00:01
Okay, then, let's jump in immediately and start talking
about inflammation of the gallbladder or cholecystitis.
00:08
Most of the time, cholecystitis is going to
be due to gallstones.
00:11
It's a complication of those and their obstruction
of either the cystic duct or the common bile duct.
00:18
So, that would be calculus cholecystitis.
In the acute setting, you suddenly impact the ducts,
the cystic duct or common bile duct with the stone
and you get acute inflammation
with associated edema, dilation of the duct,
and there's intense pain.
00:38
You may have a more chronic slow motion
form of a calculus cholecystitis
where it's a little bit of obstruction
over and over and over again,
the associated inflammation with time can lead
to fibrosis of the gallbladder or the cystic duct.
00:53
And this is not associated with that
intense acute onset pain.
00:57
But there will be mechanical irritation
from the gallstones.
01:02
You may have small recurrent attacks of acute cholecystitis
that resolve but the ongoing inflammation
in the biliary tree
definitely increases the risk of malignancy,
either in the gallbladder or in the biliary ducts.
01:19
There is also acalculous cholecystitis.
So, acalculous meaning no stone.
01:24
The gallbladder inflammation in this case
is probably due to bile stasis
and then, that kind of stasis with or without kind of sludging, without a formal stone
may cause secondary ischemia.
01:37
This is usually in the chronically ill population.
It may also occur in immunocompromised hosts.
01:43
And so, someone who's been in the hospital
for a long time may develop symptoms
related to inflammation of the gallbladder.
Ultrasound may not find any stone.
01:54
The overall epidemiology of this.
So, in the same way that gallstones,
Choleliths were common in women,
occur in ages around 40 to 50.
02:04
Cholecystitis is also going to be more common in women
than in men with a peak incidence in the ages 40 to 50.
02:12
It doesn't occur just
because you have gallstones.
02:15
Only about 10% of patients who actually have gallstones
will develop either acute or chronic cholecystitis.
02:22
Other risk factors associated with cholecystitis,
inflammation of the gallbladder
include pregnancy or hormone therapy
that has to go along with the fact
that women get it more
commonly than men.
02:32
And this has to do with the effects of estrogen on the
production of bile salts versus conjugated bilirubin
and the relative levels of the different
constituents within the gallbladder.
02:43
So, it's all related mostly to cholelith formation.
Older age clearly is associated with this.
02:50
The Native American and Hispanic populations have a higher
incidence of choleliths otherwise, in any other setting,
and so, will have a higher incidence also
of cholecystitis and obesity and diabetes,
again, associated with the formation of stones,
so, that's going to be a risk factor for the inflammation associated with stones.
03:12
The pathophysiology overall,
so, in calculous cholecystitis,
not really a hard thing to understand.
Gallstones that form,
typically, within the gallbladder itself are -
move out into the cystic duct
and then, can block the biliary tree,
leading to distension and associated inflammation.
03:32
And it's shown here at the junction of the
cystic duct and the common bile duct.
03:36
But it can occur more distally
or more proximally.
03:41
In acalculous cholecystitis, there's
relative biliary stasis, no stone.
03:46
The gallbladder will be distended
as a result of that stasis.
03:50
And then, there's secondary vascular
compromise that leads to the inflammation.
03:56
Clinical presentation overall is going to be mostly pain
and it's going to be pain in the right upper quadrant.
04:02
So, you will have the patient describe
to you that I have this pain.
04:09
It's usually post-prandial, so, it's associated
with eating food. It can be prolonged for up to hours.
04:15
It's happening post-prandially because
that's when the gallbladder is ejecting its contents
or attempting to eject its contents
into the duodenum.
04:24
In particularly, in fatty meals which will cause
a greater contraction of the gallbladder
through the effects of cholecystokinin,
you will have more effects following a meal.
04:36
There may be radiation to the right scapula,
so, posterior and then, on the right side.
04:43
That's the so called Boas sign.
You may have pain during palpation.
04:49
That's a Murphy sign. So, you press
and it's like, "Oh, I don't like that."
You may also have a palpably enlarged gall bladder.
That's the Courvoisier sign.
04:58
So, all these signs that are classic.
They don't have to be present.
05:02
So, you need to have a reasonably high index
of suspicion in the appropriate patient
with the symptomatology of post-prandial pain
in the right upper quadrant.
05:12
There may be, depending, because
this is inflammation, there may be fever.
05:16
The kind of systemic manifestations.
And the patient won't feel like eating.
05:20
There may be nausea and vomiting.
Again, whenever you dilate a viscus
anywhere within the body, that is perceived
as pain and can drive nausea and vomiting.
