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PubMedDate not supplied

[Personal experience in 71 consecutive patients with acute cholecystitis].

PURPOSE: Acute cholecystitis is one of the most frequent abdominal inflammatory processes. If untreated or misdiagnosed it can result in severe complications such as gallbladder rupture, abscesses, or peritonitis. We retrospectively reviewed a series of 71 consecutive patients with surgical confirmation of acute cholecystitis and now compare the results of the diagnostic techniques we used preoperatively. MATERIAL AND METHODS: Over 16 months, 71 consecutive patients (42 women and 29 men; age range: 34-84 years, mean: 58) with acute abdominal pain were operated on for acute cholecystitis at Cardarelli Hospital, Naples. Abdominal plain film was performed in 65 of 71 cases, abdominal US in 69 and abdominal CT in 6. On abdominal plain films, we retrospectively searched the following signs: densities projected over the gallbladder, linear calcifications in gallbladder walls, gallbladder enlargement, focal gas collections within the gallbladder, and air-fluid levels in the gallbladder lumen. On US images we looked for: gallbladder wall thickening (> 3 mm), intraluminal content in the gallbladder, pericholecystic fluid, US Murphy's sign, and gallbladder distension. On CT images, we investigated: gallbladder distension, wall thickening, intraluminal content, pericholecystic fluid, and inflammatory changes in pericholecystic fat. Associated complications of cholecystitis were also searched on all images. RESULTS: On plain abdominal films we found densities projected over the gallbladder (16.9%) and linear calcifications in the gallbladder wall (4.6%). Abdominal US demonstrated gallbladder wall thickening (56.5%), one or more gallstone(s) (85.5%), pericholecystic fluid (14.5%), gallbladder distension (46.4%), and US Murphy's sign (39.1%). Abdominal CT showed gallbladder wall thickening (83.3%), gallbladder distension (66.6%), pericholecystic fluid (66.6%), gallstones (50%), inflammatory changes in pericholecystic fat (33.3%), and increased bile density (> 20 HU) (33.3%). CONCLUSIONS: US appears to be the most useful imaging technique in patients with suspected acute cholecystitis, for both screening and final diagnosis. CT plays a limited role in the early assessment of these patients, but can be a useful tool in diagnosing acute cholecystitis in patients with questionable physical findings or in investigating related complications.

Acute Disease↗

PubMed2000

["Acute cholecystitis"--laparoscopic cholecystectomy is often possible. Results of a multicenter study by the East German Study Group for Performance Assessment and Quality Assurance in Surgery].

With the introduction of laparoscopic cholecystectomy (LCE) the method became very fast successful in clinical practice. To describe the actual situation we initiated in 1994/95 a clinical multicenter study with the name CESAQ. 29 hospitals participated in the study. 4,675 cholecystectomies were performed, a total number of 2,960 patients were operated upon with the laparoscopic and 1,468 with the conventional technique. Furthermore, conversion to open cholecystectomy was necessary in 247 cases. One part of the study focused on the results achieved for patients with acute cholecystitis. 9.4% of the laparoscopic but 37.3% of the conventional cholecystectomies were performed due to acute cholecystitis. We differentiated a simple (adhesions to gallbladder, hydrops) and complicated form (empyema, gangrenous gallbladder) of acute cholecystitis. Treating acute cases the incidence of intraoperative (simple 8.3%, complicated 12.1%) and specific postoperative complications (simple 9.2%, complicated 6.9%) was higher compared to elective procedures (intraoperative 4.6%, specific postoperative 3.7%). This is well known from the experience of open surgery. Nevertheless there were lower general complication rates (simple 5.5%, complicated 5.2%) and no mortality in acute cholecystitis when LCE was performed. Considering an early conversion to open cholecystectomy in cases of severe acute cholecystitis the indication for LCE can be made generously. Great surgical experience in LCE is a requirement for the laparoscopic management of acute cholecystitis.

Acute Disease↗

PubMedDate not supplied

[Acute cholecystitis--early or delayed cholecystectomy].

