When a stone stops in the cystic duct (for example during a colic caused by a biliary calculus), this can cause difficulty in
biliary outflow and, eventually, complete obstruction. Retention can cause an
obstacle to the outflow of bile that is known as bile duct hydrops. The hydrops
begins with the symptoms of local inflammation. It is a complication of
cholelithiasis, due to the exclusion of the gallbladder from the biliary
circulation, due to a blockage of the cystic duct or of the neck of the
gallbladder itself by a biliary calculus. The mucosa of the gallbladder absorbs
the bile pigments and other components of the bile secreting mucus; the cavity
is thus filled with a mucoid solution and increases in size. This condition can
be further complicated, in the case of superinfection, with an empyema, or it
can undergo perforation. More rarely a gallbladder infarction can occur.
1.surgical intervention of removal of hydropic
gallbladder in laparoscopy.
2. CT, documents hydropic cholecyst, arrows
In clinically more evident cases, a tense and elastic gallbladder can be palpated under the costal arch, which, in cases of pure hydrops, is not particularly painful to pressure. Ultrasound is evident in an enlarged gallbladder without signs of inflammation. Depending on the position, the calculations can be easily identified, but if they are located exclusively in the cystic duct, their identification may be a little more difficult. Also CT is indicated in study.
Hydrops can cause scar wounds on the gallbladder wall with calcium deposits ("porcelain
gallbladder"). To avoid further complications it is necessary to perform a
cholecystectomy in the interval between one colonic and another. The
superinfection of the bile that leads to a cholecyst empyema is particularly
dangerous. Therefore, when diagnosing a case of hydrops of the gallbladder it is
necessary to intervene urgently by subjecting the patient to surgery because an
increase in the clinical picture could even cause a risk for the patient's life.
By empyema of the gallbladder we mean the bacterial infection of the contents of
a previously hydropic gallbladder. In this process the gallbladder ends up being
filled with pus. In this situation there is a risk of perforation resulting in
extremely severe purulent peritonitis, followed by sepsis and shock. As in the
case of cholecystitis and cholangitis, the possible microorganisms start from
the intestinal tract. The most frequent are the E. coli, enterococci, Klebsiella,
clostridia and enterobacteria in general.
Clinically an empyema of the gallbladder manifests itself with significant pain
in the right hypochondrium, both spontaneous and pressure, and abdominal tension.
Patients are very suffering and have high fever. On ultrasound, the gallbladder
empyema distinguishes itself from a simple hydrops due to its corpuscle content
and thickened walls. Laboratory analyzes indicate intense inflammation, with
neutrophilic leukocytosis that almost always exceeds 20,000 elements / u.L.
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Bottom of the hydropic gallbladder, in the center, with omental bridles adhered to the bottom and body of the gallbladder, such as a red onion, at the top the liver, of chocolate brown color. |
The therapy of the gallbladder empyema consists in the use of broad-spectrum
antibiotics and in the immediate surgical removal of the gallbladder. In these
cases a laparoscopic cholecystectomy can not be considered, unlike what happens
in an elective removal of the gallbladder. In fact, in order to ascertain with
certainty whether a perforation or penetration into adjacent organs is produced,
a wide opening of the dome is required; in other words it is essential to
realize a cholecystectomy with a conventional approach. It is also mandatory to
prolong the post-surgical antibiotic treatment for a period of 10-14 days.
Since the common bile duct and the Wirsung pancreatic duct, in 80% of cases,
have a common outlet, when a calculation obstructs the distal portion of the
common duct, in addition to cholestasis an obstacle to the drainage of
pancreatic juices is produced, with the result to have acute pancreatitis. This
causes a retention that affects the pancreatic parenchyma and which, in the long
run, causes acute pancreatitis. Another associated pathological condition may
consist of a cholangitis, with infection and the recovery of germs in the
biliary tract. Finally, for purulent exudate from the walls of the gallbladder
you can have first a "platoon" for intervention of the topic and subsequently
adherences between omentum and gallbladder.
In all cases of acute pancreatitis, it must be discarded with absolute certainty,
performing an ultrasound, that biliary lithiasis is present; in case of doubt an
endoscopic retrograde cholangiography (ERCP) should be performed. If possible,
you will have to extract the calculation that causes the obstruction
endoscopically.
Once the calculation is extracted, the clinical picture usually improves rapidly,
especially the epigastric pain. At the same time, laboratory values must
regress towards normal in the first 24 hours after surgery. In any case, it must
be taken into account that ERCP can cause pancreatitis due to the mechanical
manipulation of the duodenal papilla and the diffusion of the contrast medium
into the pancreatic duct.
Gastroenterology