ACUTE CHOLECYSTITIS

ETIOPATHOGENESIS
1. ACUTE CALCULUS CHOLECYSTITIS-
90% OF CASES -
OBSTRUCTION IN THE NECK OF THE
GALL BLADDER OR IN THE CYSTIC
DUCT BY A GALL STONE –
DISTENTION – ACUTE INFLAMATION-
SECONDARY BACTERIAL INFECTION
 ACUTE ACALCULOUS
CHOLECYSTITIS

10% OF CASES-
BURNS,DEHYDRATION,,SEVERE
SEPSIS,RECENT
CHILDBIRTH,TORTION OF GALL
BLADDER, DIABETES MELLITUS.
RARELY PRIMARY BACTERIAL
INFECTION.
 PATHOLOGY
MORPHOLOGY IS SAME IN BOTH
TYPES EXCEPT FOR PRESENCE &
ABSENCE OF GALL STONES
GROSS- GALLBLADDER IS DISTENDED
& TENSE

SEROSA- FIBRINOUS EXUDATE

MUCOSA-BRIGHT RED.
LUMEN – PUS MIXED WITH BILE
ACUTE CHOLECYSTITIS
 PATHOLOGY
CALCULOUS TYPE-
STONE IMPACTED IN THE NECK OR
CYSTIC DUCT.
EMPYEMA OF THE GALL BLADDER.
 PATHOLOGY

MICROSCOPY-OEDEMA,
CONGESTION,ACUTE INFLAMMATORY
EXUDATE,GANGRENOUS
NECROSIS(GANGRENOUS
CHOLECYSTITIS)
ACUTE CHOLECYSTITIS
ACUTE CHOLECYSTITIS
CLINICAL FEATURES OF ACUTE
CHOLECYSTITIS

SEVERE PAIN IN THE UPPER ABDOMEN

WITH FEATURES OF

GAURDING,HYPERAESTHESIA,
CLINICAL FEATURES OF ACUTE
CHOLECYSTITIS

TENDER PALPABLE GALLBLADDER

FEVER, LEUKOCYTOSIS

NEUTROPHILIA,SLIGHT JAUNDICE
CLINICAL FEATURES OF ACUTE
CHOLECYSTITIS

PROGNOSIS-
EARLY CHOLECYSTECTOMY-
LESS THAN 0.5% MORTALITY& RISK OF
COMPLICATIONS-
PERFORATION ,
BILIARY FISTULA,
RECURRENT ATTACKS &
ADHESIONS IS AVOIDED
 COMPLICATIONS

PERFORATION ,
BILIARY FISTULA,
RECURRENT ATTACKS &
ADHESIONS IS AVOIDED
 CHRONIC CHOLECYSTITIS
• ETIOPATHOGENESIS
• MIXED& COMBINED GALL STONES IS
ALWAYS PRESENT.
• SUPERSATURATION OF THE BILE
WITH CHOLESTEROL PREDISPOSED
TO BOTH GALLSTONE &
INFLAMMATION.
CHRONIC CHOLECYSTITIS

IN SOME CASES REPEATED ATTACKS

OF MILD ACUTE CHOLECYSTITIS
RESULT IN CHRONIC CHOLECYSTITIS
 PATHOLOGY

GALLBLADDER- NORMAL OR
ENLARGED OR CONTRACTED
WALL IS THICKED & GREY WHITE DUE
TO DENCE FIBROSIS & EVEN
CALCIFIED -
(PORCELAIN GALLBLADDER)
CHRONIC CHOLECYSTITIS
CHRONIC CHOLECYSTITIS
AND CHOLELITHIASIS
CHRONIC CHOLECYSTITIS AND
CHOLELITHIASIS
CHRONIC CHOLECYSTITIS
AND CHOLELITHIASIS
 PATHOLOGY

MUCOSA-
FLATTENED ,ATROPHIED
LUMEN CONTAINS MULTIPLE MIXED &
COMBINED STONES.
CHRONIC CHOLECYSTITIS
CHRONIC CHOLECYSTITIS

MICROSCOPY-
ATROPHIC MUCOSA
PENETRATION OF THE MUCOSA DEEP
INTO THE WALL OF THE
GALLBLADDER- ROKITANSKY-
ASCHOFF SINUSES
CHRONIC CHOLECYSTITIS

