It is often characterized by cholestasis, the suppression or stoppage of bile flow. The most common cause of cholestasis is extra hepatic obstruction of the biliary tract (obstructive jaundice). The biliary obstruction may be due to a gallstone, stricture, or tumor in the common hepatic duct. Patients with complete or near-complete obstruction present with progressive jaundice, a dark urine with pale stools, and pruritus.
Gallstone disease(cholelithiasis) limited to the gallbladder is often asymptomatic affect many people. Symptomatic individuals usually present with biliary colic secondary to obstruction of the cystic duct. The triad of sudden right upper quadrant tenderness, fever, and leukocytosis suggests cholecystitis, inflammation of the gall bladder.
Signs and symptoms of acute cholecystitis include nausea, vomiting, fever, abdominal pain, and right upper quadrant tenderness. Severe pain that begins in the mid-epigastrium, moves to the right upper quadrant, and may radiate to the back and is caused by a stone lodged in a duct is designated biliary colic. This pain is extraordinarily intense and usually begins abruptly and subsides gradually. Patients may notice dark urine and scleral icterus. Most jaundiced patients have stones in the common bile duct at the time of surgery. Cholecystectomy, the surgical removal of the gall bladder, is the most common procedure for cholecystitis and cholelithiasis.
Preoperative Considerations for Cholecystectomy: Patients most commonly present to the operating room for cholecystectomy, relief of extra hepatic biliary obstruction, or both. The most common procedure is a cholecystectomy. Most patients with acute cholecystitis are stabilized medically prior to cholecystectomy. Medical treatment includes nasogastric suction, intravenous fluids, antibiotics, and opioid analgesics. Those in whom the acute attack resolves may defer surgery for a later time, whereas those suffering serious complications may require emergency cholecystectomy. Cholecystitis usually occurs in critically ill patients, and is associated with a high risk of gangrene and perforation; emergency operation is usually indicated in these patients.
Patients with extra hepatic biliary obstruction from whatever cause readily develop vitamin K deficiency. Vitamin K should be given parenterally but requires 24 h for a full response. High bilirubin levels may be associated with an increased risk of postoperative renal failure; generous preoperative hydration is advised. Long-standing extra hepatic obstruction (> 1 year) produces secondary biliary cirrhosis and portal hypertension.
Intraoperative Considerations: if biliary obstruction is complicated with cirrhosis and other hepatic manifestation consider all anesthetic management for liver disease otherwise routine anesthesia care with the following considerations will be sufficient
- Emergency surgery for acute cholecystitis or common bile duct obstruction in patients who have been vomiting necessitates fluid and electrolyte replacement. Many of these patients have an ileus and should be considered at increased risk of pulmonary aspiration of gastric contents.
- Endotracheal intubation with a cuffed tube minimizes the risk of pulmonary aspiration should reflux occur.
- All opioids can cause spasm of the sphincter of Oddi (a sphincter or an opening at the opening of common bile duct to the duodenum) to varying degrees, their use has been questioned when an intraoperative examination of bile duct and gall bladder is contemplated
- In patients with biliary tract obstruction, a prolonged duration of action of drugs primarily dependent on biliary excretion should be anticipated. Agents dependent on renal elimination are preferable. Urinary output should be monitored with an indwelling catheter.
- Maintenance of perioperative diuresis is desirable.