INTRODUCTION: In our population biliary tract diseases are the most frequent surgical entity. If the diagnosis of acute cholecystitis is relatively clear and the time from onset of the disease does not exceed 72 hours, early cholecystectomy is recommended. The aim of this prospective study was to use certain analytical procedures in order to compare early and late results of early and delayed cholecystectomy. MATERIAL AND METHODS: 240 patients were divided into two groups: Group I: patients treated by early cholecystectomy and Group II: patients treated by delayed cholecystectomy. We compared the following: intraoperative findings, postoperative morbidity and mortality, complications, average number of patient-days and histopathological changes. RESULTS: During the investigated period (1998-1999), 599 (35.95%) patients with acute and 1.067 (64.05%) patients with chronic cholecystitis were treated at the Clinic of Abdominal and Endocrine Surgery of the Clinical Center Novi Sad. Out of 599 patients with acute cholecystitis, 489 (81.63%) patients underwent surgery, whereas 110 (18.37%) were treated conservatively. In regard to chronic cholecystitis, 963 (90.25%) patients were surgically treated, and 104 (9.75%) patients were conservatively treated. All patients from Group I were operated within 24-48 hours from onset of the disease or during 24 hours of hospitalization. They were hospitalized due to signs of cholecystitis for the first time, whereas this was the second hospitalization for all patients from Group II, 42 +/- 2.3 days after first hospitalization on average. Regarding sick leave in Group I patients it was calculated as follows: hospital days + home treatment and it made 32 +/- 3.7 days. In Group II it was calculated as follows: first hospitalization + home treatment + second hospitalization + home treatment making 53 +/- 6.7 days. CONCLUSIONS: The number and type of early and late complications in Group II patients justifies early cholecystectomy; in acute cholecystitis, cholecystectomy should be performed within 24-48 hours from the onset of the disease; in regard to late, early cholecystectomies are characterized by significantly shorter period of recovery and sick leave.

Acute Disease↗

PubMedDate not supplied

The laparoscopic challenge of cholecystitis.

OBJECTIVE: To evaluate the efficacy of laparoscopic cholecystectomy (LC) in acute and chronic cholecystitis and compare it with the open procedure. METHODS: This is a 5-year retrospective analysis performed at our hospital. Surgical treatment of gallbladder disease was performed in 1003 patients. Acute cholecystitis was present in 120 (11.9%) patients, and chronic cholecystitis was present in 830 (88.1%). Acute patients underwent surgery within 72 hours of symptom onset. The patients selected for LC or open cholecystectomy (OC) depended on the severity of disease, comorbid factors, and surgeon's preference. We reviewed age, sex, operating time, length of stay, perioperative complications, conversion rates, and cost. RESULTS: Patients chosen to undergo LC for acute cholecystitis tended to be younger females. Patients treated with LC for acute or chronic cholecystitis on average had a shorter operating time and length of hospital stay when compared with patients treated with OC (P < 0.005 by ANOVA with Bonferroni). Conversion rates (CR) for all LC decreased considerably from the first to the fifth year: 9% in 1995 (10/103), 9% 1996 (22/232), 4% in 1997 (8/188), 2% in 1998 (5/226) and 2% in 1999 (5/193). CONCLUSIONS: LC appears to be a reliable and cost-effective procedure for acute and chronic cholecystitis; however, the surgical approach should be chosen with caution because of the potential spectrum of technical difficulties. CR is also improving as surgeons' experience broadens.

Acute Disease↗

PubMedDate not supplied

Genetic analysis of xanthogranulomatous cholecystitis: precancerous lesion of gallbladder cancer?

Xanthogranulomatous Cholecystitis is a chronic inflammatory disease of the gallbladder, a variant of the chronic cholecystitis. As xanthogranulomatous cholecystitis is occasionally seen with carcinoma of the gallbladder, the association with cancer is a controversial issue. A focal type of xanthogranulomatous cholecystitis is found simultaneously with gastric cancer diagnosed preoperatively. The resected specimen was genetically studied. Polymerase chain reaction amplification, single-strand conformational polymorphism analysis for mutation of p53 showed no abnormality indicating that less association with cancer in which the mutation of p53 is often seen. Etiopathologic factors of xanthogranulomatous cholecystitis might have relation with cancer, but xanthogranulomatous cholecystitis itself may not be the direct cause for cancer.

