CHRONIC CHOLECYSTITIS

CHRONIC CHOLECYSTITIS& JaundiceByMohamed Riad

The term chronic cholecystitis is applied clinically to all chronic affections of the gall bladder which include calculi, chronic inflammation, metabolic disorders (cholesterosis) and neurogenic dysfunction ( dyskinesia). Chronic calcular cholecystitis (gall stones) is the most common (95%). The other forms of chronic cholecystitis includes:Chronic Non-Calcular Cholecystitis: Cholesterolosis of the gall bladder: Strawberry Bladder Biliary dyskinesia: surgery aggrevates symptoms

CHRONIC CALCULAR CHOLECYSTITIS GALL STONESGallstones are the commonest biliary pathology. In 95% of cases of chronic cholecystitis, stones are found in the gall bladder .Gall stones are more common in western countries. (may be related to diet) .It is more common in female 3 : 1 . The main varieties of gall stones recognized are: Mixed stones (80%)Cholesterol stones (15%)Pigment stones (5%)Calcium carbonate stones

Mixed stones (80%)Occur in infected gallbladders Composition: Concentric laminae of cholesterol (the major component), calcium carbonate, calcium phosphate, calcium bilirubinate, calcium palmitate and proteins around an organic nucleus.Number & size: Always multiple and often occurs in groups of similarly sized stones, each group representing an acute attack of cholecystitis. Surface and colour: Faceted and brown. Cut surface: Laminated with alternate dark and light zones of pigment and cholesterol. X-ray appearance: Typical signet-ring shadow on X-ray.

Cholesterol stones (15%)Composition: Pure cholesterol.Number & size: Solitary and large (cholesterol solitaire) or multiple and small. Surface and colour: Mamillated and white or yellow. Cut section: Radiate structure X-ray appearance: radiotranslucent

Pigment stones (5%)More common in the Far East than in the West. Occur in non-infected gallbladders or bile ducts.Composition: Mainly of calcium bilirubinate. Number & size: Multiple, small, irregular, friable. Surface& colour: Dark green or black.Cut section: Amorphous on section X-ray appearance: Radiotranslucent

Calcium carbonate stones These are very rare and sometimes the gallbladder is found to contain an emulsion of calcium carbonate (lime water bile). In these cases the wall of the gallbladder is usually calcified.

AetiologyA) Cholesterol and mixed stonesMetabolic factors: Cholesterol is insoluble in water, and is held in solution by the detergent action of bile acids and phospholipids with which it forms micelles. An increase in cholesterol concentration or a decrease in the bile salt concentration results in supersaturation of bile with cholesterol. Nucleation is the crystallization of cholesterol on a nidus (e.g. Mucous). Crystals can form on a nidus.Infection: the radiolucent centers of many gallstones may represent mucous plugs originally formed around bacteria.Bile stasis: Gallbladder contractility is reduced by oestrogen, in pregnancy and after truncal vagotomy.

B) Pigment stonesHaemolysis due to increased bilirubin production. Strictures (found in the ducts) due to stasis. Infestations of the biliary tree by Ascaris Lumbricoides (most common in oriental countries). E. Coli is often found in the bile of these patients and produces the enzyme glucuronidase, which converts the bilirubin into its unconjugated insoluble form, which precipitates as the calcium salt.

Complications of gall stones: Migration: Obstruction of the cystic duct or common bile duct. Inflammation: (cholecystitis, cholangitis or pancreatitis). Ulceration and fistula formation with duodenum gall stone ileus. Malignant change in long-standing cases.

Clinical Features of Chronic Cholecystitis: It is common in middle-aged females who are usually fatty, fertile, filthy, forty female. (5 F)Symptoms:Sometime, Asymptomatic, and gall stones discovered accidentally by US, However, if there is symptoms, they are aggravated by fatty foods, these symptoms includes: Flatulent dyspepsia: This is commonly associated with heart burn and water brushing. Pain: This may be fixed to the right hypochondrium or may be referred to the right shoulder or to the back. In calcular cases, biliary colic may occur if a stone migrates to the bile duct or obstructs the cystic duct.

Jaundice: Uncomplicated stones of the gall bladder are rarely the cause of jaundice. Jaundice is liable to occur in: If infection develops and causes cholangitis. If a stone migrates and obstructs the common bile duct.Rarely a big stone in Hartmann's pouch 'presses on the common bile duct from the outside and causes obstruction, This may be helped by associated oedema.

