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PubMed1994

Diagnosis of acute cholecystitis with color Doppler sonography: significance of arterial flow in thickened gallbladder wall.

OBJECTIVE: Thickening of the gallbladder wall is a common though nonspecific sonographic finding. The purpose of this study was to determine if color Doppler sonography shows arterial flow in thickened gallbladder walls more frequently in patients with cholecystitis than in patients with other causes of thickening of the wall. SUBJECTS AND METHODS: Seventy-six patients with thickened gallbladder walls (> or = 3 mm) were prospectively examined with color Doppler sonography. When arteries were detected, Doppler waveforms were used to determine resistive indexes. The final diagnosis was based on pathologic reports, results of percutaneous cholecystostomy, and clinical records. RESULTS: Of the 23 patients (30%) with cholecystitis (11 acute, 12 chronic), nine (39%) had arterial flow and 14 (61%) had no arterial flow. Of the 53 patients (70%) without cholecystitis, 20 (38%) had arterial flow and 33 (62%) had no arterial flow (p = 1.00). The mean resistive indexes (+/- 1 SD) for patients with and without cholecystitis were 60% +/- 13% and 65% +/- 9%, respectively (p = 0.33). No significant difference in the detection of arterial flow was found between patients with acute cholecystitis and those with chronic cholecystitis. CONCLUSION: The presence of arterial flow in the thickened gallbladder wall is nonspecific and of limited value in the diagnosis of cholecystitis.

Acute Disease↗

PubMed2006

Risk factors of acute cholecystitis after endoscopic common bile duct stone removal.

AIM: To evaluate the risk factors of acute cholecystitis after endoscopic common bile duct (CBD) stone removal. METHODS: A total 100 of patients who underwent endoscopic CBD stone removal with gallbladder (GB) in situ without subsequent cholecystectomy from January 2000 to July 2004 were evaluated retrospectively. The following factors were considered while evaluating risk factors for the development of acute cholecystitis: age, gender, serum bilirubin level, GB wall thickening, cystic duct patency, presence of a GB stone, CBD diameter, residual stone, lithotripsy, juxtapapillary diverticulum, presence of liver cirrhosis or diabetes mellitus, a presenting illness of cholangitis or pancreatitis, and procedure-related complications. RESULTS: During a mean 18-mo follow-up, 28 (28%) patients developed biliary symptoms; 17 (17%) acute cholecystitis and 13 (13%) CBD stone recurrence. Of patients with acute cholecystitis, 15 (88.2%) received laparoscopic cholecystectomy and 2 (11.8%) open cholecystectomy. All recurrent CBD stones were successfully removed endoscopically. The mean time elapse to acute cholecystitis was 10.2 mo (1-37 mo) and that to recurrent CBD stone was 18.4 mo. Of the 17 patients who received cholecystectomy, 2 (11.8%) developed recurrent CBD stones after cholecystectomy. By multivariate analysis, a serum total bilirubin level of <1.3 mg/dL and a CBD diameter of <11 mm at the time of stone removal were found to predict the development of acute cholecystitis. CONCLUSION: After CBD stone removal, there is no need for routine prophylactic cholecystectomy. However, patients without a dilated bile duct (<11 mm) and jaundice (<1.3 mg/dL) at the time of CBD stone removal have a higher risk of acute cholecystitis and are possible candidates for prophylactic cholecystectomy.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1995

Color Doppler sonography of the cystic artery: comparison of normal controls and patients with acute cholecystitis.

Color Doppler sonography was used to evaluate the length and distribution of the cystic artery in the gallbladder wall in 115 normal adults and in 54 patients with surgically proved cholecystitis. All patients were scanned with a 5 MHz curved array transducer optimized for low volume color sensitivity. A specific attempt was made to visualize the cystic artery throughout its course. Spectral Doppler waveforms were obtained to document arterial flow. The length of the cystic artery visualized was analyzed as a quartile percentage length of the anterior gallbladder wall. The distribution of the cystic artery flow also was analyzed in specific quartiles. Of 54 patients with acute cholecystitis, 26% had cystic artery length greater than half of the anterior gallbladder wall, compared with 2% of 115 normal controls (P < 0.001); 19% of patients with cholecystitis had flow in the distal (fundal) quartile, compared to 0% of normal controls (P < 0.0001). Although the presence or absence of flow in the gallbladder is not a reliable finding to establish the diagnosis of acute cholecystitis, length of cystic artery visualized is a potentially useful criterion to suggest the diagnosis of acute cholecystitis, especially in cases in which flow in the distal fundal quartile of the gallbladder. The usefulness of color Doppler sonography in acute cholecystitis is limited owing to the fact that it is insensitive, and many patients with cholecystitis have no detectable flow or have normal flow patterns.