Adenocarcinoma↗

PubMedDate not supplied

Infectious factors in acute acalculous cholecystitis.

BACKGROUND/AIMS: The infection is shown as a secondary phenomenon in lithiasic acute cholecystitis. However, its importance in acute gallbladder inflammation without lithiasis has not been sufficiently clarified. In this context, we tried to investigate this issue by resorting to animal research. Similarly we studied the repercussions of Diclofenac (NSAID) in bacteriological features of the bile in the operated animals. METHODOLOGY: We provoked acute cholecystitis in pigs by the ligature of biliary pedicle associated to the gallbladder introduction of "Lysophosphatidylcoline". Two series of animals were used: P1 (pigs not treated with Diclofenac) with 17 pigs and P2 (pigs treated with Diclofenac) with 23. In the latter group we associated the administration of Diclofenac given before the production of acute cholecystitis and administered for 4 days. The microbiology of the bile was studied in 34 pigs. The following parameters were valorized: histological gallbladder lesions and microorganisms in bacteriological examination of the bile. RESULTS: Severe lesions of acute cholecystitis were registered in 82.3% of the animals. Positive bile cultures were registered in 64.1% of group P1 and 65.5% in the group P2. The simultaneous administration of Diclofenac in the P2 group did not cause a regression of gallbladder lesions or in microbial agents in the bile in relation to the first group (P = 0.649, and P = 0.781, respectively). CONCLUSIONS: Our investigations allow us to conclude by valorization the infection factor in acute acalculous cholecystitis. On the other hand, the absence of repercussion of Diclofenac in acute acalculous cholecystitis was demonstrated not only in histological gallbladder lesions, but also in bile infection.

Acute Disease↗

PubMed2002

Ultrasound is not a useful screening tool for acute acalculous cholecystitis in critically ill trauma patients.

Acute acalculous cholecystitis remains a diagnostic challenge in critically ill trauma patients. Laboratory studies are nonspecific and associated injuries or mental status changes may mask clinical signs and symptoms. We conducted a retrospective study to assess the utility of ultrasound in the diagnosis of acute acalculous cholecystitis. We hypothesized that ultrasound is inadequate as a screening tool for acute acalculous cholecystitis. The abdominal ultrasounds of all patients undergoing evaluation for acute acalculous cholecystitis in a 40-month period at our Level I trauma center were reviewed. Thickened gallbladder wall, pericholecystic fluid and emphysematous gallbladder were considered positive sonographic criteria. Sludge, cholelithiasis, and hydrops were considered suggestive. Patients who did not undergo cholecystectomy had their gallbladders evaluated either during subsequent laparotomy or at autopsy or they were discharged from the hospital without need for intervention. Sixty-two patients were included. Twenty-one patients underwent cholecystectomy for presumed acute acalculous cholecystitis. The data revealed a sensitivity of 30 per cent (6/20) and a specificity of 93 per cent (39/42) for ultrasound evaluation. Twenty patients had subsequent hepatobiliary scans [hepato-iminodiacetic acid (HIDA)] with a sensitivity of 100 per cent (12/12) and specificity of 88 per cent (7/8). Our data do not support ultrasound as a reliable routine screening tool for acute acalculous cholecystitis. Despite its convenience as a bedside procedure ultrasound has insufficient sensitivity to justify its use and a more sensitive diagnostic tool should be used.

Acute Disease↗

PubMed2003

Percutaneous cholecystostomy in the management of acute cholecystitis.