Toxic features: A patient with long standing gall bladder infection may complain of myositis, fibrositis or myocarditis.

Signs:Murphy's sign: There is tenderness below the tip of the ninth right costal cartilage, and if pressure is applied while the patient is in inspiration, she catches her breath.

Boas' sign: may be positive.

A palpable gall bladder: This may be detected in the right hypochondrium. It represents a mucocele of the gall bladder. It is caused by obstruction of the cystic duct usually by a stone, and distention of the gall bladder with mucus.

Differential Diagnosis: Sometimes chronic cholecystitis gives rise to features similar to the features of duodenal ulcer or chronic appendicitis and it is not infrequent to find the three conditions associated together as an abdominal triad in one patient (Wilkies triad). Saint's triad refers to cholecystitis, diverticulitis and hiatus hernia. The history is of great importance. The following diagnostic measure is helpful: ultrasonography

Treatment of chronic gall bladder disease: A. Medical Treatment: For mild non-calcular cases, the items are: Regulation of diet with restriction of fats. Antibiotics. Cholagogues as magnesium sulphate to help drainage of bladder. Choleretics to increase the flow of the bile (bile salts and olive oil). Antispasmodics to help drainage and relieve pain,

B. Surgical treatment: cholecystectomy either open or laparoscopic Open cholecystectomy: Steps of the operation: Incision; Abdominal exploration:Identification of the anatomy: (Callot's triangle),Removal of the gall bladder. Drainage:

Fundus first cholecystectomy: IndicationsIn the presence of marked adhesions; the anatomy of the structures in the porta hepatis cannot be easily identified. When the cystic duct is congenitally absent. If cholecystostomy was previously done.

Exploration of the common bile duct: After cholecystectomy, the common bile duct should be opened and probed in the following conditions: If there is history of recurrent jaundice. If the duct is unduely dilated. If a stone or stricture is felt from the outside.

Laparoscopic cholecystectomy (LC): LC has become the "gold standard" in treatment of symptomatic gall stone disease. It has the following advantages over open cholecystectomy: Less postoperative pain. Shorter hospital stay. Earlier return to work. Better cosmetic result.

Complications of cholecystectomy: A- General:Haemorrhage and shock. Pulmonary complications (bronchopneumonia and lung collapse). Acute dilatation of the stomach and paralytic ileus. B- Local: Injury to important structures in the porta hepatis such as the right branch of the hepatic artery, the common bile duct (causing biliary fistula or stricture of CBD) and the portal vein. Subphrenic abscess. Post cholecystectomy dyspepsia.

The symptoms of chronic cholecystitis may persist after operation ( post-choecystectomy syndrome ) due to one of the following factors: Wrong diagnosis; the dyspepsia was due to another cause. Wrong time; late after onset of cholangitis or another complication. Wrong way; the surgeon has missed a stone in the common bile duct, caused a stricture or left a big stump of the cystic duct, which may maintain the infection. Wrong patient; this is the neurotic patient who always complains.

JAUNDICEDefinition: It is a state of yellow discoloration of the skin, mucous membranes and sclera due to retention of bilirubin in the blood. The central nervous system, cerebrospinal fluid, milk and saliva are not discoloured.

Normal bile metabolism:

Classification of Jaundice:Haemolytic jaundice: There is excessive production of bilirubin due to destruction of large numbers of RBC's.

It is seen in cases of incompatible blood transfusion, erythroblastosis foetalis, severe haemolytic anaemia and snake poisoning, but the jaundice of surgical importance is congenital haemolytic jaundice.

The amount of conjugated bilirubin reaching the intestine is in excess, i.e. there is an exaggeration of the normal cycle. It follows that urobilinogen is secreted in excess in stools and in urine, but still there is no billirubin in urine. Bile salts do not accumulate in the blood.

Hepatocellular jaundice: There is a disturbance of liver cells due to viral hepatitis, liver cirrhosis or chemical poisons as alcohol, chloroform and carbon tetrachloride.

There are two elements working together: Disturbance of the liver cell, which causes inability to conjugate the normal amount of bilirubin reaching it, i.e. some will be retained in the blood and cannot be secreted in urine (attached to protein). Oedema, which causes partial obstruction of the bile canaliculi, therefore some of the conjugated bilirubin will be regurgitated into the blood and can pass through the kidney.

