischemic bowel disease, perforation, peritonitis, and sepsis.
Diverticular disease is a common condition where pouches called diverticula bulge out from the colon wall, usually where blood vessels penetrate the colon. Diverticulosis is the presence of diverticula without inflammation, while diverticulitis occurs when diverticula become inflamed or infected, usually due to hard stool getting stuck in a diverticulum. Diverticulitis ranges from uncomplicated cases treated with antibiotics to complicated cases involving abscesses, fistulas, or perforation requiring surgery. Risk factors include low-fiber diet, aging, and high blood pressure.
1. Acute pancreatitis is inflammation of the pancreas that can range from mild to severe. It is most often caused by gallstones or excessive alcohol use.
2. Diagnosis is supported by laboratory tests showing elevated pancreatic enzymes in blood and urine, along with abdominal imaging showing swelling or inflammation of the pancreas.
3. The clinical course and severity can be predicted using scoring systems like Ranson's criteria that evaluate markers of organ failure over the first 48 hours. Early identification of severe cases allows for more aggressive management to reduce mortality risk.
This document discusses gallstones and gallbladder disease. It begins with the anatomy of the biliary tree and gallbladder. Gallstone formation occurs when bile becomes supersaturated, causing crystals and stones to form. Stones are typically cholesterol-based or pigment-based. Complications include chronic cholecystitis, acute cholecystitis, and choledocholithiasis. Treatment involves imaging studies, antibiotics, and often laparoscopic cholecystectomy to definitively treat the condition.
Acute cholecystitis is inflammation of the gallbladder most commonly caused by a gallstone blocking the cystic duct (90-95% of cases). It presents with right upper quadrant pain, fever, nausea, and a positive Murphy's sign on examination. Diagnosis is made using ultrasound and blood tests showing leukocytosis. Treatment involves antibiotics, pain control, and early laparoscopic cholecystectomy within 1 week to prevent complications like gangrenous cholecystitis or gallbladder perforation. Conservative management with cholecystectomy delayed 4-6 weeks is also an option for mild cases.
The document describes the anatomy and pathophysiology of gallstones (cholelithiasis). It details the anatomy of the gallbladder and biliary ductal system. It explains the formation of cholesterol stones and pigment stones, and lists risk factors for gallstone development. Potential complications are outlined, including biliary colic, cholecystitis, pancreatitis, and jaundice. Diagnosis involves ultrasound and liver function tests. Treatment typically involves cholecystectomy for symptomatic patients.
This document discusses cholelithiasis (gallstones) and cholecystitis (inflammation of the gallbladder). It covers the anatomy of the gallbladder and biliary tree. Common causes of gallstones include altered gallbladder function and supersaturated bile. Gallstones can be asymptomatic, cause biliary colic, or lead to complications like cholecystitis, pancreatitis and obstruction. Acute calculous cholecystitis is usually caused by a gallstone obstructing the cystic duct. Clinical features include right upper quadrant pain and tenderness. Investigations include ultrasound and blood tests. Treatment is usually laparoscopic cholecystectomy.
Gallstones are concretions that form in the biliary tract, usually in the gallbladder. Cholelithiasis refers to gallstones in the gallbladder, while choledocholithiasis refers to gallstones in the common bile duct. Treatment depends on whether gallstones are asymptomatic or symptomatic. Asymptomatic gallstones may be managed expectantly, while symptomatic gallstones usually require surgical removal of the gallbladder (cholecystectomy) or other interventions if complications occur.
The document discusses the anatomy, histology, physiology, carcinogenesis, clinical presentation, diagnosis, staging, and treatment of gastric cancer. It notes that gastric cancer typically presents with nonspecific symptoms like abdominal pain or weight loss. Diagnosis involves endoscopy with biopsy. Staging involves endoscopic ultrasound or CT scan to evaluate tumor invasion and lymph node involvement. Treatment depends on stage but may include surgery, chemotherapy, and radiation. Screening high-risk individuals can detect early gastric cancer and improve outcomes.
This document outlines the presentation, causes, diagnosis, treatment, and nursing care of volvulus, which is the twisting of a loop of intestine that cuts off blood flow. It most commonly affects the sigmoid colon. Key points include that volvulus can be acute, sub-acute, or chronic; surgical intervention is usually needed to untwist the intestine; and nursing care involves pain management, fluid replacement, monitoring for complications, and educating patients and families.
