Transcript Empyema of the gall bladder

Dr .Muayad Abass Fadhel
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Gall bladder is a pear-shaped structure
7.5–12 cm long,
with a normal capacity of about 35–50 ml
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The anatomical divisions are a fundus, a
body and a neck that terminates in a narrow
infundibulum
The cystic duct is about 3 cm in length.
Its lumen is usually 1–3 mm in diameter.
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the cystic duct joins the common hepatic
duct in 80% of cases,in supradudenal portion
it may extend down into the retroduodenal
or even retropancreatic part of the bile duct
before joining.(low insertion)
the cystic duct may join the right hepatic duct
or even a right hepatic sectorial duct
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The common hepatic duct is usually less than
2.5 cm long and is formed by the union of
the right and left hepatic ducts.
The common bile duct is about 7.5 cm long
and is formed by the junction of the cystic
and common hepatic ducts.
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CBD is divided into four parts:
the supraduodenal portion, about 2.5 cm long, running in
the
free edge of the lesser omentum;
• the retroduodenal portion;
• the infraduodenal portion, which lies in a groove on the
posterior surface of the pancreas;
• the intraduodenal portion, which passes obliquely
through the
wall of the second part of the duodenum, where it is
surrounded
by the sphincter of Oddi, and terminates by opening
on the summit of the ampulla of Vater.
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The cystic artery, a branch of the right
hepatic artery.
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The most dangerous anomalies are where the
hepatic artery takes a tortuous course on the
front of the origin of the cystic duct, or the
right hepatic artery is tortuous and the cystic
artery short. The tortuosity is known as the
‘caterpillar turn’ or ‘Moynihan’s hump’
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Lymphatics
The lymphatic vessels of the gall bladder
(subserosal and submucosal) drain into the
cystic lymph node of Lund (the sentinel
lymph node)
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Bile, is composed of 97% water, 1–2% bile
salts and 1% pigments, cholesterol and fatty
acids.
The liver excretes bile at a rate estimated to
be approximately 40 ml h–1.
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1-Reservoir for bile.
During fasting, resistance to flow through
the sphincter is high, and bile excreted by the
liver is diverted to the gall bladder. After
feeding, the resistance to flow through the
sphincter of Oddi is reduced, the gall bladder
contracts, and the bile enters the duodenum.
These motor responses
of the biliary tract are in part effected by the
hormone CCK.
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2- concentration of bile by active absorption
of water, sodium chloride and bicarbonate 5–
10 times.
3- secretion of mucus
approximately 20 ml is produced per day.
With total obstruction of the cystic duct in a
healthy gall bladder, a mucocele developson
account of this function of the mucosa of the
gall bladder.
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Plain radiograph
1- radio-opaque gallstones in 10% of
patients
the centre of a stone may contain radiolucent
gas in a triradiate or biradiate fissure, and
this gives rise to characteristic dark shapes
on a radiograph – the ‘Mercedes-Benz’ or
‘seagull’ sign.
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2- calcification of the gall bladder, a so
called ‘porcelain’ gall bladder
,PREMALIGNANT in up to 25% of patients. SO
indication for cholecystectomy.
 3-Gas may be seen in the wall of the gall
bladder
(emphysematous cholecystitis).
 4-Gas in the biliary tree may be seen after
endoscopic sphincterotomy or surgical
anastomosis
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■ Ultrasound: stones and biliary dilatation
■ Plain radiograph: calcification
■ Magnetic resonance cholangiopancreatography:
anatomy
and stones
■ Multidetector row computerised tomography scan:
anatomy, liver, gall bladder and pancreas cancer
■ Radioisotope scanning: function
■ Endoscopic retrograde cholangiopancreatography:
anatomy, stones and biliary strictures
■ Percutaneous transhepatic cholangiography: anatomy
and
biliary strictures
■ Endoscopic ultrasound: anatomy and stones
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Ultrasonography
biliary calculi,
the size of the gall bladder,
the thickness of the gall bladder wall,
the presence of inflammation around the gall
bladder,
the size of the common bile duct and,
occasionally, the presence of stones within the
biliary tree.
show a carcinoma of the pancreas occluding the
common bile duct.
In OBSTRUCTIVE JAUNDICE identify intra- and
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extrahepatic biliary dilatation and the level of
obstruction.
the cause of the obstruction may also be
identified,
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Endoscopic ultrasonography :
 It provides accurate imaging of the common
bile duct and is particularly useful in
detecting
stones within the bile
ducts,choledocholithiasis.
