Acalculous Gangrenous Cholecystitis Research Articles

Creative Resource Utilization in Rural Settings

Cholecystostomy tubes are an established treatment option for patients with acute cholecystitis who are considered high risk for cholecystectomy. This is typically done as an interventional radiology procedure through a pigtail catheter inserted percutaneously. A 63-year-old diabetic male presented to our remote Emergency Department in rural North-Western Victoria (Modified Monash Model 4), with severe, stabbing epigastric pain. Despite normal bloods and imaging, the patient became progressively unwell necessitating a diagnostic laparoscopy and open conversion, which revealed acute acalculous gangrenous cholecystitis. A cholecystectomy was attempted and subsequently abandoned as safe dissection within Calot's triangle, without damaging biliary structures, was not possible. Based on the limited available resources at our rural center, a urinary (Foley) catheter was placed in the gallbladder and Hartmann's pouch sutured around it to act as a temporizng cholecystostomy tube while awaiting transfer to a tertiary center. The Foley catheter was removed after 6 weeks with no further intervention required with the patient making a full recovery. Compared to patients in urban areas, rural residents are more likely to experience health-care disadvantages, including increased likelihood to undergo procedures by specialists operating outside of their scope of practice and higher rates of emergency-related intensive care unit admissions. Despite this, and regardless of acuity, specialist availability, or resource distribution, patients will continue to present to rural services with serious medical issues. In such situations and in resource-poor settings, creative solutions are required to temporize ill patients, as we have reported, and represent an important facet of care in a rural setting.

Acute-on-Chronic Mesenteric Ischemia Successfully Managed by Superior and Inferior Mesenteric Artery Reimplantation and Cholecystectomy for Gangrenous Gallbladder

Acute-on-chronic mesenteric ischemia (CMI) leading to gallbladder gangrene is a rare event, and successful use of mesenteric arterial reimplantation with regard to contaminated field is not reported. In contaminated field from gangrenous gallbladder due to acute-on-CMI, reimplantation of the superior and inferior mesenteric artery (SMA and IMA, respectively) for revascularization is a feasible option, and was used to revascularize in this patient. SMA and IMA require one anastomosis at the aorta, and it was successfully used in contaminated field to revascularize the threatened bowel. In acute-on-CMI, with contaminated field, reimplantation of SMA makes one of an option in surgical armamentarium of using autologous tissue and it reduces number of anastomosis in infected field. Acalculous gangrenous cholecystitis is a rare pathology associated with acute-on-CMI.

AB161. 182. Emphysematous cholecystitis: case report on a rare, life threatening presentation

: A 78-year-old gentleman with type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and hypertension presented to the emergency department with sudden onset of severe right upper quadrant with associated vomiting. White cell count showed a leukocytosis of 24×10×9/L and a C-reactive protein of 57 mg/L. An ultrasound abdomen revealed no acute gallbladder or biliary pathology. Computed tomography of the abdomen revealed pericholecystic fat stranding, an air-liquid level within the gallbladder and gas dissecting along a significant portion of the gallbladder wall—findings consistent with emphysematous cholecystitis, grade 3 with associated perforation and small volume of portal venous gas. Our patient underwent an emergency laparotomy with cholecystectomy. Pathology examination revealed acute acalculous gangrenous cholecystitis. Our patient required a 5-day admission to intensive care unit post-operatively. Emphysematous cholecystitis was first described at autopsy in 1901 by Stolz, who characterized emphysematous cholecystitis by the presence of air within the gallbladder and/or the biliary tree in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. Emphysematous cholecystitis is a potentially life-threatening anaerobic infection, is a variant of acute cholecystitis. The mortality rate for acute emphysematous cholecystitis however is 15–50%. Despite the high mortality associated with gangrene and gallbladder perforation, patients with emphysematous cholecystitis do not exhibit alarming clinical signs of sepsis, and the presenting symptoms are often nonspecific and initially indistinguishable from those of uncomplicated acute cholecystitis. Patients with diabetic neuropathy may not experience typical right upper quadrant pain and maybe present with a paucity of symptoms.

Acalculous Gangrenous Cholecystitis in Absence of Typical Risk Factors

Acute acalculous cholecystitis (AAC) is typically seen as a complication in severely ill, hospitalized patients. We report a case of acute gangrenous acalculous cholecystitis in an outpatient. 47-year-old African-American male presented with acute onset of epigastric abdominal discomfort and multiple episodes of vomiting persisting over one day. He denied having any fever or chills, change in bowel habits, dysphagia, weight loss, change in appetite, blood in stools, recent travel history or NSAID/alcohol use. He had a history of hypertension and hyperlipidemia. On exam, he was afebrile, BP 100/60 mmhg, HR 110 /min. He had tenderness in the epigastrium and right upper quadrant of his abdomen. Murphy's sign was positive. The initial blood tests including liver function tests and lipase were normal except for an elevated white cell count. An US of RUQ was obtained revealed, gall bladder wall thickening along with edema and pericholecystitc fluid collection. No gall stones were seen. Blood cultures were obtained, and the patient was started on antibiotics empirically. A HIDA scan revealed no uptake of contrast in the gall bladder one hour after contrast admission, confirming the diagnosis of AAC. Surgery was consulted and cholecystectomy was performed. Removed gall bladder appeared inflamed with early signs of gangrene. Acute acalculous cholecystitis (AAC) is defined as inflammation of the gall bladder without presence of gallstones. It is typically seen in severely medically or surgically ill, hospitalized patients. Altthough not common, cases of AAC in out patients with no significant risk factors have been reported. Physical examination and laboratory data are often unreliable in diagnosis of AAC, and diagnosis mainly rests on imaging studies. AAC has an extremely fulminant course leading to gall bladder gangrene in 50% of patients and perforation in 10 % of patients. Even with treatment, the mortality rate is about 30%. Hence, early diagnosis and treatment are warranted. In very few patients, atherosclerosis-causing changes in microcirculation of gall bladder, atherosclerotic changes can leading to ischemia at cellular level, thereby causing inflammation have been postulated to be causing AAC. Our patient presented in the outpatient setting and was diagnosed to have acute gangrenous acalculous cholecystitis. Given the high mortality rates AAC should be kept in dfferentials even in the outpatient settings.

