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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
department To know To be able
Base departments
1 Anatomy, topographical
anatomy (departments of
Aanatomy of human,
Topographical anatomy and
operative surgery)
Anatomy and topographical
anatomy of liver, gallbladder and
biliary system.
To conduct palpation of
liver and gallbladder.
2 Morphology (department of
Pathoanatomy &
Morphology)
Morphological description of
acute cholecystitis.
To define morphological
changes, inherent the
different types of acute
cholecystitis.
3 Anatomy, topographical
anatomy (departments of
Anatomy of human,
Topographical anatomy and
operative surgery)
Surgical approach, methods of
operations
To choose the adequate
method of surgery
4 Biological chemistry
(department of Biological
chemistry )
Test interpretation of surgical
diseases
To interpretate the blood
tests in patients with an
acute cholecystitis.
5 Internal diseases (department
of Internal diseases)
Interpretation of examination of
organs of abdominal region
To conduct an examination
patient with an acute
cholecystitis.
Type clinical departments
1
General surgery (department
of General surgery)
Basic principles of work of
surgical department and
operating block in emergency.
Hospitalize a patient to
surgical department, to
prepare to the treatment
and diagnostic options and
surgery.
2 Department of Internal
diseases
Methods of diagnostics of acute
cholecystitis and its
complications, pathogenesis and
clinical variants.
To find out the complaints
of patient, collect
anamnesis of disease,
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
from bile cultures
Proportions of isolated
organisms (%)
Gram-negative organisms
Escherichia coli
Klebsiella spp.
Pseudomonas spp.
Enterobacter spp.
31–44
9–20
0.5–19
5–9
Gram-positive organisms
Enterococcus spp.
Streptococcus spp.
Staphylococcus spp.
3–34
2–10
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 inflamed and
edematous. In the most severe cases (5 to 10%), this process can lead to ischemia and necrosis of the
gallbladder wall. More frequently, the gallstone is dislodged, and the inflammation gradually
resolves.
Gallstone Pathogenesis. Bile represents the route of excretion for certain organic solids, such as
bilirubin ana cholesterol, the major organic solutes in bile are bilirubin, bile salts, phospholipids, and
cholesterol. Bilirubin is the breakdown product of red blood cells and is conjugated with glucuronic
acid before being excreted. Bile salts solubilize lipids and facilitate their absorption. Phospholipids
(lecithin) are synthesized in the liver in conjunction with bile salt synthesis. The final major solute of
bile is cholesterol. The normal volume of bile secreted daily by the liver is 600 to 1200 ml.
Cholesterol is highly nonpolar and insoluble in water. The key to maintaining cholesterol in solution
is the formation of both micelles, a bile salt-phospholipid-cholesterol complex, and cholesterol-
phospholipid vesicles. Present theory suggests that in states of excess cholesterol production, these
large vesicles may also exceed their capability to transport cholesterol, and crystal precipitation may
occur. Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and
phospholipids.
Gallstones represent a failure to maintain certain biliary solutes, primarily cholesterol and calcium
salts, in a solubilized state. Gallstones are classified by their cholesterol content as either cholesterol or
pigment stones. Pigment stones are further classified as either black or brown. Pure cholesterol
gallstones are uncommon (10%), with most cholesterol stones containing calcium salts in their center.
In most populations, 70 to 80% of gallstones are cholesterol, and black pigment stones account for
most of the remaining 20 to 30%.
An important biliary precipitate in gallstone pathogenesis is biliary "sludge," which refers to a
mixture of cholesterol crystals, calcium bilirubinate granules, and a mucin gel matrix. Biliary
sludge has been observed clinically in prolonged fasting states or with the use of long-term total
parenteral nutrition. Both of these conditions are also associated with gallstone formation. The finding
of macromolecular complexes of mucin and bilirubin, similar to biliary sludge in the central core of
most cholesterol gallstones, suggests that sludge may serve as the nidus for gallstone growth.
The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and
pregnancy, hemolytic diseases, and cirrhosis.
The morphological displays of acute cholecystitis carry making progress destructive character
often. As a rule, a process is begun with a mucus coat, where a desquamation of epithelium is, was
swollen mucus shell and submucous layer, infiltration their leucocytes. Subserosal dilation of blood
vessels takes place, bile often with the admixtures of mucus and fibrin. Such changes are
characteristic for a catarrhal cholecystitis.
At subsequent progress of passionately destructive changes in a mucus shell which loses the
protective properties, a process spreads on other layers of wall of gallbladder. There is a considerable
oedema of all of layers, their infiltration by different cells, microorganisms. The paretic broaden blood
vessels, there are diffuse hemorrhages. Muscular layers loosed a capacity for contraction. In a serosa
there is a desquamation of mesotelium, laying of fibrin. Such changes are characterized as a
phlegmonous cholecystitis. Accumulation of pus inside the gallbladder is determined as an empyema
of gallbladder. Total destruction of the gallbladder wall is specific for gangrenous cholecystitis. Thus
to the gall-bladder large omentum, colon or its mesentery, wall of duodenum can be fixed. The
conglomerate of tissues which are saturated with an exsudate – paravesical mass (infiltrate) appears in
the total.
Perforation of the gallbladder occurs in up to 10% of cases of acute cholecystitis. Perforation
is a sequela of ischemia and gangrene of the gallbladder wall and occurs most commonly in the
gallbladder fundus. The perforation is most frequently (50% of cases) contained within the
subhepatic space by the omentum, duodenum, liver, and hepatic flexure of the colon, and a localized
abscess forms. Less commonly, the gallbladder perforates into an adjacent viscus (duodenum or colon),
resulting in a cholecystoent-eric fistula. Rarely, the gallbladder perforates freely into the peritoneal
cavity, leading to generalized peritonitis.
Emphysematous cholecystitis develops very rarely, more commonly in males and in patients
with diabetes mellitus. Severe right upper quadrant pain and generalized sepsis are frequently present
because of Enterococcus, Klebsiella and Clostridia species.
