Gall bladder.2. Chronic calcular cholecystitis Flashcards by Waleed Eldahshan

Chronic Calcular Cholecystitis

Alternative names
ETIOLOGY
TYPES AND PATHOLOGY
CLINICAL PICTURE
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
TREATMENT

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Alternative names for Chronic Calcular Cholecystitis

GALL BLADDER STONES

2. CHOLELITHIASIS

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ETIOLOGY of Chronic Calcular Cholecystitis

A- Cholesterol & Mixed Stones :

B- Pigment Stones :

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Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

Disturbed bile salts / cholesterol ratio : (Lithogenic theory)
Bile stasis
Infection (in mixed stones only) :

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Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

The normal ratio
The disturbed ratio
The Etiology of disturbance

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The normal ratio in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

25:1

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The disturbed ratio in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

13:1 or less )> the cholesterol precipitates (lithogenic bile).

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lithogenic bile in The disturbed ratio in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

bile containing disturbed bile salts : cholesterol ratio )> 13:1 or less )> the cholesterol precipitates

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The Etiology of disturbance in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

a) Decrease in bile salt pool

b) Increased cholesterol in bile

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Pathogenesis of Decrease in bile salt pool in The Etiology of disturbance in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

Chronic liver disease.
Crohn’s disease.
Surgical removal of the terminal ileum

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Chronic liver disease in Pathogenesis of Decrease in bile salt pool in The Etiology of disturbance in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

causes Decrease hepatic bile salts synthesis

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Crohn’s disease in Pathogenesis of Decrease in bile salt pool in The Etiology of disturbance in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

causes inflammation of the terminal ileum which is the site of entero-hepatic circulation

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Surgical removal of the terminal ileum in Pathogenesis of Decrease in bile salt pool in The Etiology of disturbance in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

done in Right hemi colectomy

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Pathogenesis of Increased cholesterol in bile in The Etiology of disturbance in Disturbed bile salts / cholesterol ratio : (Lithogenic theory) in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

D.M, obesity or increase dietary fat intake.

2. Estrogen increases cholesterol level in bile.

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Pathogenesis of Bile stasis in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

Gall bladder contractility is reduced by

a) Oral contraceptive pills.
b) Repealed pregnancy.
c) Patients on long-term parenteral nutrition. (Dec release of cholecystokinin)
d) After truncal vagotomy.
e) D.M & obesity ( neuropathy)

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Pathogenesis of infection in Etiology of Cholesterol & Mixed Stones of CCC in ETIOLOGY of Chronic Calcular Cholecystitis

Bacteria & epithelial debris provides the nidus for stone formation

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Monaghan aphorism

The stone is the tomb of organism

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Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

1) Hemolytic anemia:(especially spherocytosis)
2) Hepatic cirrhosis :
3) Infection by E. coli
4) Parasitic infestation

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Pathogenesis of Hemolytic anemia in Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

Excessive destruction of RBCs which results in increase of bile pigments (black pigment stones).

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Pathogenesis of Hepatic cirrhosis in Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

decrease ability of the liver to conjugate bilirubin
decrease hepatic bile salt synthesis
Cirrhosis increases all types of gallstones, but black pigment stones are the commonest

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The commonest stones in Pathogenesis of Hepatic cirrhosis in Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

black pigment stones

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Pathogenesis of Infection by E. coli in Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

E. coli secretes p- glucoronidase enzyme

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p- glucoronidase enzyme in Pathogenesis of Infection by E. coli in Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

secreted by E.coli
deconjugates bilirubin diglucoronide to insoluble bilirubin which combines with calcium & ppts as calcium bilirubinate (brown pigment stones).

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Pathogenesis of Parasitic infestation in Etiology of Pigment Stones in ETIOLOGY of Chronic Calcular Cholecystitis

Ascariasis lumbricoides & Clonorchis sinensis Reach the CBD and predispose infection by E coli forming brown pigment stones.

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TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. The right classification of stones 2. Department classification of stones 3. Etiological classification of stones

The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. Pure cholesterol stones 2. Mixed cholesterol stones 3. Black pigment stones 4. Brown pigment stones

Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. composition 2. number 3. size 4. color 5. shape

Composition of Pure cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Nearly 100% cholesterol

Composition of Mixed cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

60% cholesterol Plus 1. calcium carbonate 2. calcium phosphate 3. calcium palmitate.

Composition of Black pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Calcium bilirubinate

Composition of Brown pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Mainly Calcium bilirubinate Plus 1. calcium palmitate 2. calcium carbonate

Number of Pure cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Mainly Single "cholesterol solitaire" or multiple up to 4

Number of Mixed cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

multiple

Number of Black pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

multiple

Number of Brown pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

multiple

Size of Pure cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Large> 2.5 cm.

Size of Mixed cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

small < 2.5 cm.

Size of Black pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

small < 2.5 cm.

Size of Brown pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

small < 2.5 cm.

Color of Pure cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

White

Color of Mixed cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

yellow

Color of Black pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Tarry black

Color of Brown pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Brown

Shape of Pure cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Rounded or oval & mamillated.

