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PubMedDate not supplied

Percutaneous cholecystostomy for the diagnosis and treatment of acute calculous and acalculous cholecystitis.

PURPOSE: To determine the safety, efficacy, and diagnostic utility of percutaneous cholecystostomy in patients with suspected calculous or acalculous cholecystitis. PATIENTS AND METHODS: Percutaneous cholecystostomy guided with ultrasound (US) was performed in 58 consecutive hospitalized patients with suspected acute cholecystitis (28 with calculous, 30 with acalculous disease) who were not surgical candidates. RESULTS: The gallbladder was successfully catheterized in all 58 patients; 48 patients (83%) had a final diagnosis of acute cholecystitis. Clinical benefit was seen in 26 of 28 patients (93%) with calculous cholecystitis and in 16 of 20 patients (80%) with acalculous disease. The six patients who did not respond had pathologic evidence of transmural inflammation, and five had a gangrenous wall. The gallbladder was excluded as the source of sepsis in 10 patients with suspected acalculous cholecystitis. These patients' conditions did not improve after percutaneous cholecystostomy. Of the 48 patients with cholecystitis, 18 underwent cholecystectomy, 25 recovered and had their catheters removed, and five died of other causes with their catheters in place. There was one major complication, and seven minor complications. CONCLUSION: Percutaneous cholecystostomy is efficacious in both calculous and acalculous cholecystitis, but it may be most useful in the diagnosis of acalculous cholecystitis.

Acute Disease↗

PubMed1998

Xanthogranulomatous cholecystitis.

Xanthogranulomatous cholecystitis exists in a small but significant proportion of routine cholecystectomy specimens. A few recent reports have shown a possible association of this disease with carcinoma of the gallbladder. All cholecystectomized specimens were prospectively evaluated over a period of two and half years in a single surgical unit to examine the incidence of xanthogranulomatous cholecystitis and its association, if any, with carcinoma of the gallbladder in an area that is prone to gallbladder diseases. A total of 460 cholecystectomies were performed for various gallbladder diseases. Histological confirmation revealed chronic cholecystitis in 311 (67.6%) cases, carcinoma of the gallbladder in 62 (13.5%), acute cholecystitis in 29 (6.3%), xanthogranulomatous cholecystitis in 41 (8.9%), and xanthogranuloma and carcinoma of the gallbladder in one case (0.2%) only. Almost all cases were suspected to have chronic cholecystitis on clinical and ultrasonographic features. Two specimens on gross examination showed mass lesions, and hence were suspected to be carcinoma of the gallbladder. Subsequent frozen section and histopathology demonstrated xanthogranulomatous cholecystitis. Only one case of xanthogranuloma was found to be associated with carcinoma of the gallbladder but no firm association could be established between xanthogranulomatous cholecystitis and carcinoma of the gallbladder.

Acute Disease↗

PubMed1994

Morphine cholescintigraphy in the evaluation of hospitalized patients with suspected acute cholecystitis.

OBJECTIVE: The authors determined if the diagnosis of acute cholecystitis can be accurately made or reliably eliminated by the use of morphine-augmented radionuclide cholescintigraphy (morphine cholescintigraphy [MC]) in hospitalized patients in whom the diagnosis is in doubt. SUMMARY/BACKGROUND DATA: Diagnosis of acute cholecystitis, calculous or acalculous, may be difficult in patients hospitalized for abdominal pain or other illnesses. Clinical signs often are obscure, and routine imaging studies are nonspecific or associated with a high incidence of false-positive tests. The authors report the use of MC in the evaluation of 163 hospitalized patients for acute cholecystitis over an 8-year period. METHODS: All patients suspected to have acute cholecystitis initially had standard cholescintigraphy performed, which showed nonvisualization of the gallbladder, and then were given morphine sulfate (0.05-0.1 mg/kg, intravenously). Patients were divided into the following three groups: I--acute abdominal pain (N = 53); II--hospitalized for associated illness (N = 49); and III--critically ill (N = 61). RESULTS: Overall, MC confirmed the diagnosis of acute cholecystitis in 75 patients (46%), including 23 cases of acalculous cholecystitis. Visualization of the gallbladder occurred within 60 minutes of intravenous administration of morphine sulfate in all patients. Cystic duct obstruction and, presumably, the diagnosis of acute cholecystitis was excluded in 79 patients, including 38 who were critically ill. There were eight false-positive and one false-negative studies. Morphine cholescintigraphy had a sensitivity of 99%, a specificity of 91%, a positive predictive value of 0.9, a negative predictive value of 0.99, and an overall accuracy of 94%. CONCLUSIONS: In hospitalized patients with nonvisualization of the gallbladder after standard cholescintigraphy, MC is highly accurate, especially in predicting the absence of acute cholecystitis in patients with known risk factors.

