Chronic cholecystitis treatment

ITS A LONG STANDING SWELLING AND IRRITATION OF GALL BLADDER

TREATMENT
NON SURGICAL TREATMENT  
Analgesics may be given for pain .Severe pain require opiates ,which is given along with hyoscine butylbromide ( to counteract spasm of sphincter of Oddi ).Ptient should be put on low-fat diet until cholecystectomy.
MEDICAL DISSOLUTION OF GALL STONES
Gall stone can be dissolved as long as they are radiolucent and gall bladder is functioning.Some drugs can work such as bile acids ,chenodeoxycholic acid .Ursodeoxycholic acid .
EXTRACORPOREAL LITHOTRIPSY 
Extracorporeal shock wave lithotripsy can disrupt gall stones and allow debris to pass into bile duct and beyond. It is suitable for patients with 1-3 stones in a functioning gall bladder.
SURGICAL TREATMENT
Prophylactic antibiotics e.g. 2nd generation cephalosporin should be given.Premedications.provision is made for peroperative cholangiography.

LAPAROTOMY  
Give incision in right paramedian or right subcostal incision ( Kocher's incision ) and examine all abdominal organs .inclding gall bladder.

CHOLECYSTECTOMY 
Isolate the gall bladder area with packs .Aspirate the gall bladder if it greatly distend through fundus via trocar and cannula attached to a suction apparatus.Grasp the neck of gall bladder with sponge-holding forceps.Display the junction of cystic ,common hepatic and bile ducts via dissection and identify cystic artery and its relation to common hepatic duct .Cholangiography is performed ,to confirm the anatomy of biliary tree and to check for stones in main duct .Ligate the cystic duct and then divide it .Dissect the gall bladder from its bed ,rom below and upwards .dividing the peritoneum on gall bladder. Secure hemostasis and close the abdominal wall.Drainage is not mandatory ,if used ,it should be a 3mm closed suction drain.

WITH SEVERE INFLAMMATION IN CALOT'S TRIANGLE  
Open the gall bladder ,extractall stones and bile ,and excise as much of wall of gall ladder as possible.Cystic duct opening is closed by cargut suture from within .An alternative is cholecystostomt.

OTHER SURGICAL TECHNIQUES
CHOLECYSTOSTOMY
PERCUTANEOUS CHOLECYSTOLITHOTOMY
LAPAROSCOPIC CHOLECYSTECTOMY
MINICHOLECYSTECTOMY …..... read more

Gall bladder disease symptoms or chronic cholecystitis

PROLONG FASTING AND OLDER AGE WITH GALL STONES

CAN PRECIPITATE GALL BLADDER DISEASE SYMPTOMS

CHRONIC CHOLECYSTITIS   is invariably associated with gall stones.It may develop after repeated episodes of acute cholecystitis but more often develop insidiously without any precedind clinically evident acute attacks .The gall bladder wall becomes thickened by fibrosis and relatively indistensible .The gall bladder wall is infiltrated with chronic inflammatory cells ,lymphocytes ,plasma cells and macrophages.Glandular outpouchings are formed by the lining of the mucosa and are known as Aschoff - Rokitansky sinuses. If obstructive jaundice occurs ,it is due to a stone impacted in the common bile duct.

The gall bladder does not usually distend ,as the wall is relatively rigid due to fibrosis consequent on the associated chronic cholecystitis.Mucocele ,this ocurrs when a stone impacts in the neck of the gall bladder in the absence of infection in the bile.The bile is absorbed from the gall bladder,and  mucus is secretedinto it from the mucus secreting cells of the epithelium.The lack of inflammation in the wall allowsthe gall bladder to distend to several times its normal size.The gall bladder is usually palpable below the costal margin.The wall of a mucocele is usually very thin and is easily ruptured at surgery.cholestrolosis ,this is a condition where  lipid laden macrophages accumulate in the gall bladder mucosa to produce yellowish flecks in a reddish mucosa ,appearing  like the surface of a strawberry - hence the alternative name " strawberry  gall bladder " .This is often a symptomless condition but may accompany or pedispose to cholestrole stones.

SYMPTOMS AND SIGNS  

May be asymptomatic for years,may progress  to symptomatic gall bladder disease or to acute cholecystitis ,or present with complications.PAIN in right hypochondrium ,radiate between shoulder blades is frequent .it can occur after eating but not so closely related as peptic ulcer.It begins gradually 15 - 30 minutes after meal and last for 30 -90 minutes ,its duration is several hours ,but it must be less than 12 hours.severity is varying from mild to excruciating .it can precipitated by taking fatty foods,and relieved by analgesic drugs ,associated with nausea and vomiting .

FLATULENT DYSPEPSIA it is a feeling of fullness after food associated wih belching and heartburn.It is brought on by a large or a fatty meal.

TENDERNESS present in  the right hypochondrium ,just below the tip of 9th rib where edge of rectus abdominus muscle crosses the costal margin ( gall blader  point ) .

MURPHY's SIGN  may be positive .This is elicited  by asking the patient to breathe in whilst gently pressing the gall bladder point with your thumb pointing towards feet , Patient will experience pain and catch her breath just before the zenith of inspiration.