CLASSIFICATION
Classification of gallbladder diseases and biliary system (WHO, ICD – 10):
Stone of gallbladder
with an acute cholecystitis к 80.0
with other cholecystitis к 80.1
without a cholecystitis к 80.2
Stone of bile ducts
with a cholecystitis к 80.4
with a cholangitis к 80.3
without a cholecystitis or cholangitis к 80.5
Other forms of cholelithiasis к 80.8
An acute acalculous cholecystitis к 81.0
A chronic acalculous cholecystitis к 81.1
Other forms of cholecystitis к 81.8
Hydrops of gallbladder к 82.1
Fistula of gallbladder к 82.3
Cholangitis к 83.0
The perforation of bile ducts к 83.2
Stricturae of common bile duct к 83.8
Fistula of bile ducts к 83.3
Postcholecistectomy syndrome к 91.5
By morphological changes distinguish:
Catarrhal cholecystitis Simple
Phlegmonous cholecystitis
Gangrenous cholecystitis
Emphysematous cholecystitis
Destructive
The most often complications of acute cholecystitis:
1. Paravesical mass.
2. Paravesical abscess.
3. Empyema of gallbladder.
4. Perforation of gallbladder.
5. Peritonitis (localized, spread, total).
6. Choledocholitiasis.
7. Obstruction of common bile duct.
8. Obstructive jaundice.
9. Biliary pancreatitis.
10. Cholangitis.
11. Abscesses of liver.
The separate form of pathology is a cholecystpancreatitis, that combination of inflammation of
gall-bladder and pancreas.
CLINIC PICTURE
The clinical picture of acute cholecystitis depends on morphological changes in a gall-bladder,
duration of process, presence of complications, individual features. It follows to notice that direct
dependence between clinical information and pathological changes is observed not always.
As a rule, a disease is begun with a twinge in right subcostal area, which can be irradiation in a
right shoulder-blade, supraclavicular area, suprashoulder and in small of the back. Sometimes pain
increases during inspiration. In parts sick there are great crumble pains in the area of heart, right
shoulder-blade and left shoulder, which are irradiation from the overhead half of abdomen (symptom
of Botkin, or cholecyst-cardiac syndrome). Gradual distribution of pain from right subcostal area in
other parts of abdomen can be at development of peritonitis.
Other important features are nausea and vomiting which often arises up on height of pain
attack and does not bring a facilitation. On the initial stages of disease vomiting more frequent by
stomach content, later in vomit the masses a bile appears often. Characteristic is a loss of appetite,
general weakness, decline of capacity. Patients feel bitter taste and dryness, sometimes belch is
present. The delay of gases and emptying, inflation of abdomen which more frequent is at a
destructive process and during development of peritonitis can disturb part of patients.
When a cholecystitis was complicated the obstruction of common bile duct, patients can notice
jaundice of skin, brighten excrement masses.
At questioning it is possible to find out information about the use in eve the disease of spicy
food.
At objective patients are inspected on height of pain attack uneasy. Hyperemia of person
appears on the early stages, later, especially at progress of destructive processes, a skin becomes pale,
covered sweat, acrocyanosis is determined. Appearance of jaundice of skin and mucous shells testifies
to violation of arcade of bile on ducts or about the defeat of liver. A tongue is usually covered white or
yellow stratifications, at case of destructive cholecystitis - dry.
The temperature of body at a simple cholecystitis can not change or be subfebrile. At a
destructive cholecystitis a temperature rises till 38-39°С, that characteristically also for development
of septic complications.
Hart rate gradually increase to the extent of progress of disease and can pass ahead the height
of temperature reaction.
At the thorax investigation it is possible to define lag in breathing of right half, that it is related
to strengthening of pain on inspiration. At palpation between sternoclaidomastoideus muscle
peduncles or above a collar-bone arises up pain (phrenicus-sign). In the case of development of
pleurisy proper objective symptoms is marked.
At the examination of abdomen for thin people it is possible to see enlarged gallbladder in
right subcostal area. The right half of abdomen limitedly takes part in the act of breathing. It is
possible to look after displacement of belly-button up to the top and to the right, that arises up in
connection with reduction of muscles of right half of abdomen.
Supperficial an deep palpation is painful with tenderness at the right epigastrium. It is
sometimes possible palpate painful bottom of gallbladder. At formation of perivesicular mass in right
subcostal area determined painfully, immobile compression without clear limits.
By Palpation it is possible to define the row of characteristic symptoms of acute cholecystitis:
the Kehr’s sign - painful palpation and tenderness are maximal at the point of gallbladder;
the Karavanov’s sign - carefully pressing the area of right subcostal area, there is pain. A hand is
detained - pain calms down. Ask a patient to cough - pain increases acutely.
the Murphy’s sign - place a left hand so that four fingers lay on a costal arc, and the first finger
pinned the projection of gall-bladder - inspiratory arrest with deep palpation in the right upper
quadrant;
the Ortner’s sign - pain arises up at percussion of costal arch on the right.
In transition an inflammatory process on a parietal peritoneum the symptoms of its irritation
are determined – rebound tenderness.
At auscultation of abdomen at a pain attack it is possible to define weakening or/and absence
of intestinal noises. Combination of the last sign with the displays of destructive cholecystitis is an
unfavorable criterion which specifies on development of peritonitis.
At combination of cholecystitis with a pancreatitis (acute biliary pancreatitis) pain and
muscular tenderness take the upper half of abdomen, symptoms, characteristic for a pancreatitis, are
determined.
ADDITIONAL METHODS OF INVESTIGATION WBC appears at laboratory research, change of shift leucocytes’ formula to the left. As a rule,
changes depend on the depth of morphological changes in the gallbladder wall. At the destructive
forms of cholecystitis, and also at development of septic complications, the concentration of urea is
increased. In the development of jaundice a hyperbilirubinemia is determined, mainly due to direct
bilirubin; the colour of urine changes, a positive reaction is determined on bilious pigments.
