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8/8/2019 Duty - Reporting

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What is a hiatal hernia?

A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Although hiatal

hernias are present in approximately 15% of the population, they are associated with symptoms in only a minority of those afflicted.

Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the

diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach. In individuals with hiatal hernias, the opening of

the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus andinto the chest. Although hiatal hernias are occasionally seen in infants where they probably have been present from birth, most hiatal hernias in adults

are believed to have developed over many years.

What causes a hiatal hernia?

It is thought that hiatal hernias are caused by a larger-than-normal esophageal hiatus, the opening in the diaphragm through which the esophagus

passes from the chest into the abdomen; as a result of the large opening, part of the stomach "slips" into the chest. Other potentially contributing

factors include:

1. A permanent shortening of the esophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid)

which pulls the stomach up.

2. An abnormally loose attachment of the esophagus to the diaphragm which allows the esophagus and stomach to slip upwards.


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Are there different types of hiatal hernias?

Hiatal hernias are categorized as being either sliding or para-esophageal.

Sliding hiatal hernias

Sliding hiatal hernias, the most common type of hernia, are those in which the junction of the esophagus and stomach, referred to as the gastro-

esophageal junction, and part of the stomach protrude into the chest. The junction may reside permanently in the chest, but often it juts into the chest

only during a swallow. This occurs because with each swallow the muscle of the esophagus contracts causing the esophagus to shorten and to pull up

the stomach. When the swallow is finished, the herniated part of the stomach falls back into the abdomen. Para-esophageal hernias are hernias in


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which the gastro-esophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the

chest beside the esophagus. The para- esophageal hernias themselves remain in the chest at all times and are not affected by swallows.

Para-esophageal hiatal hernias

A para-esophageal hiatal hernia that is large, particularly if it compresses the adjacent esophagus, may impede the passage of food into the stomach

and cause food to stick in the esophagus after it is swallowed. Ulcers also may form in the herniated stomach due to the trauma caused by food that is

stuck or acid from the stomach. Fortunately, large para-esophageal hernias are uncommon.

What are the symptoms of hiatal hernia?

The vast majority of hiatal hernias are of the sliding type, and most of them are not associated with symptoms. The larger the hernia, the more likely it

is to cause symptoms. When sliding hiatal hernias produce symptoms, they almost always are those ofgastroesophageal reflux disease (GERD) or its

complications. This occurs because the formation of the hernia often interferes with the barrier (lower esophageal sphincter) which prevents acid from

refluxing from the stomach into the esophagus. Additionally, it is known that patients with GERD are much more likely to have a hiatal hernia than

individuals not afflicted by GERD. Thus, it is clear that hiatal hernias contribute to GERD. However, it is not clear if hiatal hernias alone can result i n

GERD. Since GERD may occur in the absence of a hiatal hernia, factors other than the presence of a hernia can cause GERD.

Symptoms of uncomplicated GERD include:

y heartburny regurgitation

y nausea

How does a hiatal hernia cause GERD?

Normally, there are several mechanisms to prevent acid from flowing backwards (refluxing) up into the esophagus. One mechanism involves a band of

esophageal muscle where the esophagus joins the stomach called the lower esophageal sphincter that remains contracted most of the time to prevent

acid from refluxing or regurgitating. The sphincter only relaxes when food is swallowed, allowing food to pass from the esophagus and into the

stomach. The sphincter normally is attached firmly to the diaphragm in the hiatus, and the muscle of the diaphragm wraps around the sphincter. The

muscle that wraps around the sphincter augments the pressure of the contracted sphincter to further prevent reflux of acid.

Another mechanism that prevents reflux is the valve-like tissue at the junction of the esophagus and stomach just below the sphincter. The esophagus

normally enters the stomach tangentially so that there is a sharp angle between the esophagus and stomach. The thin piece of tissue in this angle,

composed of esophageal and stomach wall, forms a valve that can close off the opening to the esophagus when pressure increases in the stomach,for example, during strenuous exercise.

When a hiatal hernia is present, two changes occur. First, the sphincter slides up into the chest while the diaphragm remains in it s normal location. As

a result, the pressure normally generated by the diaphragm overlying the sphincter and the pressure generated by the sphincter no longer overlap, and

as a result, the total pressure at the gastro-esophageal junction decreases. Second, when the gastro-esophageal junction and stomach are pulled up

into the chest with each swallow, the sharp angle where the esophagus joins the stomach becomes less sharp and the valve-like effect is lost. Both

changes promote reflux of acid.

How is a hiatal hernia diagnosed?

Hiatal hernias are diagnosed incidentally when an upper gastrointestinal x-ray orendoscopy is done during testing to determine the cause of upper

gastrointestinal symptoms such as upperabdominal pain. On both the x-ray and endoscopy, the hiatal hernia appears as a separate "sac" lying

between what is clearly the esophagus and what i s clearly the stomach. This sac is delineated by the lower esophageal sphincter above and the

diaphragm below. The hernia may only be visible during swallows, however.

How is a hiatal hernia treated?

Treatment of large para-esophageal hernias causing symptoms requires surgery. During surgery, the stomach is pulled down into the abdomen, the

esophageal hiatus is made smaller, and the esophagus is attached firmly to the diaphragm. This procedure restores the normal anatomy.