Acute Disease↗

PubMedDate not supplied

Percutaneous cholecystostomy in acute cholecystitis in high-risk patients: an analysis of 69 patients.

BACKGROUND: Optimal treatment of acute cholecystitis in high-risk patients with acute cholecystitis continues to be a difficult therapeutic problem. With the development of more advanced radiological imaging techniques, percutaneous cholecystostomy (PCS) has been presented as an effective treatment alternative in critically ill patients. This paper reports our experiences of percutaneous cholecystostomy in the treatment of acute cholecystitis in a well defined high-risk patient group. METHODS: The data concerning 69 high-risk patients with acute cholecystitis treated by percutaneous cholecystostomy in Oulu University Hospital and Kokkola Central Hospital were analyzed. RESULTS: Ultrasound showed gallbladder stones in 71% (49/69) of the patients and 29% of them presented with acalculous cholecystitis. After PCS, pain diminished in 94% (61/65), fever in 90% (35/39), CRP values in 87% (53/61) and leucocyte count in 84% (46/55) of the patients. Before PCS, the CRP value was 132+/-106 mg/l and after PCS 79+/-73 mg/l (P = 0.001) and corresponding leucocyte counts were 14.7+/-5.0 and 9.3+/-3.2 (P = 0.001), respectively. The antegrade cholecystocholangiography was performed in 29 patients after PCS, and common bile duct stones were detected in 8 patients; these stones were treated by endoscopic papillotomy. Complications after PCS occurred in 17 patients (26%), but only two patients required emergency laparotomy. Mortality was 19% (13/69). Acute cholecystitis alone was the cause of death in only three patients. Mostly, fatal outcome was caused by the serious underlying diseases. CONCLUSION: According to our results, PCS should be the method of choice in high-risk patients with acute cholecystitis.

Acute Disease↗

PubMed2000

Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis.

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.

Acute Disease↗

PubMed1999

[Laparoscopic cholecystectomy. A recommendable indication in acute cholecystitis?].

While laparoscopic cholecystectomy has become the procedure of choice for the elective treatment of symptomatic cholecystolithiasis the question whether patients with acute cholecystitis should be operated laparoscopically or conventionally is still debated. Nevertheless, more and more surgeons tend to use the laparoscopic approach even in patients with acute cholecystitis. Of 1006 laparoscopic cholecystectomies performed at our hospital 42 were done for acute cholecystitis. Conversion to an open procedure was necessary in only one patient because of severe inflammatory changes. The overall mortality was zero. The average age was 45.9 years for all patients and 50.4 years for those with acute cholecystitis. The average operating time in patients with acute cholecystitis was 81 minutes compared to 62 minutes in patients who underwent elective laparoscopic cholecystectomy. The complication rate and the average hospitalization time did not differ significantly between the two groups. Our own data as well as the data retrieved from the literature seem to indicate that laparoscopic cholecystectomy is superior to the open procedure in the treatment of acute cholecystitis. Prerequisite is that the operation is performed less than 72 hours after the onset of the symptoms by an experienced operating team and the readiness to convert to open procedure if necessary. Under those circumstances laparoscopic cholecystectomy seems to be the treatment of choice for acute cholecystitis.

Acute Disease↗

PubMedDate not supplied

Liver abscess due to acute cholecystitis. Report of five cases.

Acute cholecystitis is one of the most frequent causes of admissions to surgical departments. The development of liver abscesses is an uncommon and underrated complication of acute cholecystitis. In this study we report on our experience with the treatment of 5 cases of liver abscesses secondary to acute cholecystitis. All 5 cases were characterised by a lengthy period between the onset of acute cholecystitis symptoms and the subsequent diagnosis of a secondary liver abscess. In 4 out of 5 patients, admission for liver abscess occurred 12, 30, 50 and 120 days, respectively, after the acute cholecystitis episode. The liver abscesses were successfully treated with percutaneous drainage under US guidance (4 cases) and 4 patients underwent percutaneous cholecystostomy to treat the acute cholecystitis. After resolution of the acute phase, an elective cholecystectomy was performed in 4 out of 5 cases. Failure to diagnose acute cholecystitis at onset or inappropriate treatment of the condition could lead to the development of liver abscesses.

Acute Disease↗

PubMedDate not supplied

Verres needle decompression of distended gallbladder to facilitate laparoscopic cholecystectomy in acute cholecystitis: a prospective study.