Shape of Mixed cholesterol stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Faceted & laminated

Shape of Black pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Rounded or oval

Shape of Brown pigment stones in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Rounded or oval

the reason why Shape of Mixed cholesterol stones is Faceted & laminated in Difference between types of stones in The right classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

facets after resolution of infection Laminated : cut section show layers due multiple episodes of infection each episode is represented by a layer

Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. cholesterol stones 2. pigment stones 3. mixed stones

Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. incidence | 2. composition

incidence of cholesterol stones in Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

incidence of pigment stones in Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

incidence of mixed stones in Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

90%

composition of cholesterol stones in Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

includes pure cholesterol stones

composition of Pigment stones in Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

includes black cholesterol stones

composition of mixed stones in Difference between types of stones in Department classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

includes mixed cholesterol and brown pigment stones

Etiological classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

Primary pure metabolic stones Secondary to infection stones

Composition of Primary pure metabolic stones in Etiological classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. pure cholesterol stones | 2. black pigment stones

Composition of Secondary to infection stones in Etiological classification of stones in TYPES AND PATHOLOGY of Chronic Calcular Cholecystitis

1. mixed cholesterol stones | 2. brown pigment stones

CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. TYPE OF PATIENT 2. Symptoms 3. Examination

TYPE OF PATIENT in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Fatty, filthy (very good appetite), fertile, females, > 40 years 2. Exceptions to this rule are, however too frequent.

Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1) Mainly silent and asymptomatic 2) Pain 3) Fatty (biliary) dyspepsia following fatty meal 4) Picture of complications

Mainly silent and asymptomatic in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

Discovered accidentally by U.S.

Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

a) Biliary ache | b) Recurrent attacks of biliary colic

Biliary ache in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Pathogenesis: 2. Character 3. Site 4. Radiation

Pathogenesis of Biliary ache in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

Due to chronic inflammation of Gall bladder

Character of Biliary ache in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

Dull constant ache

Site of Biliary ache in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

often occurs in the right hypochondrium.

Radiation of Biliary ache in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

Sometimes radiating to 1. The epigastrium, 2. Right infrascapular region 3. The right shoulder.

Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Pathogenesis 2. onset 3. course and duration 4. Radiation 5. Association

Pathogenesis of Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Pain may be precipitated by fatty meal | 2. Due to stone impacted in Hartman's pouch or cystic duct

onset of Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

usually starts abruptly and reaches maximum intensity within 60 minutes

course and duration of Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. The pain generally continues without fluctuation and resolves gradually over 2-6 hours 2. Pain lasting longer than 6 hours should raise the suspicion for acute cholecystitis

Pain lasting longer than 6 hours in course and duration of Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

should raise the suspicion for acute cholecystitis

Radiation of Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

Sometimes radiating to 1. The epigastrium, 2. Right infrascapular region 3. The right shoulder.

Association of Recurrent attacks of biliary colic in Pain in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

There may be nausea or vomiting during the attack

Fatty (biliary) dyspepsia following fatty meal in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. List of symptoms | 2. Pathogenesis

List of symptoms of Fatty (biliary) dyspepsia following fatty meal in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Flatulence, 2. Bloating 3. Excessive eructation. 4. Nausea 5. Heartburn

Pathogenesis of Fatty (biliary) dyspepsia following fatty meal in Symptoms in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Due to disturbed bile salts / cholesterol ratio )> dec bile salts 2. Due to chronic cholecystitis )> gall bladder unable to contract

Examination in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Tenderness at the tip of the 9th costal cartilage 2. Murphy's sign :(non specific) 3. A palpable gall bladder

Murphy's sign in Examination in CLINICAL PICTURE of Chronic Calcular Cholecystitis

1. Non specific 2. If continuous gentle pressure is exerted over right hypochondrium while the patient takes a deep breath, there will be a "catch" of breath before the end of inspiration.

A palpable gall bladder in Examination in CLINICAL PICTURE of Chronic Calcular Cholecystitis

Only in case of mucocele & empyema

DIFFERENTIAL DIAGNOSIS of Chronic Calcular Cholecystitis

1) Chronic peptic ulcer. 2) Reflux oesophagitis & hiatus hernia. 3) Chronic relapsing pancreatitis. 4) Colitis.

INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Laboratory | 2. Radiological

Laboratory investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Serum total & direct bilirubin | 2. ALP and gamma GT

Findings of Serum total & direct bilirubin, ALP and gamma GT in Laboratory investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

* They should be normal. | * Elevated levels directs attention to the possibility of silent stone in CBD

Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1) Abdominal U.S : Investigation of choice. 2) Endoscopic retrograde cholangio-pancrcatography ( ERCP) : 3) Oral cholecystography (not done now) : 4) Plain X-ray abdomen :( unreliable)

Investigation of choice in INVESTIGATIONS of Chronic Calcular Cholecystitis

Abdominal U.S

Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Advantages | 2. Findings

Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis ( 2 - 2 - 2)

1. Advantages of the procedure itself 2. Competency in detecting stones and other gallbladder pathology 3. Competency to image adjacent structures

Advantages of the procedure itself in Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Non-invasive, rapid, inexpensive & easy to perform (can be performed at the bedside). 2. Uses no ionizing radiation (safe in pregnant patients).

