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PubMed1997

Laparoscopic versus open cholecystectomy in acute cholecystitis.

Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.

Acute Disease↗

PubMed1980

Acute cholecystitis. Comparison of ultrasound and intravenous cholangiography.

The clinical diagnosis of acute cholecystitis may sometimes be difficult. We compared the accuracy of abdominal ultrasound and intravenous cholangiography in patients with acute cholecystitis. Forty patients with histories and physical findings of acute cholecystitis had intravenous cholangiography and gray-scale abdominal ultrasonography soon after admission. Thirty-four of the 40 patients had surgically and pathologically proved acute cholecystitis. Thirty-one of the 34 patients had positive ultrasound findings. The intravenous cholangiographic findings were present in 27 of the 34 patients with acute cholecystitis. We describe the sonographic findings of acute cholecystitis. Ultrasound of the abdomen is recommended as the initial screening procedure in patients suspected of having acute cholecystitis.

Acute Disease↗

PubMed1984

The management of acute cholecystitis in the elderly.

This paper assesses the value of hepatobiliary scanning and surgical treatment of acute cholecystitis in patients above the age of 60 years over a 3 year period (1980-1982). During this period 382 cholecystectomies for biliary disease were performed in 257 women and 125 men with mean ages of 55 X 6 and 61 X 1 years respectively. Of the 382, 208 were older than 60, with a female to male ratio of 1 . 3:1. Acute cholecystitis occurred in 74 of the 208 patients; they were subjected to early cholecystectomy. Biliary tract imaging using 99 m technetium-labelled diisopropyl-IDA (DISIDA) proved valuable in confirming the diagnosis of acute cholecystitis. Of 85 patients over 60 years who underwent hepatobiliary scanning with a presumptive diagnosis of acute cholecystitis, 74 had positive scans and acute cholecystitis was confirmed at subsequent operation in these cases. There were two false positive and nine negative scans showing that biliary scintigraphy proved to be a rapid non-invasive and sensitive method of diagnosing acute cholecystitis. The advent of hepatobiliary scanning has strengthened our surgical strategy in the management of acute cholecystitis in the elderly and allows early elective surgery with an acceptable morbidity and in this series no mortality.

Acute Disease↗

PubMed1986

[Cholecystitis in accident surgery].

Out of a large number of cholecystectomies four cases are reported. In some cases, the gallbladder was involved in the traumatic lesion itself but there are also cases, in which the cholecystitis developed independently of the primary lesion. Beside abdominal trauma which leads to a disruption of the organ wall we also see an inflammatory disease of the gallbladder after perforation during liver blind punction. In another case a patient with gall stone history developed acute cholecystitis after operative treatment of a collum femuris fracture. The fourth case shows acute cholecystitis which also arose after operative treatment of bone fracture in an acalculous bile vesicle. Acute cholecystitis after severe trauma not inflicting the organ itself is a severe, life threatening complication. One step to acute acalculous cholecystitis is the sludge formation in the gallbladder which can be recognized by ultrasonography. The pathogenetic mechanisms which lead to sludge phenomenon and later to acute cholecystitis are multifactorial. Some theories which try to explain this phenomenon are discussed. In each case the development of cholecystitis after trauma is a dangerous complication which urgently demands nonconservative treatment.

Adult↗

PubMed1997

[Postoperative and post-traumatic acute cholecystitis. Value of ultrasound diagnosis].

An often unrecognized but potentially fatal complication, mostly seen in posttraumatic patients under intensive care, is reactive acute cholecystitis. On account of the high specificity of ultrasound diagnosis in the biliary system we decided to examine the ultrasound criteria for early detection of posttraumatic cholecystitis. Ultrasound of the abdomen was performed prospectively, seven times on different days, in each of 40 artificially respirated patients under intensive care conditions over a period of 12 months. The results show that artificial respiration, parenteral feeding and previous trauma can lead to tardive (28/40) wall-thickening or to a three-layered wall of the gallbladder (9/40). In 22.5% of patients (9/40) we found the sonographic signs of acute cholecystitis. In correlation with the clinical signs, cholecystectomy was indicated in only two patients. The preoperative ultrasonographic findings and clinical signs of 23 patients with the diagnosis of acute reactive cholecystitis were analysed retrospectively. We found good correlation between sonographic and clinical signs of acute cholecystitis in 21 of these 23 patients. Our study shows that the morphological correlate of a thickened three-layered gallbladder wall can occur in the context of systemic alterations, even if there is no underlying cholecystitis. The diagnosis of acute reactive cholecystitis and the indication for cholecystectomy should be based on the synopsis of pathologic and clinical findings.