CHRONIC INFLAMMATION
THROUGHOUT THE WALL
VARIABLE DEGREE OF FIBROSIS
 CHRONIC CHOLECYSTITIS
ROKITANSKY- ASCHOFF SINUSES
 CHRONIC CHOLECYSTITIS
ROKITANSKY- ASCHOFF SINUSES
 CLINICAL FEATURES OF
CHRONIC CHOLECYSTITIS

FAT ,FERTILE,FEMALE OF FORTY OR

FIFTY WITH EPIGASTRIC
DISCOMFORT ESPECIALLY AFTER A
FATTY MEAL
• CONSTANT DULL ACHE IN THE RIGHT
HYPOCHONDRIUM & EPIGASTRIUM &
TENDERNESS OVER THE RIGHT
UPPER ABDOMEN.
 CLINICAL FEATURES OF
CHRONIC CHOLECYSTITIS

• NAUSEA & FLATULENCE ARE

COMMON.OCCATIONALLY BILIARY
COLIC.
• ULTRASOUND,CT,MRI
 CARCINOMA OF THE
GALLBLADDER

• INCIDENCE-MORE FREQUENT IN
FEMALES,7TH DECADE
• USUALLY SLOW GROWING,MAY
REMAIN UNDETECTED UNTIL THE
TIME IT IS WIDELY SPREAD &
RENDERED INOPERABLE.
 ETIOLOGY OF CARCINOMA
GALLBLADDER

1. CHOLELITHIASIS &
CHOLECYSTITIS_ FOUND IN 75% OF
CASES.PORCELLAIN GALLBLADDER
IS PERTICULARLY PRONE TO
DEVELOP CANCER
 ETIOLOGY OF CARCINOMA
GALLBLADDER

2.CHEMICAL CARCINOGENS
STRUCTURALLY SIMILAR TO BILE
ACIDS- METHYLE CHOLANTHRENE,
NITROSAMINES
PESTICIDES,WORKERS ENGAGED IN
RUBBER INDUSTRY.
 ETIOLOGY OF CARCINOMA
GALLBLADDER

3.PREVIOUS SURGERY ON
BILIARY TRACT.
4.INFLAMMATORY BOWEL
DISEASE
 PATHOLOGY
SITES-
COMMON SITE IS THE FUNDUS
FOLLOWED INFREQUENCY BY NECK
OF THE GALLBLADDER.
 PATHOLOGY
GROSS –
1.INFILTRATING TYPE-
IRREGULAR AREA OF DIFFUSE
THICKENING & INDURATION OF THE
GALLBLADDER WALL, IT MAY HAVE
DEEP ULCERATION,WALL IS FIRM.
 GROSS

2.FUNGATING TYPE-

IRREGULAR FRIABLE PAPILLARY OR

CAULIFLOWER LIKE GROWTH
PROJECTING INTO THE LUMEN OR
INFILTRATING INTO THE WALL &
BEYOND.
 MICROSCOPY

90% ADENOCARCINOMAS
WELL DIFFERENTIATED TO POORLY
DIFFERENTIATED, PAPILLARY.
MOST ARE NONMUCIN SECRETING ,
SOME ARE COLLOID TYPE.
 MICROSCOPY

5%- SQUAMOUS CELL

CARCINOMAS,ADENOSQUAMOUS
CELL CARCINOMAS
CARCINOMA GALLBLADDER
 GALLBLADDER
ADENOCARCINOMA
 GALLBLADDER
ADENOCARCINOMA
METASTATIC GALLBLADDER CARCINOMA -
SKULL AND FEMURS
 CLINICAL FEATURES OF
CARCINOMA GALLBLADDER

SLOW GROWING ,CAUSES

SYMPTOMES LATE IN THE
COURSE OF THE DISEASE.
 CLINICAL FEATURES OF
CARCINOMA GALLBLADDER

OFTEN DIAGNOSIS IS MADE

WHEN GALLBLADDER IS
REMOVED FOR CHOLELITHIASIS
 CLINICAL FEATURES OF
CARCINOMA GALLBLADDER

SYMPTOMATIC CASES HAVE PAIN

JAUNDICE,MASS ,ANOREXIA &
WHEIGHT LOSS.
BY THIS TIME ,GROWTH HAS ALREADY
SPREAD LOCALLY & HAS
METASTASIZED-REGIONAL LYMPH NODES,
LUNG ,PERITONEUM,GIT,BONE
 GALLSTONES
( CHOLELITHIASIS )