An esophageal stricture is a narrowing of the esophagus caused by damage to the esophageal lining from acid reflux, corrosive chemicals, radiation therapy, or other irritants. Over time, inflammation and scar tissue formation can cause the esophagus to gradually narrow. Patients experience progressive difficulty swallowing foods and liquids. Diagnosis involves barium swallow tests, pH monitoring, and endoscopy to evaluate the esophagus. Treatment consists of dilation procedures to widen the esophagus, acid-suppressing medications, stents, or sometimes surgical replacement of the esophagus.
this presentation includes anatomy physiology function of peritoneum ,also includes cause of peritonitis its severity ,various scoring system investigation and treatment.It includes the recent advancement and latest articles from latest books of surgery.
Diverticulosis and diverticular diseaseDoha Rasheedy
74 slides•33.1K views
This document discusses diverticular disease, specifically diverticulosis and acute diverticulitis. It covers the epidemiology, pathophysiology, clinical presentation, investigations including CT and barium enema, differential diagnosis, and Hinchey classification of diverticulitis severity. Diverticulosis is asymptomatic protrusions in the colon wall that become symptomatic as diverticulitis in 20% of cases from obstruction, inflammation, or perforation. Risk factors include low fiber diet and increased age. CT is the best imaging method to diagnose and stage diverticulitis.
This document provides an overview of acute gastrointestinal bleeding. It defines upper gastrointestinal bleeding and discusses its causes, including variceal and non-variceal sources. Signs and symptoms are outlined. The approach involves taking a thorough history and physical exam. Key lab tests include CBC, LFTs, coagulation panels and endoscopy. Treatment depends on the bleeding source, and may include endoscopic methods, radiological embolization, surgery, or medications like PPIs and vasoactive drugs. Complications are also reviewed.
This document discusses urinary retention, including its types, causes, clinical features, investigations, management, and prognosis. Urinary retention is defined as the inability to void despite bladder distention. It can be acute, chronic, or acute-on-chronic. Common causes in males include benign prostatic hyperplasia and urethral stricture. Clinical features depend on whether retention is acute or chronic. Initial management involves relieving the obstruction through catheterization. Long-term management depends on identifying and treating the underlying cause. Complications can include bladder and kidney damage if not properly treated.
This document provides an overview of gallbladder and biliary diseases. It discusses gallbladder anatomy and physiology, cholelithiasis (gallstone formation), complications of gallstones like cholecystitis, choledocholithiasis, and gallbladder cancer. It also covers obstructive jaundice, describing bilirubin metabolism and different causes of obstruction like gallstones, strictures, and pancreatic masses. The clinical features of obstructive jaundice are jaundice, dark urine, pale stool and abdominal pain. Investigations include liver function tests and imaging like ultrasound or CT to identify the cause of obstruction.
Gallstone disease is common, affecting 11-36% of people based on autopsy reports. Gallstones can be asymptomatic or cause biliary colic, acute cholecystitis, or other complications. The document discusses the epidemiology, types, natural history, complications, clinical features, diagnosis, and treatment of gallstone disease and acute cholecystitis. Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones and acute cholecystitis to prevent future attacks or complications.
This document discusses intestinal obstruction, including its definition, causes, clinical features, investigations and management. Intestinal obstruction occurs when bowel contents cannot pass through normally due to a mechanical or functional blockage. Clinical features depend on the location and cause of obstruction and may include pain, vomiting, distension and constipation.
Describes the concept of a surgical abdomen, acute abdominal pain, emergency intervention and approach to management, including the controversial use of analgesic and antibiotics in emergency room.
Cholecystitis is inflammation of the gallbladder that is usually caused by gallstones blocking the cystic duct. It presents with pain in the right upper abdomen that is initially intermittent but becomes constant and severe. Symptoms also include fever, nausea, vomiting, and diarrhea. Diagnosis is usually made based on symptoms and confirmed with ultrasound or CT scan showing gallbladder wall thickening and inflammation. Treatment involves antibiotics, pain medication, and fluid resuscitation to control symptoms prior to definitive treatment with laparoscopic surgery to remove the inflamed gallbladder.
