ACUTE CHOLECYSTITIS

1. ACUTE CHOLECYSTITIS ETIOPATHOGENESIS 1. ACUTE CALCULUS CHOLECYSTITIS- 90% OF CASES - OBSTRUCTION IN THE NECK OF THE GALL BLADDER OR IN THE CYSTIC DUCT BY A GALL STONE –DISTENTION – ACUTE INFLAMATION- SECONDARY BACTERIAL INFECTION

2. ACUTE ACALCULOUS CHOLECYSTITIS 10% OF CASES- BURNS,DEHYDRATION,,SEVERE SEPSIS,RECENT CHILDBIRTH,TORTION OF GALL BLADDER, DIABETES MELLITUS. RARELY PRIMARY BACTERIAL INFECTION.

3. PATHOLOGY MORPHOLOGY IS SAME IN BOTH TYPES EXCEPT FOR PRESENCE & ABSENCE OF GALL STONES GROSS- GALLBLADDER IS DISTENDED & TENSE SEROSA- FIBRINOUS EXUDATE MUCOSA-BRIGHT RED. LUMEN – PUS MIXED WITH BILE

4. ACUTE CHOLECYSTITIS

5. PATHOLOGY CALCULOUS TYPE- STONE IMPACTED IN THE NECK OR CYSTIC DUCT. EMPYEMA OF THE GALL BLADDER.

6. PATHOLOGY MICROSCOPY-OEDEMA, CONGESTION,ACUTE INFLAMMATORY EXUDATE,GANGRENOUS NECROSIS(GANGRENOUS CHOLECYSTITIS)

7. ACUTE CHOLECYSTITIS

8. ACUTE CHOLECYSTITIS

9. CLINICAL FEATURES OF ACUTE CHOLECYSTITIS SEVERE PAIN IN THE UPPER ABDOMEN WITH FEATURES OF GAURDING,HYPERAESTHESIA,

10. CLINICAL FEATURES OF ACUTE CHOLECYSTITIS TENDER PALPABLE GALLBLADDER FEVER, LEUKOCYTOSIS NEUTROPHILIA,SLIGHT JAUNDICE

11. CLINICAL FEATURES OF ACUTE CHOLECYSTITIS PROGNOSIS- EARLY CHOLECYSTECTOMY- LESS THAN 0.5% MORTALITY& RISK OF COMPLICATIONS- PERFORATION , BILIARY FISTULA, RECURRENT ATTACKS & ADHESIONS IS AVOIDED

12. COMPLICATIONS PERFORATION , BILIARY FISTULA, RECURRENT ATTACKS & ADHESIONS IS AVOIDED

13. CHRONIC CHOLECYSTITIS • ETIOPATHOGENESIS • MIXED& COMBINED GALL STONES IS ALWAYS PRESENT. • SUPERSATURATION OF THE BILE WITH CHOLESTEROL PREDISPOSED TO BOTH GALLSTONE & INFLAMMATION.

14. CHRONIC CHOLECYSTITIS IN SOME CASES REPEATED ATTACKS OF MILD ACUTE CHOLECYSTITIS RESULT IN CHRONIC CHOLECYSTITIS

15. PATHOLOGY GALLBLADDER- NORMAL OR ENLARGED OR CONTRACTED WALL IS THICKED & GREY WHITE DUE TO DENCE FIBROSIS & EVEN CALCIFIED - (PORCELAIN GALLBLADDER)

16. CHRONIC CHOLECYSTITIS

17. CHRONIC CHOLECYSTITIS AND CHOLELITHIASIS

18. CHRONIC CHOLECYSTITIS AND CHOLELITHIASIS

19. CHRONIC CHOLECYSTITIS AND CHOLELITHIASIS

20. PATHOLOGY MUCOSA- FLATTENED ,ATROPHIED LUMEN CONTAINS MULTIPLE MIXED & COMBINED STONES.

21. CHRONIC CHOLECYSTITIS

22. CHRONIC CHOLECYSTITIS MICROSCOPY- ATROPHIC MUCOSA PENETRATION OF THE MUCOSA DEEP INTO THE WALL OF THE GALLBLADDER- ROKITANSKY- ASCHOFF SINUSES

23. CHRONIC CHOLECYSTITIS CHRONIC INFLAMMATION THROUGHOUT THE WALL VARIABLE DEGREE OF FIBROSIS

24. CHRONIC CHOLECYSTITISROKITANSKY- ASCHOFF SINUSES

25. CHRONIC CHOLECYSTITISROKITANSKY- ASCHOFF SINUSES

26. CLINICAL FEATURES OF CHRONIC CHOLECYSTITIS FAT ,FERTILE,FEMALE OF FORTY OR FIFTY WITH EPIGASTRIC DISCOMFORT ESPECIALLY AFTER A FATTY MEAL • CONSTANT DULL ACHE IN THE RIGHT HYPOCHONDRIUM & EPIGASTRIUM & TENDERNESS OVER THE RIGHT UPPER ABDOMEN.

