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Biliary Passage
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* Gall Bladder *

Ligamentum teres

Fundus
Porta hepatis
Gall
Bladder Body

Hepatic artery
Neck
Common bile duct
Cystic duct Portal vein

Porta hepatis
Right hepatic duct and artery Left hepatic duct and
Artery
Cystic a.
Accessory cystic arteries Common hepatic duct

Inferior surface of liver Hepatic A.

Common bile duct

Gall Bladder

Hartmann's
pouch Cystic duct

I.V.C. Portal V.
Common bile duct
Opening to lesser
sac Hepatic A.

1st part of duodenum

Gastro-duodenal a-

2nd part of duodenum

Head of pancreas

Common bile duct

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Acute cholecystitis
 Incidence: More common in fatty , fertile , female , above 40
years (4F ) .
 Aetiology:
A. Predisposing factors:
1. Stones of gall bladder are the main predisposing factors.
2. Chronic cholecystitis → recurrent acute exacerbation.
3. Rarely , bacteraemia , septicaemia & typhoid fever.
B. Organisms:
• Usually gram negative bacilli especially E. Coli .
•Rarely infection by typhoid bacilli .
•Clostridia may occur in diabetic patients .
C. Route of Infection:
•Along the lumen of GB in calcular cholecystitis.
•Lymphatic or blood spread in non calcular cholecystitis.
 Pathology: There are 2 types:

1. Acute calcular cholecystitis : ( 98% of cases )

• This occurs on top of chronic calcular cholecystitis leading to
obstruction of Hartmann's pouch , neck of gall bladder or cystic
duct → stasis and infection .
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• The condition may progress as follows:

a. Catarrhal inflammation: The gall bladder is congested ,
oedematous & distended by mucous → mucocele of gall bladder
. The wall is thickened with loss of its serosal lustre.
b. Suppurative inflammation: Multiple micro-abscesses in the
wall of gall bladder →gall bladder is disended with pus →
empyema of gall bladder.
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Empyema
of gall bladder

c. Gangrenous inflammation:(rare ). Persistence of obstruction

→ high pressure inside gall bladder → obstruction of blood
supply in the wall or thrombosis of blood vessels → gangrene
and perforation of the wall.

Gangrenous cholecystitis
d. Emphysematous cholecystitis: Rare, in diabetics due to
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infection with anerobic gas forming organism e.g colistridia.

Emphysematous cholecystitis

2. Acute non-calcular cholecystitis :(Rare , 2%)

• It is more dangerous than calcular cholecystitis .
• This occur in ICU patient suffering from major
burn, major trauma , sever shock or infection
(eg. typhoid).
• Changes in the composition of bile or ischaemia
of G.B , may be the cause.
• The condition is very serious because it is
unsuspected and diagnosis is delayed .
• Ultrasound is diagnostic & treatment is urgent
cholecystectomy.
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 Consequences and Complications:

1. With treatment , resolution in most cases , the stone

dislodges and the obstruction is relieved with drainage of bile
and gradual resolution of inflammation .
2. Chronicity is the commonest complications , with more stones
formation and recurrent acute exacerbations.
3. Local spread of infection leading to ascending cholangitis ,
cholangiohepatitis and descending pancreatitis.
4.Gangrene & Perforation :(rare )
• This usually leads to localized peritonitis ( as a defensive
mechanism the greater omentum , duodenum and colon adhere
to the gall bladder ) or rarely ( 1 % ) generalized peritonitis .
• The fundus is th most liable because it is the least vascular part
of the G.B .
• Less commonly perforation may occur at the neck due to pressure
necrosis by an impacted stone.
• Gangrene of gall bladder is rare because it has numerous
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vascular supply from the undersurface of liver in addition to

cystic artery .
4. Cholecystoduodenal , cholecystointestinal or cholecystobiliary fistulae
5. Jaundice which may be due to:
• Ascending cholangiohepatitis.
• Oedema of of C.H.D or C.B.D.

• A stone in the Hartmann's pouch or cystic duct obstructing the

C.B.D. (Mirrizi syndrome)

 Clinical Picture:

A.Symptoms:
1. Characteristic patient (4F) with history of previous biliary pain
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and fatty dyspepsia.

2. Biliary Pain:
• The initial symptom , is intermittent colic diffuse upper
abdominal pain ( visceral pain due to stone obstructing GB )
• With inflammation of serosa and irritation of parietal
peritoneum , pain becomes dull aching and localized to the
right hypochondrium .
• Pain may referred to the right shoulder, epigastrium & back
below the scapula.
• Pain persists for more than 6 hours . ( in biliary colic pain lasts
for less than 6 hours )

3.Fever , Anorexia , headach & maliase .

4 . Nausea and vomiting ( reflex once or twice but if repeated it
indicate complications ).
5. Jaundice , rarely occur (mention the causes).
B. Examination:
a- General: A characteristic patient , high temperature , tacchycardia
and jaundice.
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b-Local:
1. Tenderness, rebound tenderness and rigidity in the right
hypochondrium maximum at the tip of right 9th. costal cartilage
leading to difficult to palpte GB distention .
2.Limitation of abdominal mobility with respiration in the right
hypochondrium.
3. A mass may be felt below the right costal margin in empyema or
mucocele of G.B. (mention the characters of G.B. mass). It is
difficult to palpate due to tenderness and rigidity .
4. Murphy's sign : A gentle pressure is applied just below the right
costal margin then ask the pt, to take a deep breath ~ the pt. will
catch her breath. Sonographic Murphy's sign is more accurate
in the diagnosis .

