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PubMed2000

Altered mucin core peptide expression in acute and chronic cholecystitis.

Human mucin genes include membrane-bound mucins (MUC1, MUC3, MUC4) and secretory mucins (MUC2, MUC5AC, MUC5B, MUC6). Our aim was to determine mucin gene expression in human gallbladder cell lines, normal gallbladder from liver donors (N = 7) and surgical specimens with mild chronic cholecystitis (N = 29), chronic cholecystitis (N = 48), and acute and chronic cholecystitis (N = 27). MUC1 mRNA was ubiquitous; however, only rare MUC1 immunoreactivity was detected. MUC3, MUC5AC, MUC5B, and MUC6 mRNA were present in all gallbladder specimens and cell lines examined. Prominent MUC3, MUC5AC, MUC5B, and MUC6 immunoreactivity was present in 86-100% of normal gallbladders. The frequency of MUC5AC reactivity was decreased in specimens with acute cholecystitis (P < 0.05). In contrast, MUC2-reactivity was absent in normal gallbladder and present in 53.8% of acute cholecystitis specimens (P < 0.05). Surface epithelium is characterized by MUC3, MUC5AC, and MUC5B, whereas deeper mucosal folds display MUC5B and MUC6 immunoreactivity. Gallbladder epithelium demonstrates a unique and diverse pattern of mucin core proteins that becomes altered with increasing degrees of inflammation.

Acute Disease↗

PubMed2003

Influence of cholecystitis state on pharmacological response to cholecystokinin of isolated human gallbladder with gallstones.

We studied the influence of the inflammatory state of the gallbladder with gallstones on its response to cholecystokinin (CCK). Responses to CCK were evaluated in isolated human gallbladder strips incubated with pharmacological antagonists. Gallbladders from patients with gallstones were classified as having mild and severe chronic cholecystitis. Healthy gallbladders were collected from liver donors. In donor gallbladders, the CCK contraction was abolished with the CCK-A receptor antagonist, L-364718, and significantly reduced by indomethacin. In gallbladders with gallstones, only mild cholecystitis showed a decreased contraction to CCK. In gallbladders with gallstones, no involvement of prostaglandins in the CCK response was observed. In severe cholecystitis, CCK contractile effect was reduced by the serotonin receptor antagonist methysergide. In healthy gallbladder, the contraction provoked by CCK is mediated by CCK-A receptors and modulated by prostaglandins. The presence of gallstones in the gallbladder is correlated with a loss of prostaglandins-modulated CCK contraction. However, the excessive release of serotonin in advanced cholecystitis normalizes the contraction to CCK, suggesting that the state of cholecystitis affects the pool of inflammatory mediators responsible for gallbladder CCK-altered motility.

Acetylcholine↗

PubMed1999

Emergency cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly.

BACKGROUND: The morbidity and mortality rates associated with acute cholecystitis are higher in the elderly. This study reports the results of treatment of acute cholecystitis in the elderly with emergency ultrasonographically guided percutaneous cholecystostomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones diagnosed by percutaneous cholangiography. METHODS: From January 1989 to December 1998, 92 patients aged over 70 years were treated for acute gallstone cholecystitis. A group of 84 patients with ultrasonographic signs of severe cholecystitis or an American Society of Anesthesiologists score of II to IV were submitted to ultrasonographically guided percutaneous cholecystostomy. Transcatheter cholangiography was performed in all patients and endoscopic sphincterotomy was performed before operation in patients with common bile duct stones. After resolution of the acute phase and treatment of any associated diseases, patients were submitted to cholecystectomy. RESULTS: Cholecystostomy was performed successfully in 83 patients and permitted resolution of the acute attack in all after a mean period of 1.8 days. Cholangiography yielded a diagnosis of non-gallstone obstruction in one patient and common bile duct stones in 19 patients; preoperative endoscopic sphincterotomy and stone extraction was performed in 18 patients. Elective cholecystectomy was then performed in 70 patients with no deaths and a morbidity rate of 24 per cent. CONCLUSION: Combining emergency ultrasonographically guided percutaneous cholecystostomy, preoperative endoscopic treatment of common bile duct stones and subsequent elective cholecystectomy constitutes an optimal treatment regimen for acute gallstone cholecystitis in selected elderly patients with a mortality rate of zero in the authors' experience.