 In addition, it has been shown to be highly
accurate in diagnosing and stataging both
pancreatic and periampullary cancers.
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Technetium-99m (99mTc)-labelled
derivatives of iminodiacetic acid (HIDA,
IODIDA)
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Oral cholecystography and intravenous
cholangiography
historical interest
discarded
replaced by more accurate imaging
modalities
Percutaneous transhepatic cholangiography
Endoscopicretrogradecholangiopancreatograp
hy
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Peroperative cholangiography
Operative biliary
endoscopy(choledochoscopy)
Postoperative T-tube cholangiography
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Gallstones are the most common biliary
pathology.
10–15% of the adult population in the USA.
asymptomatic in the majority (> 80%).
Approximately 1–2% of asymptomatic
patients will develop symptoms requiring
cholecystectomy per year,
cholecystectomy one of the most common
operations performed by general surgeons.
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three main types:
cholesterol,
pigment (brown/black)
mixed stones. ,
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Cholesterol or mixed stones contain 51–99%
pure cholesterol plus an admixture of calcium
salts, bile acids, bile pigments and
phospholipids.
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The process of gallstone formation is complex
Obesity,
high-calorie diets and
Certain medications can increase the secretion of
cholesterol and supersaturate the bile, increasing
the lithogenicity of bile.
. 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.
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Pigment stone Less than 30% cholesterol.
There are two types – black and brown.
Black stones are largely composed of an
insoluble bilirubin pigment polymer mixed with
calcium phosphate and calcium bicarbonate.
Overall, 20–30% of stones are black.
Black stones accompany haemolysis, usually
hereditary spherocytosis or sickle cell disease.
For unclear reasons, patients with cirrhosis have
a higher instance of pigmented stones.
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Brown pigment stones contain calcium
bilirubinate, calcium palmitate and calcium
stearate, as well as cholesterol.
Brown stones are rare in the gall bladder.
They form in the bile duct and are related to
bile stasis and infected bile.
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Brown pigment stones are also associated
with the presence of foreign bodies within
the bile ducts such as endoprosthesis stents)
or parasites such as Clonorchis sinensis and
Ascaris lumbricoides
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80% asymptomatic
Right upper quadrant or epigastric pain,
may radiate to the back.
colicky,
more often is dull and constant.
dyspepsia,
flatulence, food intolerance, particularly to
fats,
some alteration in bowel frequency.
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Biliary colic is typically present in 10–25% of
patients. This is described as a severe right
upper quadrant pain that ebbs and flows for
minutes to hours associated with nausea and
vomiting
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Jaundice may result if a stone migrates from
the gall bladder and obstructs the common
bile duct.
Rarely, a gallstone can lead to bowel
obstruction (gallstone ileus).
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acute cholecystitis :
When symptoms do not resolve, but progress
to continued pain
with fever and leucocytosis,
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In the gallbladder
■ Biliary colic
■ Acute cholecystitis
■ Chronic cholecystitis
■ Empyema of the gall bladder
■ Mucocele
■ Perforation
In the bile ducts
■ Biliary obstruction
■ Acute cholangitis
■ Acute pancreatitis
In the intestine
■ Intestinal obstruction (gallstone ileus)
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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
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history
physical examination with
confirmatory radiological studies
In the acute phase,
the patient may have right upper quadrant
tenderness that is exacerbated during inspiration
by theexaminer’s right subcostal palpation
(Murphy’s sign).
A positive Murphy’s sign suggests acute
inflammation and may be associated with a
leucocytosis and moderately elevated liver
function test
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A mass may be palpable as the omentum
walls off an inflamed gall bladder.
Fortunately, in the majority of cases, this
process is limited by the stone slipping back
into the body of the gall bladder and the
contents of the gall bladder escaping by way
of the cystic duct. This achieves adequate
drainage of the gall bladder and enables the
inflammation to resolve.
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If resolution does not occur, an empyema of
the gall bladder may result. The wall may
become necrotic and perforate, with the
development of localised peritonitis. The
abscess may then perforate into the
peritoneal cavity with a septic peritonitis –
however, this is uncommon, because the gall
bladder is usually localised by omentum
around the perforation.
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A palpable, non-tender gall bladder
(Courvoisier’s sign)
. This usually 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 gall
bladder epithelium, leading to a mucocele
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Most authors would suggest that it is safe to
observe patients with asymptomatic
gallstones, with cholecystectomy only being
performed for those patients who develop
symptoms or complications of their
gallstones.
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in diabetic patients,
congenital haemolytic anaemia
those due to undergo bariatric surgery for
morbid obesity,
Because increased risk of complications from
gallstones.