BACKGROUND: The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 14-30% in high risk patients. An alternative approach in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy. OBJECTIVE: To evaluate the efficacy and safety of percutaneous cholecystostomy as the initial treatment of acute cholecystitis in high risk patients. METHODS: Eighty consecutive patients (42 men, 38 women) underwent ultrasound-guided percutaneous cholecystostomy over a 5 year period. Sixty-five patients suffered from acute calculous cholecystitis, 4 patients had acalculous cholecystitis, and 11 patients had sepsis of unknown origin. RESULTS: Sixty-eight patients improved after the percutaneous gallbladder drainage, 10 patients died from co-morbid disease and 2 patients died from biliary peritonitis. During a 1 year follow-up, 32 of the patients underwent interval cholecystectomy, 4 additional patients died from a co-morbid disease, 18 patients did not suffer from any gallbladder symptoms, and 14 were lost to follow-up. CONCLUSIONS: Percutaneous cholecystostomy is an effective contribution to the treatment of acute cholecystitis in high risk patients.

Acute Disease↗

PubMed2003

Dengue fever with acute acalculous cholecystitis.

Dengue fever (DF) with acute acalculous cholecystitis is rarely reported. To investigate the incidence, treatment, and prognosis of acute acalculous cholecystitis in DF patients, we retrospectively studied 10 patients with DF and acute acalculous cholecystitis. From October 2001 to July 2002, 131 patients were diagnosed with DF. Ten of 131 DF patients (7.63%) had complications of acute acalculous cholecystitis. Two patients underwent cholecystectomy and one underwent percutaneous transhepatic gallbladder drainage due to poor resolution of acute acalculous cholecystitis. We found acute acalculous cholecystitis in a small proportion of patients with DF. In our experience, closely monitoring vital signs to avoid shock and correct thrombocytopenia to avoid bleeding could be adequate for most patients. In some cases, surgical treatment may be needed for DF fever patients with complications of diffuse peritonitis.

Acute Disease↗

PubMed1992

[The usefulness of the emergency hepatobiliary scintigraphy to rule out acute cholecystitis--43 patients report].

We studied emergency hepatobiliary scintigraphy in the 43 patients to rule out acute cholecystitis. After injection of 185-222 MBq (5-6 mCi) of 99mTc-EHIDA or 99mTc-HIDA, serial static scintigraphic images were obtained up to 7 hours in maximum. Of 43 patients in this study, 20 had a normal scan and finally in all of them cholecystitis was ruled out. Of the 43 patients, 14 had an abnormal scan (nonvisualized gall bladder). In 10 of them the diagnosis of acute cholecystitis was confirmed after emergency cholecystectomy. The other 9 patients of 43 had an incomplete scan mainly due to liver dysfunction. Four of them had acute cholecystitis in the cholecystectomy. These results indicate that acute cholecystitis can be excluded by the findings of gall bladder visualization in hepatobiliary scintigram. We concluded that emergency hepatobiliary scintigraphy is very useful to rule out acute cholecystitis.

Acute Disease↗

PubMedDate not supplied

A case of emphysematous cholecystitis managed by laparoscopic surgery.

BACKGROUND: Emphysematous cholecystitis is a rare condition caused by ischemia of the gallbladder wall with secondary gas-producing bacterial proliferation. The pathophysiology and epidemiology of this condition differ from that in gallstone-related acute cholecystitis. This report illustrates a case of emphysematous cholecystitis successfully treated by laparoscopic surgery. METHODS: An 83-year-old female patient was admitted to the hospital with acute abdominal syndrome. Clinical examination and blood tests suggested acute cholecystitis. Plain radiography revealed a circular gas pattern in the right upper quadrant suggestive of emphysematous cholecystitis. Subsequent computed tomography confirmed the presence of gas in the gallbladder wall and a gas-fluid level within the organ. RESULTS: Emergency laparoscopic cholecystectomy was successfully performed during which bubbling of the gallbladder wall was observed. Intraoperative cholangiography revealed no bile duct stones or biliary obstruction. The patient made an unremarkable recovery from surgery with no postoperative complications or admission to the intensive care unit. Pathological analysis revealed full-thickness infarctive necrosis of the gallbladder. Bacterial cultures grew Clostridium perfringens. CONCLUSIONS: This case illustrates a typical case of emphysematous cholecystitis successfully treated by laparoscopic surgery. It contributes to suggestions from other reports that this condition can be safely treated by the laparoscopic approach.

Aged, 80 and over↗

PubMed1988

Acalculous hypersensitivity cholecystitis: hypothesis of a new clinicopathologic entity.