Ultrasound is the most useful radiologic examination in the patient with suspected
cholecystitis. First, in the patient without known gallstones, ultrasound is a sensitive test for
establishing the presence or absence of gallstones. Additional findings suggestive of acute cholecystitis
include thickening (>4 mm) and layering of the gallbladder wall, and pericholecystic fluid. Focal
tenderness directly over the gallbladder (sonographic Murphy sign) is also suggestive of acute
cholecystitis. Ultrasound has a sensitivity and a specificity of 85% and 95%, respectively, for
diagnosing acute cholecystitis. Informing of method grows till about 100% at application of three-
dimensional ultrasound. Specific contra-indications are not to application of this method.
Radionuclide scanning is used less frequently for the diagnosis of acute cholecystitis but may
provide additional information in the atypical case. Nonfilling of the gallbladder with the radiotracer
"99Tc-hepato-iminodiacetic acid (HIDA) indicates an obstructed cystic duct and, in certain clinical
settings, is highly sensitive (95%) and specific (95%) for acute cholecystitis.
MRCP and drip infusion cholangiography with CT (DIC-CT) are informative in bile duct
investigation.
Useful to diagnostics, especially differential, there can be a thermography. Development of
destructive forms of cholecystitis is accompanied the acute strengthening of intensity of infrared in the
area of gall-bladder which is registered a device.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis at an acute cholecystitis is more frequent all conducted with the acute
surgical diseases of organs of abdominal region (by a perforative ulcer, acute appendicitis, acute
nonbiliary pancreatitis, acute intestinal obstruction), right-side basal pleuropneumonia, heart attack of
myocardium (by an cholecysto-cardial syndrome), pathology of the kidney and urino-excretory
system. Decision for verification of diagnosis are blood tests, ultrasound of liver and biliary system,
intravenous pyelography, chest X-ray, ECG.
Diagnostic criteria and severity assessment criteria for acute cholecystitis according the Tokyo
Consensus Meeting (2007) and Guideline (2013) are presented at the Table 2 and Table 3.
Table 2. Diagnostic criteria for acute cholecystitis
A. Local signs of inflammation
B. Systemic signs of inflammation
C. Imaging findingsa
(1) Murphy’s sign, (2) RUQ mass/pain/tenderness
(1) Fever, (2) elevated CRP, (3) elevated WBC count
Imaging fi ndings characteristic of acute cholecystitis
---------------------------------------------------------------------------------------------------------------------
Definite diagnosis
(1) One item in A and one item in B are positive
(2) C confirms the diagnosis when acute cholecystitis is suspected clinically
--------------------------------------------------------------------------------------------------------------------- Note: acute hepatitis, other acute abdominal disease, and chronic cholecystitis should be excluded a Imaging findings of acute cholecystitis
Ultrasonography
• Sonographic Murphy sign (tenderness elicited by pressing the gallbladder with the ultrasound probe)
• Thickened gallbladder wall (>4 mm, if the patient does not have chronic liver disease and/or ascites or right heart
failure)
• Enlarged gallbladder (long axis diameter >8 cm, short axis diameter >4 cm)
• Incarcerated gallstone, debris echo, pericholecystic fluid collection
• Sonolucent layer in the gallbladder wall, striated intramural lucencies, and Doppler signals
MRI
• Pericholecystic high signal
• Enlarged gallbladder
• Thickened gallbladder wall
CT
• Thickened gallbladder wall
• Pericholecystic fl uid collection
• Enlarged gallbladder
• Linear high-density areas in the pericholecystic fat tissue
Tc-HIDA scan (technetium hepatobiliary iminodiacetic acid scan)
• Non-visualized gallbladder with normal uptake and excretion of radioactivity
• Rim sign (augmentation of radioactivity around the gallbladder fossa)
Table 3. Severity assessment criteria for acute cholecystitis .
Mild (grade I) acute cholecystitis
“Mild (grade I)” acute cholecystitis does not meet the criteria of “severe (grade III)” or
“moderate (grade II)” acute cholecystitis. It can also be defined as acute cholecystitis in a
healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder,
making cholecystectomy a safe and low-risk operative procedure.
Moderate (grade II) acute cholecystitis
“Moderate” acute cholecystitis is associated with any one of the following conditions:
1. Elevated WBC count (>18 000/mm3)
2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 ha
4. Marked local inflammation (biliary peritonitis, pericholecystic abscess, hepatic abscess,
gangrenous cholecystitis, emphysematous cholecystitis) . a Laparoscopic surgery should be performed within 96 h of the onset of acute cholecystitis
Severe (grade III) acute cholecystitis
“Severe” acute cholecystitis is associated with dysfunction of any one of the following
organs/systems
1. Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≥5 µg/kg per
min, or any dose of dobutamine)
2. Neurological dysfunction (decreased level of consciousness)
3. Respiratory dysfunction (PaO2/FiO2 ratio <300)
4. Renal dysfunction (oliguria, creatinine >2.0 mg/dl)
5. Hepatic dysfunction (PT-INR > 1.5)
6. Hematological dysfunction (platelet count <100 000/mm3).
Fig. 1. Flowcharts for the management of acute cholecystitis.
GB, gallbladder; LC, laparoscopic cholecystectomy
MANAGEMENT
A choice of rational method of treatment at an acute cholecystitis is important for the increase
of efficiency of treatment of such patients. Most widespread is active tactic. It foresees hospitalization
of all patients with an acute cholecystitis in surgical permanent establishment, urgent examination and
leadthrough at first o'clock all of patient of conservative measures which have also on a purpose
preparation to the possible operation. Flowcharts for the management of acute cholecystitis according
the Tokyo Consensus Meeting (2007) and Guideline (2013) is presented at the Fig.1.
Conservative therapy consists of complex measures which influence on the different links of
disease.
In the first days of patients limit in the reception of meal, afterwards appoint a diet № 5 by
Pevzner,s.
For the improvement of outflow of bile spasmolytic preparations are propose: No-Spanum 2,0,
Papaverinum 2% - 2,0 (i/v, i/m), Platyphyllinum 0,2% - 1,0, Atropinnum 0,1% - 1,0 subcutaneously.
The last two preparations - hyposecretion of glands of mucus shell, pancreas also.