Since sliding hiatal hernias rarely cause problems themselves but rather contribute to acid reflux, the treatment for patients with hiatal hernias is usually

the same as for the associated GERD. If the GERD is severe, complicated, or unresponsive to reasonable doses of medications, surgery often is

performed. At the time of surgery, the hiatal hernia is eliminated in a manner similar to the repair of para-esophageal hernias. However, in addition, part

of the upper stomach is wrapped around the lower sphincter to augment the pressure at the sphincter and further prevent acid reflux.


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Hiatal Hernia At A Glance

y A hiatal hernia is an anatomical abnormality of the esophagus.

y Hiatal hernias contribute to gastro-esophageal reflux disease (GERD).

y

The symptoms in individuals with hiatal hernias parallel the symptoms of the associated GERD.

y The treatment of most hiatal hernias is the same as for the associated GERD.

http://www.medicinenet.com


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HIATAL HERNIA

A hiatal hernia occurs when part of your stomach pushes upward through your diaphragm. Your diaphragm normally has a

small opening (hiatus) that allows your food tube (esophagus) to pass through on its way to connect to your stomach. The

stomach can push up through this opening and cause a hiatal hernia.

In most cases, a small hiatal hernia doesn't cause problems, and you may never know you have a hiatal hernia unless your

doctor discovers it when checking for another condition. But a large hiatal hernia can allow food and acid to back up into

your esophagus, leading to heartburn and chest pain. Self-care measures or medications can usually relieve thesesymptoms, although a very large hiatal hernia sometimes requires surgery.

SYMPTOMS

Small hiatal hernias

Most small hiatal hernias cause no signs or symptoms.

Large hiatal hernias

Larger hiatal hernias can cause signs and symptoms such as:

Heartburn

Belching

Chest pain

Nausea


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CAUSES

A hiatal hernia occurs when weakened muscle tissue allows your stomach to bulge up through your diaphragm. It's not

always clear why this happens, but pressure on your stomach may contribute to the formation of hiatal hernia.

How a hiatal hernia forms

Your diaphragm is a large dome-shaped muscle that separates your chest cavity from your abdomen. Normally, your

esophagus passes into your stomach through an opening in the diaphragm called the hiatus. Hiatal hernias occur when the

muscle tissue surrounding this opening becomes weak, and the upper part of your stomach bulges up through the

diaphragm into your chest cavity.

Possible causes of hiatal hernia

Hiatal hernia could be caused by:

Injury to the area

An inherited weakness in the surrounding muscles

Being born with an unusually large hiatus

Persistent and intense pressure on the surrounding muscles, such as when coughing, vomiting, or straining during a bowel

movement or while lifting heavy objects

RISK FACTORS

Hiatal hernia is most common in people who are:

Age 50 or older

Obese

Smokers

DIAGNOSTICS

A hiatal hernia is often discovered during a test or procedure to determine the cause of heartburn or chest or upper

abdominal pain, such as:

An X-ray of your upper digestive tract. During a barium X-ray, you drink a chalky liquid containing barium that coatsyour upper digestive tract. This provides a clear silhouette of your esophagus, stomach and the upper part of your small

intestine (duodenum) on an X-ray.

Using a scope to see inside your digestive tract. During an endoscopy exam, your doctor passes a thin, flexible tube

equipped with a light and video camera (endoscope) down your throat and into your esophagus and stomach to check for

inflammation.

TREATMENT


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Most people with hiatal hernia don't experience any signs or symptoms, and won't need treatment. If you experience signs

and symptoms, such as recurrent heartburn and acid reflux, you may require treatment, which can include medications or

surgery.

Medications for heartburn

If you experience heartburn and acid reflux, your doctor may recommend medications, such as:

Antacids that neutralize stomach acid.Over-the-counter antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums,may provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some

antacids can cause side effects, such as diarrhea or constipation.

Medications to reduce acid production.Called H-2-receptor blockers, these medications include cimetidine (TagametHB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 75). H-2-receptor blockers don't act as quickly as

antacids, but they provide longer relief. Stronger versions of these medications are available in prescription form.

Medications that block acid production and heal the esophagus.Proton pump inhibitors block acid production andallow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid

24HR) and omeprazole (Prilosec OTC). Stronger versions of these medications are available in prescription form.

Surgery to repair a hiatal hernia

In a small number of cases, a hiatal hernia may require surgery. Surgery is generally reserved for emergency situations

and for people who aren't helped by medications to relieve heartburn and acid reflux. Hiatal hernia repair surgery is often

combined with surgery for gastroesophageal reflux disease.

An operation for a hiatal hernia may involve pulling your stomach down into your abdomen and making the opening in

your diaphragm smaller, reconstructing a weak esophageal sphincter, or removal of the hernia sac. In some cases, this is

done using a single incision in your chest wall (thoracotomy) or abdomen (laparotomy). In other cases, your surgeon may

insert a tiny camera and special surgical tools through several small incisions in your abdomen. The operation is then

performed while your surgeon views images from inside your body that are displayed on a video monitor (laparoscopic

surgery).