This document provides an overview of acute appendicitis, including its embryology, anatomy, pathophysiology, clinical presentation, diagnosis, and management. It notes that appendicitis is most commonly caused by luminal obstruction and is the most frequent abdominal surgery. Clinical diagnosis involves abdominal pain shifting to the right lower quadrant along with nausea, anorexia, and tenderness. Imaging studies like ultrasound, CT, and MRI can help diagnose appendicitis and reduce negative appendectomy rates. Treatment involves antibiotic therapy for uncomplicated cases or appendectomy, which is most often performed laparoscopically.
Volvulus is a twisting of the intestine resulting in blood vessel compression and ischemia. There are three main types: midgut, cecal, and sigmoid volvulus. Risk factors include chronic constipation, abnormal intestinal contents, and congenital malrotation. Signs include abdominal distension, pain, vomiting, and rapid heart rate. Diagnostic tests include abdominal x-rays, blood work, barium enema, and CT scan. Treatment depends on the type but may include surgery, sigmoidoscopy, or monitoring for signs of ischemia. Complications can be dehydration, ischemic bowel disease, perforation, peritonitis, and sepsis.
Diverticular disease is a common condition where pouches called diverticula bulge out from the colon wall, usually where blood vessels penetrate the colon. Diverticulosis is the presence of diverticula without inflammation, while diverticulitis occurs when diverticula become inflamed or infected, usually due to hard stool getting stuck in a diverticulum. Diverticulitis ranges from uncomplicated cases treated with antibiotics to complicated cases involving abscesses, fistulas, or perforation requiring surgery. Risk factors include low-fiber diet, aging, and high blood pressure.
1. Acute pancreatitis is inflammation of the pancreas that can range from mild to severe. It is most often caused by gallstones or excessive alcohol use.
2. Diagnosis is supported by laboratory tests showing elevated pancreatic enzymes in blood and urine, along with abdominal imaging showing swelling or inflammation of the pancreas.
3. The clinical course and severity can be predicted using scoring systems like Ranson's criteria that evaluate markers of organ failure over the first 48 hours. Early identification of severe cases allows for more aggressive management to reduce mortality risk.
This document discusses gallstones and gallbladder disease. It begins with the anatomy of the biliary tree and gallbladder. Gallstone formation occurs when bile becomes supersaturated, causing crystals and stones to form. Stones are typically cholesterol-based or pigment-based. Complications include chronic cholecystitis, acute cholecystitis, and choledocholithiasis. Treatment involves imaging studies, antibiotics, and often laparoscopic cholecystectomy to definitively treat the condition.
This document provides an overview of gallbladder and biliary diseases. It discusses gallbladder anatomy and physiology, cholelithiasis (gallstone formation), complications of gallstones like cholecystitis, choledocholithiasis, and gallbladder cancer. It also covers obstructive jaundice, describing bilirubin metabolism and different causes of obstruction like gallstones, strictures, and pancreatic masses. The clinical features of obstructive jaundice are jaundice, dark urine, pale stool and abdominal pain. Investigations include liver function tests and imaging like ultrasound or CT to identify the cause of obstruction.
Gallstone disease is common, affecting 11-36% of people based on autopsy reports. Gallstones can be asymptomatic or cause biliary colic, acute cholecystitis, or other complications. The document discusses the epidemiology, types, natural history, complications, clinical features, diagnosis, and treatment of gallstone disease and acute cholecystitis. Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones and acute cholecystitis to prevent future attacks or complications.
Disorders of the gallbladder and biliary tract include gallstones, cholecystitis, cholangitis, and cancer. Gallstones are usually cholesterol stones in Western countries and pigment stones in Asia. Risk factors for cholesterol stones include age, female sex, obesity, and genetics. Cholecystitis occurs due to gallstone obstruction and inflammation. Obstructive lesions can cause cholangitis and secondary biliary cirrhosis. Biliary atresia is a neonatal condition requiring transplantation. Gallbladder and cholangiocarcinomas are associated with gallstones and inflammation.
