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Ministry of Healthcare of Ukraine Danylo Halytsky Lviv National Medical University Department of Surgery # 1 Acute Cholecystitis

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Ministry of Healthcare of Ukraine Danylo Halytsky Lviv National Medical University Department of Surgery # 1 Acute Cholecystitis MINISTRY OF HEALTHCARE OF UKRAINE DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF SURGERY # 1 ACUTE CHOLECYSTITIS Guidelines for Medical Students Lviv - 2019 Approved at the meeting of the surgical methodological commission of Danylo Halytsky Lviv National Medical University (Meeting report № 56 on May 16, 2019) Contributors: GERYCH I. D. - PhD, professor, head of the Department of Surgery №1, Danylo Halytsky Lviv National Medical University VARYVODA E. S. – PhD, associate professor, Department of Surgery №1 KOLOMIYTSEV V. I. – PhD, associate professor, Department of Surgery №1 KHOMYAK V. V. – PhD, assistant professor, Department of Surgery №1 MARINA V. N. - MD, assistant professor, Department of Surgery №1 Referees: ANDRYUSHCHENKO Viktor Petrovych – PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University OREL Yuriy Glibovych - PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University Responsible for the issue first vice-rector on educational and pedagogical affairs at Danylo Halytsky Lviv National Medical University, corresponding member of National Academy of Medical Sciences of Ukraine, PhD, professor M.R. Gzegotsky 1. Background. Cholelithiasis (gallstone disease), inflammatory diseases of gall-bladder (cholecystitis), bile ducts considerable place among patients with pathology of organs of alimentary tract. Gallstone disease remains one of the most common medical problems leading to surgical intervention. Cholelithiasis affects approximately 10% of the adult population in the world. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 50 years of age and 30% of those over age 70 have biliary calculi. With every year the amount of these patients increase, and a cholecystitis occupies the second place after appendicitis. In the US, approximately 700,000 cholecystectomies are performed every year. In fact, this group of patients represents between 50 and 70 % of surgical admissions for acute cholecystitis. Swift scientific and technical progress in medicine was instrumental in the origin of new perspective directions in treatment of gallstone disease is the use of preparations for dissolution of concrements, shock wave extracorporal and contact lithotripsy, open and laparoscopic operations. Such operation, as cholecystectomy, was first executed by Carl Langenbuch in 1882 and remains basic in surgical treatment of patients with uncomplicated cholecystitis. During many years a method was utilized in whole the world. Low postoperative morbidity and mortality, minimal probability of trauma of bile ducts, especially at the chronic form of disease, convincingly enough testified to it. However, development and perfection of endoscopic technique changed surgery of gall-bladder stone disease high-quality. Inculcated in clinical practice in 80th the method of laparoscopic cholecystectomy under video guidance F. Dubois, P. Mouret becomes the method of choice and on this time all more often successfully used in patients with an acute cholecystitis. Duration of lesson: 4 hours Learning Objectives: To know (α = I; α = II): determination of concept is “gallstone disease”, “acute cholecystitis”; modern understanding of aetiology and pathogenesis of acute cholecystitis; classification of acute cholecystitis and complications; morphologic changes are in a gall-bladder and bile ducts; features of clinical symptoms depending on the different forms of cholecystitis; frequency of complications and clinical signs; diagnostic possibilities of additional methods of investigation (laboratory tests, X-ray, ultrasonography, computed tomography, magnetic resonance imaging, cholescintigraphy, endoscopic retrograde cholangiopancreatography); differential diagnostics of acute cholecystitis; surgical treatment of acute cholecystitis; principles of surgery; biliary drainage: indications and methods. Able to (α = II; α = III): propose a diagnosis; define the form of cholecystitis; analyse the laboratory tests and investigations data; conduct the differential diagnosis of acute cholecystitis with acute appendicitis, acute pancreatitis, intestinal obstruction, perforative ulcer; formulate a final diagnosis; appoint treatment; define indications to surgery; diagnose the complication of cholecystitis (choledocholithiasis, jaundice, cholangitis, biliary pancreatitis, empyema, abscess, peritonitis, hepatitis); appoint postoperative treatment. Practical skills: capture of anamnesis and its analysis; examination of patients with liver, gallbladder and bile ducts disease; determination of signs, characteristic for a chronic and acute cholecystitis; interpretion of laboratory tests data and examination; formulation of indication and contraindication for surgical treatment; choose the method of surgery or mini-invasive treatment. 