Acute acalculous cholecystitis is common, accounting for 5% to 10% of cases of acute cholecystitis. Although originally attributed to stasis and inspissated bile with subsequent obstruction of the cystic duct, acalculous cholecystitis has more recently been attributed to gallbladder ischemia from such conditions as hypotension or vasculitis. However, a significant number of cases of acute acalculous cholecystitis occur with no obvious cause. This report notes acute acalculous cholecystitis, diagnosed in 12 patients from 1982 to 1987, that was apparently precipitated by initiation of antibiotic therapy. Histologic sections of these gallbladders each disclosed a massive eosinophilic infiltrate. Two of the patients had identical signs, symptoms, and abnormal laboratory values during a previous course of erythromycin. These findings subsided when the antibiotic therapy was discontinued. We hypothesize that a significant cause of acute acalculous cholecystitis may be a hypersensitivity reaction to concurrent antibiotic therapy. Such patients should have antibiotic therapy halted or altered, which, it is hoped, will result in resolution of symptoms and avoidance of unnecessary laparotomy.

Acute Disease↗

PubMed1987

Posttraumatic acute cholecystitis. Relationship to the initial trauma.

Posttraumatic acute cholecystitis is an often unrecognized and potentially fatal complication seen among patients hospitalized for trauma, and differs in etiology from cholecystitis which develops de novo. The cause, although not yet clearly defined, is believed to be related to bile stasis, ischemia, bacterial infection, sepsis, the activation of factor XII, and the Shwarzman reaction. A case is described in which a 53-year-old man with pelvic fractures developed acute acalculous cholecystitis and died of multiple organ failure 3 weeks following cholecystectomy. The histopathological findings are also reported; these are most likely attributed to the Shwarzman reaction or the activation of the factor XII pathways. There has been a tendency to regard posttraumatic acute acalculous cholecystitis as induced by trauma, and calculous as mere coincidence. We believe, however, that it is not calculous but histopathological findings that determine whether acute cholecystitis following trauma was more than coincidence or just mere coincidence. Although progress in clinical care has improved the chances of survival of severely traumatized patients, posttraumatic acute cholecystitis has been increasing in frequency. We cannot be careful enough in judging the relationship of this fatal complication to the initial trauma.

Acute Disease↗

PubMed1986

The rim sign: association with acute cholecystitis.

In a retrospective analysis of 218 hepatobiliary studies in patients clinically suspected of acute cholecystitis, a rim of increased hepatic activity adjacent to the gallbladder fossa (the "rim sign") has been evaluated as a scintigraphic predictor of confirmed acute cholecystitis. Of 28 cases with pathologic confirmation of acute cholecystitis in this series, 17 (60%) demonstrated this sign. When associated with nonvisualization of the gallbladder at 1 hr, the positive predictive value of this photon-intense rim for acute cholecystitis was 94%. When the rim sign was absent, the positive predictive value of nonvisualization of the gallbladder at 1 hr for acute cholecystitis was only 36%. As this sign was always seen during the first hour postinjection, it can, when associated with nonvisualization, reduce the time required for completion of an hepatobiliary examination in suspected acute cholecystitis.

Acute Disease↗

PubMed1981

Ultrasonic detection of acute cholecystitis with pericholecystic abscesses.

Perforation of the gallbladder is a life-threatening complication of acute cholecystitis that is often difficult to diagnose at an early stage. Standard radiographic and laboratory tests have not been reliable in identifying patients with this complication. In contrast, biliary sonography correctly diagnosed pericholecystic abscesses preoperatively in three patients with acute cholecystitis. The ultrasonic appearance of acute cholecystitis with a pericholecystic abscess was similar in all three patients. There was an extraluminal fluid collection located contiguous to a thick-walled gallbladder in the fundic region. The fluid collection was constant in location and could be seen in at least two different views. Two of these three patients had acalculous cholecystitis; the initial clinical diagnosis in one was pancreatitis, and in the other alcoholic hepatitis. Biliary sonography, by demonstrating a thickened gallbladder wall in the absence of ascites, strongly suggested that these two patients had acute acalculous cholecystitis, and not hepatitis or pancreatitis. The ultrasonic examination was a critical factor in the decision for prompt surgery instead of continued nonoperative management in these patients. These data suggest that not only can biliary sonography aid in the diagnosis of acute cholecystitis, calculous as well as acalculous, but can also visualize a pericholecystic abscess when it is present.