FORMED FROM CONSTITUENTS OF

BILE- CHOLESTEROL,BILE PIGMENTS
& CALCIUM SALTS ALONG WITH
OTHER ORGANIC COMPONENTS.
 GALLSTONES
( CHOLELITHIASIS )

• 4Fs
FEMALE
FAT
FERTILE
FORTY
 RISK FACTORS

1.GEOGRAPHIC FACTORS

QUITE PREVALENT IN ENTIRE

WESTERN WORLD
BLACKS AND EASTERN WORLD ARE
RELATIVELY FREE
 RISK FACTORS

2.GENETIC FACTORS-
FIRST DEGREE RELATIVES – HAVE
INCREASED SECRETION OF DIETARY
CHOLESTEROL IN BILE
 RISK FACTORS

3.AGE- STEADY INCREASE WITH

ADVANCING AGE .PRESENT AT 50s &
60s.
4.SEX- F:M = 2:1 ESPECIALLY IN
MULTIPAROUS WOMEN.
 RISK FACTORS FOR
CHOLELITHIASIS
• 5. DRUGS –
WOMEN ON OESTROGEN THERAPY
OR ON BIRTH CONTROL PILLS HAVE
HIGHER INCIDENCE.- DUE TO
PRODUCTION OF LITHOGENIC BILE-
CHOLESTATIC EFFECT OF
OESTROGEN.
 RISK FACTORS FOR
CHOLELITHIASIS

6.GIT DISEASES –
CROHN’S DISEASE, ILEAL
RESECTION, ILEAL BYPASS
SURGERY- INTERFERE WITH
ENTEROHEPATIC CIRCULATION.
 RISK FACTORS FOR
CHOLELITHIASIS

FACTORS IN PIGMENT GALLSTONES-

HAEMOLYTIC
ANAEMIAS,HEPATOCELLULAR
DISEASE,CIRRHOSIS.
 PATHOGENESIS

1.PATHOGENESIS OF
CHOLESTEROL,MIXED GALL STONES
& BILIARY SLUDGE
CHOLESTEROL IS INSOLUBLE IN
WATER.CAN BE SOLUBALISED BY
ANOTHER LIPID.
 PATHOGENESIS

CHOLESTEROL &
PHOSPHOLIPID(LECITHIN)
ARE SECRETED INTO BILE AS
BILAYERED VESICLES & ARE
CONVERTED INTO MIXED MISCELLES
BY BILE ACIDS.
 PATHOGENESIS

IF THERE IS EXCESS OF
CHOLESTEROL CHOLESTEROL RICH
VESICLES REMAIN BEHIND TO FORM
CHOLESTEROL CRYSTALS.
 PATHOGENESIS OF
CHOLELITHIASIS

1. SUPERSATURATION OF BILE –
A. INCREASED SECRETION OF
CHOLESTEROL IN THE PRESENCE OF
NORMAL BILE ACIDS & LECITHIN.
 PATHOGENESIS OF
CHOLELITHIASIS

B.REDUCED BILE ACID POOL,

C.INCREASED CONVERSION OF
CHOLIC ACID TO DEOXYCHOLIC ACID-

B & C FAVOUR HYPERSECRETION

OF CHOLESTEROL
 PATHOGENESIS OF
CHOLELITHIASIS

2.CHOLESTEROL NUCLEATION

BY CHOLESTEROL MONOHYDRATE
WITH PRONUCLEATING FACTORS
LIKE MUCIN & NONMUCIN
GLYCOPROTEINS.
 PATHOGENESIS OF
CHOLELITHIASIS

ANTINUCLEATING FACTORS ARE

APOLIPOPROTEINS
AI & AII
 PATHOGENESIS OF
CHOLELITHIASIS

• 3.GALLBLADDER HYPOMOTILITY-

DECREASE IN CHOLECYSTOKININ
RECEPTORS IN THE GALLBLADDER-
STASIS- BILIARY SLUDGE &
LITHOGENESIS
 PATHOGENESIS OF PIGMENT
STONES