LIFE STYLE AND HOME REMEDIES

Lifestyle changes may help control the signs and symptoms of acid reflux caused by a hiatal hernia. Consider trying to:

Eat several smaller meals throughout the day rather than a few large meals.

Avoid foods that trigger heartburn, such as chocolate, onions, spicy foods, citrus fruits and tomato-based foods.

Avoid alcohol.

Limit the amount of fatty foods you eat.

Sit up after you eat, rather than taking a nap or lying down.

Eat at least three hours before bedtime.

Lose weight if you're overweight or obese.

Stop smoking.

Elevate the head of your bed 6 inches (about 15 centimeters).

Work to reduce the stress in your daily li fe.


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Diaphragmatic hernia

A diaphragmatic hernia is a birth defect in which there is an abnormal opening in the diaphragm, the muscle that helps you breathe.

The opening allows part of the organs from the belly (stomach, spleen, liver, and intestines) to go up into the chest cavity near the

lungs.

Causes

A diaphragmatic hernia is caused by the improper joining of structures during fetal development. As a result, the abdominal organs

such as the stomach, small intestine, spleen, part of the liver, and the kidney appear in the chest cavity. The lung tissue on the

affected side is thus not allowed to completely develop.

Congenital diaphragmatic hernia is seen in 1 out of every 2,200 to 5,000 live births. Most affect the left side. Having a parent or

sibling with the condition slightly increases your risk.

Symptoms

Severe breathing difficulty usually develops shortly after the baby is born, because of ineffective movement of the diaphragm and

crowding of the lung tissue, which causes collapse. The reason why this occurs is not known.

Other symptoms include:

y Bluish colored skin due to lack of oxygen

y Rapid breathing (tachypnea)y Fast heart rate (tachycardia)

Exams and Tests

The pregnant mother may have excessive amounts of amniotic fluid. Fetal ultrasound may show abdominal contents in the chest

cavity.Examination of the infant shows:

y Irregular chest movements

y Absent breath sounds on affected side

y Bowel sounds heard in the chesty Abdomen feels less full on examination by touch (palpation)

A chest x-ray may show abdominal organs in chest cavity.


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Treatment

A diaphragmatic hernia is an emergency that requires surgery. Surgery is done to place the abdominal organs into the proper

position and repair the opening in the diaphragm.

See: Diaphragmatic hernia repair - congenital

The infant will need breathing support until he or she recovers from surgery. Some infants are placed on a heart/lung bypass

machine, which gives the lungs a chance to recover and expand after surgery.If a diaphragmatic hernia is diagnosed during pregnancy (around 24 to 28 weeks), fetal surgery may be considered.

Outlook (Prognosis)

Congenital diaphragmatic hernia is a very serious disorder. The outcome of surgery depends on how well your baby's lungs have

developed. Usually the outlook is very good for infants who have enough lung tissue.

With advances in neonatal and surgical care, survival is now greater than 80%.

Possible Complications

y Lung infections

y Other congenital problems

When to Contact a Medical Professional

Go to the emergency room or call the local emergency number (such as 911). A diaphragmatic hernia is a surgical emergency.

Prevention

There is no known prevention.

Alternative Names

Hernia - diaphragmatic; Congenital hernia of the diaphragm

References

Ehrlich PF, Coran AG. Diaphragmatic hernia. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of

Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 101.


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The chest cavity includes the heart and lungs. The abdominal cavity includes the liver, the stomach, and the small and large

intestines. The two regions are separated by the diaphragm, the large dome-shaped muscle.

When the diaphragm develops with a hole in it, the abdominal organs can pass into the chest cavity. The lung tissue on the affected

side is compressed, fails to grow normally, and is unable to expand after birth. As the child begins to breathe, cry, and swallow, air

enters the intestines that are protruding into the chest. The increasing size of the intestines puts pressure on the other side of the

chest, lung, and heart and can quickly cause a life-threatening situation.

The indications for a diaphragmatic hernia repair include:


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y chest X-rays showing diaphragmatic hernia

y severe breathing difficulty (respiratory distress) shortly after birthy prenatal ultrasound often identifies a diaphragmatic hernia

An incision is made in the upper abdomen, under the ribs. The abdominal organs are gently pulled down through the opening in the

diaphragm and positioned into the abdominal cavity.

The hole in the diaphragm is repaired and the incision is stitched closed. A tube is placed in the chest to allow air, blood, and fluid to

drain so the lung can re-expand.


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The lung tissue may be underdeveloped on the affected side, and the outcome depends upon the development of the lung tissue.

Infants who survive may have some long-term lung disease.

US National Library of Medicine

National Institutes of Health


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Congenital diaphragmatic hernia (CDH) is a congenital malformation (birth defect) of

the diaphragm. The most common type of CDH is aBochdalek hernia; other types

includeMorgagni's hernia, diaphragm eventration and central tendon defects of

the diaphragm. Malformation of the diaphragm allows the abdominal organs to push into

the chest thereby impeding properlung formation.

CDH is a life-threatening pathology in infants, and a major cause of death due to two

complications: pulmonary hypoplasia and pulmonary hypertension.[1] Experts disagree

on the relative importance of these two conditions, with some focusing on hypoplasia,

others on hypertension.[2] Newborns with CDH often have severe respiratory

distress which can be life-threatening unless treated appropriately.