Disorders of the gallbladder and biliary tract are common and include cholelithiasis (gallstones), cholecystitis (inflammation of the gallbladder), and cholangitis (inflammation of the bile ducts). Cholelithiasis affects 10-20% of adults in developed countries and is usually asymptomatic, though it can cause pain. Gallstones may lead to complications like cholecystitis, cholangitis, pancreatitis, or gallstone ileus. Chronic inflammation from gallstones or repeated bouts of cholecystitis can result in chronic cholecystitis. Left untreated, cholecystitis can progress to complications involving perforation or fistula formation. Obstruction of
This document discusses urolithiasis (kidney stones) and pyelonephritis (kidney infection). It provides details on the epidemiology, causes, clinical presentation, diagnosis and treatment of both conditions. Kidney stones are most commonly calcium-based and affect 10% of the population. Presentation includes flank pain, nausea and hematuria. Diagnosis is via CT scan and treatment involves shockwave lithotripsy, ureteroscopy or percutaneous nephrolithotomy. Pyelonephritis is a bacterial kidney infection usually from ascending infection. It causes fever, flank pain and urinary symptoms. Treatment is hospitalization and IV antibiotics for severe cases or oral antibiotics otherwise.
Mental health nursing …..National mental health program.pptxVijayalakshmi UHM
11 slides•262 views
The slide presents the details of national mental health program which includes aims ,objectives strategise ,approaches and components. Objective of this ppt is to improve the knowledge among the nursing students for their mental health nursing subject and it’s useful ppt with detailed information regarding national mental health program…
Document que va acompanyar la presentació de l'infermer Sergio García a la cinquena trobada de la comunitat de pràctica del projecte europeu HEROES, celebrada, de forma telemàtica, el 5 de febrer de 2025.
Pharmacology of Ethyl and Methyl Alcohol: Mechanisms, Kinetics, and ToxicologyShivankan Kakkar
21 slides•49 views
This presentation provides an in-depth overview of the pharmacology of ethyl and methyl alcohol, focusing on their mechanisms of action, pharmacokinetics, metabolism, and toxicological effects. It covers key aspects relevant to MBBS students, including ethanol metabolism, alcohol dehydrogenase pathways, methanol toxicity, and antidotes such as fomepizole and ethanol. The slides are structured as per the CBME curriculum to enhance understanding of alcohol poisoning, its management, and clinical implications. Ideal for medical students preparing for exams and case-based discussions in pharmacology.
Chair, Joyce O'Shaughnessy, MD, discusses HR+, HER2- metastatic breast cancer in this CME/MOC/NCPD/CPE/AAPA/IPCE activity titled “Targeting PIK3CA/AKT1/PTEN and Other Alterations in HR+, HER2- MBC: Navigating the Evidence and Guidance for Use.” For the full presentation, downloadable Practice Aid, and complete CME/MOC/NCPD/CPE/AAPA/IPCE information, and to apply for credit, please visit us at https://bit.ly/4eQwW8y. CME/MOC/NCPD/CPE/AAPA/IPCE credit will be available until February 5, 2026.
Nervous System (part 4) and disease conditionsAvantika Gupta
111 slides•42 views
The peripheral nervous system (PNS) is a network of nerves that sends and receives information between the brain and spinal cord and the rest of the body: It consists of nerves and ganglia transmitting signals between the CNS, organs, limbs, and skin.
SOMATIC NERVOUS SYSTEM:- The somatic nervous system (SNS) is a part of the peripheral nervous system that controls muscles and relays sensory information to the brain and spinal cord.
AUTONOMIC NERVOUS SYSTEM:- It is a control system that acts largely unconsciously and regulates bodily functions, such as the heart rate, its force of contraction, digestion, respiratory rate, pupillary response, urination, and sexual arousal.
SYMPATHETIC NERVOUS SYSTEM :- It is a network of nerves that activates the body's "fight-or-flight" response when a person is stressed, in danger or physically active.
PARA-SYMPATHETIC NERVOUS SYSTEM :- The parasympathetic nervous system (PSNS) is a network of nerves that relaxes the body after periods of stress or danger. It also helps run life-sustaining processes, like digestion, when you feel safe and relaxed.
Trigeminal neuralgia is a condition that causes intense pain similar to an electric shock on one side of the face. It affects the trigeminal nerve, which carries signals from the face to the brain.
Bell’s Palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side. . It is the most common cause of facial paralysis worldwide.
Peripheral neuropathies are a group of disorders that affect the peripheral nerves, which are the nerves outside the brain and spinal cord.
CIDP is a rare autoimmune disorder that causes chronic inflammation and demyelination of the peripheral nerves. This leads to damage to the myelin sheath, which disrupts nerve function and causes a range of symptoms.
Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles.