In case of pain non-narcotic analgesics should be widely used (Diclophenac, Ketorolac,
Ketoprofen), and also in combination with spasmolytics (Baralginum, Spasganum, Spasmalgonum,
Baralgitax). Introductions of these facilities combine with antihistaminic preparations: 1%
Dimedrolum, 2,5% Diprazinum, 1-2% Suprastinum and others like that, which potenciated the action
of analgetics and have a certain sedative effect. Narcotic analgetics appointing is not desirable as a
result of their the spastic effect on sphincter of Oddi. However, at a necessity introduction, they are
combined with spasmolytics. Good anaesthetic an effect the Novocaine blockade of the round
ligament of liver has.
Antibacterial therapy is recommended (Table 4). It is expedient to use antibiotics which must
ability be concentrated in a bile: Cefoperazone, Ceftazidime, Doxycycline - concentrated in a bile
even in the conditions of obstructive jaundice. If it necessary, the аntibacterial preparations of other
groups (Ciprofloxacin, Metronidazole, and other) should be used.
With the purpose of support of general homoeostasis infusion therapy is applied. At presence
of obstructive jaundice the volume of infusion must be increased with diuretic preparations
(Furosemid) and hepatoprotectors (Essenciale, Lypoic acid, Thiotriazolin, Lipamid, and other).
Table 4 Antimicrobial recommendations for acute biliary infections (TG-13)
Community-acquired biliary infections Healthcare-associated biliary
infectionse
Severity Grade I Grade II Grade IIIe
Antimicrobial
agents
Cholangitis Cholecystitis Cholangitis and cholecystitis Cholangitis and cholecystitis Healthcare-associated
cholangitis and cholecystitis
Penicillin-based
therapy
Ampicillin/sulbactamb is not
recommended without an
aminoglycoside
Ampicillin/sulbactamb is not
recommended without an
aminoglycoside
Piperacillin/tazobactam Piperacillin/tazobactam Piperacillin/tazobactam
Cephalosporin-
based therapy
Cefazolina, or cefotiama, or
cefuroximea, or ceftriaxone, or
cefotaxime ± metronidazoled
Cefmetazole,a Cefoxitin,a
Flomoxef,a Cefoperazone/
sulbactam
Cefazolina, or cefotiama, or
cefuroximea, or ceftriaxone, or
cefotaxime ± metronidazoled
Cefmetazole,a Cefoxitin,a
Flomoxef,a Cefoperazone/
sulbactam
Ceftriaxone, or cefotaxime, or
cefepime, or cefozopran, or
ceftazidime ± metronidazoled
Cefoperazone/sulbactam
Cefepime, or ceftazidime, or
cefozopran ± metronidazoled
Cefepime, or ceftazidime, or
cefozopran ± metronidazoled
Carbapenem-
based therapy
Ertapenem Ertapenem Ertapenem Imipenem/cilastatin,
meropenem, doripenem,
ertapenem
Imipenem/cilastatin,
meropenem, doripenem,
ertapenem
Monobactam-
based therapy
- - - Aztreonam ± metronidazolec Aztreonam ± metronidazoled
Fluoroquinolone-
based therapyc
Ciprofloxacin, or levofloxacin, or
pazufloxacin ± metronidazoled
Moxifloxacin
Ciprofloxacin, or levofloxacin, or
pazufloxacin ± metronidazoled
Moxifloxacin
Ciprofloxacin, or levofloxacin, or
pazufloxacin ± metronidazolec
Moxifloxacin
- -
a Local antimicrobial susceptibility patterns (antibiogram) should be considered for use
b Ampicillin/sulbactam has little activity left against Escherichia coli. It is removed from the North American guidelines
c Fluoroquinolone use is recommended if the susceptibility of cultured isolates is known or for patients with β-lactam allergies. Many extended-spectrum β-lactamase (ESBL)-
producing Gram-negative isolates are fluoroquinolone-resistant
d Anti-anaerobic therapy, including use of metronidazole, tinidazole, or clindamycin, is warranted if a biliary-enteric anastomosis is present. The carbapenems,
piperacillin/tazobactam, ampicillin/sulbactam, cefmetazole, cefoxitin, flomoxef, and cefoperazone/sulbactam have sufficient anti-anerobic activity for this situation
e Vancomycin is recommended to cover Enterococcus spp. for grade III community-acquired acute cholangitis and cholecystitis, and healthcare-associated acute biliary infections.
Linezolid or daptomycin is recommended if vancomycin-resistant Enterococcus (VRE) is known to be colonizing the patient, if previous treatment included vancomycin, and/or if
the organism is common in the community
Surgical management of acute cholecystitis Operations at times of performance may be divided on:
1. Urgent operation - performs during the first 6-12 hours since admission of patient to the department
by vital indications, when an acute cholecystitis was complicated widespread peritonitis.
2. Early operation - performs during the first 24-72 hours since admission of patient to the
department, when conducted therapy for such patients is unsuccessful.
3. Delayed early operation – performs in 3-7 days, after calming down of the acute signs of
cholecystitis and complications.
4. Elective operation - performs in different terms after discharge of patient from the department.
The optimal surgical treatment for acute cholecystitis was recommended by Tokyo Guidelines (2013)
according to the grade of severity:
Grade I (Mild) acute cholecystitis: Early laparoscopic cholecystectomy is the preferred procedure.
Grade II (Moderate) acute cholecystitis: Early cholecystectomy is recommended in experienced
centers. However, if patients have severe local inflammation, early gallbladder drainage (percutaneous
or surgical) is indicated. Because early cholecystectomy may be difficult, medical treatment and
delayed cholecystectomy are necessary.
Grade III (Severe) acute cholecystitis: Urgent management of organ dysfunction and management
of severe local inflammation by gallbladder drainage should be carried out. Delayed elective
cholecystectomy should be performed when cholecystectomy is indicated.
Operative Risk Factors. A careful evaluation of the overall general medical condition of the patient is
necessary before selection of the appropriate management for the patient with acute cholecystitis,
especially complicated with obstructive jaundice. The preoperative assessment should include the usual
evaluation of cardiac risk factors, respiratory status, and renal function, as well as overall performance
status measured by one of several performance scales (APACH II, ASA, SOFA). In addition, patients
have several further physiologic abnormalities, which require careful evaluation. These abnormalities
include alterations in hepatic and pancreatic function, the gastrointestinal barrier, immune function,
hemostatic mechanisms, and wound healing. Hepatic protein synthesis, hepatic reticuloen-dothelial
function, and other aspects of hepatic metabolism may be significantly altered in patients with
obstructive jaundice. In addition, endotoxemia may contribute to renal, cardiac, and pulmonary
insufficiency observed in patients with acute cholecystitis.
