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PubMed1992

Acute cholecystitis: a complication in severely injured intensive care patients.

Acute cholecystitis is an often unrecognized and potentially life-threatening complication seen among ICU patients with multiple injury. To investigate the epidemiology of this entity and to evaluate significant etiologic precursors, a prospective clinical and sonographic study was performed in 45 consecutive patients (mean age, 29 years) treated for multiple trauma (mean ISS, 27) in the ICU. Eight of 45 patients developed a cholecystitis during intensive care treatment (18%). Six patients recovered with conservative therapy; in two instances a cholecystectomy was necessary. There was no mortality as a result of cholecystitis. A significant relationship between the severity of the initial trauma (p less than 0.05), the number of blood transfusions (p less than 0.01), and the incidence of acute cholecystitis was found. Other factors such as prolonged shock, respiratory failure, or parenteral alimentation were less prevalent and were not temporally related to the onset of the disease. All patients had large amounts of narcotics administered over a prolonged period, so that narcotic-induced biliary stasis appeared to be another eminent factor involved in the genesis of posttraumatic cholecystitis. Our results lead to the conclusion that acute cholecystitis occurs with an unexpectedly high incidence and that a high remission rate can be expected following conservative treatment provided that appropriate serial ultrasound examinations are performed.

Acute Disease↗

PubMed2004

Can gangrenous cholecystitis be prevented?: a plea against a "wait and see" attitude.

BACKGROUND/AIMS: A delay in recognizing and treating an inflamed gallbladder may increase the risk of a necrotic evolution and represent a critical factor affecting the progression of the inflammatory process. Aim of the study is to assess the therapeutic attitude in patients with histologically proved gangrenous cholecystitis, to find out whether it could play a role in the progression of the inflammatory condition. METHODOLOGY: Twenty-seven patients with gangrenous cholecystitis at histology were compared with a matched-control group with phlegmonous cholecystitis. RESULTS: Age, gender, ASA score, and concomitant diseases did not differ significantly in both groups. WBC was significantly higher (P = 0.026) in patients with gangrene. Ultrasounds were unhelpful in identifying the severity of the disease. Patients with gangrenous gallbladder showed a significantly increased (P = 0.0006) admission delay compared with controls (104.3+/-15.3 hours vs. 59.7+/-7.7 hours). Surgeon's delay, morbidity and mortality were not different in both groups. CONCLUSION: Patient's delay before hospitalization may represent a crucial factor in the progression toward a more severe disease in acute cholecystitis. The time between symptoms onset and hospital admission (and consequently surgery) was significantly longer in patients with gangrenous cholecystitis, further emphasizing the need for an early (if not urgent) surgical treatment in acute cholecystitis, even with mild symptoms.

Aged↗

PubMed2006

Dengue fever related acalculous cholecystitis in a North Indian tertiary care hospital.

BACKGROUND AND AIMS: To document the clinical outcome and prognosis of acalculous cholecystitis in dengue fever. METHODS: Prospective analysis of 27 cases of dengue fever presenting to the medical emergency of a tertiary care referral hospital in Chandigarh, India. RESULTS: All patients with dengue fever presenting with abdominal pain in the year 2003 were studied by ultrasound examination for the presence of acalculous cholecystitis. Five cases presented in October and 22 cases in November. Mean age was 29.8 +/- 9.7 years and there were 21 males and six females. Mean duration of fever was 5.07 +/- 1.8 days and mean duration of body ache was 4.06 +/- 2.6 days. The mean platelet counts for all cases at presentation were 29.41 +/- 18.41 x 10(9)/L and at discharge 95.28 +/- 53.01 x 10(9)/L. The mean duration of in-hospital stay was 3.4 +/- 1.7 days. Fourteen patients presented with pain in the abdomen and were confirmed to have acalculous cholecystitis on ultrasound examination of the abdomen (mean gallbladder wall thickness was 5.2 +/- 1.03 mm). Amongst all variables assessed, the only significant difference seen was that the duration of in-hospital stay was 1.68 days more in the group with acalculous cholecystitis. CONCLUSION: Acalculous cholecystitis should be strongly suspected in patients with dengue fever presenting with abdominal pain. Our study has shown that acalculous cholecystitis occurred in 14 out of 27 patients with dengue fever.

Acalculous Cholecystitis↗

PubMed1992

Laparoscopic cholecystectomy for acute cholecystitis.