[edit]Types of congenital diaphragmatic hernia

[edit]Bochdalek hernia

Main article: Bochdalek hernia

The Bochdalek hernia, also known as a postero-lateral diaphragmatic hernia, is the

most common manifestation of CDH, accounting for more than 95% of cases. [3][4] In this

instance the diaphragm abnormality is characterized by a hole in the postero-lateral

corner of the diaphragm which allows passage of the abdominal viscera into the chest

cavity. The majority of Bochdalek hernias (80-85%) occur on the left side of the

diaphragm, a large proportion of the remaining cases occur on the right side, and a

small fraction are bilateral i.e., left and right sided defects.[3][5]

[edit]Morgagni's hernia

Morgagni's Hernia


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This rare anterior defect of the diaphragm is variably referred to as Morgagnis,

retrosternal, or parasternal hernia. Accounting for approximately 2% of all CDH cases, it

is characterised by herniation through the foramina of Morgagni which are located

immediately adjacent to the xiphoid processof the sternum.[3] The majority of hernias

occur on the right side of the body and are generally asymptomatic; However newborns

may present with respiratory distress at birth similar to Bochdalek hernia. Additionally,

recurrent chest infections and gastrointestinal symptoms have been reported in those

with previously undiagnosed Morgagni's hernia.[6][7] In asymptomatic individuals

laparoscopic surgical repair is still recommended as they are at risk of a strangulated

intestine.

[edit]Diaphragm eventration

The diagnosis of congenital diaphragmatic eventration is used when there is abnormal

displacement (i.e. elevation) of part or all of an otherwise intact diaphragm into the chest

cavity. This rare type of CDH occurs because in the region of eventration the diaphragm

is thinner, allowing the abdominal viscera to protrude upwards. This thinning is thought

to occur because of incomplete muscularisation of the diaphragm, and can be found

unilaterally or bilaterally.[8] Minor forms of diaphragm eventration are asymptomatic,

however in severe cases infants will present with respiratory distress similar to

Bochdalek hernia.[9]

[edit]Pathophysiology

It involves three major defects.

A failure of the diaphragm to completely close during development.

Herniation of the abdominal contents into the chest

Pulmonaryhypoplasia

[edit]Morbidity and mortality

Congenital Diaphragmatic Hernia has a mortality rate of 40-62% [10], outcomes being

more favorable in the absence of other congenital abnormalities. Individual rates varygreatly dependent upon multiple factors; size of hernia, organs involved, additional birth

defects or genetic problems, amount of lung growth, age and size at birth, type of

treatments, timing of treatments, complications such as infections and lack of lung

function.


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[edit]Presentation and diagnosis

This condition can often be diagnosed before birth and fetal intervention can sometimes

help, depending on the severity of the condition.[11] Infants born with diaphragmatic

hernia experience respiratory failure due to both pulmonary hypertension andpulmonary hypoplasia. The first condition is a restriction of blood flow through the lungs

thought to be caused by defects in the lung. Pulmonary hypoplasia or decreased lung

volume is directly related to the abdominal organs presence in the chest cavity which

causes the lungs to be severely undersized, especially on the side of the hernia.

Survival rates for infants with this condition vary, but have generally been increasing

through advances in neonatal medicine. Work has been done to correlate survival rates

to ultrasound measurements of the lung volume as compared to the baby's head

circumference. This figure known as the lung to head ratio (LHR).

Treatment

First step in management is orogastric tube placement and securing the airway

(intubation). The baby will usually be immediately placed on a ventilator. ECMO has

been used as part of the treatment strategy at some hospitals.[12][13]

Diaphragm eventration is typically repaired thoracoscopically, by a technique called

plication of the diaphragm.[14] Plication basically involves a folding of the eventrated

diaphragm which is then sutured in order to take up the slack of the excess diaphragm

tissue.


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CHOLECYSTITIS

Cholecystitis (ko-luh-sis-TIE-tis) is an inflammation of the gallbladder. Your

gallbladder is a small, pear-shaped organ on the right side of your abdomen, just

beneath your liver. The gallbladder holds a digestive fluid called bile that's released

into your small intestine.

In many cases, cholecystitis is caused by gallstones that block the tube leading out

of your gallbladder. This results in a buildup of bile that can cause inflammation.

Other causes of cholecystitis include infection, injury and tumors.

If left untreated, cholecystitis can lead to serious complications, such as tissue

damage, tears in your gallbladder and infection that spreads to other parts of your

body. Once diagnosed, cholecystitis requires a hospital stay. Treatment for

cholecystitis often eventually includes gallbladder removal.

SYMPTOMS

Signs and symptoms of cholecystitis may include:

Severe, steady pain in the upper right part of your abdomen that, if left untreated,

may last several hours or days and gets worse when you breathe deeply

Pain that radiates from your abdomen to your right shoulder or back

Tenderness over your abdomen when it's touched


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Sweating

Nausea

Vomiting

Loss of appetite

Fever

Chills

Abdominal bloating

Cholecystitis signs and symptoms usually occur after a meal, particularly a large

meal or a meal high in fat.