5 . Boas’ sign : An area of hyperaeshtesia between 9-11 ribs posterior

on the right side ( below right scapula ).
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 Investigations:

1. Blood picture: Shows leucocytosis.

2. Liver function tests are usually normal or rarely serum biIlirubin
may be raised.
3. Ultrasonography: (Most important & first investigation)
• It Shows distended G.B., thick wall, micro abscesses & serosal
oedema.
• It shows 98 % of GB stones and 1/3 of bile duct stones .
• Dilatation of CBD and intrahepatic biliary passage indicates
stones in the CBD .
• It is non-invasive, easy & inexpensive.
4. Plain x-ray : ( replaced by U/S & rarely done nowadays )
• It shows radio-opaque stones (10-20 %) .
• Presence of air in the GB in emphysematous cholecystitis .
5. CT scan may be needed in doubtful cases .
6. HIDA scan : 99mTc is given IV to be excreted rapidly by the liver
to visualize the biliary passage . Non-visualization of GB
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indicate obstruction of cystic duct and confirm the diagnosis of

acute cholecystitis .

 D.D : of pain in the right hypochondrium

1- Hepatobiliary diseases :
Biliary colic Acute cholecystitis Cholangitis

Pain pain in right hypochondrium

Duration usually less than 6 usually more than 6 hours Few days
of pain hours

Fever no fever low grade fever high fever & rigor

leucocytosis no leucocytosis Mild leucocytosis Severe leucocytosis

jaundice no jaundice usually no jaundice Jaundice (

Charcot’s triade )

• Chronic cholecystitis
• Hepatitis and amoebic liver abscess
2- Acute pancreatitis
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3- High retrocaecal or Subhepatic acute appendicitis.

4-Perforated duodenal ulcer.
5. Intestinal obstruction
6-Urinary diseases:Right acute pyelitis, right renal colic, right
pyonephrosis.
7-Pneumonia in the lower lobe of right lung .

 Treatment: Two options but ultimitly the definitive treatment

is laparoscopic cholecystectomy :

I) The first option is is early cholecystectomy :

• Indications : It is recommended for all patients diagnosed
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within 3 days of the onset with uncomplicated cholecystitis and

fit for surgery.
• Advantage: Early surgery is easy , minimize total
hospitalization and early return to work, less morbidity and
mortality and avoid complications.
II) The second option is conservative treatment followed by
delayed (interval) cholecystectomy (6 weeks after
complete cure of the acute attack).
• Indications : patients diagnosed after 3 days of the onset of
cholecystitis
• Advantages:
1. 90% of cases respond to conservative treatment.
2. Patient can not sustain major operation.
3. The operation may be dangerous (adhesions & the tissue are
friable).
• Contraindications: If pain and tenderness spread across the
abdomen.
• Methods:
1. Rest in the modified Fowler's position.
2. Stop oral feeding & I.V. fluids.
3. Ryle's tube suction.
4. Antispasmodics to relax the sphincter of Oddi.
5. Sedatives as pethidine or NSAID (morphia is contraindicated
because it causes spasm of sphincter of Oddi).
6. Antibiotics: Effective against gram -ve aerobes as
cephalosporines or gentamycine .
7. Observation: Pulse, temp. , B.P , severity of pain & tenderness
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, size of the mass , early manifestations of complications and

ultrasound .
• Result of conservative treatment:
1. In 90% of cases the acute attack subside → delayed or
interval cholecystectomy after 6 weeks .
2. Rarely failure of conservative treatment or development of
complications :
a) In fit patient : urgent cholecystectomy . or
b) In unfit patient : cholecystostomy ( the fundus of gall

bladder is opened , remove of stones and drainage of gall

bladder by a tube for one week ) followed after 6 weeks by
elective cholecystectomy .

 Urgent cholecystectomy : After rapid pre-operative preparation ( within

few hours ) , cholecystectomy should be done as emergency in the

following patients :
1- Elderly diabetic ( high mortality & morbidity with time)
2- Pain and tenderness spread across the abdomen(Suggest perforation)
3- Deterioration of the general condition of the patient under
conservative treatment .
4- Development of complications .
5- Acute non-calcular cholecystitis .
6- Doubtful diagnosis with deterioration of the general condition of the
patient .
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 There is conservative treatment in acute cholecystitis while in

acute appendicitis there is no conservative treatment due to the

followings
Acute cholecystitis Acute appendicitis
1- GB receive arterial supply 1- Appendix receive only single
from cystic artery and many arterial supply only from
blood vessels from the appendicular artery and its tip
undersurface of the liver . receive an end branch from
this artery .
2-Less virulent organism 2-Highly virulent organism
3-GB has thin wall dispensable 2-Appendix has thick rigid wall
with mild increase in its intra- indispensable with marked increase in

luminal pressure . its intra- luminal pressure .

4- Rare late perforation 4- Early common perforation