Sixty-eight cases of acute cholecystitis managed by laparoscopic cholecystectomy (LC) are reviewed. Thirty-two patients were admitted up to 10 days after onset of symptoms and 31 were completed by LC. One patient was referred from intensive care with gangrenous acalculus cholecystitis and was completed by LC but required subsequent laparotomy to control a bleeding omental vessel. Five patients were admitted with recurrent attacks of pain and histology confirmed resolving acute cholecystitis. Thirty patients had LC on routine operating lists, having recently had pain within 10 days of admission. Histology confirmed acute cholecystitis or resolving acute cholecystitis in these patients. All were completed by LC. Laparoscopic cholecystectomy is a very effective treatment for acute cholecystitis if complete dissection of anatomy can be performed.

Acute Disease↗

PubMed1987

Striated intramural gallbladder lucencies on US studies: predictors of acute cholecystitis.

Ultrasound scans of 51 consecutive patients with gallbladder wall thickening were reviewed, and specific sonographic features were correlated with surgical and clinical follow-up. Two patterns of thickening were identified as specific indicators of the presence or absence of acute cholecystitis. "Striated" wall thickening, consisting of several alternating, irregular, discontinuous, lucent and echogenic bands, was seen in eight of 13 patients (62%) with acute cholecystitis. This pattern was not encountered in any of the patients who did not have acute cholecystitis. Conversely, "three-layer" thickening, consisting of a single circumferential lucent zone between two relatively uniform echogenic layers, was seen in only one of 13 patients (8%) with acute cholecystitis but in 11 of 38 patients (29%) with other diagnoses. Other abnormalities, including the presence of intramural echogenic foci and wall irregularities, were more frequently seen in patients with acute cholecystitis but were not as helpful. Use of these features may suggest or help exclude a diagnosis of acute cholecystitis in those patients in whom the cause of gallbladder wall thickening is otherwise not apparent.

Acute Disease↗

PubMed1992

Acute calculous cholecystitis. What is new in diagnosis and therapy?

The management of patients with acute calculous cholecystitis has changed during recent years. The etiology of acute cholecystitis is still not fully understood. Infection of bile is relatively unimportant since bile and gallbladder wall cultures are sterile in many patients with acute cholecystitis. Ultrasonography is first choice for diagnosis of acute cholecystitis and cholescintigraphy is second best. Percutaneous puncture of the gallbladder that can be used for therapeutic drainage has also diagnostic qualities. Early cholecystectomy under antibiotic prophylaxis is the treatment of choice, and has been shown to be superior to delayed surgery in several prospective trials. Mortality can be as low as 0.5% in patients younger than 70-80 years of age, but a high mortality has been reported in octogenerians. Selective intraoperative cholangiography is now generally accepted and no advantage of routine cholangiography was shown in clinical trials. Percutaneous cholecystostomy can be successfully performed under ultrasound guidance and has a place in the treatment of severely ill patients with acute cholecystitis. Laparoscopic cholecystectomy can be done safely in patients with acute cholecystitis, but extensive experience with this technique is necessary. Endoscopic retrograde drainage of the gallbladder by introduction of a catheter in the cystic duct is feasible but data are still scarce.

Acute Disease↗

PubMed1998

Ultrasound-guided percutaneous cholecystostomy as an initial treatment for acute cholecystitis in elderly patients.

BACKGROUND/AIMS: Acute cholecystitis may atypically present itself in the elderly, thus causing diagnostic and therapeutic problems, and it is well recognized as a high-risk condition for morbidity. The outcome has been attributed to the presence of severe co-morbid disease. In an attempt to minimize the postoperative morbidity and mortality, we performed ultrasound-guided percutaneous transhepatic cholecystostomy (PC) on elderly patients with acute cholecystitis for both initial treatment and subsequent diagnosis of their biliary tract disorders. METHODS: Those being more than 70 years old, had acute episode of cholecystitis for more than 48 h and still had positive Murphy's signs and distended gallbladders were candidates for ultrasound-guided PC. RESULTS: Forty-two elderly patients underwent ultrasound-guided PC. Once the condition of each patient showed signs of improvement and stability, cholangiography was performed via PC tube. The results of the cholangiography showed 20 patients with gallbladder stones, 16 with common bile duct stones and 6 with acalculous cholecystitis. Once stable enough, 32 patients underwent definite surgery, 18 having cholecystectomies, 14 having cholecystectomies and choledocholithotomies. The 6 patients with acalculous cholecystitis had the PC tube removed 3 weeks later, without further surgery. Two patients had gallbladder stones removed by choledochofiberscope. Two patients had common bile duct stone removed by endoscopic sphincteroplasty. Although postoperative complications occurred in 5 patients (11.9%), no instance of operative mortality was found. CONCLUSION: Our findings lead us to conclude that the use of PC in the early treatment of acute cholecystitis in elderly patients can decrease postoperative morbidity and mortality.