It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction, inhibiting the excitatory effects of the neurotransmitter acetylcholine throughout neuromuscular junctions.
Guillain-Barré Syndrome (GBS) is a rare autoimmune disorder that occurs when the immune system mistakenly attacks the nerves, leading to muscle weakness, numbness, and tingling.
Guillain-Barré syndrome (GBS) Or Landry's paralysis It is a disorder in which the body's immune system attack part of the peripheral nervous system.
Dystonia is a neurological disorder characterized by involuntary muscle contractions, leading to abnormal postures, movements, and tremors.
Chorea is a symptom that causes involuntary muscle movements. There are several possible causes of chorea. It’s a common symptom of Huntington’s disease or a neurological condition.
2. CHOLELITHIASIS
• Most common biliary pathology
• it is estimated that gallstones are present in 10-
15% of the adult population in the USA
• they are asymptomatic in the majority (>80%)
• in the UK the prevalence of gallstones at the
time of death is estimated to be 17% and may
be increasing
• Approximately 1-2% of asymptomatic patients
will develop symptoms requiring
cholecystectomy per year, making
cholecystectomy one of the most common
operations performed by general surgeons
3. Aetiology
• 3 main types:
• cholesterol (80% in USA)
• pigment (80% in Asia)
• mixed stones
– 51-99% pure cholesterol
– admixture of calcium salts, bile acids, bile
pigments and phospholipids
4. • Cholesterol which is insoluble in water is
secreted from the canalicular membrane
in phospholipid vesicles.
• Whether cholesterol remains in solution
depends on
– the concentration of phospholipids and bile
acids in bile and
– the type of phospholipids and the bile acid
5. • Micelles formed by the phospholipid hold
cholesterol in a stable thermodynamic
state
• when bile is supersaturated with
cholesterol or bile acid concentrations are
low, unstable unilamellar phospholipid
vesicles form from which cholesterol
crystals nucleate and stones may form.
6. Factors associated with gallstone
formation
Impaired gall bladder
function
Emptying
Absorption
Excretion
Supersaturated bile
Age
Diet- high calorie
Obesity
Genetics
Sex
Cholesterol
Glycoprotein
Infection
Mucus
Absorption/ Enterohepatic circulation of bile
acids
Cholestyramine
Deoxycholate
(increase the secretion of cholesterol and
supersaturate the bile, increasing lithogenicity of
bile)
Faecal enteric flora
Ileal resection
Bowel transit time
7. • Nucleation of cholesterol monohydrate
crystals from multilamellar vesicles is a
crucial step in gallstone formation
• abnormal emptying of the gall bladder may
promote the aggregation of nucleated
cholesterol crystals, hence removing
gallstones without removing the gall
bladder inevitably leads to gallstone
recurrence.
8. Pigment stones
• Name used for stones with <30% cholesterol
• there are two types:
• black
– black stones are largely composed of an insoluble
bilirubin pigment polymer mixed by calcium
phosphate and calcium bicarbonate
– 20-30% of stones are black
– incidence rises with age
– accompany haemolysis, usually hereditary
spherocytosis or sickle cell disease,
haemoglobinopathies
– patients with cirrhosis and biliary stasis have a higher
incidence of pigmented stones
9. • brown
– contain calcium bilirubinate
– calcium palmitate
– calcium stearate
– cholesterol
• rare in gallbladder
• form in the bile duct and related to bile
stasis and infected bile
10. • Stone formation is related to the
deconjugation of bilirubin diglucuronide by
bacterial beta- glucuronidase.
• Insoluble unconjugated bilirubinate
precipitates
• Brown pigment stones are also associated
with the presence of foreign bodies within
the bile ducts such as endoprosthesis
(stents), E coli or parasites such as
Clonorchis sinensis and Ascaris
lumbricoides
11. Clinical presentation
• Right upper quadrant pain
• Epigastric pain
• radiate to back
• colicky or dull and constant
• others:
– dyspepsia
– flatulence
– food intolerance
– particularly to fats
12. • altered bowel frequency
• Biliary colic is typically present in 10-25%
of patient
• described as a severe right upper
quadrant pain that ebbs and flows
associated with nausea and vomiting.
• Pain may radiate to the chest
• the pain is usually severe and may last for
minutes or even several hours
13. • Frequently, the pain starts during the night, waking the
patient.
