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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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2 Biliary System
Type Pathophysiology Radiology
37
Acute
calculous
cholecystitis
Chronic
calculous
cholecystitis
Unresolved blockage of the cystic duct by
gallstone➔stasis, pressure, infection, and
inammation
• Persistent pain, tenderness, and presence of
Murphy’s sign
Gray-scale ultrasound image of the gallbladder
demonstrates echogenic gallstones (arrow) with
posterior shadowing in a thick-walled
(arrowhead) gallbladder, highly consistent with
acute calculus cholecystitis
Recurrent attacks of biliary colic➔cause
inammation and scarring➔chronic
inammatory change
Acalculous
cholecystitis
Sagittal abdominal CT image with IV
contrast demonstrates a diffusely calcied
gallbladder (arrow) with partially calcied
calculi in the fundus (arrowhead), highly
consisted with chronic calculous cholecystitis
Gallbladder stasis and ischemia➔local
inammatory process in the gallbladder wall
• Occurs in critically ill patients, multiple organ
system failure, immunodeciency, diabetes,
trauma, burns, cardiogenic shock,
TPN➔secondary infection with enteric
pathogens is common
Gray-scale ultrasound image of the
gallbladder demonstrates a thick-walled
gallbladder (arrow) with trace pericholecystic
uid (arrowhead), no calculi were seen on
examination, consistent with acute acalculous
cholecystitis
38
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. H. Sohail et al.
Acute cholecystitis
Characteristics Inammation of the gallbladder that occurs due to occlusion of the cystic duct or impaired
emptying of the gallbladder
Presentation Right upper quadrant pain, epigastric pain, fever, nausea, vomiting, and/or jaundice
Pathogens Most common are Escherichia coli, Enterococcus, Klebsiella, and Enterobacter
Labs: Complete blood count, LFTs, and amylase/lipase
Physical exam: Positive Murphy’s sign
Complete blood count showing leukocytosis and polymorphonuclear leukocyte predominance
Liver function tests if elevated→raise concerns for cholangitis, choledocholithiasis, or Mirizzi
syndrome
Diagnosis
Amylase and lipase→if elevated→indicative of gallstone pancreatitis→MRCP or ERCP to clear
stone from CBD
Diagnostic
modality
Right upper
quadrant
ultrasound
CT scan of
abdomen
Characteristics Radiology
88% sensitivity, 80%
specicity for acute
cholecystitis→improved
diagnostic ability for
cholelithiasis
Non-mobile gallstones,
gallbladder wall
thickening, and
pericholecystic uid
Dilated CBD >6mm
indicates
choledocholithiasis
• Age over 60, add
1mm per decade to
normal CBD size
Not indicated for
diagnosis of acute
cholecystitis
94% sensitivity, 60%
specicity for acute
cholecystitis→
misses radiolucent
stones (isodense with
bile)
Provides superior
anatomic information
Gray-scale ultrasound image of the gallbladder
demonstrates a thick- walled gallbladder (arrow)
with pericholecystic uid (arrowhead), consistent
with acute cholecystitis. Note dependent sludge in
the gallbladder
(A) Coronal and (B) axial abdomen CT images with
IV contrast demonstrate soft-tissue attenuating
biliary sludge (arrow) in a dilated CBD.Intrahepatic
pneumobilia (arrowhead) is seen on the axial image,
raising concerns for cholangitis.
2 Biliary System
Acute cholecystitis
HIDA scan
97% sensitivity, 90%
specicity for acute
cholecystitis
Allows identication of
bile ow (failure of
gallbladder to
ll→demonstrates
obstruction of cystic
duct→diagnoses
cholecystitis)
Morphine increases
sphincter of Oddi
pressure allowing
adequate back pressure
for tracer to enter cystic
duct
Identies bile leak
Determines gallbladder
function (dyskinesia or
hyperkinesia) via the
physiologic ejection of
the gallbladder if biliary
dyskinesia is suspected
→Normal EF 35–80%
39
AP hepatobiliary scan images at (A) 60 mins and
(B) 18hours following 4.4mCi Tc-99m mebrofenin
injection demonstrate no radiotracer uptake in the
gallbladder, consistent with acute cholecystitis. Note
the liver (L) and bowel uptake (arrows)