Abdominal Pain↗

PubMed1987

Enterogastric reflux in suspected acute cholecystitis.

Ninety patients undergoing Tc-99m disofenin hepatobiliary scintigraphy for suspected acute cholecystitis were assessed for enterogastric reflux. Seventy-seven cases showed bowel activity by one hour and were included in the study. Twenty-six percent (20/77) showed definite enterogastric reflux. The gastric activity tended to clear rapidly, even though patients remained supine during examination. Six of 20 patients (30%) with enterogastric reflux had gallbladder visualization. Of these six, one had acute cholecystitis and one had resolving acute cholecystitis with gallstone pancreatitis. There was one case each of pancreatitis, amebic abscess, sepsis, and one normal. Thus, of 20 patients with enterogastric reflux, 16 had acute cholecystitis (80%). Twenty-three of seventy-seven patients (30%) had surgically proven acute cholecystitis: of these, 16 of 23 (70% sensitivity) had gastric reflux, and 50 of 54 without acute cholecystitis did not have reflux (93% specificity). The overall accuracy of enterogastric reflux for acute cholecystitis is 86%. Gastric reflux seen on cholescintigraphy is a secondary sign of acute cholecystitis. Reflux may be related to duodenal irritation from the adjacent inflamed gallbladder.

Acute Disease↗

PubMed1987

Acute cholecystitis: diagnosis with radionuclide angiography.

Radionuclide angiography and cholescintigraphy were performed with a bolus injection of technetium-99m disofenin in 65 patients with suspected acute cholecystitis. Acute cholecystitis was surgically confirmed in 23 of 25 cases in which radionuclide angiographic findings were positive (i.e., showed focal increased flow to the gallbladder region) (positive predictive value, 92%). Sensitivity and specificity of radionuclide angiography for detecting acute cholecystitis were 72% and 94% for cholescintigraphy. Three patients with scintigraphically visible gallbladders (at 45 minutes, 2.4 hours, and 4.5 hours) and positive angiograms had severe acute cholecystitis and abscess. All 20 patients with positive radionuclide angiographic and scintigraphic results had transmural acute cholecystitis. None of the nine patients with acute cholecystitis and false-negative angiograms had abscess or gangrene of the gallbladder. Use of radionuclide angiography may enable the prediction of the severity of acute cholecystitis, as nine of 25 patients with positive findings had either gangrenous cholecystitis or pericholecystic abscess. Positive findings on radionuclide angiograms may preclude the need to obtain delayed (beyond 1 hour) cholescintiscans.

Acute Disease↗

PubMed1997

The changing face of emphysematous cholecystitis.

Emphysematous cholecystitis is a variant of acute cholecystitis characterized by the presence of gas in the gall bladder lumen, wall or pericholecystic tissues in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. In the past, the diagnosis has relied on the plain abdominal radiograph (AXR), since there are no clinical features to separate this condition from simple acute cholecystitis. The apparently high mortality and morbidity associated with emphysematous cholecystitis has previously emphasized the importance of emergency cholecystectomy. We have reviewed eight cases of emphysematous cholecystitis presenting to this hospital over the last 5 years. The diagnosis was made on AXR in only one of these cases. Ultrasound (US) scans were performed in all eight cases, of which five were positive and three negative, due to non-visualization of the gall bladder. In the three negative cases, the diagnosis was made on subsequent CT scans. On initial clinical examination, only one of the eight patients appeared systemically unwell and conservative management was employed in five of the patients. The remaining three patients underwent cholecystectomy within 3-5 days because of continuing signs or symptoms. It is concluded that the AXR is relatively insensitive in the diagnosis of emphysematous cholecystitis. As a result of the regular use of US in suspected hepatobiliary disease, emphysematous cholecystitis is being diagnosed with increased frequency, uncovering a broad spectrum of disease ranging from mild to severe. Previously, failure to separate milder cases from simple acute cholecystitis may have been responsible for reports of unremitting severity and progression requiring emergency cholecystectomy. Based on clinical assessment, conservative surgical management is possible in a significant proportion of patients.