Acute Disease↗

PubMed2006

Prognostic parameters for the prediction of acute gangrenous cholecystitis.

BACKGROUND/PURPOSE: The aim of this study was to identify preoperative prognostic parameters for gangrenous cholecystitis to differentiate this subgroup of patients with acute cholecystitis in order to provide immediate surgical therapy. METHODS: The medical records of patients who had an emergency cholecystectomy with the diagnosis of acute cholecystitis between January 2002 and June 2005 were reviewed retrospectively. Univariate and multivariate analysis were performed on the data. RESULTS: Out of 203 individuals with the clinical diagnosis of acute cholecystitis, 21 (10.3%) patients had a histological diagnosis of gangrenous cholecystitis. Multivariate analysis demonstrated an independent association of male sex, diabetes mellitus and white blood cell (WBC) count with the development of acute gangrenous cholecystitis. CONCLUSIONS: The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14 900/mm(3). Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.

Chi-Square Distribution↗

PubMed1981

Acute acalculous cholecystitis.

Sixty-three patients, 49 men and 14 women, developed acute cholecystitis without gallbladder stones. Only eight patients had a history suggestive of gallbladder disease. In 17 patients cholecystitis developed in the postoperative period, and cholecystitis occurred in 7 patients who had extensive trauma. The signs and symptoms did not differ markedly from those found when acute cholecystitis is associated with cholelithiasis. Pain and tenderness in the right upper abdominal quadrant, vomiting, abdominal distention, decreased bowel sounds, jaundice and fever were common. Thirty (47.6 percent) gallbladder specimens had gangrene, and perforation occurred in five instances. Bacteria were cultured from 28 of 43 bile specimens. E. coli was the most common organism. A high incidence of acalculous gallbladders is found when acute cholecystitis occurs in the postoperative period or after trauma and in children. Decreased blood flow to the gallbladder, cystic duct obstruction and concentrated bile are necessary to produce experimental cholecystitis. These factors are probably necessary in humans also. Decreased gallbladder perfusion caused by shock, congestive heart failure and arteriosclerosis probably contributed to the development of acute acalculous cholecystitis in these patients.

Acute Disease↗

PubMed1982

Comparison of ultrasonography, computerized tomography, and radionuclide imaging in the diagnosis of acute and chronic cholecystitis.

Seventy-five patients with abdominal pain in the right upper quadrant who were subsequently confirmed operatively and histologically to have acute or chronic cholecystitis underwent radionuclide imaging of the biliary tree, ultrasonography, and/or computerized tomography before operation. fifty-eight of the patients had acute cholecystitis and 17 had chronic cholecystitis and cholelithiasis. Analysis of our data indicates that ultrasonography is an accurate and better screening test than cholescintigraphy in the diagnosis of chronic cholecystitis and cholelithiasis, but it is less accurate in the detection of acute cholecystitis. On the other hand, radionuclide imaging is highly sensitive and specific in the early diagnosis of acute cholecystitis, but it is poor in the diagnosis of chronic cholecystitis and cholelithiasis unless the cystic duct is obstructed. CT scanning is more expensive than ultrasonography but may be extremely helpful in problematic cases such as the diagnosis of the cause in biliary obstruction or in imaging of the pancreas.

Acute Disease↗

PubMed2006

Cholecystitis after metallic stent placement in patients with malignant distal biliary obstruction.

BACKGROUND & AIMS: Cholecystitis after metallic stent (MS) placement is an issue requiring attention. From our experience, cholecystitis seemed to occur mainly in patients with tumor involvement to the cystic duct orifice. The aim of the present study was to identify risk factors for cholecystitis in patients treated with covered or uncovered MS. METHODS: We analyzed 246 patients who received MS placement (covered MS in 171 and uncovered in 75) between August 1997 and May 2005 for the treatment of unresectable distal malignant biliary obstruction. Causative diseases were as follows: pancreatic cancer in 162, papillary cancer in 10, bile duct cancer in 41, and metastatic nodes in 33 patients. Tumor involvement to orifice of the cystic duct (OCD) was diagnosed based on cholangiography and intraductal ultrasonography. RESULTS: Cholecystitis after MS placement was found in 13 patients (5.3%). There was no significant difference in the incidence of cholecystitis between covered (5.8%) and uncovered (4.0%) MS. By univariate analysis, tumor involvement of the OCD, MS placed above the papilla, and stricture located at midportion were associated significantly with cholecystitis. By multivariate analysis, only tumor involvement of the OCD was a risk factor, with an odds ratio of 47.206 (95% confidence interval, 5.84-381.60). CONCLUSIONS: Cholecystitis after MS placement is associated with tumor involvement to the orifice of the cystic duct, regardless of the type of stent.