Acute Disease↗

PubMed2006

Impact of treatment policies on patient outcomes and resource utilization in acute cholecystitis in Japanese hospitals.

BACKGROUND: Although currently available evidence predominantly recommends early laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis, this strategy has not been widely adopted in Japan. Herein, we describe a hospital-based study of patients with acute cholecystitis in 9 Japanese teaching hospitals in order to evaluate the impact of different institutional strategies in treating acute cholecystitis on overall patient outcomes and medical resource utilization. METHODS: From an administrative database and chart review, we identified 228 patients diagnosed with acute cholecystitis who underwent cholecystectomy between April 2001 and June 2003. In order to examine the relationship between hospitals' propensity to perform LC and patient outcomes and/or medical resource utilization, we divided the hospitals into three groups according to the observed to expected ratio of performing LC (LC propensity), and compared the postoperative complication rate, length of hospitalization (LOS), and medical charges. RESULTS: No hospital adopted the policy of early surgery, and the mean overall LOS among the subjects was 30.9 days. The use of laparoscopic surgery varied widely across the hospitals; the adjusted rates of LC to total cholecystectomies ranged from 9.5% to 77%. Although intra-operative complication rate was significantly higher among patients whom LC was initially attempted when compared to those whom OC was initially attempted (9.7% vs. 0%), there was no significant association between LC propensity and postoperative complication rates. Although the postoperative time to oral intake and postoperative LOS was significantly shorter in hospitals with high use of LC, the overall LOS did not differ among hospital groups with different LC propensities. Medical charges were not associated with LC propensity. CONCLUSION: Under the prevailing policy of delayed surgery, in terms of the postoperative complication rate and medical resource utilization, our study did not show the superiority of LC in treating acute cholecystitis patients. The timing of surgery and discharge was mainly determined by the institutional policy in Japan, rather than by the clinical course of the patient; however, considering the substantially less postoperative pain and shorter recovery time of LC compared to OC, LC should be actively applied for the treatment of acute cholecystitis. If the policy of early surgery were universally applied, the advantage of LC over OC may be more clearly demonstrated.

Acute Disease↗

PubMed2005

The appearance of myofibroblasts and the disappearance of CD34-positive stromal cells in the area adjacent to xanthogranulomatous foci of chronic cholecystitis.

We investigated the distribution of myofibroblasts and CD34-positive stromal cells in normal gallbladder and its pathological conditions (cholecystitis, n=25) using immunohistochemistry and in situ hybridization. In the wall of normal gallbladder, myofibroblasts were generally absent from all layers, but many CD34-positive stromal cells were observed in the connective tissue layer. In chronic cholecystitis with mild perimuscular fibrosis, a small to moderate number of myofibroblasts appeared in the mucosal layer. In chronic cholecystitis with marked perimuscular fibrosis, a small to large number of myofibroblasts appeared predominantly in the connective tissue layer, whereas the number of CD34-positive stromal cells decreased at the same location, although the number of myofibroblasts increased. In chronic cholecystitis with xanthogranulomatous foci, a small to large number of myofibroblasts were observed in the periphery of the xanthogranulomatous reaction and adjacent area. In contrast, CD34-positive stromal cells were completely absent or were limited to the area just around the xanthogranulomatous reaction. Induction of collagen type I and III mRNA was predominantly observed in the cytoplasm of myofibroblasts associated with the marked fibrosis, which consisted primarily of mature collagen fibers, and in the cytoplasm of myofibroblasts around the xanthogranulomatous reaction, respectively. Finally, myofibroblasts were observed in all subtypes. The increased number of myofibroblasts was most prominent in the connective tissue layer of chronic cholecystitis with marked perimuscular fibrosis or in the area adjacent to xanthogranulomatous foci of chronic cholecystitis. Under these conditions, CD34-positive stromal cells tended to disappear from the connective tissue layer, which exhibited an increase in myofibroblasts.