Competency in detecting stones and other gallbladder pathology in Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. The sensitivity & specificity in detecting stones is > 95% 2. Detects other gallbladder pathology beside stones, such as chronic cholecystitis (by wall thickness) or carcinoma

Competency to image adjacent structures in Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Adjacent upper abdominal structures can be imaged at the same time. 2. It reveals the CBD diameter which should be normal

Dilated CBD in Competency to image adjacent structures in Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Directs attention to the possibility of silent stone in CBD. 2. Incidence of Silent stone in CBD in patients with gall stones

Incidence of Silent stone in CBD in patients with gall stones in Dilated CBD in Competency to image adjacent structures in Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

10-20%

Findings of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Echogenic foci with posterior acoustic shadowing | 2. This foci is mobile with movement of the patient

Meaning of Echogenic foci in Findings of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

solid structure

Meaning of Posterior Acoustic shadowing in Findings of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

100% reflection of sonar waves )> stones

Indications of ERCP in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

Done ONLY if stone in CBD is suspected by : a) Persistent elevation in ALP, gamma GT, total & direct bilirubin. b) Abdominal U.S reveals dilated CBD or IHBR.

IHBR in Indications of ERCP in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

stands for Intra hepatic biliary radical

Oral cholecystography in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Indication | 2. Finding

Indication of Oral cholecystography in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

Not done now

Finding of Oral cholecystography in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

Radio-lucent stones appear as multiple filling defects

Plain X-ray abdomen in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

1. Percentage of radio-opaque gall stones | 2. The reason why Plain X-ray abdomen is unreliable

Percentage of radio-opaque gall stones in Plain X-ray abdomen in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

10-15%

The reason why Plain X-ray abdomen is unreliable in Plain X-ray abdomen in Radiological investigations in INVESTIGATIONS of Chronic Calcular Cholecystitis

as Percentage of radio-opaque gall stones is 10-15%

Treatment of Chronic Calcular Cholecystitis

I. Cholecystectomy either open or better laparoscopic II. Non- surgical treatment of gall stones ( Not practical )

The Standard treatment in Treatment of Chronic Calcular Cholecystitis

Cholecystectomy either open or better laparoscopic

Indications of Cholecystectomy either open or better laparoscopic in Treatment of Chronic Calcular Cholecystitis

Management depends on the age and the general fitness for surgery: * In elderly or unfit patients it is wise to leave the patient for regular follow-up. * In young fit patients it is recommended to do cholecystectomy * The presence of D.M. favors cholecystectomy

the reason why In young fit patients it is recommended to do cholecystectomy in Indications of Cholecystectomy either open or better laparoscopic in Treatment of Chronic Calcular Cholecystitis

as the life span of the patient is long and there is a high chance for occurrence of complications

the reason why The presence of D.M. favors cholecystectomy in Indications of Cholecystectomy either open or better laparoscopic in Treatment of Chronic Calcular Cholecystitis

because if acute cholecystitis occurs it is likely to pass rapidly to gangrene

Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

1) Dissolution therapy 2. Extracorporeal shock - Wave Iithotripsy (ESWL). 3. Percutaneous cholecystolithotomy.

Dissolution therapy in Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

1. Definition 2. INDICATIONS 3. DURATION OF THERAPY 4. SUCCESS RATE

Definition of Dissolution therapy in Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

Oral dissolution with bile acids : Chenodeoxycholic acid or ursodeoxycholic acid.

INDICATIONS of Dissolution therapy in Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

1. Pure cholesterol gallstones. 2. The stones should ideally be less than 1.5 cm diameter. 3. The stones should he few in number (<4). 4. The gall bladder should he functioning (can contract).

DURATION OF THERAPY of Dissolution therapy in Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

6 months to 2 years of therapy

SUCCESS RATE of Dissolution therapy in Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

1. 60% after 2 years | 2. after this, half the successful patients will develop recurrent stones within 5 years

The reason why Extracorporeal shock - Wave Iithotripsy (ESWL) is Not recommended in Non- surgical treatment of gall stones ( Not practical ) in Treatment of Chronic Calcular Cholecystitis

as it may cause calcular obstructive jaundice

GaIl stones in relation to other diseases

1. Saint's triad | 2. Wilkie's Triad

Saint's triad in GaIl stones in relation to other diseases

A Triad of : | Gall stones, Hiatus hernia & Diverticulosis coli.

Wilkie's Triad in GaIl stones in relation to other diseases

A Triad of : | Chronic cholecystitis, Chronic peptic ulcer & Recurrent appendicitis.

A Triad of : | Gall stones, Hiatus hernia & Diverticulosis coli.

Saint's triad

A Triad of : | Chronic cholecystitis, Chronic peptic ulcer & Recurrent appendicitis.

Wilkie's Triad

Gall bladder.2. Chronic calcular cholecystitis Flashcards

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