Aged↗

PubMed2005

Antibiotic use in acute cholecystitis: practice patterns in the absence of evidence-based guidelines.

OBJECTIVES: Antibiotics are frequently administered in acute cholecystitis for preoperative prophylaxis or postoperative treatment. The optimal timing, choice, and duration of antibiotics are unclear. METHODS: We conducted a retrospective review of all cases of acute cholecystitis between 1996 and 2001 at the American University of Beirut Medical Centre. A survey among general surgeons was also performed to describe the pattern of antibiotic prescribing in uncomplicated acute cholecystitis. A MEDLINE search for guidelines for antibiotic use in acute cholecystitis was conducted. RESULTS: The number of cases of acute cholecystitis was 79. The mean duration of postoperative antibiotic therapy was 5 days. There was no correlation between the severity of symptoms, gallbladder description, or positive gallbladder culture and the use of antibiotics postoperatively. Sixty five percent of interviewed surgeons would continue antibiotic therapy postoperatively for 3 or more days. Search of the medical literature failed to provide clear guidelines for antibiotic use in acute cholecystitis. CONCLUSIONS: The use of antibiotics in patients with acute cholecystitis is erratic and costly. Prospective studies are needed to better study the effectiveness of a short course of antibiotics in uncomplicated cases. The role of gallbladder culture in guiding antibiotic therapy should be defined as routine cultures add to the cost without evident benefit.

Adult↗

PubMed2001

Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy is increasingly being employed as the initial surgical approach in patients with acute cholecystitis. Gangrenous cholecystitis will be unexpectedly encountered in a proportion of these patients. The applicability of laparoscopic techniques and its outcome in this group of patients remain poorly defined. This paper presents our experience with laparoscopic cholecystectomy in the treatment of patients with gangrenous cholecystitis. METHODS: From January 1994 to March 1999, 281 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Operative and histopathologic data were obtained and the subgroup with gangrenous cholecystitis identified (53 of 281, 18.8%). Laparoscopic cholecystectomy was the initial surgical approach in 44 (83%) and was successfully completed in 30 of 44 (68%) patients. Conversion to an open cholecystectomy became necessary in 14 of 44 (32%). A retrospective review comparing these two groups of patients was performed. RESULTS: Of the 44 patients, there were 25 males and 19 females, with a mean age of 64.6 years. Mean duration of symptoms prior to presentation was 2.3 and 2.9 days in the laparoscopic and conversion groups, respectively. Clinical presentation included the presence of right upper quadrant pain (98%), leukocytosis (91%), fever (16.3%), and jaundice (9%). Liver function test abnormalities included elevations of alkaline phosphatase (25%), aspartate aminotransferase (20.4%), alanine aminotransferase (22.7%), and total bilirubin (18.1%). Ultrasonography revealed the presence of gallstones (88.6%), gallbladder wall thickening (52.3%), and pericholecystic fluid (20.5%). Air in the gallbladder wall and intraluminal membranes were present in 2 patients and 1 patient, respectively. Nuclear scans performed in 29 patients revealed cystic duct obstruction in all 29. The rim sign was present in 1 patient. A laparoscopic cholecystectomy was attempted in 44 of 53 patients and was successfully completed in 30 (68%). Conversion to an open procedure became necessary in 14 of 44 (32%). No difference in preoperative factors was noted among the two groups. The mean duration of surgery in patients undergoing a successful laparoscopic cholecystectomy was 107 minutes versus 110 minutes when conversion was necessary. There were no deaths in the study population. Morbidity occurred in 40% of the laparoscopic group and 71% of the conversion group. No patient in the laparoscopic group required admission to the intensive care unit. In contrast, 4 of 14 patients in the conversion group required a mean of 2.6 days in the intensive care unit. Postoperative hospital stay was 3.3 versus 5.5 days in the two groups, respectively. CONCLUSIONS: Preoperative factors did not predict conversion in patients undergoing laparoscopic cholecystectomy for presumed acute cholecystitis who are found to have gangrenous cholecystitis. Duration of surgery is not significantly prolonged and outcome in terms of morbidity, admission to the intensive care unit, and hospital stay are significantly better in patients in whom laparoscopic cholecystectomy is successful.