Abscess↗

PubMedDate not supplied

[Acute cholecystitis: timing of surgery].

The authors report their own experience about 156 cases of acute cholecystitis observed between January 1991 and October 1992. The most part of the patients were between 30 and 65 years old (84 cases observed). In 27 cases, for the positive evolution of the pathology, it was put on practice a non operative treatment. The other 129 cases were treated surgically. The patients with lithiasic cholecystitis were 148; those affected by non lithiasic cholecystitis were 5; and 3 of them presented an acute cholecystitis as a manifestation of a carcinoma. Between the various diagnostic methods, the echography, executed in emergency, is considered as an indispensable one, for having changed completely the diagnostic approach. It is discussed, particularly, the timing of surgery, an aspect able to influence considerably the therapeutic iter and its results. There are analysed the criteria for whom some authors are favourable to a medical treatment of the acute cholecystitis, postponing the operation, while other of them are favourable to an early surgical treatment. The authors' casuistry put in evidence 110 operations effectuated in emergency (< 12 hours), 19 operations after an 12-72 hours interval, no operations at a long distance (1-10 months). The results are to be considered satisfactory: 1 deceased (on 129 operated cases, 0.78%); 10 immediate complications (7.75%): 8 suppurations of the wound, 1 biliar fistula and 1 internal hemorrhage after video-laparoscopic operation; 2 late complications (1.55%): they were relapsing gallstones. The aim of this work is to offer a contribution to codification of the treatment of the acute cholecystitis, on the ground of the acquired experience.

Acute Disease↗

PubMed1993

[Acute cholecystitis in a traumatologic patient sample].

Among the patients of the Accident Hospital of the Co-operative Trade Association Tübingen, there were 11 cases of acute cholecystitis between 1985 and 1991. Acute cholecystitis occurred after polytrauma (n = 5), multiple fractures (n = 2), head injury (n = 1), fracture of femoral neck (n = 1) or elective hip surgery (arthrodesis, total hip replacement) (n = 2). The mean age was 57 (16-89) years, acute cholecystitis was confirmed 27 (6-54) days after trauma of surgery. 7 cases presented as acute acalculous cholecystitis, whereas in 4 cases of acute cholecystitis cholecystolithiasis was present. 9 patients were treated via cholecystectomy; one juvenile paraplegic recovered after conservative treatment, one 82-year old female was in too bad condition for surgery so that percutaneous cholecystostomy had to be performed prior to cholecystectomy. 10 patients recovered without complication, one 89-year old multi-morbid male died after cholecystectomy. Analysis of the clinical course prior to the occurrence of acute cholecystitis showed a high incidence of shock, frequent blood transfusion, long-time respiratory therapy and parenteral nutrition as well severe trauma, and high cumulation of opiate therapy in this group of patients. Diagnosis was confirmed by ultrasound in all patients, clinical symptoms and laboratory data being mostly unspecific.

Adolescent↗

PubMed1993

[Clinical study of gallbladder cancer associated with acute cholecystitis].

The clinical features of gallbladder carcinoma associated with acute cholecystitis and problems in diagnosing this condition by ultrasonography were investigated. Nine cases of gallbladder cancer with acute cholecystitis and 51 cases of gallbladder cancer without acute cholecystitis were reviewed. There were no obvious differences between those two groups as far as depth of invasion, location of cancer, and the prevalence of gallstones were concerned. However, there was a tendency for detection of cancer associated with acute cholecystitis by ultrasound to be more difficult than detection of cancer without acute cholecystitis. Macroscopic examination of resected specimens showed that superficial or flat type cancers tended to occur more often in cases of acute cholecystitis. This is considered to be the main cause of the difficulty in diagnosing such cancer by ultrasound.

Acute Disease↗