Acute Disease↗

PubMed1996

CT evaluation of acute cholecystitis: findings and usefulness in diagnosis.

OBJECTIVE: The purpose of our study was to describe the CT findings of acute cholecystitis and apply previously proposed CT criteria for its diagnosis. MATERIALS AND METHODS: We retrospectively reviewed CT scans of 29 patients with proven acute cholecystitis. Scans were reviewed for gallstones, gallbladder distension, bile density, wall thickening, pericholecystic fluid, subserosal edema, pericholecystic stranding, and sloughed membranes. Previously published criteria were applied to determine the percentage of patients that met positive criteria for acute cholecystitis. RESULTS: The most common CT findings, in decreasing order of frequency, were wall thickening (n = 17), pericholecystic stranding (n = 15), distension (n = 12), pericholecystic fluid (n = 9), subserosal edema (n = 9), high-attenuation bile (n = 7), and sloughed membranes (n = 1). Of the 29 cases of acute cholecystitis, 15 met previously published CT criteria. CONCLUSION: CT can be useful in diagnosing acute cholecystitis. Common CT findings of acute cholecystitis include wall thickening, pericholecystic stranding, distention, high-attenuation bile, pericholecystic fluid, and subserosal edema. When these findings are present, the diagnosis of acute cholecystitis can be suggested. However, previously published CT criteria failed to identify a significant number of patients with acute cholecystitis.

Acute Disease↗

PubMed1997

Sonography of acute cholecystitis: comparison of color and power Doppler sonography in detecting a hypervascularized gallbladder wall.

OBJECTIVE: We evaluated the sensitivity and specificity of power Doppler sonography compared with conventional color Doppler sonography and gray-scale sonography in diagnosing patients with acute cholecystitis. SUBJECTS AND METHODS: Seventy-six patients with right upper quadrant pain and 72 healthy volunteers underwent gray-scale sonography, conventional color Doppler sonography, and power Doppler sonography of the gallbladder. The vascularity of the gallbladder wall was scored on a scale of 0 to +3. Histology revealed acute cholecystitis in 55 patients. Histologic specimens and clinical workups showed that the remaining 21 patients suffered from other diseases. RESULTS: Sensitive sonographic features such as the positive Murphy's sign (in 96% of patients with acute cholecystitis), calculi (95%), and a thickened gallbladder wall (73%) lacked specificity (71%, 38%, 67%, respectively) for diagnosing acute cholecystitis. In our study, the sensitivity of power Doppler sonography was 95% compared with 33% for color Doppler sonography in revealing a hypervascularized gallbladder wall. Power Doppler sonography revealed hyperemia within a nonthickened gallbladder wall in four patients with surgically proven acute cholecystitis. Specificity of power Doppler sonography was 86% compared with 95% for conventional color Doppler sonography. False-positive results with power Doppler sonography were caused by pancreatitis, duodenal ulcer, and gallbladder carcinoma. Interobserver variability seemed to play no significant role. No intramural hypervascularity was detected in the volunteer group. In four (4%) of 89 symptomatic patients we could not use power Doppler sonography because of the patients noncompliance. Mean values of the resistive index assessed within intramural vessels of the gallbladder showed no significant differences (p < .001) between patients with acute cholecystitis (0.73) and patients with other diseases (0.71). CONCLUSIONS: Although the sensitivity of power Doppler sonography in diagnosing acute cholecystitis was similar to that of gray-scale sonography, the specificity of power Doppler sonography was significantly higher, which may substantially improve diagnostic confidence. However, the high susceptibility of power Doppler sonography to motion artifacts makes appropriate adjustment of technical parameters much more relevant than with other sonographic imaging. The resistive index within intramural vessels has no clinical use in the diagnosis of acute cholecystitis.

