Mean value of IL-1a immunoexpression in gal- lbladder mucosa of the patients with ACC and CCC was similar (p > 0.05). Mean IHC expression of IL-6 was low (less than 2% of reaction) and also showed no significant intergroup difference (p > 0.05). Mean IHC expression of TNF-a in ACC was significantly lower than that in CCC group (p < 0.01) (Table 2, Fig. 2). Figure 1. Immunohistochemical expression of proinflammatory cytokines in gallbladder mucosa of the patients with cholelithiasis. A, C. Interleukin (IL)-1a; B. IL-6; D. Tumour necrosis factor-alpha (TNF-a) expression in columnar epithelial cells in gallbladder mucosa of the patients with chronic calculouscholecystitis; IL-1a (C) and TNF-a (D) expressions present also in inflammatory cells in lamina propria (mostly macrophages); IL-1a (E) and TNF-a (F) expressions in foamy cells (macrophages) under epithelium of gallbladder; CD68 (G) expression in histiocytic macrophages in the same patient as in Figure 1F; H. TNF-a expression in lymphoid cells of reactive lymph node (positive control); I. IL-6 localisation in keratinocytes of gingivae in chronic periodontitis (positive control); ABC technique; haematoxylin counterstained; bar = 50 μm in all cases.
This is to certify that the dissertation entitled “A STUDY ON CALCULOUSCHOLECYSTITIS IN GRH MADURAI” submitted by Dr. P. SUDHA to the Tamil Nadu Dr. M.G.R. Medical University, Chennai in partial fulfillment of the requirement for the award of M.S Degree Branch– I (General Surgery) is a bonafide research work were carried out by her under direct supervision & guidance.
hospitalised for calculouscholecystitis associ- ated to choledocholithiasis either proven or suspected, i.e. without evidence of gallstones and common bile duct (CBD) dilatation but with cholestasis and hepatic cytolysis. We hypothe- size that, also in these patients, a one-stage procedure performed by trained surgeons and in high-volume surgical centres, can decrease unnecessary endoscopic sphincterotomy and determine a shorter hospitalisation period with costs saving.
Laparoscopic cholecystectomy has been confirmed by the most recent guidelines to be the definitive treatment for acute calculouscholecystitis [1, 2], but the exact timing of the cholecystectomy remains still a matter of debate and aim of studies. Review and meta-analysis have reported clinical trials comparing early to delayed cholecystectomy in which, however, different definitions of early timing for cholecystectomy were adopted. More precisely, cholecyst- ectomy was defined early when performed within 24, 48 or 72 h and even within 96 h following the admission or 1 week following the onset of symptoms [3–10]. Some re- sults of published meta-analysis have been reported to be discordant, but mainly limited to the duration of the inter- vention . All [2, 5–9] but one  found a shorter total hospital stay when cholecystectomy was performed early. Finally, all meta-analysis failed to find any differences in overall morbidity, bile duct injury, and conversion rate when comparing the two sets of timings [2–9].
LC was initiated in 373 patients of which 84 (22.5%) were converted. Ultrasound (n = 301, 80.7%) was the main choice of imaging in patients with clinical suspicion of acute cholecystitis. Computed tomography (n = 127, 34.0% was mainly used in patients who presented with se- vere or diffuse symptoms, and magnetic resonance imaging (n = 93, 24.9%) was mainly used in patients with suspicion of bile duct stones in addition to cholecystitis. There were signs of acute calculouscholecystitis on im- aging in 314 patients (84.2%) and of acute cholecystitis without radiologically visible stones in 46 patients (12.3%). Gallstones without signs of inflammation were visible in 12 patients (3.2%), and one patient did not undergo any preoperative imaging since the patient was in line for an elective cholecystectomy due to symptomatic gallstones and there was a strong suspicion of acute cholecystitis based on clinical and laboratory findings. On histopatho- logical examination acute cholecystitis was found in 181 (48.5%), gangrenous cholecystitis in 98 (26.3%), acute on chronic cholecystitis in 48 (12.9%) and chronic cholecyst- itis in 46 (12.3%) patients.
Acute acalculous cholecystitis (AAC) is an acute inflammation of the gallbladder in the absence of gallstones. It has been diagnosed with increasing frequency in critically ill patients [1- 5]. Systemic inflammatory response and disturbances in splanchnic circulation combined with visceral hypoperfusion, and ischaemia-reperfusion injury are assumed to play impor- tant roles in the pathogenesis of AAC [6,7]. AAC has also been shown to be associated with multiple organ dysfunction syndrome [6,8]. In contrast, the more common form of acute cholecystitis, namely acute calculouscholecystitis (ACC), is caused by gallstones, which lead to occlusion, distension, oedema, bile stasis and often bacterial infection of the gall- bladder [9,10].