Acute Disease↗

PubMed2001

Ultrasonography by emergency physicians in patients with suspected cholecystitis.

This article investigates the use of bedside abdominal ultrasonography (BAU) performed by emergency physicians (EPs) to screen patients for cholelithiasis and cholecystitis. In this prospective study EPs performed BAU on 116 patients. Agreement between BAU and formal abdominal ultrasound (FUS) performed in the radiology department for detecting cholelithiasis and cholecystitis was determined using Kappa statistics. Test characteristics of BAU for detecting cholelithiasis and acute cholecystitis were calculated. Agreement between BAU and FUS was 0.71 for cholelithiasis and 0.46 for acute cholecystitis. Test characteristics of BAU for cholelithiasis were sensitivity 92%, specificity 78%, positive predictive value (PPV) 86%, negative predictive value (NPV) 88%. Test characteristics of BAU for acute cholecystitis compared with clinical follow-up were sensitivity 91%, specificity 66%, PPV 70%, NPV 90%. BAU may be used to exclude cholelithiasis and is sensitive for cholecystitis. However, when EPs with limited experience identify cholecystitis a confirmatory test is warranted before cholecystectomy.

Acute Disease↗

PubMed1975

[Intravenous cholegraphy and diaphragmatic movements in the differential diagnosis of acute cholecystitis (author's transl)].

Intravenous cholegraphy was performed in 79 patients with abdominal symptoms suggestive of acute cholecystitis. Three excretion patterns were found: 1. Opacification of the gall bladder and common bile duct. 2. Opacification of the common bile duct. 3. No opacification of the gall bladder or common bile duct. 29% showed opacification of the gall bladder and common bile duct; none of these had acute cholecystitis. 51% of cases showed opacification of the common bile duct only; 82.5% of these had acute cholecystitis. 79.4% of patients with this excretion pattern were shown to have acute cholecystitis at operation. In the other cases, absence of opacification of the gall bladder was due to obstruction of the cystic duct, caused either by concretions or fibrosis. The biliary tree was not visible in 21% of cases. The most common diagnosis was acute cholecystitis, but this excretion pattern is of limited value in differential diagnosis. The value of this examination is stressed, but it must be carried on for an adequate period. Mobility of the right diaphragm was examined preoperatively in 34 patients. Compared with patients with other diagnoses, there was a significant number of patients with acute cholecystitis who showed limited movement. The examination may be regarded as supplementary to intravenous cholegraphy in the diagnosis of acute cholecystitis.

Abdomen, Acute↗

PubMed1993

Eosinophilic and lymphoeosinophilic cholecystitis.

Eosinophilic cholecystitis (EC) is an infrequent and poorly understood inflammatory condition of the gallbladder. First described in 1949, EC may be defined as an inflammatory condition of the gallbladder in which the inflammatory infiltrate is composed predominately of eosinophils so that their presence clearly overshadows the presence of any other inflammatory cell component. In the few reports that describe EC, it has been described in association with acalculous cholecystitis, with subacute cholecystitis lasting 2 to 3 weeks and with several forms of drug therapy. This retrospective clinicopathologic study reviewed the histopathologic features of 217 consecutive cholecystectomy specimens with special clinical reference to the timing of gallbladder removal after symptoms, previous drug therapy, systemic infection, and the presence of cholelithiasis. Pathologically, 48 of these cases (22.2%) contained eosinophils to some degree. Eosinophilic cholecystitis was diagnosed in 14 (6.4%) of the specimens, and another 14 (6.4%) specimens demonstrated substantial numbers of eosinophils but also had other types of inflammatory cells in abundance, including neutrophils and lymphocytes. Of the eight patients with acalculous cholecystitis, six had substantial eosinophils in their gallbladders, whereas the other two patients had no eosinophils. In this study, EC was more prevalent than in other reported series, and it did not show any association with the timing of gallbladder removal after initial symptoms, drug therapy, or other preexisting medical conditions. Eosinophilic cholecystitis is more common than previously recognized and probably represents a subgroup of patients with a unique or hypersensitivity type of inflammatory response to altered bile. Large numbers of eosinophils in the inflammatory infiltrate occurred three times more commonly in patients with acalculous cholecystitis than in patients with cholelithiasis.