BACKGROUND/AIMS: Grasping a thick and distended gallbladder is one of the most common technical difficulties of laparoscopic cholecystectomy in acute cholecystitis. This prospective study was conducted to investigate the use of the Verres needle decompression method to facilitate laparoscopic cholecystectomy in acute cholecystitis. METHODOLOGY: Between April 1998 and April 2002, patients with acute cholecystitis scheduled to receive laparoscopic cholecystectomy emergently were included. A Verres needle was applied through the subcostal area to decompress the acute inflamed distended gallbladder after establishing pneumoperitoneum. RESULTS: In total 54 patients, 30 male and 24 female with mean age 53.50 years (range 21-80), consented to the operation. Laparoscopic cholecystectomy was performed successfully in 44 patients. The conversion of laparoscopic cholecystectomy to open surgery was needed in 10 patients (conversion rate: 18.5%). The failure to identify the triangle of Calot is the only risk factor associated with conversion. The more severe acute cholecystitis is, the higher the conversion rate is (11.5% in uncomplicated cholecystitis, 31.6% in complicated cholecystitis). No bile duct injury was noted. Postoperative morbidity happened in three cases: two port-site discharge and one subphrenic abscess. No mortality occurred. CONCLUSIONS: Verres needle decompression of the acute inflamed gallbladder did facilitate laparoscopic cholecystectomy in acute cholecystitis with low conversion rate.

Acute Disease↗

PubMed2006

The effect of season and Ramadan fasting on the onset of acute cholecystitis.

OBJECTIVE: To investigate whether Ramadan fasting and seasonal variation has any effect on the onset of acute cholecystitis. METHODS: A cross-sectional study was conducted in Faghihi and Namazee Hospitals between September 1999 to August 2004. All files of patients with definite diagnosis of gallstone induced acute cholecystitis were reviewed for age, gender, date and method of treatment in relation to seasons and Ramadan fasting month. For comparison, we used Shaaban months (prior months) and Shavval months (following months). RESULTS: Eight hundred and sixty-four files (32.7% male and 62.8% were female) with definite diagnosis of acute cholecystitis were reviewed. Mean age was 56.3 +/- 16.18 years. The frequency of acute cholecystitis was higher in summer in comparison with other seasons. The difference in the frequency of acute cholecystitis in Ramadan in comparison with Shaaban and Shavval months was not considerable. CONCLUSION: Acute cholecystitis displays seasonal characteristics; however, this seasonal variability would be influenced by other unknown environmental and genetic factors. Ramadan fasting may not precipitate the onset of acute cholecystitis.

Adult↗

PubMed2006

[Chronic cholecystitis and its clinical masks: diagnosis and differential diagnosis].

The author adduces modern data on the ethiology and pathogenesis of chronic cholecystitis and the stages of the development of biliary pathology (motorotonic disturbances of the gall bladder and the sphincter apparatus of the extrahepatic biliary tract - chronic acalculous cholecystitis - chronic calculous cholecystitis). He considers in detail the methods of diagnostics of chronic cholecystitis paying special attention to clinical (non-instrumental) methods. The author offers an original classification of physical symptoms of chronic cholecystitis, distinguishing three groups of symptoms according to their pathogenesis and clinical significance: segmentary reflectory symptoms ("exacerbation symptoms"); reflectory symptoms, localized in the right half of the body outside the segments of hepatobiliary system innervation ("severity symptoms"); irritative symptoms, observed during all the periods of chronic cholecystitis. The article contains a description of various clinical "masks" of chronic cholecystitis, which make the diagnosis more difficult: cardial, duodenal (gastrointestinal), rheumatic, solaralgic, allergic, pre-menstrual tension, and other masks, as well as a description of their differential diagnostic methods.

Cholecystitis↗

PubMed1992

Small vessel occlusion in acute acalculous cholecystitis.

Ischemia is one mechanism implicated in the pathogenesis of acute acalculous cholecystitis. Gallbladder specimen arteriography was performed to define the comparative status of cystic artery runoff in the macroscopically normal gallbladder (n = 10), in acute gallstone-associated cholecystitis (n = 10), and in acute acalculous cholecystitis (n = 7). Standardized film exposure and quantity of contrast medium administered permitted objective intergroup comparison. Compared to the macroscopically normal gallbladder, specimens of acute gallstone-associated cholecystitis exhibited arterial dilatation and extensive venous filling. In contrast, multiple arterial occlusions, with absent or minimal venous filling, were consistent features of acute acalculous cholecystitis; the degree of arteriographic abnormality for acute acalculous cholecystitis corresponded to the severity of gallbladder pathologic findings. Small vessel occlusion, on the basis of low splanchnic flow or intravascular coagulation, may be a fundamental element in the pathogenesis of acute acalculous cholecystitis.