In hepatocellular jaundice bilirubin will appear in urine (but less than in obstructive jaundice), stercobilinogen in stools will diminish, but urobilinogen may increase in urine because the part entering the enterohepatic cycle will not be completely excreted by the diseased liver cells and instead it will pass through kidneys. Bile salts may increase in blood.

Obstructive jaundice: As there is obstruction to the flow of the conjugated (free) bilirubin formed in the liver, this conjugated bilirubin regurgitates back to the blood. As it is free of protein it can pass through the kidney to the urine. As the amount reaching the intestine is negligible, faecal stercobilinogen and urinary urobilinogen will be decreased.

Obstruction of the CBD due to these causes:Within the lumen of the bile ducts: Causes in the wall: Compression from outside:

I- Within the lumen of the bile ducts: Stones. Inflammatory exudates. Inspissated bile. Parasites. II- Causes in the wall: Congenital biliary atresia. Inflammatory stricture: occurs in sclerosing cholangitis. Traumatic stricture: is usually iatrogenic following cholecystectomy, choledocholithotomy or instrumental procedures to the CBD. Malignant stricture.

III- Compression from outside: Carcinoma of the head of the pancreas. Malignant glands in the porta hepatis. Peri-ampullary carcinoma. Chronic pancreatitis or pancreatic cysts.

The commonest two causes of obstructive jaundice in surgical practice are carcinoma of the head of the pancreas and stones of bile ducts.

Type of patient: Stones are common in middle aged fatty females. Carcinoma of the pancreas in old males. Hemolytic jaundice in children or young adults.

Onset and previous history. Calcular obstruction is usually of sudden onset, associated with biliary colic, and previous attacks of similar nature are pathognomonic. Malignant obstruction is usually insidious and is painless or associated with dull pain in the upper abdomen. Infective hepatitis is usually preceded by fever, nausea and pain in the region of the liver.

Course: Calcular jaundice is usually intermittent in course. Malignant jaundice is progressive. In infective hepatitis the jaundice reaches a peak then regresses. Haemolytic jaundice usually follows a mild course with remissions which may last for long periods .

History: History of blood transfusion, exposure to poisons or receiving drugs may point to the nature of jaundice. Jaundice following cholecystectomy may be due to injury of CBD, compression by oedema or ascending cholangitis.

Examination: Discolouration: In haemolytic jaundice the skin is mildly discoloured (Lemon Coloured). In hepatocellular jaundice it is moderately discoloured (Orange Coloured) In obstruction it is deeply coloured (Olive Green). Anaemia is marked in haemolytic jaundice. Itching, haemorrhagic manifestations and bradycardia are features of obstructive jaundice. The stools are clay coloured in obstructive jaundice and at the peak of hepatocellular jaundice. They are normal in haemolytic jaundice. The urine is deeply coloured in obstructive jaundice and in infective hepatitis but in the latter condition it gradually returns to normal. In haemolytic jaundice it is not coloured due to absence of bilirubin (Acholuric jaundice).

Abdominal examination: The liver is enlarged and tender in infective hepatitis, enlarged and firm in long standing obstructive jaundice and slightly enlarged in haemolytic jaundice. The spleen is moderately enlarged in haemolytic jaundice. Ascites points to malignancy or advanced stage of liver cirrhosis. The gall bladder is distended in cases of malignant obstruction (Courvoisier's law). However if the obstruction is above the cystic duct, it will not be palpable.

In obstruction due to stone from the gall bladder it is shrunken due to previous fibrosis. However it may be palpable: If the obstruction is caused by a cholesterol stone and the gallbladder is normal. If a stone obstructs the bile duct causing jaundice and another stone obstructs the cystic duct causing a mucocele of the gall bladder. If a big stone in Hartmann's pouch obstructs both the cystic duct and the common bile duct (by pressure from the outside). If the stone is primarily formed in the bile duct.

Investigations: Fragility test for Spherocytosis. Blood in the stools favours obstruction by a malignant tumour.Assessment of amount of bile pigments in urine and stools.Liver function tests: Alk. Phosphatase elevates in obstructive jaundice . SGOT&SGPT are elevated in cholangitis .

V- Radiography: Plain X-ray may sow the shadow of stones. Cholangiography. Contraindicated in the presence of jaundice especially if, level serum bilirubin is above 2 mg %, because the dye is excreted in the same pathway of excretion of bilirubin. The diseased liver cell will fail to excrete it; moreover it may be toxic to the liver. Barium-meal examination may help to diagnose carcinoma of the head of the pancreas. Ultrasonography (investigation of choice), and computerized tomography are very helpful in difficult cases and especially for differentiation between extrahepatic and intrahepatic obstruction.