Acute Disease↗

PubMed1998

Color velocity imaging and power Doppler sonography of the gallbladder wall: a new look at sonographic diagnosis of acute cholecystitis.

OBJECTIVE: Color velocity imaging is a color sonographic technique that uses data contained in gray-scale B-mode image scan lines to determine blood flow velocity. We prospectively determined if color velocity imaging and power Doppler sonography can be used to differentiate acute from chronic cholecystitis. We analyzed the potential role of using these two color imaging techniques as an adjunct to conventional gray-scale sonography to differentiate acute from chronic cholecystitis. SUBJECTS AND METHODS: One hundred twenty-nine patients with acute right upper quadrant pain or clinically suspected cholecystitis underwent color velocity imaging and power Doppler sonography of the gallbladder as an adjunct to gray-scale sonography. Morphologic criteria were analyzed on gray-scale sonography, and the presence of flow within the gallbladder wall was assessed with color velocity imaging and power Doppler sonography. Imaging findings were compared with pathologic findings in the 50 patients who underwent cholecystectomy and with clinical and biologic findings in the 79 patients who did not undergo cholecystectomy. RESULTS: Twenty-two patients had surgically proven acute cholecystitis, 28 patients had surgically proven chronic cholecystitis, and 79 patients had no gallbladder disease. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of gray-scale sonography for revealing acute cholecystitis were 86%, 99%, 92%, 87%, and 97%, respectively. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of color velocity imaging and power Doppler sonography for revealing acute cholecystitis were 95%, 100%, 99%, 100%, and 99%, respectively. CONCLUSION: The accuracy of color velocity imaging and power Doppler sonography in revealing acute cholecystitis is significantly greater than the accuracy of gray-scale sonography.

Acute Disease↗

PubMed2001

Xanthogranulomatous cholecystitis.

Seven cases of xanthogranulomatous cholecystitis are presented, and their clinicopathological appearance is described. Three men and 4 women with xanthogranulomatous cholecystitis, aged 53-72 years old, were reviewed. Five patients had had previous attacks of acute cholecystitis lasting from 3 weeks to 6 months. Abdominal ultrasonography was performed in all patients, and computed tomography in 5 patients. Cholelithiasis and sludge were present in all patients. The gallbladder wall was thickened in all patients. On computed tomography, one patient showed no abnormal finding, and 4 patients had abnormal findings such as increased wall thickness and irregularity, and pericholecystic abnormalities. A diagnosis of gallbladder carcinoma was made preoperatively in 1 patient. During laparotomy, the gallbladders in all patients showed signs of chronic cholecystitis, and cholecystectomies were performed. Histological findings showed xanthogranulomatous cholecystitis, and 4 patients had stones in the gallbladder wall. Despite the characteristic histologic appearance of xanthogranulomatous cholecystitis, radiologic findings are nonspecific, varying from signs observed in other forms of cholecystitis to the appearance of a gallbladder neoplasm. We report here 7 cases of xanthogranulomatous cholecystitis and review the literature.

Aged↗

PubMed1999

Gangrenous cholecystitis: analysis of risk factors and experience with laparoscopic cholecystectomy.