When to see a doctor

If you have any of the signs or symptoms of cholecystitis, contact your doctor right

away. Cholecystitis itself isn't a medical emergency. But if left untreated,

cholecystitis can lead to serious, sometimes life-threatening, complications.

Cholecystitis usually requires hospitalization.

CAUSES

Your gallbladder is a small, pear-shaped organ on the right side of your abdomen,

just beneath your liver. The gallbladder holds fluid called bile that's released afteryou eat, particularly after you eat high-fat foods, to aid digestion. Bile travels out of

your gallbladder through a small tube called the cystic duct, to another tube called

the common bile duct, and then into your small intestine. Cholecystitis occurs when

your gallbladder becomes inflamed.

Cholecystitis may occur suddenly (acute cholecystitis), or it may develop slowly

over time (chronic cholecystitis).

Causes of cholecystitis include:

Gallstones. The vast majority of cholecystitis cases are the result of gallstones

that block the cystic duct, causing bile to build up and resulting in gallbladder

inflammation.


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Injury. Injury to your gallbladder particularly injury that happens as a result of

trauma to your abdomen or surgery may cause cholecystitis.

Infection. An infection within the bile can lead to gallbladder inflammation.

Tumor. A tumor may prevent bile from draining out of your gallbladder properly,

causing bile buildup that can lead to cholecystitis.

RISK FACTORS

The following factors may increase your risk of cholecystitis:

Gallstones. Most cases of cholecystitis are linked to gallstones. If you have

gallstones, you're at high risk of developing cholecystitis.

Long labor.Prolonged labor can cause damage to the gallbladder, increasing the

likelihood of developing cholecystitis in the weeks after giving birth.

Traumatic injury. Serious abdominal trauma can increase your risk of

cholecystitis.

Diabetes.Complications of diabetes can lead to gallbladder damage and increase

your risk of developing cholecystitis.

COMPLICATION

Cholecystitis can lead to a number of serious complications, including:

Gallbladder distention. If your gallbladder becomes inflamed due to bile buildup,

it may stretch and swell beyond its normal size (hydrops), which can cause pain

and increase the risk of a tear (perforation) in your gallbladder, as well as infection

and tissue death.

Infection. If bile builds up within your gallbladder, causing cholecystitis, the bilemay become infected (empyema). This infection can increase the risk of a tear in

your gallbladder that could allow the infection to spread to your blood or to other

parts of your body.

Tissue death. Untreated cholecystitis can cause tissue in the gallbladder to die

(gangrene), which in turn can lead to a tear in the gallbladder, or it may cause your

gallbladder to burst.


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Perforation. A tear (perforation) in your gallbladder may be caused by gallbladder

distention or gangrene that occurs as a result of cholecystitis.

DIAGNOSTICS

Along with a thorough physical exam, the tests and procedures used to diagnose

cholecystitis include:

Blood tests. If you have cholecystitis, a blood test may reveal that your white

blood cell count is higher than normal, which may indicate an infection. Blood tests

may also show high levels of bilirubin (an orange-yellow pigment that's released

into bile and stored in your gallbladder), alkaline phosphatase (an enzyme found in

high concentrations in your liver and bile ducts) and serum aninotransferase (liver

enzymes).

Imaging tests. Imaging tests, such as abdominal ultrasound or a computerized

tomography (CT) scan, can be used to create pictures of your gallbladder that may

reveal signs of cholecystitis.

Hepatobiliary iminodiacetic acid (HIDA) scan. By creating pictures of your

liver, gallbladder, biliary tract and small intestine, an HIDA scan can track the

production and flow of bile from your liver to your small intestine and show if bile is

blocked at any point along the way. This test is also called cholescintigraphy,

hepatobiliary scintigraphy or hepatobiliary scan.

TREATMENT

If you're diagnosed with cholecystitis, you'll be admitted to the hospital. Once

you're in the hospital, you may not be allowed to eat or drink, and you may be

given liquids through an intravenous (IV) line. Your doctor may recommend

medication for pain relief and antibiotics to fight infection.

Surgery to remove the gallbladder (cholecystectomy)

Because cholecystitis frequently recurs, most people diagnosed with cholecystitiseventually require gallbladder removal.

If you have complications of cholecystitis, such as a gangrene or perforation of your

gallbladder, you may need to have surgery immediately. If you have an infection,

you may require placement of a temporary tube through your skin into the

gallbladder to drain the infection.


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If you don't have complications, your doctor may recommend cholecystectomy

within several days or a few weeks, depending on your situation.

Cholecystectomy is most commonly performed using a tiny video camera to see

inside your abdomen and special surgical tools to remove the gallbladder

(laparoscopic cholecystectomy). The tools and camera are inserted through four

incisions in your abdomen, and the surgeon watches a monitor while guiding the

tools during surgery.

Once your gallbladder is removed, bile flows directly from your liver into your small

intestine, rather than being stored in your gallbladder. You don't need your

gallbladder to live, and gallbladder removal doesn't affect your ability to digest

food, although it can cause diarrhea.