Acute Disease↗

PubMed1989

[Percutaneous cholecystostomy in treating acute cholecystitis in patients at risk].

Percutaneous cholecystostomy was performed in 17 poor surgical risk patients. 16 patients developed acute acalculous cholecystitis postoperatively in the intensive care unit, 1 patient had an acute cholecystitis with calculi. Diagnostic imaging using CT and US was specific for acute cholecystitis in 58% only. Percutaneous cholecystostomy was the definitive treatment in 69% of the patients. Additional cholecystectomy was required in 3 patients with complicated cholecystitis, in 1 patient with bile leakage after catheter dislocation and in 1 patient with gallbladder calculi. 3 patients died, 2 of them from reasons unrelated to the gallbladder disease. Radiology-guided percutaneous cholecystostomy performed by a transhepatic approach is a safe and effective procedure for acute cholecystitis in high-risk patients.

Acute Disease↗

PubMed2000

Hepatobiliary scintigraphy is superior to abdominal ultrasonography in suspected acute cholecystitis.

BACKGROUND: Hepatobiliary scintigraphy is a very accurate test in the diagnosis of acute cholecystitis. However, ultrasonography is extensively used for the diagnosis of this disease. In this study, we directly compare the diagnostic accuracy of these techniques for acute cholecystitis. MATERIALS AND METHODS: The diagnostic accuracy of scintigraphy and ultrasonography was evaluated in 107 consecutive patients with suspected acute cholecystitis who underwent both imaging modalities within one day. The incremental diagnostic value of each modality was determined. RESULTS: The sensitivity, specificity, positive and negative predictive values, and accuracy for the diagnosis of acute cholecystitis in the entire cohort were superior for scintigraphy compared with ultrasonography. The accuracy was 92% for scintigraphy and 77% for ultrasonography. Similarly, if only surgically treated patients were considered, the accuracy of scintigraphy was 91% versus 61% for ultrasonography. The diagnostic value of scintigraphy for the entire cohort was significantly superior to ultrasonography (global, chi(2) = 58.1 vs 9.7, respectively); the addition of the information derived from the latter did not further improve the diagnostic value of scintigraphy (global, chi(2) = 58.2). CONCLUSIONS: Hepatobiliary scintigraphy has superior diagnostic accuracy for acute cholecystitis compared with ultrasonography. The addition of ultrasonography does not further improve the diagnostic accuracy of scintigraphy alone.

Acute Disease↗

PubMed2003

Emphysematous cholecystitis.

Emphysematous cholecystitis is a relatively rare variant of acute cholecystitis with infection by gas-producing organisms. Diagnosis involves the demonstration of gas within the lumen or wall of the gallbladder by ultrasound or CT scan. In contrast to acute cholecystitis, emphysematous cholecystitis occurs more commonly in elderly and diabetic patients, and is frequently associated with perforation and death. We report here a case of a 75-year old man who developed emphysematous cholecystitis.

Aged↗

PubMed2003

Xanthogranulomatous cholecystitis. Retrospective analysis of 12 cases.

Xanthogranulomatous cholecystitis is a rare variant of chronic cholecystitis characterized by severe proliferative fibrosis and accumulation of lipid-laden macrophages in areas of destructive inflammation. The macroscopic appearance generally mimics a gallbladder carcinoma. Twelve cases of xanthogranulomatous cholecystitis were identified from a retrospective analysis of the patient records of 770 cholecystectomy cases operated on in our department from January 1996 to October 2001. There were four men and eight women. Mean age of presentation was 52.5 years. Eleven patients had gallbladder stones. Seven patients had a history of acute cholecystitis and five patients of biliary colicky pain. Five cases were presented with obstructive jaundice and five with acute cholecystitis. Right upper quadrant mass was palpable in three patients. All patients underwent cholecystectomy. Open surgery was planned and performed in three patients. Laparoscopic cholecystectomy was planned in nine patients but converted to open surgery in three cases. Nine patients had an uneventful postoperative course. One patient developed wound infection and one patient a postoperative pulmonary infection. One patient developed acute abdomen in the 2nd postoperative day and was re-operated for bile peritonitis. No mortality was seen in the series.