Acalculous cholecystitis: Three Case Reports

Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder. Whilst acalculous cholecystitis accounts for approximately 10 percent of acute cholecystitis cases it is associated with a high morbidity and mortality.The condition rapidly progresses to complications such as gangrene, perforation and empyema of the gallbladder. Gangrenous cholecystitis is the most severe form and complication of acute cholecystitis. Acute acalculous cholecystitis warrants urgent surgical intervention to prevent catastrophic outcomes. We report a series of three patients that we managed for acute acalculous cholecystitis. The first patient was a 65-year-old, male who was positive of Human Immunodeficiency Virus (HIV) with a CD4 count of 165 cells/mm3 and was on antiretroviral treatment. The second patient was a 73-year-old male with no comorbidities. The last patient was a 72-year-old female with congestive cardiac failure due to hypertension. One patient had a successful laparoscopic cholecystectomy and the other two had open cholecystectomies. Two of the patients did well and were discharged whilst the third patient died in intensive care unit day 2 postoperatively. All the three patients had no evidence of gallbladder stones. Two of the histology reports confirmed acalculous gangrenous cholecystitis and the third histology showed acalculous haemorrhagic cholecystitis. Acalculous cholecystitis is a surgical emergency. Once suspected, principles of management include resuscitation, hospital admission, broad spectrum antibiotics, adequate analgesia and emergency surgery.Key words: Acalculous cholecystitis, Gangrenous cholecystitis, Cholecystectomy

Diagnosis and treatment of acute acalculous gangrenous cholecystitis in 43 cases

目的 探讨急性无结石性坏疽性胆囊炎的诊断及外科治疗方法.方法 对我院外科收治的1990-2005年43例急性无结石性坏疽性胆囊炎的临床资料进行回顾性分析.结果 急性无结石性坏疽性胆囊炎多见于老年病人,具有病因复杂,发病急骤,病情重,死亡率高等临床特点.此病一经确诊,应及时手术治疗.本组43例病人中,34例行胆囊切除术,5例行胆囊大部分切除术,4例行胆囊切除术加胆总管探查术,T形管引流术.术后1例死亡,死因为中毒性休克,多器官功能衰竭.结论 B超和实验室检查是诊断本病的主要的辅助检查手段.早期诊断、完善的术前准备,积极的手术治疗是提高本病治愈率的关键。

Acalculous Gangrenous Cholecystitis Coexisting with a Mycotic Suprarenal Aortic Aneurysm

Mycotic suprarenal aortic aneurysms are rare, and most often caused by bacteraemic spread. Acalculous cholecystitis is usually associated with major surgery and trauma. An association between acalculous gangrenous cholecystitis and a mycotic suprarenal aortic aneurysm has not been described. We present a case of a perforated gangrenous cholecystitis with an adjacent suprarenal abdominal aortic mycotic aneurysm, presenting a challenging surgical case.

Acalculous Gangrenous Cholecystitis Coexisting with a Mycotic Suprarenal Aortic Aneurysm

Mycotic suprarenal aortic aneurysms are rare, and most often caused by bacteraemic spread. Acalculous cholecystitis is usually associated with major surgery and trauma. An association between acalculous gangrenous cholecystitis and a mycotic suprarenal aortic aneurysm has not been described. We present a case of a perforated gangrenous cholecystitis with an adjacent suprarenal abdominal aortic mycotic aneurysm, presenting a challenging surgical case.

Cytomegalovirus cholecystitis and colitis associated with the acquired immunodeficiency syndrome

Cytomegalovirus (CMV) is an important cause of acalculous gangrenous cholecystitis in immunocompromised persons. We report a case of acalculous acute cholecystitis and active colitis associated with CMV in a patient suffering from the acquired immune deficiency syndrome. The condition was treated successfully with surgery and 9-(1,3,-dihydroxy-2-propoxymethyl)guanine intravenously.

Cytomegalovirus- and Cryptosporidium-associated acalculous gangrenous cholecystitis

A well-documented case of cytomegalovirus- and Cryptosporidium-associated cholecystitis is described in a 19-year-old heterosexual Haitian man who had the acquired immune deficiency syndrome and acute acalculous gangrenous cholecystitis associated with these pathogens. This case adds to the spectrum of the manifestations of the profoundly immunocompromised state.