mTypes:
1- Ch. calcular cholecystitis.
2- Ch. non calcular cholecystitis "inflammation only".
3- Cholesterolosis of gall bladder "strawberry G. B.".
4- Biliary dyskinesia "stasis gall bladder".


(1) Ch. Calcular Cholecystitis

Stones are present in 95% of cases of ch. cholecystitis.
m Predisposing Factors of stone formation:
ΠHypercholesterolaemia "Disturbed cholesterol metabolism or lymphatic obstruction".
Causes of hypercholestrolemia:
Ÿ Excess fat.
Ÿ Diabetes Mellitus.
Ÿ Contraceptive pills.
Ÿ Decrease bile salts as in liver disease or resection of the terminal ileum.
 Stasis of bile due to:
Ÿ Obstruction of cystic duct.
Ÿ Reduced gall bladder contractility by: oestrogens, in pregnancy, after trunkal vagotomy and long term parenteral nutrition.
Ž Chronic inflammation ® nucleus for stone formation E. coli is common.
 Parasitic infestation of the biliary tree by Clonorchis sinensis or Ascaris lumbricoids.
 Increase haemolysis
m Complications of Gall Stones:
1. In the gall bladder: Silent stones, acute cholecystitis, mucocele of G.B., empyema of G.B., gangrene of G.B., perforation, chronic cholecystitis and carcinoma in long standing cases.
2. In the pile ducts: Obstructive jaundice, cholangitis and acute pancreatitis.
3. In the intestine: Acute intestinal obstruction (gall stone ileus).
4. General effects: Chronic toxemia results in toxic myocarditis, myositis and arthritis.

(II) Chronic Non Calculous Cholecystitis

mCausative organism: E. coli, strept, staph, S. typhi, clostridia welchii.
mRoute of infection: Blood spread from septic foccus.
mPathology: The chronically inflammed G.B. characterized by:
1- Loss of normal luster of serosa.
2- Opaque yellow colouration due to subserous fat deposition .
3- Thickened wall.
4- Adhesions to surroundings.
5- Enlarged cystic L.N.
6- Cob-web fibrosis in the G.B. bed.
7- When opening the gall bladder ® the mucosa is inflammed and denuded of normal folds.

(III) Biliary Dyskinesia (Stasis Gall Bladder)

q Rare condition in which the symptoms of cholecystitis occur and persist without stone or infection.
q It is of 2 types ® Atonic with lax G.B. wall.
® Hypertonic due to achalasia of sphincter of Oddi.
FN.B. Achalasia in surgery:

ü Achalasia of the cardia
ü Congenital pyloric stenosis.
ü Congenital megacolon.
ü Diverticulosis coli.
ü Achalasia of sphincter of Oddi.
ü Achalasia of pelviureteric junction.


(IV) Cholesterolosis of gall bladder

mDefinition:
Cholecystitis without stone or infection but there is increase in cholesterol content of the gall bladder bile.
mAetiology: Unknown but may be due to
1- Lymphatic obstruction ® hinder absorption of cholesterol from the wall of the gall bladder.
2- Disturbed cholesterol metabolism.
mPathology:
Due to high cholesterol, it will be deposited in mucous membrane of G.B. ® it will be red and studded with yellow speck of cholesterol crystals ® (Strawberry gall bladder).
m Clinical Picture of Ch. Cholecystitis:
q Incidence:
Common with 5F: Female, fatty, fertile forty ys. of age with fatty dyspepsia.
q Symptoms:
1- Fatty dyspepsia: distension &flatulence after fatty meal.
2- Pain:
A) Dull aching pain in Rt. hypochondrium, referred to Rt. shoulder
B) Biliary colic in migrating stone.
3- Jaundice: may occur in cases of:
A) Ascending cholangitis.
B) Migrating stone ® obst. of C.B.D.
C) Big stone in Hartmann's pouch ® obst. of C.B.D. from outside.
4- Toxic features: Toxic absorption ® Myocarditis (cholecystitis heart disease), arthritis & myositis.
5- Wilkie's triad: Not infrequent to find cholecystitis, duodenal ulcer and appendicitis in one patient.
6- Saint's triad: rarely we find cholecystitis, hiatus hernia and diverticulitis in one patient.
q Signs:
1) Tenderness at tip of Rt. 9th costal cartilage.
2) Murphy's sign: If pressure is applied at the tip of the right 9th costal cartilage while the patient is in inspiration ® she catches her breath.
3) Boas 'sign may be positive.
4) Wistiphan sign: Pressure in the Right supraclavicular region cause pain in the right hypochondrium due to irritable phrenic nerve.
5) Palpable gall bladder: in cases of mucocele.
m Investigations:
1- Ultrasonography: Give an idea about the size of the G.B. and its wall thickness and presence of stones.
2- Plain x- ray:
q 15% of cases only may give radio-opaque shadows in Rt. hypochondrium.
q Lateral view excludes renal stones.
3- X-ray cholangiography:
A) Oral cholecystography
Ä10 tab. of telepaque are given at night then radiography at the morning after 12 hs.
Ä Fatty meal is given then ® radiography is done 1 :2 hours later.
B) Intravenous cholecystography ® 20cc biligraphin I.V. ® radiography after 10 min.
* Both A & B may give:
- Filling defect in the gall bladder i.e. radiotransluscent stone.
- Non functioning G.B. i.e. shows no contraction after fatty meal.
C) E.R.C.P.:'' Endoscopic retrogradee cholangio-pancreatography''.
Injection of the dye directly to the common bile duct through endoscopic cannula in the duodenal papillae ® delineation of biliary tree and pancreatic duct.
D) P.T.C.: Percutaneous transhepatic cholangiography.