DIAGNOSTIC INVESTIGATIONS

PLAIN X-RAY ABDOMEN show radio opaque gall stones.


ORAL CHOLECYSTOGRAPHY ( OCG ) presence of gall stones can be detected ( filling defects )

ULTRASONOGRAPHY demonstrates gall stones , as well as biliary calculi and dilatation of biliary tree.

CT SCAN useful for patients in whom U/S is difficult e,g. obese or those with excessive bowel gas.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY ( PTC ) or PEROPERATIVE 
CHOLANGIOGRAPHY to detect associated duct stones....... read more

Gall stones(cholelithiasis)-Gall bladder problems common in women eat high fibre diet for prevention

PATHOLOGICAL CONDITIONS OF THE GALL BLADDER ARE COMMON SURGICAL PROBLEMS....

GALL STONES ( CHOLELITHIASIS )

In medicine, gallstones (choleliths) are crystalline bodies formed within the embody by increment or concretion of normal or deviant bile components.In 80% of patients gall stones are composed predominantly of cholesterol with smaller amounts of calcium salts and bile pigments . They are referred to as mixed stones , are usually multiple with a faceted surface , and have a characteristic laminated surface on cross section. Only about 10 % of them contain sufficient calcium to be visible on a plain X-ray .Pure cholestrol stones form less than 10% of stones .They are usually solitary ( the cholestrol " solitaire " ) up to 5 cm in diameter ,and have a characteristic radial arrangement of crystals on cross section . Cholestrol stones usually form in bile which is supersaturated with cholestrol. When bile contains more cholestrol than can be solublised in the bile- acid -lecithin micelles ,crystals of cholestrol form in the bile .

The greater the concentration of bile acids and lecithin in bile ,the greater is the amount of cholestrol that can be contained in the mixed micelles .Lecithin is important because lecithin - cholestrol mixed micelles can solubilise more cholestrol than can micelles of bile acids alone .Following Crohn's disease of the terminal ileum or ileal resection thebile salt pool is reduced because of lack of absorption of bile salts ,and the liver can not make good the losses .

Such patients are prone to cholestrol stones. Oestrogen increases the hepatic synthesis of cholestrol ,and this may explain why females of child - bearing age have a higher incidence of cholestrol stones . A high animal fat ,low fibre diet is also associated with cholestrol stones because of excretion in bile of the excess cholestrol absobed from the gut.Clofibrate , a cholestrol-lowering agent ,has been implicated in cholestrol stone formation ,because it increases excretion of cholestrol in the bile . Decreased gall bladder motility probably plays a rle in aetiology of gall stones .

Cholestrol and other substances which form the nuclei for gall stone formation must remain in the gall bladder long enough for crystal growth to occur .Stasis occurs during pregnancy due to the smooth muscle relaxing effect of progesterone.Motility of the gall bladder is also decreased during starvation and total parenteral nutrition , due to decreased stimulation of the gall bladder by CCK.Stones may also form after vagotomy ,because of lack of vagal potentiation of CCK.Bile pigment stones account for about 10 % of stones in the UK.The major constituent is the calcium salt of unconjugated bilirubin.

They are associated with chronic haemolytic disease where there is breakdown of red cells with release of excessive bilirubin.Pure pigment stones occur in sickle cell disease , thalassaemia and hereditary spherocytosis .Pigment stones are found in the Far East ,where they are associated with biliary tract infection with E.coli and Bacteroides fragilis ,These organism produce beta-glucuronidase which splits bilirubin diglucuronide and releses free bilirubin.The latter combines with calcium to form the relatively insoluble calcium bilirubinate.

PATHOLOGICAL CONSEQUENCES OF GALL STONES ARE :

• Inflammation of the gall bladder ,acute cholecystitis ,chronic cholecystitis ,acute on chronic cholecystitis
• obstructive jaundice due to impaction of a stone at the lower end of the common bile duct : secondary biliary cirrhosis may result .
• ascending cholengitis
• empyema of the gall bladder.
• mucocele
• gall stone ileus __ a fistula occurs between the gall bladder and duodenum ,and a large stone enters the small bowel ,causing obstruction .usually at the terminal ileum .
• pancreatitis ,usually associated with multiple small stones .
• carcinoma of gall bladder .
• perforation of the gall bladder .
  

Medicines titled chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be given in preventive form to dissolve cholesterin gallstones. However, they may take 2 eld or longer to work, and the stones may return after communication ends.

Rarely, chemicals are passed into the gallbladder finished a catheter. The chemical apace dissolves cholesterin stones. This communication is not used rattling often, because it is difficult to perform, the chemicals can be toxic, and the gallstones may return.

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients staleness be indicated to surgery. The lack of a gall bladder does not seem to have any perverse consequences in some people. However, there is a momentous assets of the population — between 5 and 40% — who amend a information called postcholecystectomy syndrome which haw drive gastrointestinal painfulness and persistent discompose in the upper right abdomen. In addition, as some as 20% of patients amend chronic diarrhea.

Electrohydraulic damper wave lithotripsy (ESWL) of the gallbladder has also been utilised for selected patients who cannot have surgery. Because gallstones often become backwards in many patients, this treatment is not utilised very often any more.