4. Interdisciplinary integration Subject and proper № To know To be able department Base departments 1 Anatomy, topographical Anatomy and topographical To conduct palpation of anatomy (departments of anatomy of liver, gallbladder and liver and gallbladder. Aanatomy of human, biliary system. Topographical anatomy and operative surgery) 2 Morphology (department of Morphological description of To define morphological Pathoanatomy & acute cholecystitis. changes, inherent the Morphology) different types of acute cholecystitis. 3 Anatomy, topographical Surgical approach, methods of To choose the adequate anatomy (departments of operations method of surgery Anatomy of human, Topographical anatomy and operative surgery) 4 Biological chemistry Test interpretation of surgical To interpretate the blood (department of Biological diseases tests in patients with an chemistry ) acute cholecystitis. 5 Internal diseases (department Interpretation of examination of To conduct an examination of Internal diseases) organs of abdominal region patient with an acute cholecystitis. Type clinical departments 1 General surgery (department Basic principles of work of Hospitalize a patient to of General surgery) surgical department and surgical department, to operating block in emergency. prepare to the treatment and diagnostic options and surgery. 2 Department of Internal Methods of diagnostics of acute To find out the complaints diseases cholecystitis and its of patient, collect complications, pathogenesis and anamnesis of disease, clinical variants. conduct an examination of patient, ground a diagnosis, conduct a differential diagnosis, plan of additional examination. V. Contents of the topic and its structuring Pay a regard to etiologic factors which result in inflammation of gallbladder. Acute cholecystitis more frequent develops on the background of gallstone disease, less than - without it. An acalculous cholecystitis more frequent is early in life. During the reproductive years, the female-to- male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. Chronic inflammation is supported stone; an acalculous cholecystitis more frequent is complication of sphincter of Oddi and bile duct dysfunction, invasion of vermin, heterospecific and specific infection. Regardless of inflammation a cholecystitis can be accompanied by a hepatic colic, that characteristically for a calculous cholecystitis, and also periodic attacks. Periodically nascent acute inflammation calms down under the action of medical measures, or destructive changes make progress in the walls of gallbladder. The free outflow of bile recommences in the cases of calming down of process. In a gallbladder the developed fibrotic layer is saved little anymore with education between the muscular pinches of connecting fabric. In a number of cases fibrotic changes support permanent chronic inflammation of gallbladder which is instrumental in the periodic attacks. AETIOLOGY AND PATHOGENESIS Local: 1) Anatomic features of gallbladder and biliary system; 2) Defeat of wall of gallbladder by various mechanical and chemical agents. General: 1) Sensibilisation of organism; 2) Change of imunoresistance and resistance of organism; 3) Violation of the neiro-gumoral adjusting of gallbladder and biliary system. To the causing factors take: virulent microorganisms (Table 1) which gets to the wall of gallbladder by a hematogenic, lymphatic ways and from common bile duct; stagnation of bile which arises up as a result of mechanical (obstruction by a stone, narrowing of gallbladder cystic duct, innate defects) or functional disorders (spasm of sphincters, neuro-humoral dysfunction and other). More frequent all an acute cholecystitis arises up at combination of the following factors: violation of outflow of bile; presence of infection; sensibilisation of organism; damage of gallbladder wall (mechanical, chemical). Table 1 Common microorganisms isolated from bile cultures among patients with acute cholecystitis Isolated microorganisms Proportions of isolated from bile cultures organisms (%) Gram-negative organisms Escherichia coli 31–44 Klebsiella spp. 9–20 Pseudomonas spp. 0.5–19 Enterobacter spp. 5–9 Gram-positive organisms Enterococcus spp. 3–34 Streptococcus spp. 2–10 Staphylococcus spp. 0-5 Anaerobes 4–20 In 90 to 95% of cases, acute cholecystitis is related to gallstones. Obstruction of the cystic duct by a gallstone leads to biliary colic and is also the first event in acute cholecystitis. If the cystic duct remains obstructed, the gallbladder distends, and the gallbladder wall becomes
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