Adult↗

PubMed2004

Somatosensory changes in the referred pain area in patients with acute cholecystitis before and after treatment with laparoscopic or open cholecystectomy.

BACKGROUND: Visceral pain can lead to hypersensitivity in the referred pain area. In patients with chronic visceral pain this somatic hypersensitivity can persist for years. As 25%-40% of patients continue to have symptoms after cholecystectomy, whereof no explanation for pain can be offered in up to 30%, it could be hypothesized that altered sensory characteristics induced by acute cholecystitis could persist in some patients and thus be responsible for postcholecystectomy pain. The aim of this study was to investigate the somatosensory sensitivity in the referred pain area in patients with acute cholecystitis before and after cholecystectomy. METHODS: Patients with acute cholecystitis were studied before (n = 30) and after (n = 18) treatment. Sensitivity to pinprick, heat, cold, pressure and single and repeated electrical stimulation was studied in the referred pain area and in the control area on the contralateral side of the abdomen. RESULTS: Significant hypersensitivity in the referred pain area was detected in patients with acute cholecystitis. The somatic sensitivity was normalized after cholecystectomy. CONCLUSIONS: Acute cholecystitis leads to hypersensitivity in the referred pain area. Persistent hypersensitivity, as earlier reported after chronic visceral pain, was not seen aftiser cholecystectomy, indicating that this mechanism may not play a major role in patients with postcholecystectomy pain syndrome. The possible role in patients operated on for chronic gallstone pain has still to be investigated.

Abdominal Pain↗

PubMed2003

Diffuse lymphoplasmacytic chronic cholecystitis is highly specific for extrahepatic biliary tract disease but does not distinguish between primary and secondary sclerosing cholangiopathy.

Previous studies of gallbladder pathology in primary sclerosing cholangitis (PSC) have suggested that a distinctive histologic triad ("diffuse lymphoplasmacytic acalculous cholecystitis," composed of diffuse, mucosal-based, dense lymphoplasmacytic infiltrates) is commonly present in gallbladders of patients with PSC and is relatively specific for that disease. However, prior control populations have included only patients with cholecystitis/cholelithiasis and hepatitis, and have not evaluated patients with non-PSC-associated extrahepatic biliary tract disease. We recently observed cases of diffuse lymphoplasmacytic chronic cholecystitis in a subset of patients with biliary tract disease associated with lymphoplasmacytic sclerosing pancreatitis and among patients undergoing Whipple resection for pancreatic head malignancy, suggesting that diffuse lymphoplasmacytic chronic cholecystitis is not specific for PSC. We studied 20 gallbladders from patients with obstructive jaundice due to malignancies of the pancreatic head, duodenum, or ampulla and 5 gallbladders from patients with choledocholithiasis, and compared them with 20 gallbladders from patients with PSC and 20 gallbladders with cholelithiasis. The following histologic features were evaluated: degree of mucosal and deep inflammation, lymphoid nodules, epithelial metaplasia, muscular hypertrophy, Rokitansky-Aschoff sinuses, fibrosis, and cholesterolosis. Gallbladders in malignancy-associated obstructive jaundice were nearly identical to gallbladders in PSC with respect to scores for mucosal inflammation, lymphoid nodules, and frequency of diffuse lymphoplasmacytic chronic cholecystitis (60% vs. 50%, respectively). PSC gallbladders, however, were significantly more likely to contain focal or extensive epithelial metaplasia (P = 0.01). The cholelithiasis control group was characterized by lack of significant mucosal inflammation in the majority of cases (95%) and frequent Rokitansky-Aschoff sinuses, fibrosis, and muscular hypertrophy. Gallbladders in the choledocholithiasis group showed overlapping histologic features with PSC/malignancy-associated obstructive jaundice and cholelithiasis. These results suggest that a pattern of diffuse lymphoplasmacytic chronic cholecystitis is highly specific for extrahepatic biliary tract disease but does not distinguish between primary and secondary cholangiopathies.

Adolescent↗

PubMed1982

Acute acalculous cholecystitis. An increasing entity.