FN.B. Both E.R.C.P. and P.T.C. can be done together to identify a lesion obstructing the C.B.D.


E) Intra-operative cholangiography:
By direct intra-operative injection of the dye to evaluate patency of the biliary tree, and presence of missed stone.
F) Post operative cholangiography:
By injection of the dye through T tube inserted in the C.B.D. to diagnose
® Residual stone.
® Distal obstruction.
4- Duodenal intubation and aspiration of the bile, if it is diluted = failure of G.B. to concentrate bile = chronic cholecystitis.
5- Magnetic resonance cholangio-pancreatogrphy (MRCP): MRCP is considered now the standard technique to investigate the biliary system. Contrast is not necessary and with appropriate computing, a clear outline of the biliary tree and bile duct stone can be achieved. The technique will replace alternative diagnostic aids.
Q1- How can you diff. bet. oral & I.V. cholecystography from the x- ray film?
* The hepatic biliary radicals appears only in I.V. type .
Q2- What are the falacies of oral cholecystogrophy?
* The gall bladdere cann't be visualised in:
1- Patients did not take the dye tablets.
2- Patients with vomiting or diarrhea.
3- Liver diseasee as in obst. jaundice. 4- Obst. in cystic duct.
m Treatment:
(I) Medical treatment:
For mild and non-calcular cases in the form of:
1- Regulation of diet with restriction of fat.
2- Antibiotics. 3- Antispasmodics.
4- Cholagogues e.g. Mg. sulphate help in drainage.
5- Choleritics e.g. bile salts increase secretion which increase flow.
(II) Surgical treatment: "Cholecystectomy"
· Incision:
1- Kocher's subcostal incision
® Sure diagnosis. ® Fatty patient.
2- Upper right paramedian incision
® Unsure diagnosis ® Thin patient.

· Indications of exploration of C.B.D:
1- History of recurrent jaundice.
2- When gall bladder contains many stones which cann't be counted.
3- When the number of the stones found is less than that seen in x ray.
4- When C.B.D. is unduely dilated > 12mm in diameter.
5- When we feel a stone in the common bile duct.
·Complications:
a) General complications®SHIP.
b) Specific complications:
1- Injury to C.B.D
2- Ligation of Rt hepatic artery esp. in cong. anomaly.
3- Portal vein injury. 4- Post cholecystectomy syndrome:
·Definition: Persistence of symptoms after operation.
·Aetiology:
a) Wrong diagnosis: dyspepsia due to another cause e.g. peptic ulcer, Diverticulitis, Hiatus hernia.
b) Wrong time: Late interference after cholangitis had occurred.
c) Wrong technique:
Ä Injury to C.B.D.® stricture.
Ä Residual stone in C.B.D. Ä Long stump ® infection.
d) Wrong patient: Neurotic patient always complaining.
(III) New techniques for gallstones:
1) Lithotripsy {ESWL} Extracorporial Shock-Wave Lithotripsy: it has been superseded by the following 2 and 3 techniques.
2) Percutaneous cholecystolithotomy: In those who wish to retain their gallbladder or those who have had percutaneous cholecystostomy or those unfit for surgery. It is done under ultrasound control and by passing a nephroscope into the gall bladder.
3) Minicholecystectomy: The standard operation is done through a 5cm transverse incision by using special instruments.
4) Laparoscopic cholecystectomy: In this procedure pneumoperitoneum is performed and 4 puncture wounds are made in the abdomen, and the gall bladder is dissected by special instruments. Eventually, the gall bladder is delivered through the umbilical puncture. This technique is considered now the standard technique for all cases.
SOURCE: DR. AYMAN SALEM'S BOOK
Copyright: Vascular Society of Egypt (www.vsegypt.org) &Medical Educational web (www.meduweb.com)
Not to be reproduced without permission of Vascular Society of Egypt