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For patients with biliary colic or cholecystitis,
cholecystectomy is the treatment of choice in
the absence of medical contraindications.
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The timing of surgery in acute cholecystitis
remains controversial.
early intervention,
others suggest that a delayed approach is
preferable
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Conservative treatment followed by cholecystectomy
more than 90% of cases, the symptoms of acute cholecystitis
subside with conservative measures.
Nonoperative treatment is based on four principles:
1 Nil per mouth (NPO) and intravenous fluid administration.
2 Administration of analgesics.
3 Administration of antibiotics.
As the cystic duct is blocked in most instances, the
concentration of antibiotic in the serum is more important
than its concentration in bile. A broadspectrum antibiotic
effective against Gram-negative aerobes is most appropriate
(e.g. cefazolin, cefuroxime or gentamicin).
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4 -Subsequent management. When the
temperature, pulse and other physical signs
show that the inflammation is subsiding, oral
fluids are reinstated followed by regular diet.
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Ultrasonography is performed to ensure
no local complications have developed
the bile duct is of a normal size and
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.
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Conservative treatment must be abandoned if
the pain and tenderness increase; depending
on the status of the patient, operative
intervention and cholecystectomy should be
performed
If the patient has serious comorbid
conditions, a percutaneous cholecystostomy
can be performed under ultrasound control,
which will rapidly relieve symptoms.
A subsequent cholecystectomy is usually
required
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Routine early operation
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,
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BUT 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 proceeding to
operate.(INTERVAL CHOLECYSTECTOMY)
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The gall bladder filled with pus.
it may be a sequel of acute cholecystitis or
the result of a mucocele becoming infected.
The treatment is drainage and, later,
cholecystectomy.
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Acute and chronic inflammation of the gall
bladder can occur in the absence of stones
and give rise to a clinical picture similar to
calculous cholecystitis.
Acute acalculous cholecystitis is seen
particularly in
patients recovering from major surgery (e.g.
coronary artery bypass),
trauma and burns.
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In these patients, the diagnosis is often
missed, and the mortality rate is high.
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Preparation for operation
■ Full blood count
■ Renal profile and liver function tests
■ Prothrombin time
■ Chest X-ray and electrocardiogram (if over
45 years or medically indicated)
■ Antibiotic prophylaxis
■ Deep vein thrombosis prophylaxis
Informed consent
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Serious complications of laparoscopic
cholecystectomy fall into two major areas:
access complications
bile duct injuries.
If either a visceral or a bile duct injury is
suspected, conversion to an open technique
isrecommended by most surgeons.
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For patients in whom a laparoscopic approach
is not indicated or in whom conversion from a
laparoscopic approach is required, an open
cholecystectomy is performed.
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• When the anatomy of the triangle of Calot is
unclear, blind dissection should stop.
• Bleeding adjacent to the triangle of Calot
should be controlled by pressure and not by
blind clipping or clamping.
• When there is doubt about the anatomy, a
‘fundus-first’ or ‘retrograde’ cholecystectomy
dissecting on the gall bladder wall down to
the cystic duct can be helpful.
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• If the cystic duct is densely adherent to the
common bile duct and there is the
possibility of a Mirizzi syndrome (a gallstone
ulcerating through into the common duct),
the infundibulum of the gall bladder should
be opened, the stone removed and the
infundibulum oversewn.
•
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A cholecystostomy is rarely indicated but, if
necessary,
stones should be extracted, and a large Foley
catheter (14F) placed in the fundus of the gall
bladder with a direct track externally.
By so doing, should stones be left behind in
the gallbladder, these can be extracted with a
choledochoscope.
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In a situation in which sophisticated
preoperative imaging or peroperative
cholangiography is not available,
the traditional indications for
choledochotomy, which are:
1 palpable stones in the common bile duct;
2 jaundice, a history of jaundice or
cholangitis;
3 a dilated common bile duct;
4 abnormal liver function tests, in particular a
raised alkaline phosphatase.
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In 15% of patients, cholecystectomy fails to
relieve the symptoms for which the operation
was performed. ‘post-cholecystectomy’
syndrome.
problems are usually related to the preoperative
symptoms and are continuation of those
symptoms. Full investigation should be
undertaken to confirm the diagnosis
presence of a stone in the common bile duct,
a stone in the cystic duct stump
or operative damage to the biliary tree.
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best DIAGNOSED by
MRCP or ERCP.
The latter has the added advantage that, if a
stone is found in the common bile duct, it
can be removed.
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