27. CLINICAL FEATURES OF CHRONIC CHOLECYSTITIS • NAUSEA & FLATULENCE ARE COMMON.OCCATIONALLY BILIARY COLIC. • ULTRASOUND,CT,MRI

28. CARCINOMA OF THE GALLBLADDER • INCIDENCE-MORE FREQUENT IN FEMALES,7TH DECADE • USUALLY SLOW GROWING,MAY REMAIN UNDETECTED UNTIL THE TIME IT IS WIDELY SPREAD & RENDERED INOPERABLE.

29. ETIOLOGY OF CARCINOMA GALLBLADDER 1. CHOLELITHIASIS & CHOLECYSTITIS_ FOUND IN 75% OF CASES.PORCELLAIN GALLBLADDER IS PERTICULARLY PRONE TO DEVELOP CANCER

30. ETIOLOGY OF CARCINOMA GALLBLADDER 2.CHEMICAL CARCINOGENS STRUCTURALLY SIMILAR TO BILE ACIDS- METHYLE CHOLANTHRENE, NITROSAMINES PESTICIDES,WORKERS ENGAGED IN RUBBER INDUSTRY.

31. ETIOLOGY OF CARCINOMA GALLBLADDER 3.PREVIOUS SURGERY ON BILIARY TRACT. 4.INFLAMMATORY BOWEL DISEASE

32. PATHOLOGY SITES- COMMON SITE IS THE FUNDUS FOLLOWED INFREQUENCY BY NECK OF THE GALLBLADDER.

33. PATHOLOGY GROSS – 1.INFILTRATING TYPE- IRREGULAR AREA OF DIFFUSE THICKENING & INDURATION OF THE GALLBLADDER WALL, IT MAY HAVE DEEP ULCERATION,WALL IS FIRM.

34. GROSS 2.FUNGATING TYPE- IRREGULAR FRIABLE PAPILLARY OR CAULIFLOWER LIKE GROWTH PROJECTING INTO THE LUMEN OR INFILTRATING INTO THE WALL & BEYOND.

35. MICROSCOPY 90% ADENOCARCINOMAS WELL DIFFERENTIATED TO POORLY DIFFERENTIATED, PAPILLARY. MOST ARE NONMUCIN SECRETING , SOME ARE COLLOID TYPE.

36. MICROSCOPY 5%- SQUAMOUS CELL CARCINOMAS,ADENOSQUAMOUS CELL CARCINOMAS

37. CARCINOMA GALLBLADDER

38. GALLBLADDER ADENOCARCINOMA

39. GALLBLADDER ADENOCARCINOMA

41. METASTATIC GALLBLADDER CARCINOMA - SKULL AND FEMURS

42. CLINICAL FEATURES OF CARCINOMA GALLBLADDER SLOW GROWING ,CAUSES SYMPTOMES LATE IN THE COURSE OF THE DISEASE.

43. CLINICAL FEATURES OF CARCINOMA GALLBLADDER OFTEN DIAGNOSIS IS MADE WHEN GALLBLADDER IS REMOVED FOR CHOLELITHIASIS

44. CLINICAL FEATURES OF CARCINOMA GALLBLADDER SYMPTOMATIC CASES HAVE PAIN JAUNDICE,MASS ,ANOREXIA & WHEIGHT LOSS. BY THIS TIME ,GROWTH HAS ALREADY SPREAD LOCALLY & HAS METASTASIZED-REGIONAL LYMPH NODES, LUNG ,PERITONEUM,GIT,BONE

45. GALLSTONES( CHOLELITHIASIS ) FORMED FROM CONSTITUENTS OF BILE- CHOLESTEROL,BILE PIGMENTS & CALCIUM SALTS ALONG WITH OTHER ORGANIC COMPONENTS.

46. GALLSTONES( CHOLELITHIASIS ) • 4 F s FEMALE FAT FERTILE FORTY

47. RISK FACTORS 1.GEOGRAPHIC FACTORS QUITE PREVALENT IN ENTIRE WESTERN WORLD BLACKS AND EASTERN WORLD ARE RELATIVELY FREE

48. RISK FACTORS 2.GENETIC FACTORS- FIRST DEGREE RELATIVES – HAVE INCREASED SECRETION OF DIETARY CHOLESTEROL IN BILE

49. RISK FACTORS 3.AGE-STEADY INCREASE WITH ADVANCING AGE .PRESENT AT 50s & 60s. 4.SEX- F:M = 2:1ESPECIALLY IN MULTIPAROUS WOMEN.

50. RISK FACTORS FOR CHOLELITHIASIS • 5. DRUGS – WOMEN ON OESTROGEN THERAPY OR ON BIRTH CONTROL PILLS HAVE HIGHER INCIDENCE.- DUE TO PRODUCTION OF LITHOGENIC BILE- CHOLESTATIC EFFECT OF OESTROGEN.