BACKGROUND: Gangrenous cholecystitis occurs in up to 30% of patients admitted with acute cholecystitis. Factors predicting gangrenous disease in patients with acute cholecystitis remain poorly defined, making preoperative diagnosis difficult. Identification of these factors and early diagnosis of gangrenous cholecystitis will indicate more aggressive treatment, earlier operation, and a lower threshold for conversion of laparoscopic to open cholecystectomy. METHODS: We reviewed our experience with acute cholecystitis during the 2-year period of 1995 to 1996. Admitting history, physical examination, operative report, laboratory and radiology data, and pathology report were analyzed for each patient. Acute cholecystitis and its gangrenous complication were diagnosed by both gross and microscopic examination. RESULTS: One hundred fifty-four patients were admitted to the hospital with acute cholecystitis and underwent cholecystectomy; gallbladder gangrene was found in 27 (18%) of these patients. Four patients with gallbladder gangrene underwent open cholecystectomy and 23 patients underwent laparoscopic cholecystectomy, of which 15 (65%) were completed laparoscopically and 8 (35%) had open conversion as a result of severe inflammation. Risk factors for gallbladder gangrene included male gender, age older than 50 years, history of cardiovascular disease, and leukocytosis greater than 17,000 white blood cells/mL. CONCLUSIONS: Older male patients (age older than 50 years) with history of cardiovascular disease, leukocytosis greater than 17,000 white blood cells/mL, and acute cholecystitis have increased risk of gallbladder gangrene and conversion of laparoscopic cholecystectomy to open cholecystectomy. Urgent laparoscopic cholecystectomy with low threshold for conversion to open cholecystectomy should be considered in these patients at high risk for gallbladder gangrene.

Acute Disease↗

PubMedDate not supplied

Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Gangrenous cholecystitis is a severe form of acute cholecystitis with high morbidity. This study investigate the outcomes for patients undergoing cholecystectomy for gangrenous cholecystitis in the decade before and after the introduction of laparoscopic technology at our institution. METHODS: From 1982 to 2002, all patients undergoing cholecystectomy for gangrenous cholecystitis were prospectively entered into a database. Demographic data, method of surgery, and outcome variables were assessed and compared over time. RESULTS: Cholecystectomy was performed to treat gangrenous cholecystitis in 238 patients (mean age, 54 years). From 1982 to 1992, 98 patients underwent cholecystectomy for gangrenous cholecystitis, and from 1992 to 2002, 140 patients underwent the procedure. Ninety-seven patients underwent laparoscopic cholecystectomy, and 33 patients (34%) required conversion. The open and laparoscopic cholecystectomy group differed in the number of intensive care unit admissions (13% vs. 5%, P < 0.05), overall length of hospital stay (10 vs. 5.7 days, P < 0.001) and rate of intraabdominal abscesses (8% vs. 0.7%). CONCLUSION: Gangrenous cholecystitis remains a disease with high morbidity. Laparoscopic cholecystectomy shortened hospital stay and can be offered without increasing morbidity. Methods to decrease intraabdominal abscess formation in patients undergoing laparoscopic cholecystectomy for gangrenous cholecystitis are needed.

Aged↗

PubMedDate not supplied

[Laparoscopic treatment of acute cholecystitis].

Acute cholecystitis has been considered a contraindication for laparoscopic cholecystectomy after its affirmation as the golden standard for treatment of chronic cholecystitis. However, over time it has been proven that acute cholecystitis could also be managed laparoscopically, although it was technically demanding procedure, burdened with relatively high conversion rates. In this study we present our series of 26 patients, urgently admitted for acute cholecystitis. They are presented with clinical findings typical for acute cholecystitis. The diagnosis was determined using ultrasound examination, and confirmed postoperatively by pathohistological findings. In all 26 cases we managed to perform laparoscopic cholecystectomy, there were no conversion. Mean operative time was 73 +/- 21 minutes. Postoperatively, we haven't recorded any significant complications. Mean hospital stay was 4.8 +/- 2.5 days. Even though laparoscopic treatment of acute cholecystitis is technically more demanding and lengthier procedure than laparoscopic treatment of chronic cholecystitis, we consider acute cholecystitis to be a laparoscopically manageable disease. During the operation, tissue edema and hyperemia presented main technical challenge. They presented a significantly greater problem if the symptoms lasted for more than 3 days prior to operation. Therefore we suggest that laparoscopic cholecystectomy should be carried out in the first 72 hours after the onset of symptoms, since any further delay will lead to development of tissue hyperemia and edema, thus making the operation technically more demanding.

Adult↗

PubMed1987

The importance of early diagnosis of acute acalculus cholecystitis.