Adult↗

PubMed1981

Gangrene of the gallbladder: a complication of acute cholecystitis.

Eighteen cases of gangrenous cholecystitis were reviewed to better define causes of morbidity and mortality. All patients in the series presented with signs and symptoms of acute cholecystitis. Cholecystectomy was done as an emergency procedure in 12 patients, while in six patients cholecystectomy followed a failure of nonoperative therapy. Gangrenous cholecystitis in this series was commonly associated with empyema and perforation of the gallbladder. Three of six patients having cholecystectomy after failure of nonoperative treatment died, while only one of 12 patients with immediate cholecystectomy died. This series illustrates that gangrenous cholecystitis usually presents with a clinical picture identical to that of acute cholecystitis. Early operation in the natural history of acute cholecystitis should reduce the frequency as well as the morbidity and mortality of gangrenous cholecystitis.

Acute Disease↗

PubMed2004

Acute renal failure associated with Legionella pneumonia and acute cholecystitis.

BACKGROUND AND AIMS: Acute cholecystitis in critically ill patients has a high morbidity and mortality. We observed a number of patients presenting with Legionella pneumonia and acute renal failure who subsequently developed acute cholecystitis. There has previously been no reported association between Legionella pneumonia, renal failure and cholecystitis, prompting this examination of the cases and review of the available literature. METHODS: The Western Hospital patient record discharge codes (DRG) from 1993 to 2001 were searched retrospectively for all cases of Legionella pneumonia or acute renal failure requiring dialysis (ARF) at presentation or during their period of hospitalization. Acute cholecystitis was then included as a cross-search and results analysed. RESULTS: Twenty-six cases of isolated Legionella pneumonia and 112 of ARF were identified with a further 10 having both conditions simultaneously. Of these 10 cases, three were identified as also having acute cholecystitis. The combination of Legionella pneumonia and ARF was associated with an increased risk of acute cholecystitis (P = 0.002) whereas neither condition in isolation demonstrated this association. CONCLUSIONS: Patients with Legionella pneumonia can become critically ill with multiple complications including acute renal failure requiring dialysis. In this setting, they may have an increased risk of developing acute cholecystitis, which clinically can be difficult to ascertain. Diagnosis requires a high index of suspicion and vigilance.

Acute Disease↗

PubMed1982

Hepatobiliary scanning with 99mTc-PIPIDA in acute cholecystitis.

Ninety-five patients with clinically suspected acute cholecystitis underwent hepatobiliary scanning with 99mTc-PIPIDA. A positive scan (nonvisualization of the gallbladder with visualization of the common bile duct and gut) was found in 29 patients; 25 of them (86%) had surgically proven acute cholecystitis and 4 (14%) had chronic cholecystitis. Five of the 25 with acute cholecystitis had acalculous disease. A negative examination (gallbladder visualization) occurred in 63 patients; 18 (29%) had chronic cholecystitis and 45 (71%) were subsequently found to have nonbiliary disease. Three indeterminate studies (nonvisualization of both the gallbladder and gut) were obtained in patients with choledocholithiasis and chronic cholecystitis. In the evaluation of acute cholecystitis, the 99mTc-PIPIDA hepatobiliary scan was 100% sensitive and 94% specific.

Acute Disease↗

PubMed1985

Gallbladder bile in cholecystitis: in vitro MR evaluation.

Fifty-three samples of gallbladder bile were obtained at the time of cholecystectomy from patients with the clinical diagnosis of acute or chronic cholecystitis. Five bile samples from patients with clinically normal gallbladders also were obtained. Proton magnetic resonance (MR) relaxation times, protein content, and water content were determined for the bile samples, and the data were grouped according to pathologic diagnosis, which disclosed 11 cases of acute cholecystitis, 41 cases of chronic cholecystitis, and six normal gallbladders. There was no significant difference in the mean T1 and T2 values between the groups with acute and chronic cholecystitis. Patients with chronic cholecystitis were found to have more concentrated bile than those with acute cholecystitis. Protein content varied widely within both groups of patients. We conclude that T1 and T2 relaxation times do not reliably differentiate acute from chronic cholecystitis.

Bile↗