40
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Acute cholecystitis
Case Management
A. H. Sohail et al.
Management
Healthy patient
with acute
cholecystitis
Patient with acute
cholecystitis+very
high operative risk
Patient with high
likelihood of
choledocholithiasis
and acute
cholecystitis
Patient with acute
acalculous
cholecystitis
without evidence
of perforation or
necrosis
Management of cholecystitis according to Tokyo guidelines
Grade Characteristics Management
Grade I Inammatory changes
Grade II Leukocytosis
Laparoscopic cholecystectomy+antibiotics to cover gram-negative rods and
anaerobes
Percutaneous cholecystostomy tube+antibiotics to cover gram-negative rods
and anaerobes
Antibiotics to cover gram-negative rods and anaerobes
ERCP then laparoscopic cholecystectomy
Or
Laparoscopic cholecystectomy+IOC/CBDE
Percutaneous cholecystostomy tube
placement (see cholecystostomy tube
placement chart for alternate options)
Early laparoscopic cholecystectomy is the rst-line
of the gallbladder
Palpable tender mass
Marked local
inammation on
imaging
No organ dysfunction
treatment
Usually accompanied by severe local
inammation→surgeons should take the difculty
of cholecystectomy into consideration
Grade III Grade I and Grade II
ndings +organ
dysfunction
(hypotension,
respiratory failure,
kidney injury,
coagulopathy, mental
status changes)
Organ support+cholecystostomy tube
2 Biliary System
Research review
41
Reference Findings
Roulin D, Saadi A, Di Mare L, Demartines N,
Halkic N.Early versus delayed cholecystectomy
for acute cholecystitis, are the 72hours still the
rule?: a randomized trial. Ann Surg.
2016;264(5):717–22
Blohm M, Österberg J, Sandblom G, Lundell L,
Hedberg M, Enochsson L.The sooner, the better?
The importance of optimal timing of
cholecystectomy in acute cholecystitis: data from
the National Swedish Registry for Gallstone
Surgery, GallRiks. J Gastrointest Surg.
2017;21(1):33–40
Brooks KR, Scarborough JE, Vaslef SN, Shapiro
ML.No need to wait: an analysis of the timing of
cholecystectomy during admission for acute
cholecystitis using the American College of
Surgeons National Surgical Quality Improvement
Program database. J Trauma Acute Care Surg.
2013;74(1):167–74
This is a randomized clinical trial of 86 patients that found
no difference in surgical complications after an early
laparoscopic cholecystectomy compared with a delayed
cholecystectomy that included a period of antibiotics
The complication rate was 15% versus 17% in the delayed
group, with one bile duct injury in the delayed group
22% of patients were readmitted during the period of
treatment with antibiotics, and 3 patients (7%) failed initial
antibiotic therapy
➔Results from this study suggest the safety and
appropriateness of an early laparoscopic cholecystectomy
even in patients presenting more than 72h after onset of
illness
The optimal timing of cholecystectomy for patients with
acute cholecystitis seems to be within 2days after
admission but optimize patient before operating
Patients who underwent operation later during admission
were more likely to require an open procedure and sustained
signicantly longer postoperative and overall lengths of
hospitalization even in the patients who are higher risk
subgroup
Dimou FM, Adhikari D, Mehta HB, Riall
TS.Outcomes in older patients with grade III
cholecystitis and cholecystostomy tube placement:
a propensity score analysis. J Am Coll Surg.
2017;224(4):502–11.e1
This is a retrospective cohort study using Medicare
enrollment and claims data looked at patients admitted with
acute cholecystitis and organ failure (grade III), comparing
those managed with cholecystostomy with those who did not
have cholecystostomy (58% of whom had cholecystectomy
during the index admission).
They found that in-hospital mortality was similar, but the
odds of 30- and 90-day mortality were signicantly higher in
patients who underwent cholecystostomy
42
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Complications of cholecystitis and their management
Complications Characteristic Management
A. H. Sohail et al.
Complicated
cholecystitis
Progression of acute cholecystitis to gangrenous,
emphysematous, hemorrhagic or perforated
cholecystitis
Concerning signs and symptoms include age
older than 45, gallbladder thickness >4.5mm,
WBC>15,000/mm3, diabetes mellitus, and male
sex
Concerning signs on imaging: (can be seen on
ultrasound or CT scan) intraluminal or intramural
gas, irregular gallbladder wall, gallbladder abscess,
and absence of part or the entire gallbladder wall
Axial abdominal CT image with IV contrast
demonstrates gas within the gallbladder wall
(arrow) and hyperattenuating material in the lumen
which could represent hemorrhage or sludge. Bile
is seen outside of the gallbladder lumen
(arrowhead), indicating gallbladder wall
perforation. These ndings are diagnostic of
gangrenous cholecystitis
Laparoscopic cholecystectomy
May require conversion to open for
truly gangrenous disease
2 Biliary System
Complications of cholecystitis and their management
Complications Characteristic Management
43
Cholangitis Due to an acute, ascending bacterial infection of
the biliary tree caused by an obstruction (stones or
neoplasm)
See table for management of cholangitis
Coronal HASTE MR image without IV contrast
and (B) axial VIBE MR image with IV contrast
demonstrate a 7mm obstructing common bile duct
calculus (arrow on A) with enhancement of the
biliary system (arrowheads on B), concerning for
cholangitis
44
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Complications of cholecystitis and their management