PREVENTION

Because most cases of cholecystitis are caused by gallstones, you can reduce your

risk of cholecystitis by taking the following steps to prevent gallstones:

Don't skip meals. Try to stick to your usual mealtimes each day. Skipping meals

or fasting can increase the risk of gallstones.

Exercise most days of the week. Being inactive may increase the risk of

gallstones, so incorporate physical activity into your day. If you haven't been active

lately, start slowly and work your way up to 30 minutes or more of activity on most

days of the week.

Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can

increase the risk of gallstones. Aim to lose 1 or 2 pounds (0.5 to about 1 kilogram)

a week.

Maintain a healthy weight.Obesity and being overweight increase the risk of

gallstones. Work to achieve a healthy weight by reducing the number of calories

you eat and increasing the amount of physical activity you get. Once you achieve a

healthy weight, work to maintain that weight by continuing your healthy diet and

continuing to exercise.


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In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Severe

illness and, rarely, tumors of the gallbladder may also cause cholecystitis.

Acute cholecystitis causes bile to become trapped in the gallbladder. The buildup of bile

causes irritation and pressure in the gallbladder. This can lead to bacterial infection and

perforation of the organ.

Gallstones occur more frequently in women than men. Gallstones become more

common with age in both sexes. Native Americans have a higher rate of gallstones.

Symptoms

The main symptom is abdominal pain that is located on the upper right side or upper

middle of the abdomen. The pain may:

y Be sharp, cramping, or dull

y Come and go

y Spread to the back or below the right shoulder blade

y Occur within minutes of a meal

Other symptoms that may occur include:

y Abdominal fullness

y Clay-colored stools

y Fever

y Nausea and vomiting

y Yellowing of skin and whites of the eyes (jaundice)

Exams and Tests

A physical exam will show that your abdomen is tender to the touch.

Your doctor may order the following blood tests:

y Amylase and lipase

y Bilirubin

y Complete blood count ( CBC) -- may show a higher than normal white blood cell count

y Liver function tests

Imaging tests that can show gallstones or inflammation include:

y Abdominal ultrasound


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y Abdominal CT scan

y Abdominal x-ray

y Oral cholecystogram

y Gallbladder radionuclide scan

Treatment

Seek immediate medical attention for severe abdominal pain.

In the emergency room, patients with acute cholecystitis are given fluids through a vein

and antibiotics to fight infection.

Although cholecystitis may clear up on its own, surgery to remove the gallbladder

(cholecystectomy) is usually needed when inflammation continues or recurs. Surgery is

usually done as soon as possible, however some patients will not need surgery right

away.

Nonsurgical treatment includes pain medicines, antibiotics to fight infection, and a low-

fat diet (when food can be tolerated).

Emergency surgery may be necessary if gangrene (tissue death),

perforation, pancreatitis, or inflammation of the common bile duct occurs.

Occasionally, in very ill patients, a tube may be placed through the skin to drain the

gallbladder until the patient gets better and can have surgery.

Outlook (Prognosis)

Patients who have surgery to remove the gallbladder usually do very well.

Possible Complications

y Empyema (pus in the gallbladder)

y Gangrene (tissue death) of the gallbladder

y Injury to the bile ducts draining the liver (a rare complication of cholecystectomy)

y Pancreatitis

y Peritonitis (inflammation of the lining of the abdomen)

When to Contact a Medical Professional

Call your health care provider if severe abdominal pain persists.

Call for an appointment with your health care provider if symptoms of cholecystitis recur

after an acute episode.


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Prevention

Removal of the gallbladder and gallstones will prevent further attacks. Follow a low-fat

diet if you are prone to gallstone attacks.


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Gangrenous Cholecystitis

These gallstones caused the gallbladder to become gangrenous. Fortunately, it could

be removed. The gangrene was most likely caused by the impaiment or total occlusion

of bloodflow secondary to the size and quantity of the stones.

This is an older photo, when clear plastic rulers cost only 5 cents. Pathologists canstill buy much of their equipment at the hardware store.

Most people have heard of the "F"'s for gallstone disease, though of course most

anybody can get gallstones.

y feamale

y fat

y fertile


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y forty

y fair-skinned

y flatulent


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What is

Minimally Invasive Surgery ?

Minimally Invasive Surgery (MIS, in german: MIC) is a new kind of surgery whichgets more and more common nowadays. Another well-known expression is

'endoscopic surgery'. With this method, a surgical operation is performed by the help

of:

a small endoscopic camera

several long, thin, rigid instruments

through natural body openings or small artificial incisions ('keyhole surgery').

In comparison to the usual, open surgery, there exist several advantages for the

patient:

y less pain, less strain of the organism

y faster recovery

y

small injuries (aesthetic reasons)y economic gain (shorter illness time)

On the other hand, there exist some important disadvantages for the surgeon, too:

y restricted vision

y difficult handling of the instruments


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y very restricted mobility

y difficult hand-eye coordination

y no tactile perception

Typical instrument arrangement for the cholecystectomy (gall bladder removal). This

is the most frequently done minimally-invasive operation. The endoscopic camera is

put in the abdoman through the navel, the instruments through small incisions with

approximately 5-15 mm diameter. In the upper left corner, the endoscopic view is

displayed.