Adult↗

PubMed1984

Low sensitivity of sonography and cholescintigraphy in acalculous cholecystitis.

Acalculous cholecystitis is difficult to diagnose by clinical means or contrast radiography. Because sonography and cholescintigraphy have both been shown to do well in the diagnosis of calculous cholecystitis, the sensitivity of these newer imaging methods was assessed retrospectively in 33 proven cases of acalculous cholecystitis. The sensitivities to acalculous cholecystitis for sonography (67%) and for cholescintigraphy (68%) were not as high as has been reported for these tests in calculous cholecystitis. Reasons for the lower sensitivity with each test and the pathogenesis of acalculous cholecystitis are discussed.

Acute Disease↗

PubMed1994

Gallstones in critically ill patients with acute calculous cholecystitis treated by percutaneous cholecystostomy: nonsurgical therapeutic options.

OBJECTIVE: Patients with acute calculous cholecystitis require removal of gallstones (generally cholecystectomy), as acute cholecystitis is likely to recur if gallstones are left in situ. The purpose of this study was to assess the role of nonsurgical techniques for treating gallstones in critically ill patients with acute calculous cholecystitis managed by percutaneous cholecystostomy. MATERIALS AND METHODS: Twenty-six critically ill patients with complex medical and surgical problems who were in intensive care units underwent emergent percutaneous cholecystostomy for acute calculous cholecystitis. Seven of the 26 patients subsequently died of multiple organ failure. Curative gallstone therapies were tried in the surviving 19 patients, seven of whom underwent elective surgical cholecystectomy. Nonsurgical management was attempted in 12 of 19 patients, including six with terminal disease who were treated with long-term gallbladder drainage, three who were treated with methyl tert-butyl ether for stone dissolution, two who had percutaneous cholecystolithotomy, and one who had a gallbladder stone that had passed into the common bile duct and was retrieved endoscopically. RESULTS: Long-term gallbladder drainage was successful in all six patients with terminal disease in whom it was attempted; they experienced no further episodes of cholecystitis. In four of the other six patients treated with nonsurgical therapies (percutaneous cholecystolithotomy, stone dissolution with methyl tert-butyl ether, and endoscopic removal), gallstones were successfully removed and no further therapy was required. Percutaneous therapies failed in two patients, who then had cholecystectomy. CONCLUSION: Nonsurgical gallstone therapies should be attempted in high-risk patients with acute calculous cholecystitis. Some patients may benefit from long-term catheter drainage of the gallbladder.

Acute Disease↗

PubMed1995

Acute cholecystitis in an animal model: findings on color Doppler sonography.

OBJECTIVE: The purpose of our study was to evaluate the color Doppler findings of acute cholecystitis in a controlled canine model. MATERIALS AND METHODS: Fourteen animals had a laparotomy: cystic duct ligation was done in eight, and incision with closure was performed in six control subjects. Animals were scanned in a blinded fashion preoperatively, immediately postoperatively, and on postoperative days 1-5. On postoperative day 5, a hepatobiliary scan was done with 2 mCi (74 MBq) 99mTc-mebrofenin. Blinded histopathology was performed and correlated with imaging. RESULTS: Flow was seen in the wall of each gallbladder at some point during the postoperative course, demonstrating vascular patency. Hepatobiliary scintigraphy confirmed cystic duct status in 12 cases; two animals died before radionuclide imaging was complete. Color Doppler signal decreased in the gallbladder wall in ligated dogs from postoperative day 1 to postoperative day 3 (p = .03 versus controls at postoperative day 2) and increasingly returned by postoperative day 5. Hyperemia was seen in only two cases (both with severe necrotizing cholecystitis) and only at postoperative day 5. Although not statistically significant, a weak trend of increasing flow with more severe pathologic grades of cholecystitis was observed (p = .20). CONCLUSIONS: In this animal model, loss of vascular signal (not hyperemia) at postoperative day 2 was the finding to diagnose early acute cholecystitis, although lack of flow can also be seen in some normal subjects. Flow tended to return by postoperative day 5, and it increased in some of the more severe cases of cholecystitis. Hyperemia was a somewhat useful sign of acute necrotizing cholecystitis.

Acute Disease↗

PubMed2003

Acute acalculous cholecystitis associated with cholecystoduodenal fistula and duodenal bleeding. A case report.

