7 most important questions on Gall Bladder and cholecystitis
Q1. Which of the following are not true for emphysematous cholecystitis?
a) Usually it is associated with acalculus cholecystitis.
b) Most common with diabetes mellitus
c) Air is seen in the lumen of gall bladder causing symptoms of acute cholecystitis
d) Clostridium perfringes and other clostridia are the common causative organisms.
Q2. Prophylactic cholecystectomy is not recommended for
a) Heart transplant recipients
b) Diabetes Mellitus
c) Incidental gallstones on laparotomy
Q3. Which of the following is not an ultrasonic finding in acute cholecystitis
a) Absence of gall stones
b) Gall bladder wall thickness more than 6 mm
c) Pericholecystic fluid
d) Sonographic Murphy's sign
Q4. Which of the following is not a premalignant condition of gall bladder?
a) Porcelain gall bladder
b) Adenomyomatosis of gall bladder
c) Salmonella infection
d) Phrygian cap
Q5. Which of the following is not true regarding gall bladder cancer following cholecystectomy
a) Subsequent treatment depends on many factors including stage of disease, surgical margins, spillage etc
b) For T1 and T2 lesions cholecystectomy is sufficient
c) The term extended cholecystectomy is preferred to radical cholecystectomy
d) Common Bile Duct (CBD) excision is not required in all cases
Q 6). A 45 year old lady presents to the HepatoBiliary Clinic with a large 3 cm stone in the neck of gall bladder eroding into the Common Bile duct (CBD) effacing about 50% of its diameter. Patient has been counselled about surgery and is willing for the same.What would be the most appropriate surgery for this patient?
a) Cholecystectomy, removal of stone and primary repair of CBD over a T tube
b) Radical Cholecystectomy
c) Cholecystectomy and use of a flap of Gall Bladder to repair the defect in CBD
d) Cholecystectomy and Roux en Y Hepaticojejunostomy
Q7) A 45 year old asian lady presents to the emergency department with complains of intermittent epigastric pain.
Pain is severe, lasts for 3-4 hours and is often associated with vomiting. Her bowel movements are normal. She is febrile (100.6F) with a heart rate of 110/min.
She has mild icterus and bowel sounds are normal. She has an inspiratory catch of breath on deep palpation. Her TLC is 13000 and bilirubin is 3.3 with a direct fraction of 2.7. Liver enzymes and alkaline phosphatase are normal.
What would be the next investigation?
a) X ray chest and abdomen
d) Contrast enhanced CT
Emphysematous cholecytitis is seen in elderly patients with male to female ratio of 3:1.
It is mostly caused by clostridia species and commonly seen in diabetics.
It is usually but not always associated with aclaculus cholecystitis.
CT scan is the investigation of choice and air is not seen in the lumen of gallbladder but in the wall of gallbladder.
Treatment is emergency cholecystectomy.
Diabetes mellitus was earlier thought to be associated with increased compications of cholelithiais and cholecystitis but recent literature suggests that Diabetes is not associated wuth increasesd complications.
The indication of surgery for cholelithiasis remain the same in diabetis mellitus.
Cardiac transplant patients have a high prevalence of biliary tract disease, Studies reported in the surgical literature seem to favor prophylactic cholecystectomy for patients identified with cholelithiasis preoperatively. Patients with asymptomatic cholelithiasis before transplantation commonly develop symptoms and often complications after transplantation
Ultrasound has a sensitivity of 85% and specificity of 95% in diagnosing acute cholecystitis. If the wall thickness is more than 4 mm, it is suggestive of Acute Cholecystitis.
After gall bladder removal surgery if the histopathology report suggests malignany, many preoperative and intra operative factors have to be considered.
These are duration of symptoms, previous history of jaundice,laparoscopic or open surgery, difficulty and blood loss in surgery, spillage of bile, if an endobag was used or not for gallbladder retrieval. The most important is to define the T stage in the gallbladder .
For T1a and selected T1b lesions (those lesions which do not have neural, lymphatic) simple cholecystectomy suffices, however for T2 lesions, extended cholecystectomy is the procedure of choice
The term extended cholecystectomy is preferred to radical these days because radical can be anything ranging from wedge excision of liver to resection, of duodenum, CBD or even a Whipple's procedure
Extended cholecystectomy entails cholecystectomy + removal of lymph nodes in periportal , hepatoduodenal, right coeliac, posterior pancreaticodudenal and pericholedochal + 2 cm wedge excision of liver.
CBD excision is not always necessary and required only in some select conditions
Sabiston text book of surgery 19 th edition
This patient has typical feature of Mirizzi's syndrome named after the Pablo Mirizzi. (Read about the times and work of Mirizzi here)
It is a rare condition in which stone gets impacted in the neck of Gall Bladder. The stone compresses the CBD externally or can lead to fistula formation with the CBD.
Patients generally present with pain abdomen, jaundice and fever.
The Csendes classification of Mirizzi syndrome is
Type 1: external compression of the common bile duct
Type 2: a cholecystobiliary fistula is present involving less than one third the circumference of the bile duct
Type 3: a fistula is present involving up to two thirds the circumference of the bile duct
Type 4: a fistula is present with complete destruction of the wall of the bile duct
Mirizzi Syndrome Treatment
Type 1 - Mirizzi syndrome treatment is fundus first cholecytectomy or partial cholecystectomy
For Type 2 to 4 the best treatment would be cholecystectomy and Roux en Y hepaticojejunostomy. A flap of gall bladder may sometimes be used if it appears healthy.
Ref: Complications of Gallstones: The Mirizzi Syndrome, Gallstone Ileus, Gallstone Pancreatitis, Complications of “Lost” Gallstones
Surgical Clinics of North America - Volume 88, Issue 6
Ref- Yeo: Shackelford's Surgery of the Alimentary Tract, 7th ed.
The lady presents with typical features of acute cholecystitis. A female in 40s with right upper quadrant pain most often than not has gallstones.Ultrasound is the 1st diagnostic modality for detection of acute cholecystitis. It shows wall thickness more than 4 mm with pericholecystic fluid. X ray and CT are not much sensitive in detecting gall stones.
Cholecystectomy in Cirrhosis
1. Hard friable brittle liver is difficult to retract
2. Limited exposure of porta, Calot's Triangle and Gall bladder
3. Portal hypertension and Colaterals bleed
4. Coagulopathy- which should be corrected
Saharia Criteria for primary CBD Stone
1. Previous Choleystectomy with or without CBD exploration
2. Two years of asymptomatic period after biliary tract surgery
3. Soft, Friable, earthy stones
4. Absence of long cystic duct, biliary stricture