05:33
Making the diagnosis. Laboratory tests will help
but they're not going to be that specific.
05:38
Imaging is going to eventually
make the appropriate diagnosis
but you may see elevations of bilirubin
and alkaline phosphatase.
05:45
And, again, alkaline phosphatase is a reasonably good biomarker
for obstruction anywhere within the biliary tree.
05:52
Notably, bilirubin and alk phos can be completely
normal in relatively uncomplicated cases.
05:58
So, you can't use that to
rule out cholecystitis.
06:02
Overall, the transaminases or the transferases
are not going to be particularly elevated.
06:07
There's not a lot of the hepatocyte damage.
There will be a leukocytosis because this is inflammation.
06:12
So, we will drive an elevated white cell
count, predominantly, neutrophils.
06:17
Ultrasound as I said, is going to be your test of choice.
So, you will see gallbladder wall thickening and edema.
06:23
That's an inflammation.
You may see dilated bile ducts
somewhere along the biliary tree, depending
on where the stone has impacted.
06:32
You will often be able to identify a stone or a sludge.
You can also see a sonographic Murphy's sign.
06:41
So, what that is remember,
Murphy's sign, positive Murphy's sign
is you palpate the right upper quadrant and they go "ouch".
Now, you do that with the sonograph
or with the echo probe and they go "ouch",
sonographic Murphy's sign.
06:56
That will make the diagnosis in the
vast majority of cases.
07:01
However, there can be equivocal
ultrasounds and in that case,
what we would do is an hepatobiliary
iminodiacetic acid HIDA scan.
07:11
A HIDA scan is a radiotracer and it's taken up
and metabolized in the same way that bile acids
or that bile precursors are in the liver and we
can watch as that radiotracer is metabolized by the liver
and then, accumulated within either the gallbladder
or following kind of squeezing of the gallbladder by meals
or whatever, you can see it eject into the
cystic duct and then, the common bile duct.
07:43
If you have abnormalities in terms of the formation of
the HIDA tracer through the liver and into the gallbladder
or if you have abnormal motion of the
radiotracer from the gallbladder
through the cystic duct and into the common
bile duct, that can be indicative
and is used as a diagnostic evaluation for
saying that there is then a cholecystitis.
08:10
Computer tomography overall can be used
but it's not going to be as useful.
08:15
And magnetic resonance,
cholangiopancreatography,
specifically, looking for areas of bile duct
thickening or inflammation may also be used.
08:30
How are we going to manage this?
So, in an initial setting before you call
your friendly neighborhood surgeon,
you're going to give analgesia, fluid hydration,
electrolyte correction, antiemetics
because they're vomiting, antibiotics
to cover then secondary bacterial infections in the setting of this inflammation.
08:48
Surgery is going to be what you need to do.
You have to do a cholecystectomy
and remove the gallbladder and that will
remove then the source of the inflammation
along with the presumed stone
that's going to be there.
09:04
You can do this as an endoscopic procedure,
the endoscopic retrograde cholangiopancreatography,
ERCP if there's a stone and you need to dilate
a duct, that may be a way to do this
but in general, I think that most patients
will probably end up going to surgery.
09:21
You may want to calm down an acute cholecystitis if it's
really hot, very inflamed, you may not operate immediately.
09:30
You'll give analgesia, fluid hydration, antiemetics
and antibiotics and wait for the thing to cool down.
09:36
And then, you'll go in and remove it.
09:39
The complications depending on the degree of
inflammation and necrosis and secondary infection, etc.
09:45
is that you can get emphysematous cholecystitis.
09:47
In fact, that's now the microorganisms
within the ascending bile
is become - start fermenting and you see air
within the wall of the gallbladder or the ducts.
10:03
That's a very bad sign.
You can get a gallstone ileus.
10:07
So, if gallstones make it into kind of the
distal part of the gall duct system,
then, you can get in the duodenum,
a secondary ileus.
10:23
So, the bowel will kind of quit functioning
and won't have its normal peristaltic motion.
10:28
You're going to have perforation of the gallbladder
with severe infection, inflammation, and ischemia.
10:34
Hepatic duct obstruction, so, within the portion
of the biliary tree within the hepatic, within the liver,
can become secondarily obstructive due
to edema and/or other inflammation.
10:51
The so called Mirizzi syndrome and clearly,
with ongoing inflammation,
particularly, with chronic cholecystitis,
you have an increased risk of malignancy, up to two-fold.
11:03
And that's another strong indication to
do the surgery and remove that tissue
before it develops cholangiocarcinoma.
With that, we've covered cholecystitis.