Although acute acalculous cholecystitis (AAC) accounts for less than 10% of acute cholecystitis in the adult population, gangrene and perforation are much more frequent compared to the usual cases of acute cholecystitis (calculus cholecystitis). However, spontaneous biliary-enteric fistula is well recognized in AAC, 90% of which are cholecystoduodenal fistula (CDF) though it is an uncommon disorder. The majority of the CDF are caused by cholelithiasis. As patients are usually associated with complicated clinical illness, the diagnosis is often difficult to make and required surgery is often delayed. We have studied a rare complication of acute acalculous cholecystitis which was presented as intermittent upper gastrointestinal bleeding. Ulceration of the superficial branch of the cystic artery has been observed due to acalculous cholecystitis associated with a cholecystoduodenal fistula. We have performed a transfixing ligation of the bleeding vessel, cholecystectomy and simple closure of the CDF. We have finally made a diagnosis of early gallbladder cancer through a frozen section. There was no serious complication after the operation and the patient has achieved an uneventful recovery.

Acute Disease↗

PubMed1986

Hepatobiliary scintigraphy. Increasing the accuracy of the preoperative diagnosis of acute cholecystitis.

The ability of hepatobiliary scintigraphy (HBS) to influence accurately the clinical diagnosis of acute cholecystitis was assessed prospectively in 70 consecutive patients with suspected acute cholecystitis. Before and after HBS, the referring surgeons completed a questionnaire on the probability of acute cholecystitis. Accuracy of diagnosis was assessed by clinical follow-up and chart review in all patients and by surgical and pathological evaluation in the 31 patients who underwent laparotomy. There were 27 patients with positive HBS results and 40 with negative HBS results; the results for three patients were indeterminate. None of the positive or negative HBS results were confirmed to be inaccurate. Negative results influenced diagnosis more often than did others. Results were negative in 13 patients whose assigned probability of acute cholecystitis was very high before HBS; in all 13 the assigned probability was very low after HBS, and in none of these patients was acute cholecystitis confirmed subsequently. These results support the use of hepatobiliary scintigraphy before proceeding to urgent cholecystectomy in patients with a clinical diagnosis of acute cholecystitis.

Acute Disease↗

PubMed2006

Calculous cholecystitis and hepatic cirrhosis as sonographic co-confounders for gallbladder evaluation.

OBJECTIVE: To compare the sonographic features of gallbladder in symptomatic calculous cholecystitis and cirrhosis with silent cholelithiasis. DESIGN: Cross-sectional, observational study. DURATION: From October 2003 to May 2005. SETTING: Radiology Department, Dow University of Health Sciences and Civil Hospital (DUHS/CHK), Karachi. METHODOLOGY: Two hundred adult patients of both genders were studied after dividing into two groups. Group A had clinically suspected calculous cholecystitis and group B had patients from outpatient department and medical wards with clinical diagnosis of cirrhosis, with incidentally diagnosed cholelithiasis. The sonographic features of gallbladder were determined and compared. Significance was computed for the sonographic variables including morphological features as well as demographic features by Chi-square and t-test, keeping significance at p< .001 RESULTS: Group A (with calculous cholecystitis) had 100 patients with mean age of 47 +/- 3.2 years with 71 females. Group B (cirrhosis with silent cholelithiasis) comprised of 100 patients with mean age of 38 +/-4.2 years with 58 females. Among them, 54 were hepatitis C virus(HCV) positive, 38 had positive serology for Hepatitis B virus (HBV) positive and 08 had positive serology for both. Both groups had more multiple than single calculi. The average size of the largest calculus was 1.5 cm in group A and 1.2 cm in the group B. The mean gallbladder wall thickness was greater in cirrhotic than in the other group (4.9 vs. 4.2 cm, p-value 0.7). Gallbladder wall irregularity was significantly more common in group B than in group A (57 vs. 25 mm, p=0.001). The pericholecystic fluid layer thickness was significantly greater in the cirrhotic group (18.5 +7.1 vs. 5.7 +1.8 mm, p< 0.001). Positive sonographic Murphy's sign was positive in 89% calculous cholecystitis cases and 77% of the cirrhotic group. CONCLUSION: The sonographic findings of thickened wall of the gallbladder with pericholecystic fluid and positive sonographic Murphy's sign are common in both calculous cholecystitis and in asymptomatic cholelithiasis with cirrhosis. However, in the present series, those with cholecystitis had statistically significant greater irregularity of gallbladder wall and majority of those with cirrhosis had a significantly greater thickness of wall and a pericholecystic layer in excess of 1 cm.