The optimal treatment for acute cholecystitis is essentially early cholecystectomy, and the use of
an established optimal surgical treatment for each grade of severity of acute cholecystitis is necessary.
Early laparoscopic cholecystectomy is indicated for patients with Grade I (Mild) acute cholecystitis,
because laparoscopic cholecystectomy can be performed in most of these patients. Early laparoscopic
or open cholecystectomy (within 72 h after the onset of acute cholecystitis) is required in patients with
Grade II (Moderate) acute cholecystitis in experienced centers, but for some patients with Grade II
(Moderate) acute cholecystitis, it is difficult to remove the gallbladder surgically because of severe
inflammation limited to the gallbladder. This severe local inflammation of the gallbladder is defined
by factors such as >72 h from the onset, a white blood cell count >18,000, and a palpable tender mass
in the right upper abdominal quadrant. Continued medical treatment or drainage of the contents of the
swollen gallbladder by percutaneous transhepatic gallbladder drainage or surgical cholecystostomy is
preferable, and a delayed cholecystectomy after the improvement of inflammation of the gallbladder is
indicated. Among patients with Grade II (Moderate), for those with serious local complications
including biliary peritonitis, pericholecystic abscess, liver abscess or for those with gallbladder
torsion, emphysematous cholecystitis, gangrenous cholecystitis, and purulent cholecystitis, emergency
surgery is conducted (open or laparoscopic depending on experience) along with the general
supportive care of the patient. The urgent management of Grade III (Severe) acute cholecystitis is
always necessary because the patients have organ dysfunction, and the simultaneous drainage of the
gallbladder contents is required to treat the severe inflammation of the gallbladder. Delayed (elective)
cholecystectomy is required 2 to 3 months later, after the improvement of the patients’ general
condition when cholecystectomy is indicated.
The timing of the surgical management of patients with acute cholecystitis undergoing
percutaneous transhepatic gallbladder drainage (PTGBD) is another. PTGBD is known to be an
effective option in critically ill patients, especially in elderly patients and patients with complications.
Cholecystectomy is often performed following PTGBD after an interval of several days. However,
performing a cholecystectomy 2 weeks later is also common. Overall, early cholecystectomy
following PTGBD is preferable when the patient’s condition improves, and if the patient has no
complications. Complications of PTGBD sometimes occur, such as intrahepatic hematoma,
pericholecystic abscess, biliary pleural effusion, and biliary peritonitis, which may be caused by
puncture of the liver and the migration of the catheter. However, such migration should be prevented.
On the other hand, PTGBA (percutaneous transhepatic gallbladder aspiration) is often used by many
facilities, and produces good treatment outcomes.
Choice of method of cholecystectomy. Until the first half of the 1990s, there were opinions that
laparoscopic surgery was not indicated in patients with acute cholecystitis. Open cholecystectomy was
the standard technique. However, more recently, laparoscopic surgery has also been introduced for
acute cholecystitis, and is now generally considered to be the first option for surgery, similar to open
cholecystectomy. Several reports, including randomized controlled trials (RCTs) comparing
laparoscopic cholecystectomy and open cholecystectomy, have indicated that laparoscopic
cholecystectomy is associated with a significantly shorter postoperative hospital stay and a lower
incidence of complications. A meta-analysis has also shown that laparoscopic cholecystectomy not
only resulted in treatment effects similar to those produced by open cholecystectomy, but that it is also
a useful surgical procedure in terms of its low mortality and morbidity. However, the above reports
have failed to examine its use for acute cholecystitis according to the grade of severity. Laparoscopic
cholecystectomy is not recommended for all cases of acute cholecystitis due to the possibility of
patients in whom cholecystectomy is difficult because of severe inflammation. Uncontrolled
coagulopathy is one of the few current contraindications to laparoscopic cholecystectomy. In addition,
patients with severe chronic obstructive pulmonary disease or congestive heart failure may not tolerate
the pneumoperitoneum required for performing laparoscopic surgery. Currently, the major
contraindication to completing a laparoscopic cholecystectomy is an inability to clearly identify all of
the anatomic structures. A liberal policy of converting to an open operation when important anatomic
structures cannot be clearly defined represents good surgical judgment rather than a complication. The
conversion rate for elective laparoscopic cholecystectomy is about 5%, whereas the conversion rate in
the emergency setting for acute cholecystitis may be as high as 30%.
The technical difficulty of laparoscopic cholecystectomy is increased in several clinical settings.
Laparoscopic cholecystectomy can be performed safely in acute cholecystitis, albeit with a higher
conversion rate and operative time than in the elective setting. Morbid obesity, once believed to be a
relative contraindication to the laparoscopic approach, is not associated with a higher conversion rate.
Longer trocars and instruments and increased intra-abdominal pressure may be helpful in these
patients. Prior upper abdominal surgery may increase the difficulty of, or preclude the use of,
laparoscopic cholecystectomy. However, placement of a Hasson cannula often reveals few adhesions
or adhesions that can be dissected laparoscopically permitting completion of a laparoscopic
cholecystectomy. Laparoscopic cholecystectomy has also been completed safely in patients with
cirrhosis, although difficulty retracting the firm liver and increased bleeding from collaterals have
been noted.
On the other hand, there has been a change in the perioperative management of open
cholecystectomy patients in the last few years, and the current management aims to reduce
postoperative pain and encourage early ambulation and early discharge. These changes show that, in
terms of the postoperative course, open cholecystectomy with mini-incision is able to produce as good
results as those obtained by laparoscopic cholecystectomy, although the superiority of laparoscopic
cholecystectomy as a surgical technique for acute cholecystolithiasis can be recognized. In fact, a
RCT was carried out to reappraise the use of laparoscopic cholecystectomy and open cholecystectomy
by a subcostal muscle transection mini-incision. This study indicated that no significant differences
were observed between the two types of cholecystectomies with regard to the rate of postoperative
complications, the degree of pain at discharge, the duration of sick leave, and the direct medical cost.
