Tuesday, February 18, 2014

Gallbladder Disease and Medical Malpractice

Gallbladder Disease and Medical Malpractice
Gallbladder Disease and Medical Malpractice
Gallbladder disease encompasses a wide range of clinical conditions including cholelithiasis (gallstones in the gallbladder), choledocholithiasis (gallstones in the approved bile duct), cholecystitis (inflammation of the gallbladder from obstruction of the biliary tree), and ascending cholangitis (infection of the biliary tree) . The most approved admittable presenting spot related to the gallbladder is cholecystitis. Patients reveal with biliary colic and fever. Cholecystitis is caused mostly by stones obstruction the cystic duct (90%)  which is the duct attaching the gallbladder to the favorite bile duct. The other 10% are due to stones obstructing the approved bile duct. The well-liked bile duct leads to the diminutive intestine, and is also fed by the hepatic duct coming from the liver (recognize anatomical recount below) . Risk factors for cholecystitis mirror those for cholelithiasis (simple biliary colic)  and include increasing age, female sex, determined ethnic groups, obesity or rapidly weight loss, drugs, and pregnancy.


Acute calculous (stones)  cholecystitis is caused by obstruction of the cystic duct, leading to distention of the gallbladder. As the gallbladder becomes distended, blood trudge and lymphatic drainage are compromised, leading to mucosal ischemia and necrosis.Acalculous cholecystitis is less approved and far more unsafe than calculous cholecystitis with a worthy higher mortality rate. It is caused by conditions associated with biliary stasis including considerable illnesses (many), major surgery, severe trauma and burns, sepsis, long term TPN (total parenteral nutrition), prolonged fasting, and diabetes.


An estimated 10-20% of Americans have gallstones (cholelithiasis or choledocholithiasis), and as many as one third of these people beget acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most approved major surgical scheme performed by general surgeons, resulting in approximately 500,000 operations annually.Most patients with acute cholecystitis have a complete remission within 1-4 days. However, 25-30% of patients either require surgery or effect some complication. The mortality rate for calculous cholecystitis is 4%. Perforation of the gallbladder leading to intraabdominal abscess and sepsis occurs in 10-15% of cases.


The most approved presenting symptom of acute cholecystitis is classically described as upper abdominal hurt, often radiating to the tip of the legal scapula. Although the afflict may initially be described as colicky, it becomes constant in virtually all cases. Nausea and vomiting are generally expose, and patients may narrate fever. In elderly patients, damage and fever may be absent, and localized tenderness may be the only presenting designate. Cholecystitis is differentiated from biliary colic by the persistence of constant severe hurt for more than 6 hours and the presence of fever.

Physical examination may dispute fever, tachycardia, and tenderness in the RUQ or epigastric spot, often with guarding or rebound. A palpable gallbladder or fullness of the RUQ is note in 30-40% of cases. Jaundice (Yellowing of the eyes and skin)  may be eminent in approximately 15% of patients. The absence of physical findings does not rule out the diagnosis of cholecystitis. Many patients show with diffuse epigastric hurt without localization to the RUQ. Elderly patients and patients with diabetes frequently have atypical presentations, including absence of fever and localized tenderness with only vague symptoms.


Lab studies have found that no combination of laboratory or clinical values are useful in identifying patients at high risk for acute cholecystitis. Although laboratory criteria are not gracious in identifying all patients with cholecystitis, the following findings may be useful in arriving at the diagnosis: Leukocytosis with a left shift, elevated liver function enzymes, elevated bilirubin and alkaline phosphatase, elevated amylase and lipase.

Imaging studies include expressionless x-rays (15% will prove gallstones, air in the gallbladder wall represents emphysematous cholecystitis due to gas forming bacteria and has a very high mortality rate), ultrasound (95% sensitivity for picking up gallstones), hepatobiliary scintigraphy (HIDA scan)  which is 95% true, CT and MRI (greater than 95% just), ERCP (endoscopic retrograde cholangiopancreatography)  to diagnosis popular bile duct stones, intraoperative cholangiogram (for diagnosing accepted bile duct stones) .


For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics. Antibiotics must veil the most well-liked organisms. Bacteria that are commonly associated with cholecystitis include E coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species.Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis. Surgery is usually performed after symptoms have subsided but during the hospitalization for acute illness. For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic plot to an start surgical contrivance is approximately 5%.

Complications and Prognosis:

Bacterial proliferation within the obstructed gallbladder results in empyema of the organ. Patients with empyema may have a toxic reaction and may have more marked fever and leukocytosis. The presence of empyema frequently requires conversion from laparoscopic to start cholecystectomy. In some instances, a gargantuan gallstone may erode through the gallbladder wall into the duodenum, impacting the terminal ileum and causing a gallstone ileus.

For uncomplicated cholecystitis, the prognosis is marvelous, with a very uncouth mortality rate. In patients who are critically ill with cholecystitis, the mortality rate approaches 50-60%, especially in the setting of gangrene or empyema. Once complications such as perforation/gangrene invent, the prognosis becomes less ample. In patients who are critically ill with acalculous cholecystitis and perforation or gangrene, the mortality rate can be as high as 50-60%.

Medical accurate Concerns:

The major apt liability in the treatment of gallstones rests with the surgeon and interventional endoscopist. Specific issues for the surgeon include current bile duct injury, trocar-induced bowel wound and lost stones during laparoscopic cholecystectomy.

Delays in making the diagnosis of acute cholecystitis result in a higher incidence of morbidity and mortality. This is especially proper for ICU patients who earn acalculous cholecystitis. The diagnosis should be considered and investigated promptly in order to prevent abominable outcomes.

Surgeons must win the time to identify and protect the accepted bile duct. An intraoperative cholangiogram is useful in this regard. Inadvertent puncture or laceration of the well-liked bile duct is a catastrophic complication that is not easily remedied and is the most favorite surgical misadventure resulting in litigation. Over 70% of lawsuits bewitching iatrogenic favorite bile duct injury are resolved in favor of plaintiffs by verdict or by settlement. Routine cholangiography leads to intraoperative detection of such injuries.


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