Cholecystitis胆囊炎PPT课件

Cholecystitis,klsstats,1,OVERVIEW,Cholecystitis, a common condition usually resulting from complications of cholelithiasis ,kllass, occurs in two forms, acute and chronic.,2,Acute cholecystitis requires urgent intervention, typically with antibiotics followed by cholecystectomy klsstektm. In the setting of acute cholecystitis, cholecystectomy is optimally performed soon after the diagnosis is made. If urgent cholecystectomy is not feasible, operation can be delayed until after the acute episode has resolved, and then the operation may be performed electively, provided that the acute process can be controlled, and the symptoms resolve rzlv.,3,Chronic cholecystitis is the manifestation of ongoing, intermittent inflammation or so-called biliary colic. Patients with this condition benefit symptomatically from elective cholecystectomy. A less common version of cholecystitis is acute acalculous cholecystitis, which occurs most often in critically ill patients. Although gallstones are, by definition, absent in this condition, cholecystectomy specimens in patients with acute acalculous cholecystitis often reveal biliary sludge.,4,Anatomy of Gallbladder,5,The gallbladder is a reservoir rezvw: (r) located on the undersurface of the right of the liver, within the cystic fossa(胆囊窝); it is separated from the hepatic parenchyma prekm by the cystic plate, which is composed of connective tissue closely applied to the Glisson capsule and elongating the hilar plate . Sometimes the gallbladder is deeply embedded in the liver, but occasionally it occurs on a mesenteric attachment and may be susceptible to volvulus vlvjls.,6,Anatomy of the plate system. A, Cystic plate, above the gallbladder. B, Hilar plate, above the biliary confluence and at the base of the quadrate lobe. C, Umbilical plate, above the umbilical portion of the portal vein. Large, curving arrows indicate the plane of dissection of the cystic plate during cholecystectomy and of the hilar plate during approaches to the left hepatic duct.,7,The gallbladder varies in size and consists of a fundus, a body, and a neck The tip of the fundus usually, but not always, reaches the free edge of the liver and is closely applied to the cystic plate. The cystic fossa is a precise anterior landmark to the main liver incisura insir.,8,9,The neck of the gallbladder makes an angle with the fundus and creates the Hartmann pouch, which may obscure the common hepatic duct and constitute a real danger point during cholecystectomy.,The cystic duct arises from the neck or infundibulum of the gallbladder and extends to join the common hepatic duct. Its lumen usually measure depending on the type of union with the common hepatic duct. The mucosa mjkos of the cystic duct is arranged in spiral folds known as the valves of Heister. Although the cystic duct joins the common hepatic duct in its supraduodenal segment in 80% of cases, it may extend downward to the retroduodenal or retropancreatic area.,10,Triangle of Calot,The commonly accepted working definition of the triangle of Calot recognizes, however, the inferior surface of the right lobe of the liver as the upper border and the cystic duct as the lower border. Dissection of the triangle of Calot is of key significance during cholecystectomy, because in this triangle runs the cystic artery, often the right branch of the hepatic artery, and occasionally a bile duct, which should be displayed before cholecystectomy.,2018年6月14日2时21分,11,If there is a replaced or accessory common or right hepatic artery, it usually runs behind the cystic duct to enter the triangle of Calot.,2018年6月14日2时21分,12,Main variations in gallbladder and cystic duct anatomy：,Duplicated gallbladder.,2018年6月14日2时21分,13,Occasionally, the cystic duct may join the right hepatic duct or a right hepatic sectoral duct,14,Septum of the gallbladder.,Diverticulum ,davtkjlm of the gallbladder.,2018年6月14日2时21分,15,Different types of union of the cystic duct and common hepatic duct: angular union (a), parallel union (b), spiral union (c).,2018年6月14日2时21分,16,ACUTE CHOLECYSTITIS,17,Pathogenesis of Acute Cholecystitis,The cause of acute cholecystitis is an impacted gallstone in the outlet of the gallbladder, either in the infundibulum or in the cystic duct . The impacted gallstone results in gallbladder distension and edema with acute inflammation, which eventually can result in venous stasis and obstruction, followed by thrombosis(血栓) of the cystic artery.,2018年6月14日2时21分,18,Ultimately, ischemia（缺血） and necrosis（坏死） of the