1. CHRONIC HAEMOLYSIS- INCREASED

LEVEL OF UNCONJUGATED
BILIRUBIN IN THE BILE.
2.ALCOHOLIC CIRRHOSIS
 PATHOGENESIS OF PIGMENT
STONES

3.CHRONIC BILIARY TRACT

INFESTATION BY PARACYTES
4.GENETIC FACTORS
 TYPES OF GALLSTONES

3 MAJOR TYPES
PURE GALLSTONES,
MIXED GALLSTONES,
COMBINED GALLSTONES
 PURE GALLSTONES-

3TYPES-
1. PURE CHOLESTEROL STONES
2. PURE PIGMENT STONES
3.PURE CALCIUM CARBONATE
STONES
 PURE CHOLESTEROL STONES

• SOLITARY ,OVAL ,FAIRLY LARGE-3cm OR

MORE,SMOOTH,HARD,WHITISH YELLOW
,GLISTENING
• CUT SURFACE RADIATING GLISTENING
CRYSTALS-MUCOSAL MACROPHAGES IN
THE GALLBLADDER CONTAIN
CHOLESTEROL(CHOLESTEROLOSIS)
• RADIOLUCENT
PURE CALCIUM CARBONATE
GALLSTONES

RARE,
MULTIPLE GREY WHITE
SMALL,FACETED ,HARD
NO CHANGE IN THE
GALLBLADDER WALL
 PURE PIGMENT STONES
COMPOSED OF BILE PIGMENT-
CALCIUM BILIRUBINATE
MULTIPLE,JET BLACK,SMALL LESS
THAN 1cm,HAVE MULBERRY LIKE
EXTERNAL SURFACE,SOFT &
FRIABLE
NO CHANGE IN THE GALLBLADDER
WALL.
 MIXED GALL STONES
80% OF GALLSTONES

CONTAIN MORE THAN 50%

CHOLESTEROL MONOHYDRATE PLUS
CALCIUM SALTS,BILE
PIGMENTS,&FATTY ACIDS.
 MIXED GALL STONES
• ALWAYS
MULTIPLE,MULTIFACETED,VARY IN
SIZE FROM A SAND GRAIN TO 1cm OR
MORE.
• ON SECTION –LAMINATED
ALTERNATING DARK PIGMENT LAYER
 MIXED GALL STONES
• PALE WHITE LAYER OF
COMBINATION OF
PIGMENT,CHOLESTEROL, CALCIUM
CARBONATE LAID DOWN IN LAYERS
AT DIFFERENT TIMES
• ALWAYS ACCOMPANIED BY CHRONIC
CHOLECYSTITIS
COMBINED GALLSTONES

10% OF GALLSTONES
SOLITARY, LARGE,SMOOTH SURFASED.
IT HAS A PURE GALLSTONE NUCLEUS &
OUTER SHELL OF MIXED GALLSTONE OR
MIXED GALLSTONE NUCLEUS WITH PURE
GALLSTONE SHELL- ASSOCIATED WITH
CHRONIC CHOLECYSTITIS
GALLSTONES
CLINICAL MANIFESTATIONS

50% - NO SYMPTOMS-DIAGNOSED BY
CHANCE DURING INVESTIGATION
FOR SOME OTHER CONDITION.

SYMPTOMS APPEAR WHEN

COMPLICATIONS DEVELOP
 COMPLICATIONS

1. CHOLECYSTITIS-
TYPICAL BILIARY COLIC
PRECIPITATED BY FATTY
MEAL,NAUSEA ,VOMITING ,FEVER
WITH LEUKOCYTOSIS & HIGH SERUM
BILIRUBIN.
 COMPLICATIONS

2.CHOLEDOCHOLITHIASIS-

STONES PASSED DOWN INTO

THE EXTRAHEPATIC BILIARY
PASSAGES – PAIN &
OBSTRUCTIVE JAUNDICE.
 COMPLICATIONS OF
GALLSTONES

3. MUCOCELE OR HYDROPS OF THE

GALLBLADDER-

STONES IN THE NECK OF THE

GALLBLADDER- DISTENDED
GALLBLADDER CONTAINING CLEAR
WATERY OR MUCINOUS SECRETION
 COMPLICATIONS OF
GALLSTONES

4.BILIARY FISTULA-

RARE BETWEEN BILIARY

SYSTEM & BOWEL OR THE
SKIN.
 COMPLICATIONS OF
GALLSTONES

5.GALL STONE ILEUS-

GALLSTONE IN THE INTESTINE-
INTESTINAL OBSTRUCTION.

6.CARCINOMA GALLBLADDER.