Endoscopic procedures in the human abdoman are also called 'laparoscopy'. The cholecystectomy is

used as prototypic application for our demonstrator.


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CHOLECYSTECTOMY

Cholecystectomy (ko-lay-sis-TEK-tuh-me) is a surgical procedure to remove your

gallbladder a pear-shaped organ that sits just below your liver on the upper right

side of your abdomen. Your gallbladder collects and stores bile a digestive fluid

produced in your liver.

Cholecystectomy may be necessary if you experience pain from gallstones that

block the flow of bile. Cholecystectomy is a common surgery, and it carries only a

small risk of complications. In most cases, you can go home the same day of your

cholecystectomy.

Cholecystectomy is most commonly performed using a tiny video camera to see

inside your abdomen and special surgical tools to remove the gallbladder. Doctors

call this laparoscopic cholecystectomy.

WHY ITs DONE

Cholecystectomy is used to treat gallstones and the complications they cause. Your

doctor may recommend cholecystectomy if you have:

Gallstones in the gallbladder (cholelithiasis)

Gallstones in the bile duct (choledocholithiasis)

Gallbladder inflammation (cholecystitis)

Pancreas inflammation (pancreatitis)

RISK

Cholecystectomy carries a small risk of complications including:

Bile leak

Bleeding

Blood clots


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Death

Heart problems

Infection

Injury to nearby structures, such as the bile duct, liver and small intestine

Pancreatitis

Pneumonia

Your risk of complications depends on your overall health and the reason for your

cholecystectomy. Emergency cholecystectomy carries a higher risk of complications

than does a planned cholecystectomy.

How you prepapre

To prepare for cholecystectomy, your surgeon may ask you to:

Drink a solution to clean out your intestines. In the days before your

procedure you may be given a prescription solution that flushes stool out of your

intestines.

Eat nothing the night before your surgery. You may drink a sip of water withyour medications, but avoid eating and drinking at least four hours before your

surgery.

Stop taking certain medications and supplements. Tell your doctor about all

the medications and supplements you take. Continue taking most medications as

prescribed. Your doctor may ask you to stop taking certain medications and

supplements because they may increase your risk of bleeding.

Shower using a special soap. Your doctor may give you a special antibacterial

soap to use before your surgery.

Prepare for your recovery

Plan ahead for your recovery after surgery. For instance:

Plan for a hospital stay. Most people go home the same day of their

cholecystectomy, but complications can occur that require one or more nights in the

hospital. If the surgeon needs to make a long incision in your abdomen to remove


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your gallbladder, you may need to stay in the hospital longer. It's not always

possible to know ahead of time what procedure will be used. Plan ahead in case you

need to stay in the hospital by bringing personal items, such as your toothbrush,

comfortable clothing and books or magazines to pass the time.

Find someone to drive you home and stay with you. Ask a friend or family

member to drive you home and stay close the first night after surgery.

What you can expect

During your cholecystectomy

Cholecystectomy is performed using general anesthesia, so you won't be aware

during the procedure. Anesthesia drugs are given through a vein in your arm. Once

the drugs take affect, your health care team will insert a tube down your throat to

help you breathe. Your surgeon then performs the cholecystectomy using either alaparoscopic or open procedure.

Minimally invasive (laparoscopic) cholecystectomy

During laparoscopic cholecystectomy, the surgeon makes four small incisions in

your abdomen. A tube with a tiny video camera is inserted into your abdomen

through one of the incisions. Your surgeon watches the picture on a monitor in the

operating room as special surgical tools are inserted through the other incisions in

your abdomen and your gallbladder is removed.

Next you'll undergo cholangiography, a special X-ray to check your bile duct forabnormalities. If your surgeon finds gallstones or other problems in your bile duct,

those may be remedied. Then your incisions are sutured, and you're taken to a

recovery area. Laparoscopic cholecystectomy takes one or two hours.

Laparoscopic cholecystectomy isn't appropriate for everyone. In some cases your

surgeon may begin with a laparoscopic approach and find it necessary to make a

larger incision because of scar tissue from previous operations or complications.

Traditional (open) cholecystectomy

During open cholecystectomy your surgeon makes a 6-inch (about 15 cm) incision

in your abdomen below your ribs on your right side. The muscle and tissue are

pulled back to reveal your liver and gallbladder. Your surgeon then removes the

gallbladder. The incision is sutured, and you're taken to a recovery area. Open

cholecystectomy takes one or two hours.


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After cholecystectomy

You'll be taken to a recovery area as the anesthesia drugs wear off. Then you'll be

taken to a hospital room to continue recovery. Recovery varies depending on your

procedure:

Laparoscopic cholecystectomy.People are often allowed to go home the same

day as their surgery, though sometimes a one-night stay in the hospital is needed.

In general, you can expect to go home once you're able to eat and drink without

pain and are able to walk unaided. It takes about a week to fully recover.

Open cholecystectomy.Expect to spend two or three days in the hospital

recovering. Once at home, it may take four to six weeks to fully recover.

Result

Cholecystectomy can relieve the pain and discomfort of gallstones. Conservative

treatments, such as dietary modifications, usually can't stop gallstones from

recurring. Cholecystectomy is the only way to prevent gallstones.