At the moment, laparoscopic cholecystectomy is comprehensively preferred as the surgical treatment
for acute cholecystitis. However, the first priority is the safety of the patients. With this in mind, open
minimally invasive surgery can be considered to be as effective as laparoscopic surgery.
Laparoscopic Cholecystectomy Laparoscopic surgery requires a space for visualization and instrument manipulation, and this space
is usually created by establishing a pneumoperitoneum with carbon dioxide. Special hollow
insufflation needle (Veress) with a retractable cutting sheath is inserted into the peritoneal cavity
through a supraumbilical incision and used for insufflation. Once an adequate pneumoperitoneum has
been established, a 10-mm trocar is inserted through the supraumbilical incision. The laparoscope is
then inserted through the umbilical port, and an examination of the peritoneal cavity is performed.
Additional trocars are inserted under direct vision. Most surgeons use a second 10-mm trocar placed
subxiphoid and two additional 5-mm trocars positioned subcostally in the right upper quadrant in the
midclavicular and anterior axillary lines. Five-millimeter cameras and 3-mm instruments are also
available.
The two smaller ports are used for grasping the gallbladder and placing it in the ideal position for an
antegrade cholecystectomy. The lateral port is used to retract the gallbladder cephalad, elevating the
inferior edge of the liver and exposing the gallbladder and the cystic duct. The medial 5-mm cannula
is used to grasp the gallbladder infundibulum and to retract it laterally to further expose the triangle
of Calot. This maneuver may require bluntly taking down any adhesions between the omentum or
duodenum and the gallbladder. The junction of the gallbladder and cystic duct is identified by
stripping the peritoneum off the gallbladder neck and removing any tissue surrounding the gallbladder
neck and the proximal cystic duct. Once the cystic duct is identified, an intraoperative
cholangiogram may be performed by passing a cholangiogram catheter into the cystic duct. Once the
cholangiogram is completed, two clips are placed distally on the cystic duct, and it is divided. A large
cystic duct may require placement of a pretied loop ligature to provide a secure closure.
The next step is the identification and division of the cystic artery. The artery is usually
encountered running parallel to and behind the cystic duct. Once the artery is identified and isolated,
clips are placed proximally and distally on the artery, and it is divided. Once the artery and any
branches are controlled, the gallbladder is dissected out of the gallbladder fossa by use of either a
hook or spatula cautery. The peritoneum overlying the gallbladder is placed on tension by use of the
two grasping forceps, and the peritoneum and adventitia between the gallbladder and liver are divided
with the cautery. Just before the gallbladder is removed from the liver, the operative field is carefully
searched for hemostasis, and adequate placement of the cystic duct and artery clips is confirmed.
The gallbladder is then dissected off the liver and is usually removed through the umbilical port. The
fascial defect and skin incision may need to be enlarged to remove the gallbladder and contained
gallstones. If the gallbladder has been entered during the dissection or if it is acutely inflamed or
gangrenous, the gallbladder may be placed in a plastic specimen retrieval bag before it is removed from
the peritoneal cavity.
Complications of laparoscopic cholecystectomy were reported soon after its introduction, and
include bile duct injury, intraperitoneal hemorrhage needing laparotomy, bowel injury, and hepatic
injury, as well as the commonly observed complications associated with conventional open
cholecystectomy, such as wound infection, ileus, atelectasis, deep vein thrombosis, and urinary tract
infection. Laparoscopic cholecystectomy is not always associated with a higher incidence rate
compared with open cholecystectomy, but any serious complication that requires re-operation and/or
prolonged hospitalization may become a serious problem for patients, even those who firmly believe
that laparoscopic cholecystectomy is less invasive. In spite of many improvements in the technique
and equipment, as well as the surgeon’s learning curve, the BDI rate remains high compared to open
cholecystectomy.
Open Cholecystectomy
Open cholecystectomy can be performed through either an upper midline or a right subcostal
(Kocher) incision (small incision can be used for minilaparotomy). Identification and division of the
cystic duct and artery initially limit bleeding from the gallbladder for the remainder of the dissection.
With lateral traction on the gallbladder neck, the peritoneum overlying the triangle of Calot is
incised, and the cystic duct is identified and ligated. Cholangiography is performed at this time if
indicated. The cystic duct is then ligated both proximally and distally and divided. Similarly, the
cystic artery is ligated and divided after it is carefully traced onto the gallbladder. If the anatomy
cannot be clearly identified, the gallbladder should be dissected from the fundus downward toward the
gallbladder neck (antegrade cholecystectomy), making the ductal and vascular anatomy easier to
identify. The gallbladder is dissected out of the gallbladder bed by incising the overlying peritoneum
with cautery. At this point, cystic duct cholangiography is performed. Rarely, a small duct entering the
gallbladder from the liver is encountered and should be ligated. A closed suction drain is placed if
there is concern about the security of the cystic duct closure (e.g., as in gangrenous cholecystitis).
Indications and significance of gallbladder drainage
Although early cholecystectomy, a one-shot definitive treatment for acute cholecystitis, remains
the reference standard, perioperative mortality rates in elderly or critically ill patients are reported to
be high (up to 19 %). Therefore, PTGBD is considered a safe alternative, especially in surgically high-
risk populations. There is no doubt that PTGBD with administration of antibiotics can convert a septic
cholecystitis into a non-septic condition. From a technical point of view, it is a rather uncomplicated
procedure with a low complication rate reported (range from 0 to13%). A systematic reviews report
that 30-day or in-hospital mortality after PTGBD is high (15.4 %), but that procedure-related
mortality is low (0.36 %). Of note, mortality is predominantly related to the severity of the underlying
disease rather than the ongoing gallbladder sepsis.
For patients with moderate (grade II) disease, gallbladder drainage should be used only when a
patient does not respond to conservative treatment. For patients with severe (grade III) disease,
gallbladder drainage is recommended with intensive care. Predictors for failure of conservative
treatment are: age above 70 years old, diabetes, tachycardia and a distended gallbladder at admission.