• Minor episodes of the same discomfort may occur
intermittently during the day
• Dyspeptic symptoms may coexist and be worse after
such an attack.
• As the pain resolves, the patient is able to eat and drink
again, often only to suffer further episodes of this nature
over a period of a few weeks and then no more trouble
for some months
• Jaundice may result if a stone migrates from the
gallbladder and obstructs the common bile duct. Rarely,
a gallstone can lead to bowel obstructions
14. Natural History
Asymptomatic
1-2% per year 0.2% per year
Acute
cholecystitis
Biliary colic
5% per year
symptoms
Chronic
cholecystitis
Gall bladder
carcinoma
0.08%
symptomatic
patients
Bile duct
stone
Pancreatitis
Cholangitis
Jaundice
15. Complications of Gallstones
• Biliary colic
• Acute cholecystitis
• Chronic cholecystitis
• Mucocoele
• Empyema of the gall
bladder
• Perforation
• Biliary obstruction
• Acute cholangitis
• Acute pancreatitis
• Intestinal obstruction
• (gallstone ileus)
16. Complications
• Acute cholecystitis:
• due to obstruction of the neck of
gallbladder or cystic duct by a stone
resulting in a chemical inflammatory
reaction. Bacteria are cultured from the
bile in approximately 1/2 of patients with
gallstones and unrelieved obstruction in
the presence of this infected bile may
produce an empyema
• Boas' sign :hyperaesthesia below the right
scapula in cholecystitis
17. • The thickened gallbladder becomes intensely
inflamed, edematous and occasionally
gangrenous
• the fundus of the distended, inflamed gallbladder
may perforate giving rise to localised abscess
formation and occasionally to biliary peritonitis
• the commo organism implicated in inflammation
of the gallbladder are E coli, Klebsiella
aerogenes and Strep faecalis
• Staphylococci, clostridia and salmonella are
occasionally
18. Chronic cholecystitis
• Repeated bouts of biliary colic or acute
cholecystitis culminate in fibrosis,
contraction of the gallbladder nd chronic
inflammatory change my be present i the
absence of gallstones, as is the case in
the gallbladders of typhoid carriers
• the incidence of carcinoma of the
gallbladder is increased in patients with
longstanding gallstones
19. Mucocoele
• a mucocoele develops when the outlet of
the gallbladder ceomes obstructed in the
absence of infection
• the imprisoned bile is absorbed, but clear
mucus contiues to be secreted into the
distended gallbladder.
20. Choledocholithiasis
• when gallstones enter the common bile
duct, they may pass spontaneously or give
rise to obstructive jaundice, cholangitis or
acute pancreatitis
• Gallstone pancreatitis most ommonly
occurs when a small stone becomes
temporarily arrested at the ampulla of
vater
21. Gallstone ileus
• A large gallstone becomes impacted inthe
intestine
• stones large enough to block gut generally
gain access by eroding through the wall of
the gallbladder into the duodenum
22. Biliary colic
• transient obstruction of GB from an impacted
stone
• Severe gripping pain after meals an in the
evening whihc is maximal in the epigastrium and
right hypochondrium with radiation to th back
• Despite being continuous the pain may wax and
wane in intensity over several hours, vomiting
and retching are common. Resolution occurs
when the stone falls back into the gallbladder
lumen or passes onwards into the CBD
• The patient the obstruction does not resolve an
patient develops acute cholecystitis
23. Differential diagnosis of
cholecystitis
• Common
– Appendicitis
– Perforated peptic ulcer
– Acute pancreatitis
• uncommon
– Acute pyelonephritis
– Myocardial infarction
– Pneumonia- right
lower lobe
• Ultrasound scan aids
diagnosis
• Uncertain diagnosis-
do CT scan
24. Diagnosis
• A diagnosis of gallstone disease is based
on the history and physical examination
with confirmatory radiological studies such
as transabdominal U/S and radionuclide
scans
• In the acute phase, the patient may have
right upper quadrant tenderness that is
exacerbated during inspiration by the
examiner's right subcostal palpation
25. • A positive Murphy's sign may suggests acute
inflammation and may be associated with a
leucocytosis and moderately elevated liver
function tests.
• A mass may be palpable as the omentum walls
off an inflamed gallbladder. Fortunately in the
majority of cases process is limited by the stone
slipping back into the body of the gallbladder
one contents of the gallbladder escaping by way
of the cystic duct.