VI- Endoscopic retrograde cholangiopancreaticography (ERCP) for lesions in the lower part of the common bile duct (periampullary carcinoma).VII- MRCP VIII- Percutaneous transhepatic cholangiography (PTC) is useful in diagnosis of lesions in the upper part of the ducts e.g. postoperative stricture or carcinoma of the hepatic ducts. IX- Exploration is indicated in undiagnosed cases.

I. Calcular Obstructive Jaundice: Pathology: Stone (choledocholithiasis): stones may arise in the gall bladder (in most of cases), or in common bile duct (rare). Bile passages: Dilated above the stone. Distended with biliary mud or pus in cases of severe inflammation. Sometimes in advanced cases the liver fails to secrete bile and the bile ducts will contain mucus only (white bile). This indicates a grave prognosis.

Gall Bladder: Contracted in 80% of cases (Courvoisier's law). Liver: If the liver is not infected marked dilatation occurs above the stone (Hydrohepatosis). The liver becomes brown, firm and granular . In late cases biliary cirrhosis develops.

If there is infection the bile ducts above the stone will be distended with pus, multiple abscesses will form in the liver and due to the associated fibrosis dilatation is not marked.

Symptoms: Charcot's triad: Charcot's intermittent fever: Intermittent fever associated with chills and rigors. Fever may occur even in the absence of infection Intermittent pain: it may be dull in the epigastrium or lumbar region or colicky and referred. Intermittent jaundice: because the stone may be dislodged from time to time and therefore the jaundice is not so severe as in cases of cancer head of pancreas.

Signs:1) Tenderness in the epigastrium or hypochondrium. 2) Gall bladder is usually impalpable (Courvoisier's law).

Treatment of stone in the common bile duct: Pre-operative treatment: High carbohydrate diet. Vitamin K. Infusions of glucose and saline. Antibiotics.

This treatment is continued so long there is improvement because it is better to operate during a remission. However, early intervention is indicated in: Increasing jaundice. Persistent fever

A) If the gall bladder was not removed previously: ERCPOperation:If the common bile duct is abnormally wide: it should be drained by one of two methods: a-Sphincterotomy (transduodenal) b-Choledocho-duodenostomy: Side to side or end to side.

Laparoscopic technique: All the operation can be done using laparoscope.

B)Treatment of Calcular obstructive jaundice that occurs after cholecystectomy:Flushing through T-tube, with saline containing heparin or lignocaine. Pressure should not exceed 30 cm H20 to avoid bilio-venous reflux and bacteraemia. Antispasmodic drugs may be given to relax the sphincter. This method may be successful if the stone is not bigger than7 mm.

Stone dissolution: the most successful fluid injected through the T-tube is methyl tertiary butyl ether (MTBE). Results are satisfactory and the stone may dissolve within few hours.

Extraction by choledochoscope. This needs a delay for 4-6 weeks, until the tract of the tube becomes well formed and can be dilated to allow introduction of choledochoscope to extract the stone under direct vision. The above three methods are possible when the T -tube is still present.

Endoscopic extraction (ERCP): after sphincterotomy, the stone is extracted by a Dormia basket. This can be done whether a T-tube is found or not.

Surgical exploration: when all the above methods fail.

Missed stones: Stones discovered within 2 years of operation. They cause recurrent attacks of cholangitis and pain. A stone less than 7 mm may pass spontaneously and therefore, should have chance of few weeks of conservative treatment before resorting to other procedures.

Recurrent stones: Stones discovered after 2 years. Common predisposing causes are stricture of the duct or presence of non-absorbable sutures (better avoided in surgery on the bile ducts). The best treatment is choledochoduodenostomy

ItemStoneCancer headPatient:Middle aged femaleOld made.Onset:SuddenGradualPain:Colicky (Previous attacks).Dull aching or absentGeneral condition:Good.Weight loss.Gall bladder:Usually not palpable (80%)Usually palpable (95%).Course:Intermittent.ProgressiveBlood in stools:Absent.May be presentLab. Findings:Changeable.Constant X-Ray:Stone may be shown (rare).Widening of the curve of the duodenumSonogram:Echo of a stoneEcho of a tumour