Likewise, WBC >15000 cell/μl, an elevated temperature and age above 70 years old were found to be
predictors for the failure of conservative treatment at 24-h and 48-h follow-up.
PTGBD is the most common gallbladder drainage method for elderly and critically ill patients.
There are several alternatives to PTGBD. Percutaneous transhepatic gallbladder aspiration (PTGBA)
is an alternative in which the gallbladder contents are puncture-aspirated without placing a drainage
catheter. Endoscopic naso-biliary gallbladder drainage (ENGBD) and endoscopic gallbladder stenting
(EGBS) are also alternatives via the transpapillary route. With the recent improvement in endoscopic
ultrasound (EUS), EUS-guided gallbladder drainage is performed via the antrum of the stomach and
the bulbus of the duodenum. However, these alternatives are not fully examined; PTGBD is still
recognized as a standard drainage method.
Postcholecystectomy Pain Abdominal pain or other symptoms originally attributed to the gallbladder may persist or recur
months or years after cholecystectomy Recurrence of pain or other symptoms after cholecystectomy
has been reported in as many as 20% of patients. However, with improvements in biliary imaging over
the past decade, the incidence of "postcholecystectomy syndrome" has certainly decreased. Several
common causes of postcholecystectomy pain are listed in Table 5. Episodic right upper quadrant pain
associated with jaundice and chills occurring shortly after cholecystectomy is most commonly
associated with a retained common bile duct stone or bile duct injury or leak. Acute epigastric pain
not associated with jaundice may be due to unrecognized pancreatitis, peptic ulcer disease, or even
irritable bowel syndrome. Formerly, a long cystic duct stump was believed to be a potential source of
symptoms after cholecystectomy. However, with the laparoscopic technique, the cystic duct is left
long by design to minimize the risk of bile duct injuries, and no increased risk of biliary symptoms has
been observed. Finally, a small group of patients have persistent biliary-type pain after cholecystectomy
as a result of abnormalities in the sphincter of Oddi.
Table 5. Causes of postcholecystectomy pain.
Biliary Nonbiliary
Choledocholithiasis
Bile duct stricture/injury
Sphincter of Oddi dysfunction
Stenosing papillitis
Liver disease
Wound neuroma
Pancreatitis
Irritable bowel syndrome
Peptic ulcer disease
Gastroesophageal reflux disease
Questions (α =І, α =ІІ):
1. Anatomy and physiology of gallbladder and extrahepatic bile ducts.
2. Aetiology and pathogenesis of acute cholecystitis.
3. Classification of acute cholecystitis.
4. Methods of examination of the patients with an acute cholecystitis.
5. Clinical picture of acute cholecystitis in young and elderly patients.
6. Differential diagnostics of acute cholecystitis.
7. Medical program of acute cholecystitis.
8. Complication of acute cholecystitis.
9. Features of clinical picture of acute cholecystitis are at presence of concomitant pathology.
10. Clinical picture of complications of acute cholecystitis and their differential diagnostics.
11. An indication to the urgent operations at an acute cholecystitis.
12. An indication to the early operations (24-72 hours) at an acute cholecystitis.
13. Operative interferences at acute cholecystitis.
14. Operative interferences at complications of acute cholecystitis.
15. An indication to mini-invasive operative interferences (endoscopic, laparoscopic, under CT and
ultrasound guidance) at acute cholecystitis..
16. Intraoperative complications at cholecystectomy and their treatments.
17. Complications after cholecystectomy, their prophylaxis and treatment.
18. Preoperative preparation of patients with an acute cholecystitis.
19. Postoperative conduct of patients, operated concerning an acute cholecystitis.
Practical task (α =І, α =ІIІ):
1) To collect anamnesis, conduct palpation, percussion, auscultation of patient with an acute
cholecystitis;
2) To choose the most often signs of acute cholecystitis from information of anamnesis;
3) To discover and estimate protective tenderness of muscles in the right subcostal area, an acute
gallbladder or mass, presence of fluid collections in abdominal cavity;
4) To demonstrate the presence of symptoms and their degree;
5) To conduct differential diagnostics of acute cholecystitis;
6) To determine a indications for operations in acute cholecystitis;
7) To ground and formulate the previous diagnosis of basic disease, complications and concomitant
pathology;
8) To use deontology principles;
Typical tasks (α =ІІ):
1. Female, 45 y.o., after of spicy food complains with acute pain in a right subcostal area with an
irradiation in a right shoulder-blade, nausea, dryness and bitter taste in a mouth. HR - 92 b/min.,
rhythmic. BP - 135/85 mm Hg. A tongue is dry, covered with yellow stratification. Abdomen tense
and acutely painful in the right subcostal area. The signs of peritoneum irritation absent. Ortner,s sign
is positive. Preliminary diagnosis?
A. Acute cholecystitis
B. Acute pancreatitis
C. Perforated ulcer
D. Hepatitis
E. Acute appendicitis
2. Male 47 y.o., complains with pain at the right subcostal area irradiated to the back, fever till
38.70C. He is ill during 3th days. Skin is of normal colour; HR - 88 b/min., BP - 120/80 mm Hg. A
tongue is dry. An abdomen is symmetric, muscular defence in the right subcostal area is present,
where the enlarged painful gallbladder is palpable. Ortner,s sign is positive. Leucocytes – 14.2 х 109/l.
What diagnosis das patient have?
A. Empyema of gallbladder
B. Hydrops of gallbladder
C. Cholangitis
D. Acute biliary pancreatitis
E. Choledocholithiasis.
3. Patient 67 y.o. was admitted to hospital with complains on pain in right epygastrium,
temperature up to 38.4°С. He is ill for three days. During palpation the abdomen is tender; gallbladder
is enlarged and painful. Leukocytes – 18х109/l, bending neutrophiles – 19 %. Ultrasonography: large
(13.0х7.0 cm) gallbladder with thick layered wall is obstructed in the neck with 15 mm stone.
What diagnosis das patient have?