• This achieves adequate drainage of the gall
bladder and enables the inflammation to resolve
26. • If resolution does not occur, an empyema
of the gall bladder may result.
• The wall may become necrotic and
perforate with tthe development of
localised peritonitis
• The abscess may then perforate into the
peritoneal cavity with a septic peritonitis-
however, this is uncommon because
gallbladder is usually localised by
omentum around the perforation
27. • A palpable non tender gall bladder (courvoisier
sign) - more sinister diagnosis
• Results from a distal common duct obstruction
secondary to a peripancreatic malignancy
• Rarely a non tender palpable gall bladder results
from complete obstruction of the cystic duct with
reabsorption of the intraluminal bile salts and
secretion of uninfected mucus secreted by the
epithelium, leading to a mucocoele of the gall
bladder.
28. Investigations
• Blood tests: neutrophilia in acute
cholecystitis or its complications.
• Elevated serum bilirubin or alkaline
phosphatase may signify the presence of
common duct stones
• Prothrombin time should be measured if
there was presence of jaundice
29. • Plain Xray
• 15% contain calcium
• Gas seen in biliary tree if there is a fistula
between the biliary tract and the gut as in
gallstone ileus or following endoscopic
sphincterotomy
• Ultrasound
• permits inspection of the gallbladder, its wall and
its contents
• demonstrates dilation of the ultrasonic wave and
are throuwn into prominence by the acoustic
shadow they produce.
• Does not depend on hepatic excretion of
contrast, it can be used in both jaundicedd and
non jaundiced patients, and therefore has
supplanted oral cholecystography
30. Cholangiography
• IV cholangiography replacee by MRCP
which is increasingly to assess the biliary
tree non invasively whereas ERCP is
reserved for removing common bile duct
stones by endoscopic sphincterotomy
• Complications occur in up to 7% of
patients and may include cholangitis,
bleeding and acute pancreatitis
31. Management
• Admit patient
• Monitor
• Analgesics
• IV fluids
• Broad spectrum antibiotics eg cephalosporin
• NPO and pass NG tube only if patient is
vomiting
• Majority of patients settle within few days on this
regimen
• Failure to settle suggests presence of empyema
32. • Some surgeons delay operation for 2-3
months after the attack in the expectation
that the acute inflammatory reaction will
have resolved by then but most now prefer
to perform cholecystectomy during the
same admission and within 72hours of
onset of attack.
• Provided the operation is carried out by an
experienced surgeon and under antibiotic
cover the early cholecystectomy is not
associated with a increased incidence of
complications
33. • Duration of illness and hospitalisation is
reduced, and further attacks of acute
cholecystitis during the waiting period for
elective surery are averted
• it shouldd be noted that this a planned
procedure carrioed out after appropriate
investigation (U/S) and with all facilities,
on a scheduled list
34. • Laparoscopic cholecystectomy is more
difficult to perform in the acute setting but
is the method preferreed by most
surgeons
• If surrounding inflammation makes
identification of the relevant anatomical
structures difficult drainage of the
gallbladder with removal of stones
(cholecystectomy) may be performed as
an interim measures.Elective
cholecystectomy is usually performe
approximately 2 months later.
35. CHRONIC CHOLECYSTITIS
• Chronic cholecystitis is most common cause of
symp tomatic gallbladder disease.
• the patient gives history of recurrent flatulence,
fatty food intolerance, right upper quadrant pain
• pain worse after food, feeling of distension and
heartburn
• DDx: duodenal ulcer, hiatus hernia, MI, chronic
pancreatitis and gastrointestinal neoplasia.
• Symptoms for mucocoele are the same as those
for chronic cholecystitis but a nontender piriform
swelling may be palpable in the right
hypochondrium. there is little systemic upset and
no pyrexia
36. CHOLEDOCHOLITHIASIS
• Stones may be present in the common
bile duct of some 5-10% of patients with
gallstones
• there is little muscle in the wall of the bile
uct
• and pain is not a symptoms unless the
stone impedes flow through the sphincter
of Oddi
• the vast majority of stones in the common
bile duct originate in the gallbladder.