Acute Disease↗

PubMed1986

Ultrasonography of the gallbladder in patients with a clinical suspicion of acute cholecystitis.

The prevalence of ultrasonographic (US) signs described in the literature in cases of acute cholecystitis (wall thickening, increased volume, roundness and local tenderness of the gallbladder, an anechoic layer in the gallbladder wall and cholelithiasis were studied in 136 consecutive patients referred for US examination with clinically suspected acute cholecystitis (AC). Of the patients, 56 had AC, 21 chronic cholecystitis, 2 carcinoma of the gallbladder, and 57 extrabiliary diseases. In AC, frequent findings in addition to cholelithiasis were wall thickening (79%) and an increased volume (64%). Almost one third of the patients had local tenderness (sonographic Murphy sign) (29%), and 27% of the gallbladders had a rounded form. All these features were, however, rather frequently detected also in chronic cholecystitis (5-33%) and in the 2 carcinoma patients, and also sporadically in extrabiliary diseases. A anechoic layer in the gallbladder wall was the only sign confined to AC, but was detected only in 2 cases. Roundness of the gallbladder occurred only in either acute or chronic cholecystitis. The combination of at least two diagnostic findings was noticed in 91% in AC, rather frequently in chronic cholecystitis (43%) and in both carcinoma patients, but only in 1 patient in the extrabiliary disease group. Three or more signs were seen only in gallbladder diseases (48%), but AC, chronic cholecystitis or carcinoma groups could not be completely differentiated (prevalences 63, 10 and 50%).

Acute Disease↗

PubMed1979

[Diagnosis and treatment of cholecystitis].

In the period from 1963 til 1978 the authors observed 1084 patients with cholecystitis. Operations were performed on 336 patients. Acute cholecystitis was diagnosed in 190 patients, chronic calculous cholecystitis--in 128 patients, chronic acalculous cholecystitis--in 18 cases. In acute cholecystitis the active-temporizing tactics was used. Urgent operations were performed on patients with peritonitis. In other variants the conservative treatment was prescribed. When the patient's condition was stated to improve, the surgical treatment was performed if indicated. Patients with chronic calculous cholecystitis were operated on diagnosing. Chronic acalculous cholecystitis was an indication for surgery in cases of frequent attacks of hepatic colic and inefficiency of the conservative therapy.

Acute Disease↗

PubMed1981

Intravenous cholecystography is a reliable method in the diagnosis of acute cholecystitis.

To evaluate the reliability of intravenous cholecystography in the diagnosis of acute cholecystitis, 186 consecutive patients with a clinical suspicion of acute cholecystitis were investigated. The contrast medium was administered as an intravenous infusion. The gall-bladder was not visualized in 110 patients (59%), suggesting acute cholecystitis. In 105 of these patients acute cholecystitis was confirmed at operation, or by a characteristic clinical course and/or oral cholecystography done later. There were 5 false positives; four of these patients were operated on, and proved to have other serious disease of the biliary tract. Filling of the gall-bladder was obtained in 76 cases (41%). One of these patients developed acute cholecystitis with perforation of the gall-bladder, diagnosed at laparotomy. In most other patients with filling of the gall-bladder diagnoses other than acute cholecystitis were verified. Intravenous cholecystography has proved highly reliable in the diagnosis of acute cholecystitis, and can contribute to reducing the incidence of misdiagnosis.

Acute Disease↗

PubMed1994

Radiologically guided percutaneous cholecystostomy for acute cholecystitis: long-term outcome in 50 patients.

To assess the long-term outcome in patients with acute cholecystitis treated initially by percutaneous cholecystostomy, the authors reviewed the medical and radiology records of all such patients treated at their hospital from January 1990 to September 1993. Of the 50 patients, 29 had calculous and 21 had acalculous cholecystitis. In the group with calculous cholecystitis, 1 of the patients required no further treatment, 3 subsequently underwent percutaneous stone removal, 14 underwent elective cholecystectomy, 6 underwent emergency cholecystectomy and 5 died of the underlying condition shortly after cholecystostomy. In the group with acalculous cholecystitis, 12 of the patients needed no further treatment after a mean follow-up period of 12 months; 8 of these underwent follow-up ultrasound examination, which revealed gallbladder calculi in only 1 patient. Four patients underwent elective cholecystectomy, 1 underwent emergency cholecystectomy, and 4 died of the underlying condition shortly after cholecystostomy. Over the long term, 23 (79%) of the 29 patients with calculous cholecystitis underwent surgery or removal of calculi. In the other group surgery was required in only 5 (24%) of the 21 patients. The authors conclude that percutaneous cholecystostomy is a useful temporizing measure, which allows patients with calculous cholecystitis to undergo elective cholecystectomy. In most cases of acalculous cholecystitis the procedure is curative, obviating the need for cholecystectomy.