A. Acute hepatitis
B. Hydrops of gallbladder
C. Cholelithiasis, acute cholecystitis
D. Acute biliary pancreatitis
E. Choledocholithiasis.
Atypical tasks (α =ІIІ):
1. In a 42-year-old women, after consumption of fatty food, developed an acute pain in the right
upper quadrant, sclera icterus. Body temperature – 37.2°C. On examination: slight muscle rigidity in
the right upper quadrant, signs of peritoneum irritation are negative. Biochemical test: bilirubin – 51
µmol/l (mostly due to indirect), amylase – 25 g/h/l. US: enlarged gallbladder with stones from 3 to 9
mm in diameter, CBD – 7 mm.
Formulate the diagnosis.
A. Chronic calculous cholecystitis, choledocholithiasis, obstructive jaundice.
B. Acute biliary pancreatitis, choledocholithiasis, obstructive jaundice.
C. Cancer of head of pancreas.
D. Acute calculous cholecystitis, choledocholithiasis, obstructive jaundice.
E. Cholelithiasis, calculous cholecystitis, toxic hepatitis.
2. A 45-year-old women complains of colic pain in the upper right quadrant, nausea, vomiting.
Onset of the disease 48 hours ago after fatty food consumption. CBC: Hb – 127 g/l, erythrocytes – 3.7
x 1012/l, leucocytes – 14.0 x 109/l, banding neutrophils – 10% segmented neutrophils – 77%, ESR – 24
mm/h. Biochemical test: bilirubin – 19.6 µmol/l, protein – 72 g/l, glucose – 5.0 mmol/l, amylase – 22
g/h/l, AsAT – 0,4 mmol/l, AlAT – 0.6 mmol/l, Ca2+ - 2.3 mmol/l. US: gallbladder wall is thicken to 9
mm, inside the gallbladder group of large stones to 20 mm in the diameter, CBD – 6 mm.
Formulate the diagnosis.
A. Chronic calculous cholecystitis, choledocholithiasis, obstructive jaundice.
B. Acute biliary pancreatitis.
C. Chronic calculous cholecystitis, choledocholithiasis, biliary colic.
D. Acute calculous cholecystitis, acute biliary pancreatitis, obstructive jaundice.
E. Acute calculous cholecystitis.
3. In a 42-year-old women, after consumption of fatty food, developed an acute pain in the right
upper quadrant, sclera icterus. Body temperature – 37.2°C. On examination: slight muscle rigidity in
the right upper quadrant, signs of peritoneum irritation are negative. Biochemical test: bilirubin – 51
µmol/l (mostly due to indirect), amylase – 25 g/h/l. US: enlarged gallbladder with stones from 3 to 9
mm in diameter, CBD – 7 mm.
What the tactics of treatment?
A. Open cholecystectomy, choledocholithotomy, external biliary drainage.
B. Laparoscopic cholecystectomy, choledocholithotomy, external biliary drainage.
C. Open cholecystectomy.
D. Therapeutic ERCP, laparoscopic cholecystectomy.
E. Laparoscopic cholecystectomy.
MCQs (α =І, α =ІІ) 1. Operative treatment at an acute calculous cholecystitis is indicated:
A. All of patient in a urgent order
B. In default of effect from conservative therapy during 48-72 hours
C. At appearance of vomiting
D. At increase of temperature till 37,7°С
E. At exposure positive Ortner,s sign
2. The most informing methods of examination in acute cholecystitis are:
A. Computer tomography (CT)
B. Plain X-ray abdomen
C. Ultrasound examination (US)
D. Oral cholecystography
E. GI X-ray with Ba passage
3. Morphological forms of acute cholecystitis are:
A. Fibrinous
B. Phlegmonous
C. Haemorrhagic
D. Pancreatic
E. Biliary
4. For an acute “destructive” cholecystitis are characteristically:
A. Leukocytosis
B. Leukopenia
C. Eosinophilia
D. Shift of the leukocyte formula “to the left”
E. Shift of the leukocyte formula “to the right”
5. Conservative treatment of acute cholecystitis includes:
A. Antibiotics
B. Coagulants
C. Spasmolytics
D. Infusion therapy
E. Diet N 15
6. What operation is favourable at presence of small stones in the gallbladder?
A. Cholecystectomy “from a neck”
B. Cholecystectomy “from a fundus”
C. Choledocholithotomy
D. Drainage of CBD
E. Cholecystectomy does not indicated
7. The signs of an acute cholecystitis is:
A. The Meerson,s sign
B. The Ortner,s sign
C. The Halsted’s sign
D. The Oppengeym,s sign
E. The Obrazcov,s sign
8. The Myussi-Georgievskiy,s sign:
A. Sharp pain at pattering on a right costal arc
B. Pain at pressing on between the peduncles of right m. sternoclеidomastoideus
C. Pain at palpation in the projection of the gall-bladder
D. Pain at pressing on between the peduncles of left m. sternoclеidomastoideus
E. Pain at pressure round a belly-button
9. What does it mean - laparoscopic cholecystectomy?
A. Cholecystectomy by laparoscopic manipulators through a front abdominal wall under
video guidance
B. Remove of gallbladder through the stomach wall by gastroscope usage
C. Percutaneous transhepatic sclerosing of gallbladder cavity under laparoscopic guidance
D. Remove of gallbladder is during laparotomy by laparoscopic instruments
E. Cholecystectomy by minilaparotomy approach with laparoscopic instruments
10. Urgent operation is indicated at:
A. Perforation of gallbladder, peritonitis
B. Biliary pancreatitis
C. Biliary colic
D. Obstruction of the cystic duct
E. Stricture of CBD
11. In acute cholecystitis is contra-indicated the injection of:
A. No-spanum
B. Spazmalgon, Baralgin and Spazgan
C. Morphine hydrochloride
D. Omnoponum
E. Atropine sulphate
12. Base conservative therapy of an acute cholecystitis includes:
A. Spasmolytics, Analgetics, infusions, antibacterial therapy
B. Anticoagulants, spasmolytics, analgetics
C. Spasmolytics, analgetics, laxatives, infusions
D. Anaesthetic, infusions, bile-expelling preparations
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