• Primary duct stones are really rare
37. • Impaction of a stone at the sphincter obstructs
the flow of bile producing jaundice, pale stools
and dark urine
• Obstruction commonly persists for several days
but may clear spontaneously as a result of either
passage of the stone or of its disimpaction
• Small stones may pass through the common bile
duct with no symptoms
• In longstanding obstruction the bile ducts
become markely dilated and the diameter of the
CBD may exceed its upper limit of 7mm.
• Diameter greater than 10mm is usually strongly
suggestive of stone or tumour
38. • A totally obstructed duct system becomes dilled
with clear white bile as back pressure on the
hepatocytes prevents clearance of bilirubin and
mucus secretion is increased
• Infected of an obstructed biliary tract causes
cholangitis, which is characterised by attacks of
pain, pyrexia and jaundice (Charcot) frequentl
ass/w rigors
• Long standing biliary obstruction--- secondary
biliary cirrhosis
39. Treatment
• Observe patients with asymptomatic gallstones
with cholecystectomy only performed for those
patients who develop symptoms or
complications of their gallstones
• However prophylactic cholecystectomy should
be considered in diabetic patients, those with
congenital haemolytic anemia and those due to
undergo bariatic surgery for morbid obesity as
these groups are at increased risk of
complications from gallstones
40. Treatment
• for patients with biliary colic or
cholecystitis, cholecystectomy is the
treatment of choic in the absence of
medical contraindications
• the timing of surgery in acute cholecystitis
remains controversial.
• many units favour early intervention,
whereas others suggest that a delayed
approach is preferable.
41. Conservative treatment followed by
cholecystectomy
• In more than 90% of cases, the symptoms
of acute cholecystitis subside with
conservative measures. Non operative
treatment is based on four principles.
42. 1.Nil per mouth and IV fluid administration
2.Administration of analgesics
3.Administration of antibiotics: as the cystic
duct is blocked in most instances, the
concentration of antibiotics in the serum is
more important than its concentration in
bile. Cephazolin, Cefuroxime, Gentamicin
43. • Subsequent management: when the
temperature, pulse and other physical signs
show that the inflammation is subsiding, oral
fluids are reinstated followed by regular diet.
Ultrasonography is performed to ensure that no
local complications have developed, that the bile
duct is of a normal size and that no stones are
contained in the bile duct
• Cholecystectomy may be performed on the next
available list or the patient may be allowed home
to return later when the inflammation has
completely resolved
44. When to abandon conservative
treatment?
• Conservative treatment must be abandon
if the pain and tenderness; depending on
the status of the patient, operative
intervention and cholecystectomy should
be performe
• If the patient has serious comorbid
conditions a percutaneous
cholecystectomy can be performed under
ultrasound control, which will rapidly
relieve symptoms. A subsequent
cholecystectomy is usually required
45. Routine early operation
• As noted above, some surgeons advocate
urgent operation as a routine measure in
cases of acute cholecystitis.
• Provided that the operation is undertaken
within 5-7 days of the onset of the attack,
the surgeon is experienced and excellent
operating facilities are available, good
results are achieved.
46. • Nevertheless, the conversion rate in
laparoscopic cholecystectomy is five times
higher in acute than in elective surgery
• If an early operation is not indicated, one
should wait approximately 6 weeks for the
inflammation to subside before preceding
to operate
47. Cholesterosis
• aka strawberry gallbladder
• mucosa of gallbladder infiltrated with lipid
and cholesterol
• affects middle aged and elderly patients of
both sexes
• cholesterol stones found in half
• mucosa brick red and speckled with bright
yello nodules
• Management: as for chronic cholecystitis
48. Adenomyomatosis
• Mucosal diverticulosis - Rokitansky
Aschoff sinuses
• particularly addect the fundus and
penetrate the muscular layers to the
serosa
• Muscular hypertrophy and inflammatory
cell infiltrates are present
• the diagnosis may be made on careful
imaging but is often only made following
cholecystectomy as the gallbladder
normally contains stones.
49. Acute acalculous cholecystitis
• Few patients with acute cholecystitis have acalculous
inflammation
• Major surgery
• bacteria
• trauma
• pancreatitis
• complication of parenteral nutrition
• Best diagnosedd using a nuclear imaging hepatobiliary
iminodiacetic acid scan
• the inflammatory reaction in the gallbladder wall may be
intense and severe, leding to gangrene and perforation
• in ill patients, percutaneous drainage (cholecystostomy)
under ultrasound guidance may be considered, but
urgent cholecystectomy is often advisable.