Acute Disease↗

PubMed1996

Correlation of toxic signs, ultrasonographic findings and pathological changes in cholecystitis.

BACKGROUND: Cholecystitis is a frequently encountered clinical problem. What parameters are reliable in helping predict its severity? METHODS: One hundred and forty-nine cholecystectomized cases of cholecystitis were analysed of which 99 (95 calculous) cases were pathologically diagnosed as chronic cholecystitis and 50 acute (43 calculous) cholecystitis. Medical records were reviewed to determine the frequency of toxic signs. Sonographic findings (performed within three days prior to operation), and final pathological changes with respect to the thickness and echotexture of the gallbladder wall were compared. RESULTS: Of 99 chronic cholecystitis patients, 13 cases showed toxic signs. Sonography detected an abnormal wall in 64, but made a correct diagnosis in only 34 cases. A great discrepancy was found in wall thickness as measured by sonography and pathology. A discrepancy > or = 2mm was noted in 19 cases. Of 50 patients with acute cholecystitis (20 cases had complications, defined as severe acute cholecystitis), 31 cases (14 of the 20 severe acute cases) showed toxic signs. Sonographic findings demonstrated an abnormal wall in 46 cases (19 of the severe acute cases) and an accurate diagnosis in 28 cases (13 of the severe acute cases). A difference in the measurement of gallbladder wall thickness > or = 2mm was noted in 26 patients. CONCLUSIONS: Clinical toxic signs and sonographic findings could not offer sufficient information to quickly identify lifethreatening gallbladder diseases.

Acute Disease↗

PubMed1997

[Postoperative benefit after laparoscopic cholecystectomy in acute cholecystitis].

Analysed were the results of all 48 patients with acute cholecystitis, who underwent laparoscopic cholecystectomy between 1991 and 1995 in the department of general surgery, AKH, University of Vienna. In 18 cases it was necessary to convert to laparotomy. In a second step the results of these two groups of patients were compared with results of patients without acute cholecystitis, who elective underwent laparoscopic cholecystectomy. In about 2/3 of the patients with acute cholecystitis laparoscopic cholecystectomy is possible. In these cases we found a mean postoperative hospital stay of 4.4 days, with a significant difference between those with drain (5.9 days) and those without (2.7 days). In cases of laparotomy the mean postoperative stay was 7.7 days, also significant longer. These patients consumed at the first postoperative day more than 1.5 times of opioid analgetics than those, who underwent laparoscopy with acute cholecystitis, laparoscopied patients without acute cholecystitis half of this. After the second postoperative day patients after laparotomy took 3 times of opioid analgetics than patients after laparoscopy, no matter if there was an acute cholecystitis or not. The rate of conversion to laparotomy sank with the increase of experience of a surgeon. Postoperative benefit of laparoscopic treatment, as less pain and shorter hospitalisation, can be saved even in cases of acute cholecystitis. So the management should primary be laparoscopic.

Acute Disease↗

PubMed1997

Acalculous cholecystitis in patients undergoing bone marrow transplantation.

OBJECTIVE: To evaluate factors associated with acalculous cholecystitis in patients undergoing bone marrow transplantation and the role of repeat ultrasound examinations. DESIGN: Retrospective study. SETTING: University hospital, United States. SUBJECTS: 381 Patients who underwent bone marrow transplantation between 1987 and 1992. INTERVENTIONS: Abdominal ultrasound examination (n = 134), repeat ultrasound in those considered to have acalculous cholecystitis (n = 8), and acute cholecystectomy (n = 5). RESULTS: 14 Patients (4%) with acalculous cholecystitis were identified. The 8 who had had liver tissue examined also had veno-occlusive disease of the liver. It was possible to follow progressing or resolving acalculous cholecystitis by repeat ultrasound examinations. 4 Of the 5 patients treated surgically survived, compared with 3 of the 9 not operated on. CONCLUSIONS: Acalculous cholecystitis was associated with veno-occlusive disease of the liver. Repeat ultrasound examinations were valuable in showing progressing or resolving acalculous cholecystitis and may guide treatment. Cholecystectomy seems to be a safe procedure for acalculous cholecystitis in patients undergoing bone marrow transplantation.

Adult↗