Abstract: Background: When the critical view of safety (CVS) can't be obtained during dissection of Calot’s triangle in difficult gallbladder, conversion to open surgery or other “damage control” alternatives as cholecystostomy and subtotal cholecystectomy are recommended to prevent bile duct injury. Materials and methods: The medical records of all patients presented with acute calculouscholecystitis (ACC) during the study period were retrospectively reviewed and analyzed. Results: Laparoscopic cholecystectomy (LC) was attempted in 71 difficult gallbladders out of 379 patients presenting with ACC. In 6 patients (8.5%), conversion to open surgery or laparoscopic cholecystostomy was performed. Laparoscopic subtotal cholecystectomy (LSC) with dissection and control of the cystic duct was performed for the remaining 65 patients (91.5%) including 50 females (77%) and 15 males (23%) with a mean age of 42.35±12.4 years. The mean operative blood loss was 45.28±18.6 CC and the mean operative time was 96.3±24.19 minutes. There were no operative complications or mortality. The mean hospital stay was 28±17.8 hours. There was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. Conclusion: When surgery is indicated for difficult ACC, LSC with control of the cystic duct is safe with excellent outcomes. However, if the CVS can’t be achieved due to obscured anatomy at Calot’s triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury.
liver tests (alanine transaminase (ALT), aspartate trans- aminase (AST) greater than twice normal levels). Of these only 246 (58 %) had choledocholithiasis . Chang et al showed that 51 and 41 % of ACC patients without choled- ocholithiasis had elevated ALT and AST, respectively. However, increased bilirubin levels with leukocytosis may predict gangrenous cholecystitis . Padda et al demon- strated that approximately 30 % of patients with ACC without choledocholithiasis had abnormal alkaline phos- phatase (ALP) and/or bilirubin and 50 % had abnormal ALT. Among patients with ACC and choledocholithiasis, 77 % had abnormal ALP, 60 % abnormal bilirubin and 90 % elevated ALT. By multivariate analysis increased common bile duct size and elevated ALT and ALP were predictors of choledocholithiasis . The diagnostic ac- curacy increases for cholestasis tests such serum bilirubin with the duration and the severity of obstruction. Specifi- city of serum bilirubin level for CBDS was 60 % with a cut-off level of 1.7 mg/dL and 75 % with a cut-off level of 4 mg/dL ; however, mean level of bilirubin in patients with CBDS is generally lower (1.5 to 1.9 mg/dL) [119, 127]. In a prospective study, Silvestein reported the diagnostic accuracy of serum bilirubin and serum ALP at two cut-offs for each test. Serum bilirubin at a cut-off of greater than 22.23 μmol/L had a sensitivity of 0.84 (95 % CI 0.65 to 0.94) and a specificity of 0.91 (0.86 to 0.94). Bilirubin at a cut-off of greater than twice the normal limit, had a sensi- tivity of 0.42 (95 % CI 0.22 to 0.63) and a specificity of 0.97 (95 % CI 0.95 to 0.99). For ALP at a cut-off of greater than 125 IU/L, sensitivity was 0. 92 (95 % CI 0.74 to 0.99) and specificity was 0.79 (95 % CI 0.74 to 0.84). For ALP at a cut-off of greater than twice the normal limit, sensitivity was 0.38 (95 % CI 0.19 to 0.59) and specificity was 0.97 (95 % CI 0.95 to 0.99) [131, 132].
A total number of 40 specimens were selected from gallbladders with clinical and histopathological diagnosis of chronic calculouscholecystitis received in the department of pathology PSG INSTITUTE OF MEDICAL SCIENCES AND RESEARCH during the period of 2005 to 2007. Criteria for selection were 1) Histopathological confirmation of chronic calculouscholecystitis. 2) Presence of calculi accompanying the specimen. 3) Availability of sufficient mucosa and well preserved lining epithelium in sections. 4) Availability of corresponding paraffin blocks. While 36 specimens fulfilled the above criteria, 4 cases had only biliary sand in the container. 3 gallbladders resected for choledochal cysts, were taken as controls.
histochemistry, composition of calculi and metaplasia, fibrosis and mucin histochemistry, fibrosis and stone composition indicated a decrease in intraepithelial total acid mucin content in chronic calculouscholecystitis. cases with severe inflammation showed the maximum decrease in sulfomucin, concomitant increase in sialomucin scores and a high incidence of gastric metaplasia. Intestinal metaplasia on other hand did not correlate with the degree of inflammation or sialomucin content. conclusion: this study concludes that normally gallbladder epithelium contains sulfated acid mucins with traces of neutral and sialomucins. the sulfomucin content decreases in chronic calculouscholecystitis and with severe inflammation, total acid mucin content decreases, neutral mucin increases, and there is a higher incidence of gastric metaplasia and pigment stones and correlating with pigment stones. this tends to have an association with severe inflammation, higher degree of fibrosis, gastric metaplasia and presence of sialomucin. Keywords: chronic calculouscholecystitis, Gallbladder stones, Metaplasia, Mucin histo- chemistry
Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Ninety percent of cases involve stones in the cystic duct (i.e. calculouscholecystitis) with the other 10 % of cases representing acalculous cholecystitis (9). The blocking of cystic duct leads to thickening of bile, bile stasis, and secondary infection by gut organisms predominantly E. coli and bacteroids species (10). As the gallbladder becomes distended, blood flow and lymph drainage are compromised leading to mucosal ischemia and necrosis. The role of Helicobacter pylori in the pathogenesis of gallbladder diseases in humans or even its presence in the gallbladder tissue therefore remains unclear but many researchers have demonstrated the presence of Helicobacter in gallbladder of patients with calcular cholecystitis (11, 12, and 4).