Acute acalculous cholecystitis was observed to increase in frequency between 1950 and 1979, an increase that was statistically significant. The greatest part of this increase occurred between 1965 and 1979. Acute acalculous cholecystitis was also found to be associated with a higher mortality rate, more than twice that of acute calculous cholecystitis. Acute acalculous cholecystitis occurred in a variety of clinical settings including bacterial sepsis, severe trauma including surgical trauma and burns, multiple transfusions, and severe debilitation. The lesion in the gallbladder consists of intense injury of blood vessels in the muscularis and serosa similar to those induced experimentally by in vivo activation of factor XII dependent pathways. Possibly because of the intensity of vascular injury, acute acalculous cholecystitis with minimal clinical manifestations may rapidly progress to gangrene with perforation. Undelayed surgical treatment, which has become more widely accepted over the past 50 years, is essential. It may have also contributed to the increased recognition of this clinical entity.

Adult↗

PubMed2000

Myocardial infarction and acute cholecystitis: an application of sequence symmetry analysis.

Using a statewide hospital discharge database and a novel epidemiology method, sequence symmetry analysis (Epidemiology. 1996;7:478-84), I examined the relative risk for hospital admission for acute cholecystitis after admission for myocardial infarction. In sequence symmetry analysis, the ratio of the number of subjects in a fixed population who experienced two events in a "causal" vs "noncausal" temporal sequence estimates the incidence rate ratio (IRR). Of 514 patients admitted for both myocardial infarction and acute cholecystitis during a 3-year window period, 295 were admitted for myocardial infarction first and 219 for acute cholecystitis first, yielding a null sequence-adjusted IRR of 1.45 [95% confidence interval (CI) = 1.28-1.64]. A similar analysis for a known relation (myocardial infarction-->congestive heart failure, N = 27,850) showed the expected association [adjusted IRR = 1.92 (95% CI = 1.88-1.95)], whereas an analysis for a relation hypothesized not to be strong (congestive heart failure-->acute cholecystitis, N = 775) showed only a small association [adjusted IRR = 1.16 (95% CI = 1.05-1.28)]. Subgroup analysis revealed time courses that supported each relation as causal. Hospitalization for myocardial infarction may increase the risk for subsequent hospitalization for acute cholecystitis.

Acute Disease↗

PubMed1986

Does positive hepatobiliary scan in cholecystitis stay positive, and for how long?

A prospective study of 11 patients who had undergone two sequential hepatobiliary scans prior to surgery demonstrated that initially positive scans could be due to acute cholecystitis, or chronic cholecystitis with exacerbation. A second hepatobiliary scan performed four to five days later differentiated acute from chronic cholecystitis. All five patients with surgery-proven acute cholecystitis remained hepatobiliary-positive, while patients with surgery-proven chronic cholecystitis reverted back to negative hepatobiliary scans if the second hepatobiliary scan was done properly.

Acute Disease↗

PubMedDate not supplied

Acute septic cholecystitis in patients with burn injuries.

Acute cholecystitis continues to be a life-threatening complication in patients after trauma. In an 18-month period we have recognized and treated five patients with burn injuries who had acute cholecystitis. They ranged in age from 13 to 40 years. Four of the five patients had positive blood cultures and all five patients had positive bile cultures. The diagnosis was made on the basis of unexplained sepsis and an abnormal sonogram or hepatobiliary scan. Four patients underwent cholecystectomy and one patient underwent a cholecystostomy. Four patients survived and were discharged from the hospital. All five patients were receiving nutritional support. Factors such as prolonged fasting, dehydration, narcotic administration, and sepsis have been suggested as contributing factors in the development of acute cholecystitis. Acute cholecystitis is a serious complication in such patients and must be considered and treated promptly. Serial ultrasound studies have been helpful in managing patients suspected of having acute septic cholecystitis.

Adolescent↗

PubMed2003

Acute viral cholecystitis due to hepatitis A virus infection.

Acute hepatitis A virus (HAV) infection is frequent in developing countries. Although some gallbladder abnormalities are defined during the course, an acute cholecystitis is extremely rare. We here report 2 additional cases of cholecystitis due to acute HAV infection and review the previously reported 2 cases. One of our patients was admitted with jaundice and a suspicious portal mass with a presumed diagnosis of cholagiocarcinoma. The other presented with jaundice, abdominal pain, and constitutional symptoms. Both patients were planned to be operated on. During the follow-up, absence of fever, leukocytosis, acute-phase protein response, and calculus in biliary system were against the diagnosis of a bacterial cholecystitis. Moreover the course of cholecystitis was closely parallel to that of the HAV infection. Both patients were managed conservatively. It was concluded that rare, acute viral cholecystitis can develop during the course of acute HAV infection.