Most observations of acute acalculus cholecystitis have been reported in patients after trauma, after unrelated surgical treatment and in critically ill patients, patient populations in whom the diagnosis of this condition is difficult. The importance of making an early diagnosis is demonstrated by the rapid development of complicated forms of cholecystitis. The results of collective reports have indicated that 40 to 100 per cent of the patients with acute acalculus cholecystitis will have advanced disease with gangrene, empyema or perforation of the gallbladder at operation. To demonstrate the importance of early suspicion and the use of sonography in making the diagnosis of this condition, a retrospective study of 40 patients with a surgical and pathologic proved diagnosis of acute acalculus cholecystitis was conducted. The fulminant nature of this disease was underscored by the fact that 70 per cent of these patients had advanced disease. Patients were divided into two groups, those who underwent operation within 48 hours of the onset of symptoms and those whose surgical treatment was delayed. Forty per cent of the patients who underwent operation more than 48 hours after the onset of symptoms had gallbladder perforation, while only 8 per cent of the patients without a delay in surgical treatment of more than 48 hours had perforations. Since advanced disease, especially perforation, carries a much higher morbidity and mortality than uncomplicated cholecystitis, making an early diagnosis is of paramount importance. Therefore, heightened awareness on the part of physicians is a key in making an early diagnosis. In 25 per cent of the patients in this study, unexplained fever was the first sign of the disease. Although most patients later presented with more classic symptoms of cholecystitis, many of these patients still presented with confusing clinical signs and symptoms leading to a delay in diagnosis due to the coexistence of the post-trauma, postsurgical or critically ill state. Ultrasound proved to be an important adjunct to the often confusing clinical clues in making an early diagnosis. Three ultrasonographic signs in the absence of stones--1, a thickened gallbladder wall; 2, an enlarged tender gallbladder, and 3, a pericholecystic collection--were suggestive of acute acalculus cholecystitis. One of these findings was present in almost 90 per cent of the patients in this study with acute acalculus cholecystitis who underwent biliary ultrasound.

Acute Disease↗

PubMed1986

Posttraumatic and postoperative acute cholecystitis.

The development of peritonitis in hospitalized patients, especially those with significant associated illness, can be a difficult and delayed diagnosis. To ascertain the clinical presentation of acute cholecystitis in this group, a retrospective analysis was performed. Over a 10-year period 18 patients were identified who developed either posttraumatic or postoperative acute cholecystitis. The condition occurred in 12 patients admitted for some form of trauma and in six patients after elective surgery. Fever and right upper quadrant pain and tenderness were present in most. These physical findings were generally accompanied by leukocytosis (average = 16,200), hyperbilirubinemia (average = 4.2), and elevated alkaline phosphatase (average = 214). At laparotomy gangrenous cholecystitis was found in the majority, reflecting delayed diagnosis. Eleven patients had acalculous disease, and seven patients calculous cholecystitis. Three patients died, yielding a 17 per cent mortality. The majority with acalculous disease had significant underlying illness. Shock, multiple transfusions, or infection preceded acute cholecystitis in this group. Those with calculous cholecystitis were usually not as ill prior to its development. The morbidity of acute cholecystitis in previously hospitalized patients can be reduced by an awareness of the predisposing factors in those with acalculous disease. Emphasis should be placed on signs and symptoms rather than laboratory values to ensure early diagnosis and treatment of acute cholecystitis in hospitalized patients regardless of the presence or absence of gallstones.

Abdominal Injuries↗

PubMedDate not supplied

The role of ultrasonographic percutaneous cholecystostomy in treatment of acute cholecystitis.

BACKGROUND/AIMS: The Authors propose ultrasonographic percutaneous cholecystostomy in the treatment of acute cholecystitis. MATERIALS AND METHODS: During the period between July 1991-December 1993, 26 patients with acute cholecystitis (18 calculous and 8 acalculous) were observed. The cholecystostomy was performed in principle on patients aged over 70 years and in those with acalculous acute cholecystitis. To rationalize the indication for cholecystostomy in patients aged under 70 years with calculous acute cholecystitis, the Authors elaborated a Risk Score. RESULTS: The cholecystostomy was performed in 23 patients, 15 with calculous and 8 with acalculous acute cholecystitis, and was successful in 22 patients (95.7%). In the group with acalculous acute cholecystitis, the cholecystostomy was the resolutive treatment, while in that with calculous acute cholecystitis was associated, when indicated, to the surgery. CONCLUSIONS: The cholecystostomy interrupted the natural history of the disease and has a low morbidity and mortality. It is an effective and rationale contribution to the treatment of the acute cholecystitis.