gallbladder occur. Because the fundus of the gallbladder is the greatest distance from the cystic arterial blood supply, it is more sensitive to ischemia and is the most common location for necrosis of the gallbladder. The acute inflammation of cholecystitis may be complicated by（并发于） secondary biliary infection. Positive biliary cultures are found in about 20% of patients with acute cholecystitis ，the most common of which are gram-negative bacteria of gastrointestinal origin, such as Klebsiella spp. and Escherichia coli.,2018年6月14日2时21分,19,Clinical Manifestations of AC,Most patients with acute cholecystitis present with severe, constant, right upper quadrant or epigastric pain, sometimes with radiation to the subscapular area. This pain may be preceded byintermittent, self-limited bouts of abdominal pain from episodes of biliary colic.,2018年6月14日2时21分,20,Acute cholecystitis is frequently associated with fever and leukocytosis ,ljuksatss, findings that are not present in cases of uncomplicated biliary colic. Patients also may develop a Murphy sign, or inspiratory arrest on palpation of the right upper quadrant. Other presenting symptoms include nausea, vomiting, and anorexia.,21,Differential Diagnosis,Several disease processes can present similarly to cholecystitis and should be considered in the differential diagnosis. These include peptic ulcer disease（消化溃疡）, gastritis（胃炎） and gastroenteritis, irritable bowel syndrome（肠易激）, inflammatory bowel disease（炎性肠病）, right lower lobe pneumonia（右下肺炎）, and biliary dyskinesia. An initial chest radiograph is generally sufficient to assess for a right lower lobe infiltrate.The other diagnoses should be entertained and worked up appropriately in symptomatic patients without gallstones on ultrasound (US).,22,Diagnostic Evaluation and Imaging,1. Abdominal US Abdominal US（ ultrasound） is useful for assessing patients suspected to have acute cholecystitis.,23,Typical findings include gallstones, gallbladder wall thickening (4 mm), and pericholecystic fluid. In addition, the sonographer can assess for pain and inspiratory arrest when the gallbladder is directly compressed by the US probe (sonographic Murphy sign).,2018年6月14日2时21分,24,Transverse view of the gallbladder on ultrasound in a patient with calculous cholecystitis, revelaing gallstones and gallbladder wall thickening.,2018年6月14日2时21分,25,Typically, conventional gray scale imaging（灰介扫描） is used, which is highly sensitive and specific for diagnosing acute cholecystitis, with an overall accuracy of greater than 90% . Other techniques of imaging that assess blood flow, such as color velocity imaging（彩色快速成像）, may improve accuracy in selected cases.,2018年6月14日2时21分,26,2.CT Computed tomography (CT) can also help diagnose acute cholecystitis and provides more detailed anatomic information than US. CT is particularly useful in patients whose symptoms suggest a complication such as pericholecystic abscess or an alternative diagnosis. CT generally is less sensitive than US for diagnosing acute cholecystitis, particularly early in the course, when the imaging findings may be subtle.,2018年6月14日2时21分,27,The CT findings of acute cholecystitis are the same as those seen on US and include wall thickening, pericholecystic stranding, distension of the gallbladder, high-attenuation bile, pericholecystic fluid, and subserosal edema.,28,Treatment of AC,Initial treatment with antibiotics active against enteric bacteria should begin as soon as the patient is diagnosed with acute cholecystitis.In addition, oral intake should be restricted, and intravenous resuscitation should be started in preparation for surgery with parenteral analgesics administered as needed.,29,The definitive treatment for acute cholecystitis is cholecystectomy.From the time this operation was first performed in 1882 by Langenbuch, open cholecystectomy has been the standard of care for patients with acute cholecystitis. With the advent of laparoscopic cholecystectomy in the 1980s, the standard approach has changed such that cholecystectomy is now routinely performed laparoscopically.,2018年6月14日2时21分,30,Although the laparoscopic approach is now standard for most cases, it is interesting to note that two prospective, randomized studies suggested little or no difference in several outcome measures between laparoscopic versus small-incision open cholecystectomy.,2018年6月14日2时21分,31,Other novel surgical techniques have been proposed to treat patients with acute cholecystitis, including so-called minilaparoscopic cholecystectomy , which uses 