The predisposing causes in children are hemolytic disorders, (Sickle cell disease, thalassemia, red cell enzymopathy, obesity ileal resection). They have more of pigment stones, rather than cholesterol stones. Since presence of stones itself is rare the condition of acute cholecystitis is still rare an entity. Even in pediatric age group the treatment of calculouscholecystitis is cholecystectomy. Laparoscopic cholecystectomy is also possible in pediatric age group. (Ware Kinney et al J. Pediat. 1997). Acalculous disease is very uncommon may occur with similar pattern as adults and also with infections particularly Streptococci A,B, Salmonella and Leptospirosis. Our study identified one case of calculouscholecystitis with salmonella infection on bile culture but the age was in older group of 55 yrs.
with the hemorrhage and congestion of the mucosal blood vessels  From the above data, the present study showed that in calculouscholecystitis, due to the presence of gall stones and the concomitant chemical injury caused by toxic effect of lithogenic bile leads to more irritation resulting in drastic changes in all the layers of gall bladder. Whereas in acalculous cholecystitis, due to absence of stones, there will be relatively less chronic reaction when compared to calculouscholecystitis.
Only 2 cases of gall bladder perforations were encountered accounting for 3% of all gastrointestinal hollow viscus perforations. Both were due to complication of acute calculouscholecystitis. In one of the cases, who was a known diabetic, even USG did not suggest any evidence of acute cholecystitis, due to distended bowel gas disturbances. In that particular case diagnosis of acute appendicitis was made as patient had severe right iliac fossa tenderness and abdomen was opened through McBurney’s incision and intra-operatively found bile staining of intestinal loops and a normal appendix and so laparotomy was done and the gallbladder perforation was then diagnosed intra-operatively. Probably that case could have been an
Result: The common indication for laparoscopic cholecystectomy in our study was chronic calculouscholecystitis. 82% patients had chronic calculouscholecystitis which was supported by histo pathological report. It was followed by acute calculouscholecystitis (10%), acute Acalculous cholecystitis (5%), GB polyp (2%), and empyema (1%). In our study 32 patients (32%) were male and 68 patients (68%) were female. The average patient’s age undergoing laparoscopic cholecystectomy was ranging between 8 to 75 years. 11 patients (11%) were above the age 60 years. The average duration of the surgery was 88.13 minutes (range 45 – 300mins). The most common complication encountered in this study was gall stone and bile spillage intraperitoneally. Common bile duct injury, Bleeding from liver, hollow viscus injury are other intraoperative complications encountered.
Gangrenous cholecystitis (GC) is an ominous progression of acute cholecystitis in which infection, inflammation, edema, bile stasis, and ischemia lead to gallbladder necrosis and perforation. The incidence of GC ranges from 2% to 29.6% in all patients with acute cholecystitis and generally occurs in older and diabetic patients .
Background: The tuberculosis is an endemic disease in our country; it remains a major public health problem. Liver and splenic tuberculosis is a classic disease which represents 1.5% of all ga- strointestinal tuberculosis. Patients and Methods: We reported the case of a fifty-six years old pa- tient admitted in the department of surgery for acute cholecystitis, and the biological balance showed a hyperleukocytosis at 16,000 elements/mm 3 and a CRP at 25 with a light cholestasis. The
disrupt the hepatobiliary-enteric circulation of bacteria, with any abnormal tissue acting as a potential nidus of infection, a situation shown experimentally. 25 Once there is any cholestasis or further perturbation of biliary defense mechanisms, the dogs would be likely to become symptomatic for cholangitis, as seen in the experimentally manipulated cats. 25 This situation is likely to be further exacerbated should cholecystitis develop, as bacterial infection has been shown to result in proliferative activity in the bile duct epithelium. 35 In several of the chronic cases in this report, antibiotics only provided a temporary resolution of clinical signs, which then resolved with cholecystectomy suggesting a continued focus of infection. It is noteworthy that bile or gallbladder wall cultures yielded a far higher propor- tion of positive culture results than liver cultures, in agreement with Wagner et al. 11
On the contrary, the authors of the Tokyo guidelines maintain that, despite the demonstration that early cholecystectomy is indicated for acute cholecystitis in an unselected population, still it could be possible to im- prove the overall outcome of this condition tailoring the treatment according to the severity of the condition and to the patient status. They suggest a staging system based upon severity assessment criteria such as degree of local inflammation and patient conditions. According to their classification acute cholecystitis is defined as “severe (grade III)” if associated with organ dysfunction, “moder- ate (grade II)” if the completion of a cholecystectomy is likely to be difficult due to local inflammation (“criteria predicting when conditions might be unfavorable for cholecystectomy in the acute phase”), and “mild (grade I)” if it does not meet the criteria for grade II or III [19-21].