Acute Disease↗

PubMed1996

[Acute cholecystitis in periarteritis nodosa. 8 cases].

OBJECTIVES: Analyze clinical manifestations and laboratory findings in patients with periarteritis nodosa who developed acute cholecystitis in order to determine their value for prognosis and management. PATIENTS AND METHODS: We report 8 cases of acute cholecystitis which revealed or occurred as a complication of periarteritis nodosa. These were 4 men and 4 women, mean age 50 years. Periarteritis nodosa was diagnosed on the basis of histological evidence and/or clinical expression. Complimentary explorations included: sonography of the biliary tree, cholecystogram or cholangiogram in addition to diagnostic work-up for periarteritis nodosa. RESULTS: The clinical or sonographic presentation was similar to common cases of cholecystitis. However, no stone were observed in 2/8 cases. Histologically, the gall bladder showed characteristic vascular lesions suggestive of periarteritis nodosa in 7 out of 8 cases (no operation in 1 case). Cholecystitis was the inaugural sign in 2 cases. Surgery was performed for lithiasic forms. Medical management with methylprednisolone i.v. was used successfully in the alithiasic forms. In the 2 cases with inaugural solitary acute cholecystitis. lithiasis was found in the surgical specimen in 1 case; the pathology examination gave the etiological diagnosis. There was no lithiasis in one case with inaugural cholecystitis. CONCLUSIONS: The development of acute cholecystitis in patients with periarteritis nodosa is uncommon but should be treated surgically in case of lithiasis or when the cholecystitis is the inaugural sign. Unlike digestive tract involvement, periarteritis nodosa does not aggravate the clinical course. Alithiasic forms may be treated medically with corticosteroids. In our opinion, therapeutic abstention, sometimes proposed in patients with necrotizing angiitis of the gall bladder, is not always indicated as some patients can benefit from medical treatment of the underlying periarteritis nodosa.

Acute Disease↗

PubMed1997

Acalculous cholecystitis after aortic reconstruction.

BACKGROUND: Acute acalculous cholecystitis is rare in patients undergoing aortic surgery; but, this condition is associated with a high mortality rate. With their comorbid medical problems, patients undergoing aortic reconstruction may have a higher mortality associated with acute acalculous cholecystitis. STUDY DESIGN: By retrospectively reviewing patient charts, we studied the prevalence, demographics, details of antecedant aortic procedures, hospital course, and outcome of patients with acute acalculous cholecystitis after aortic surgery. RESULTS: In the past 10 years, 7 of the 996 patients who underwent aortic reconstruction at our institution developed postoperative acute acalculous cholecystitis. These patients were all nondiabetic men with a mean age of 66 +/- 4 years (range, 50 to 76 years). Previous aortic operations included four infrarenal aneurysmorrhaphies (three elective, one urgent for a ruptured aneurysm), two aortofemoral bypasses for occlusive disease, and a removal of an infected aortic prosthesis. Six patients had prolonged intraoperative hypotension and increased blood transfusion requirements. All patients had postoperative multiorgan dysfunction. The patients developed fever, leukocytosis, elevated liver function test levels, and other signs and symptoms of acute acalculous cholecystitis a mean of 32 days (range, 9 to 90 days) after operation. Preoperative diagnosis was made in five patients based on clinical examination, laboratory test results, and adjunctive noninvasive test results. Two patients required laparotomy to make the diagnosis of acute acalculous cholecystitis. Five patients underwent cholecystectomy, and two had placement of cholecystostomy tubes. Gangrene or perforation was evident in most. Overall mortality was 71 percent. CONCLUSIONS: Acute acalculous cholecystitis is the most common postoperative biliary complication after aortic surgery. The diagnosis should be entertained in patients with signs of abdominal sepsis after aortic surgery, especially those with a complicated postoperative course. Even if acute acalculous cholecystitis is diagnosed before exploration, mortality remains high.

Acute Disease↗