Adult↗

PubMedDate not supplied

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients.

BACKGROUND/AIMS: The aim of this study was to ascertain the therapeutic efficacy of percutaneous cholecystostomy in a selected group of high-risk patients who were physiologically unable to tolerate an open procedure. METHODOLOGY: We reviewed the hospital records of 11 critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis during the intensive care unit course of major underlying diseases. RESULTS: Percutaneous cholecystostomy was easily performed in all cases (feasibility rate: 100%). No procedure-related death was recorded and minor complications occurred in 2 patients (18%). Percutaneous cholecystostomy led to resolution of the sepsis in all but 1 patient with gangrenous calcolous cholecystitis who required emergent cholecystectomy (success rate: 91%). Percutaneous cholecystostomy was the permanent treatment in all patients with acalcolous cholecystitis. Among patients with calcolous cholecystitis, 4 underwent delayed elective cholecystectomy, 1 required no further treatment, and 2 eventually died from the evolution of their underlying diseases. After a mean follow-up of 25 months (range: 12-32 months), none of the patients managed non-operatively required surgery or re-hospitalization. CONCLUSIONS: Ease of performance, low complication rate, and high success rate make percutaneous cholecystostomy the procedure of choice for critically ill patients with acute cholecystitis. Whenever possible, percutaneous cholecystostomy should be followed by elective cholecystectomy. However, especially in acalcolous cholecystitis, it may constitute the definitive treatment.

Acute Disease↗

PubMedDate not supplied

Laparoscopic versus open treatment of patients with acute cholecystitis.

BACKGROUND/AIMS: The studies published so far mention a high rate of complication and conversion in laparoscopic surgical treatment of acute cholecystitis. Considering the relatively high conversion rate in cases of acute cholecystitis, it is necessary to pre-operatively estimate the chance of successful laparoscopic cholecystectomy. One of the aims of this study was to determine the factors that influence the chance of success of this technique. Another aim was to define possible advantages of the method. METHODOLOGY: From 1991 through to 1995, a total of 295 patients in whom acute cholecystitis had been diagnosed on the basis of clinical examination, laboratory data, ultrasonography and pathohistological examination, underwent operative therapy. The laparoscopic approach was attempted in 49 of these patients. Since the patients who underwent primary open surgery were markedly handicapped with regard to severity of inflammation and co-morbid factors, we identified a sub-group of these patients who were comparable to those who underwent laparoscopic cholecystectomy in accordance of the above-mentioned criteria. RESULTS: The rate of conversion (44.9%) correlated with the severity of inflammation, which was determined on the basis of leukocytosis > 10 x 10(9)/l (p = 0.004) and the pathohistological diagnosis (p = 0.005). Hence, the rate of conversion was 71.4% in cases of empyema of the gallbladder but only 29.2% in cases of edematous cholecystitis. In patients whose leukocyte count decreased within 4 days of conservative treatment, a successful laparoscopic cholecystectomy (LC) was performed in 91.7% (11/12) of cases, while 8 patients whose leukocyte count increased or showed no reduction during this time required conversion to open cholecystectomy (p = 0.0001). In cases of acute cholecystitis, the complication rate after LC is lesser in respect of wound infection (p = 0.07) and pneumonia (p = 0.04). In all patients, obesity was a risk factor for wound infection (p = 0.04). Injury to the small intestine was registered in 1 case but in no case was LC associated with injury to the bile duct. CONCLUSIONS: The degree of inflammation and its response to conservative treatment, which are determined on the basis of leukocytosis and clinical improvement, are clear indications of the chance of successful delayed laparoscopic cholecystectomy within the first week. Hence, all patients whose leukocyte count does not decrease after antibiotic treatment should be treated with open cholecystectomy (OC). The complication rate following LC is less than that following OC. Although no injury to the bile duct has been observed in cases of acute cholecystitis, major complications are possible and should not be excluded.

Acute Disease↗

PubMed1999

Acute acalculous cholecystitis--a clinical-pathological disease spectrum.

OBJECTIVE: To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). DESIGN: Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape. PATIENTS: Fifty-seven consecutive patients with AAC treated over a 9-year period. MAIN OUTCOME MEASURES: Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. RESULTS: Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. CONCLUSION: The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.

Adult↗