Some people experience mild diarrhea after cholecystectomy, though this usually

goes away with time. Most people won't experience digestive problems after

cholecystectomy. Your gallbladder isn't essential to healthy digestion.

How quickly you can return to normal activities after cholecystectomy depends onwhich procedure your surgeon uses and your overall health. People undergoing

laparoscopic cholecystectomy may be able to go back to work in a matter of days.

Those undergoing open cholecystectomy may need a week or more to recover

enough to return to work.


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Cholecystectomy

From Wikipedia, the free encyclopedia

This article needs additional citations for verification.

Please help improve this article by adding reliable references. Unsourced

material may be challenged and removed. (March 2008)

Laparoscopic Cholecystectomy as seen through laparoscope

X-Ray during Laparoscopic Cholecystectomy


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A US Navy general surgeon and an operating room nurse discuss proper procedures while

performing a laparoscopiccholecystectomy surgery.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow

the insertion of operating ports, small cylindrical tubes approximately 5-10 mm in

diameter, through which surgical instruments and a video camera are placed into

theabdominal cavity. The camera illuminates the surgical field and sends a magnified

image from inside the body to a video monitor, giving the surgeon a close-up view of the

organs and tissues. The surgeon watches the monitor and performs the operation by

manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is anesthetized and placed in the supine position on

the operating table. A scalpel is used to make a small incision at the umbilicus. Using

either a Veress needle or Hasson technique the abdominal cavity is entered. The

surgeon inflates the abdominal cavity with carbon dioxide to create a working space.

The camera is placed through the umbilical port and the abdominal cavity is inspected.

Additional ports are placed inferior to the ribs at the epigastric, midclavicular,

andanterior axillary positions. The gallbladder fundus is identified, grasped, and

retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted

laterally to expose and open Calot's Triangle (the area bound by the cystic artery, cystic

duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal

covering and obtain a view of the underlying structures. The cystic duct and the cystic

artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder isdissected away from the liver bed and removed through one of the ports. This type of

surgery requires meticulous surgical skill, but in straightforward cases can be done in

about an hour.

Recently, this procedure is performed through a single incision in the patient's

umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or

"LESS".

[edit]Procedural Risks and Complications

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut,

resulting in less pain, quicker healing, improved cosmetic results, and fewer

complications such as infection and adhesions. Most patients can be discharged on the

same or following day as the surgery, and most patients can return to any type of

occupation in about a week.


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An uncommon but potentially serious complication is injury to the common bile duct,

which connects the gallbladder and liver. An injured bile duct can leak bile and cause a

painful and potentially dangerous infection. Many cases of minor injury to the common

bile duct can be managed non-surgically. Major injury to the bile duct, however, is a

very serious problem and may require corrective surgery. This surgery should be

performed by an experienced biliary surgeon.[1]

Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that

obscure vision are discovered during about 5% oflaparoscopic surgeries, forcing

surgeons to switch to the standard cholecystectomy for safe removal of the

gallbladder.Adhesions and gangrene, of course, can be quite serious, but converting to

open surgery does not equate to a complication.

A Consensus Development Conference panel, convened by the National Institutes of

Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and

effective surgical treatment for gallbladder removal, equal in efficacy to the traditional

open surgery. The panel noted, however, that laparoscopic cholecystectomy should be

performed only by experienced surgeons and only on patients who have symptoms of

gallstones.

In addition, the panel noted that the outcome oflaparoscopic cholecystectomy is greatly

influenced by the training, experience, skill, and judgment of the surgeon performing the

procedure. Therefore, the panel recommended that strict guidelines be developed for

training and granting credentials in laparoscopic surgery, determining competence, and

monitoring quality. According to the panel, efforts should continue toward developing

a noninvasive approach to gallstone treatment that will not only eliminate existing

stones, but also prevent their formation or recurrence.

One common complication of cholecystectomy is inadvertent injury to an anomalous

bile duct known as Ducts of Luschka, occurring in 33% of the population. It is non-

problematic until the gall bladder is removed, and the tiny supravesicular ducts may be

incompletely cauterized or remain unobserved, leading to biliary leak post operatively.

The patient will develop biliary peritonitis within 5 to 7 days following surgery, and willrequire a temporary biliary stent. It is important that the clinician recognize the possibility

of bile peritonitis early and confirm diagnosis via HIDA scan to lower morbidity rate.

Aggressive pain management and antibiotic therapy should be initiated as soon as

diagnosed.

[edit]Biopsy


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After removal, the gall bladder should be sent for biopsy (pathological examination) to

confirm the diagnosis and look for an incidental cancer. If cancer is present, a

reoperation to remove part of the liver and lymph nodes will be required in most

cases. [2]

[edit]Long-Term Prognosis

A minority of the population, from 5% to 40%, develop a condition

called postcholecystectomy syndrome, or PCS.[3] Symptoms can include gastrointestinal

distress and persistent pain in the upper right abdomen.

As many as twenty percent of patients develop chronic diarrhea. The cause is unclear,

but is presumed to involve the disturbance to the bile system. Most cases clear up

within weeks, though in rare cases the condition may last for many years. It can be

controlled with drugs

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