Acute Disease↗

PubMed1984

Acute cholecystitis and thiazides.

Drugs purchased by a random sample (17 000) of the population of Jämtland county, Sweden, are continuously monitored. Patients who had been admitted to the county's only hospital with acute cholecystitis and who were part of this sample were studied, and controls matched for age and sex were drawn from the sample. The purchase of thiazides and other drugs prescribed to the patients with acute cholecystitis was compared with that of the controls. The estimated relative risk of developing acute cholecystitis in patients who had purchased thiazides in the year before admission to hospital, as compared with those who had not, was 2.1 (95% confidence limit 1.1-3.9). As it has been reliably reported that the use of thiazides is not itself associated with cholelithiasis, the association found between thiazides and cholecystitis suggests that thiazides may increase the risk of acute cholecystitis developing in a patient with gall stones.

Acute Disease↗

PubMed1984

Acute gangrenous cholecystitis: radionuclide diagnosis.

Radionuclide hepatobiliary imaging is a useful procedure for the diagnosis of acute cholecystitis. Visualization of the gallbladder essentially rules out acute cholecystitis. Nonvisualization suggests acute cholecystitis but may also be associated with chronic gallbladder disease or other conditions. We recently observed five patients in whom a rim of increased parenchymal liver activity was seen adjacent to the gallbladder fossa. All five patients had acute gangrenous cholecystitis. The rim of increased activity appears to be a useful secondary sign of acute cholecystitis.

Acute Disease↗

PubMed1985

Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs.

Sonographic findings in 497 patients with suspected acute cholecystitis were analyzed prospectively. Combined use of primary and secondary sonographic signs led to excellent positive and negative predictive values. Positive predictive values for stones combined with either a positive sonographic Murphy sign (92.2%) or with gallbladder wall thickening (95.2%) were excellent for acute cholecystitis. Positive predictive value of these signs for patients requiring cholecystectomy was even higher (99.0%). Negative predictive values for combined use of primary and secondary signs to exclude acute cholecystitis were also excellent (95.0% for no stones and negative sonographic Murphy sign). Real-time sonography alone, using both primary and secondary signs, can be definitive in nearly 80% of patients with suspected acute cholecystitis. These patients require no further imaging evaluation. Sonography should be the screening test of choice in acute cholecystitis because it is cost effective, prospectively highly accurate, quick, and better at characterizing and detecting other abdominal lesions than cholescintigraphy. A proposed algorithm is described.

Acute Disease↗

PubMed2005

[Bacteremia -- prevalence and associated factors in patients with acute calculous cholecystitis].

BACKGROUND: Bacteremia seems to increase the morbidity and mortality in clinical and surgical conditions, however the importance and factors associated with it during acute calculous cholecystitis are not well established. The purpose of this study was to determine pre-operative prevalence, associated factors and prognosis of bacteremia in patients with acute calculous cholecystitis submitted to an emergency cholecystectomy. METHODS: A prospective study of 51 patients with histological diagnosis of acute calculous cholecystitis was designed. The Bactec System was used to detect bacteremia. Mean results of clinical and laboratory analyses were related to the presence of bacteremia. RESULTS: The pre-operative prevalence of bacteremia was of 15.68%. Age (P=0.024), heart rate (P=0.026), respiratory rate (P=0.028), serum creatinine (P=0.028) and presence of systemic inflammatory response syndrome (P=0.016) were positively associated with bacteremia. Bacteremic patients had statistically higher overall (P=0.045) and infectious (P=0.039) complication rates and longer hospitalization (P<0.005) including one death. CONCLUSIONS: Patients with acute calculous cholecystitis have a considerable prevalence of bacteremia in the pre-operative period. It is associated with old age, heart rate, respiratory rate, serum creatinine and systemic inflammatory response syndrome. In patients with acute calculous cholecystitis, presence of bacteremia may be associated to severity of the condition and poor outcome related to pos-operative complications.

Adult↗