2- to 3-mm ports , and minicholecystectomy , in which a small (mean, 5.5 cm) incision is used to remove the gallbladder. A prospective, randomized trial demonstrated that minilaparoscopic cholecystectomy resulted in decreased postoperative pain and superior cosmesis when compared with conventional laparoscopic cholecystectomy, with no significant difference in operative time, blood loss, or complications,2018年6月14日2时21分,32,Laparoscopic subtotal cholecystectomy (LSC) has also been evaluated as a means of decreasing the conversion rate to open procedure in patients with acute cholecystitis.This technique, although innovative, does not have wide clinical applicability because of limited availability of instruments, specialist surgeons trained in their use, or both. Laparoscopic cholecystectomy remains the standard therapy for definitive treatment of patients with acute cholecystitis, with conversion to an open procedure if necessary.,2018年6月14日2时21分,33,In patients with a high perioperative risk from sepsis or other underlying medical comorbidities, initial treatment of acute cholecystitis with percutaneous ,pkjtens cholecystostomy tube placement is preferred . These tubes can be placed using either US or CT guidance . This procedure effectively decompresses the gallbladder, evacuating the infected bile and relieving the pain associated with gallbladder distension, and it is associated with a low complication rate .,2018年6月14日2时21分,34,In addition, most patients (80%) improve clinically within a short time . After stabilization of the patient, and if the clinical situation otherwise warrants, delayed cholecystectomy should be performed, which often can be done laparoscopically successfully. Akyrek and colleagues demonstrated decreased hospital stay and cost in high-risk patients undergoing percutaneous cholecystostomy (,klisiststmi胆囊造口)followed by early laparoscopic cholecystectomy compared with those treated conservatively with intravenous (IV) antibiotics and bowel rest followed by delayed cholecystectomy.,2018年6月14日2时21分,35,In highrisk patients in whom general anesthesia is contraindicated, percutaneous stone extraction has been used successfully. But ,This treatment modality is not widely practiced, however.,2018年6月14日2时21分,36,Timing of Surgery,The optimal interval of time between the diagnosis of acute cholecystitis and definitive treatment with cholecystectomy has been the subject of many prospective randomized trials.,2018年6月14日2时21分,37,The concern in operating on patients with early cholecystitis (typically defined as 3 days) is the potential for increased postoperative complications, including common bile duct injury. The risk of performing cholecystectomy late (weeks after the diagnosis of cholecystitis) is that a subset of patients have recurrent symptoms during the period between diagnosis and surgical treatment, which leads to recurrent hospital admissions and urgent surgery.,2018年6月14日2时21分,38,In multiple randomized prospective trials evaluating the timing of open cholecystectomy, 1.patients undergoing early operation experienced no increased perioperative morbidity or mortality and had a shorter length of hospital stay compared with patients undergoing delayed operation. 2.The results of many trials uniformly showed no significant difference in postoperative morbidity or mortality, including common bile duct injury, when surgery is performed early,2018年6月14日2时21分,39,3.It is concluded that early surgery was more cost-effective because of reduced overall length of hospital stay and avoidance of readmissions for recurrent cholecystitis or biliary colic. Although it is safe to perform cholecystectomy either early or late after an episode of acute cholecystitis, patients benefit when surgery is performed early(within 72 hours).,2018年6月14日2时21分,40,CHRONIC CHOLECYSTITIS,41,Pathogenesis and Clinical Manifestations,Chronic cholecystitis may result after one or more episodes of acute cholecystitis, or it may evolve, initially without symptoms, merely from the presence of gallstones. In most cases, patients describe one or more episodes of abdominal pain that is clinically consistent with biliary colic. The term colic is a misnomer, because the pain from chronic cholecystitis is usually constant in nature and is similar to that seen initially with acute cholecystitis, although it is self-limited and often less severe. The pain associated with chronic cholecystitis seems to be the result of intermittent obstruction of the gallbladder outflow.,42,There are numerous well-descr