Complications Characteristic Management
A. H. Sohail et al.
Gallstone ileus Caused by obstruction of the intestinal lumen from
a gallstone
A large stone in the dependent portion of the
gallbladder➔stulize into the adjacent duodenum
passes directly into the intestine
Coronal abdominal CT image with IV contrast
demonstrates multiple gallstones (arrow) in a
dilated duodenum, indicating gallstone ileus. Note
the partially visualized cholecystostomy tube
(arrowhead) and hepatic abscess (outlined arrow)
Create an enterotomy at a healthy
portion of small bowel and milk the
stone out proximally
Create the enterotomy longitudinally
and subsequently close it transversely
once the stone is extracted
Palpate bowel for additional stones
(most recurrences of gallstone ileus
occur within 3months and are due to
stones missed during the initial
operation)
If bowel necrosis is present➔ileocecal
resection
Interval cholecystectomy and takedown
of the cholecystoduodenal
stula➔should not be done at the
index operation
Gallstone pancreatitis
40% of pancreatitis cases in USA
Gallstones can obstruct the ampulla of Vater➔impaired extrusion of zymogen granules and
Characteristics
Management
activation of degradation enzymes➔pancreatic auto-digestion
Pancreatic injury is the result of excessive pressure inside the pancreatic duct
If persistent biliary obstruction➔ERCP for patients who develop cholangitis and those with
persistent bile duct obstruction
Cholecystectomy should be performed during the index admission after symptoms have
resolved—If uncomplicated pancreatitis without necrosis/abscess/pseudocyst/shock
If cholecystectomy does not take place➔25% recurrence rate of pancreatitis within 3months
2 Biliary System
Research
45
Reference Findings
Stevens CL, Abbas SM, Watters DA.How does
cholecystectomy inuence recurrence of idiopathic
acute pancreatitis? J Gastrointest Surg.
2016;20(12):1997–2001
The decision to operate versus observe is based on a
three-fold incidence of recurrent pancreatitis with
observation versus patients undergoing cholecystectomy
Acute acalculous cholecystitis
Severe inammation of the gallbladder without an obstructing stone
Characteristics
Risk factors TPN, critically ill patients, multiple organ system failure, immunodeciency, diabetes,
Presentation Presentation can be nonspecic
Diagnosis Ultrasound ndings: Distended gallbladder with thickened wall and pericholecystic
Management Percutaneous cholecystostomy is the preferred treatment option
Usually seen in critically ill patients
High risk of morbidity and mortality➔secondary infection with enteric pathogens is
common
trauma, burns, and cardiac conditions
Right upper quadrant pain/tenderness, fever, sepsis
uid
Research
Reference Findings
Treinen C, Lomelin D, Krause C, Goede M,
Oleynikov D.Acute acalculous cholecystitis in the
critically ill: Risk factors and surgical strategies.
Langenbecks Arch Surg. 2015;400(4):421–7
This review examined the three common surgical treatments
for acute acalculous cholecystitis: Open cholecystectomy,
laparoscopic cholecystectomy, or percutaneous
cholecystostomy
They found out that laparoscopic cholecystectomy is
effective in treating acute acalculous cholecystitis when the
risks of general anesthesia and the chance for conversion to
open cholecystectomy are low
46
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Functional Biliary Disorders
Functional biliary disorders
Most common in patients between age 20 and 50
Characteristics
More common in women than in men
A. H. Sohail et al.
Functional
biliary
Includes both functional gallbladder dysfunction and sphincter of Oddi dysfunction (ampullary
stenosis, papillary stenosis, and ampullary spasm)
disorders
Sphincter of Oddi consists of sphincter of
the common bile duct, sphincter of
pancreatic duct, and an ampullary
sphincter
Common
bile duct
Sphincter of Oddi function:
Sphincter of
Oddi
• Regulates the ow of bile and pancreatic
secretions into the duodenum
• Prevents reux from the duodenum into
the bile/pancreatic duct
• Regulates lling of the gallbladder
Opiates➔induce sphincter of Oddi
Sphincter
of the
common
bile duct
Sphincter
of ampulla
Pancreatic
duct
Sphincter
of the
pancreatic duct
contraction
Glucagon, cholecystokinin, and
secretin➔decreases sphincter of Oddi
Sphincter of oddi complex
basal pressure
Presentation Biliary pain (recurrent and intermittent right upper quadrant pain) that occurs in the presence of
an intact gallbladder without gallstones
Patients with biliary pain who have both dilated bile ducts+abnormal liver function tests➔not
considered to have a functional issue
Patient with biliary pain, elevated liver enzymes or bile duct dilation (but not both), and an
Rome III
criteria
absence of bile duct stones or other structural abnormalities➔considered to have functional
issue: Sphincter of Oddi dysfunction
Patients with biliary pain and no duct dilation and no serologic abnormalities➔not considered to
have functional issue
Diagnosis of functional pancreatic sphincter of Oddi dysfunction requires documented acute
recurrent pancreatitis, exclusion of all other etiologies for pancreatitis, exclusion of structural
abnormalities, and abnormal pancreatic sphincter pressures on manometry
Patient must have episodes of duration lasting at least 30minutes; episodes occurring at different
intervals; and crescendo pain that is not relieved by bowel movements, postural change, or
antacids
Exclusion of other structural disease that would explain symptoms should be excluded before
diagnosis
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