Acute Cholecystitis Patients Research Articles

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

BackgroundAlthough 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.MethodsFrom 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.ResultsNo 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.ConclusionUnder 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.

Laparoscopic Cholecystectomy for Acute Cholecystitis in Patient With Situs Viscerum Inversus

Situs viscerum inversus is a rare condition with perfect mirror image organs position. Despite the well-described existence of this condition, the implication for the treating of emergency pathology can be important following to the difficult interpretation of signs and symptoms. We report a case of acute cholecystitis in patients with known dextrocardia who was successfully treated by laparoscopic cholecystectomy. The diagnostic problems and surgical technique pitfalls are discussed.

Diagnosis and treatment of gallbladder perforation

To present our clinical experience with gallbladder perforation cases. Records of 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our clinic between 1997 and 2006 were reviewed retrospectively. Sixteen (4.8%) of those patients had gallbladder perforation. The parameters including age, gender, time from the onset of symptoms to the time of surgery, diagnostic procedures, surgical treatment, morbidity, and mortality were evaluated. Seven patients had type I gallbladder perforation, 7 type II gallbladder perforation, and 2 type III gallbladder perforation according to Niemeier's classification. The patients underwent surgery after administration of intravenous electrolyte solutions, and were treated with analgesics and antibiotics within the first 36 h (mean 9 h) after admission. Two patients died of sepsis and multiple organ failure in the early postoperative period. Subhepatic abscess, pelvic abscess, pneumonia, pancreatitis, and acute renal failure were found in 6 patients. Early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance. Upper abdominal computerized tomography for acute cholecystitis patients may contribute to the preoperative diagnosis of gallbladder perforation.

The management of acute cholecystitis in the elderly.

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

Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy

Conversion to open cholecystectomy is still required in some patients. The aim of this study was to evaluate preoperative factors associated with conversion to open cholecystectomy in elective cholecystectomy and acute cholecystitis. The records of 1,804 patients who underwent cholecystectomy from May 1992 to January 2004 were reviewed retrospectively. The demographics and preoperative data of patients who required conversion to laparotomy were compared to those with successful laparoscopic cholecystectomy. Conversion to open cholecystectomy was needed in 94 patients (5.2%),of which 44 (2.8%) had no inflammation and 50 (18.4%) had acute inflammation of the gallbladder. Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. Also, the conversion from laparoscopic to open cholecystectomy in acute cholecystitis patients was associated with greater white blood cell count, fever, elevated total bilirubin, aspartate transaminase, and alanine transaminase levels, and the various types of inflammation. None of these risk factors were contraindications to laparoscopic cholecystectomy. This may help predict the difficulty of the procedure and permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.

Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?

Background It remains unclear if sonography accurately describes the severity of gallstone disease. Methods Patients were prospectively enrolled if urgent cholecystectomy was indicated. Two radiologists, blinded to operative findings, evaluated the patients’ ultrasound imagings. Laparoscopic cholecystectomy was performed within 48 hours. The operative findings regarding gallbladder wall thickness and inflammation were compared to ultrasound results and histology. Results Fifty-five patients completed the study. Ultrasound studies exhibited a sensitivity of 60% for the diagnosis of acute cholecystitis compared to the findings at operation and 52% relative to the histologic findings. Specificity for acute cholecystitis diagnosed on ultrasound examination was 77% compared to findings at operation and 71% relative to histologic findings. The correlation coefficient of the wall thickness at ultrasound and surgery was 0.18: 0.24 for ultrasound and histology and 0.5 for surgery and histology. Conclusions Ultrasound’s ability to predict acute cholecystitis in patients with clinical symptoms appears limited.

Use of a predictive equation for diagnosis of acute gangrenous cholecystitis

Background Factors previously identified by multivariate logistic regression that were predictive for gangrenous cholecystitis (GC) were used to develop a predictive equation. Our objective was to evaluate the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of this equation for detecting GC in patients with acute cholecystitis (AC). Methods Medical records of patients who presented to a tertiary care hospital with AC were reviewed. Twenty-one patient and clinical variables were recorded. We prospectively tested the results of the following equation against pathologic diagnosis: P = e (0.7116+0.9944·DM+1.7157·WBC−1.0319·ALT·2.0518·ALP+2.7078·PCF)/(1 + e [−0.7116+0.9944·DM+1.7157·WBC−1.0319·ALT−2.0518·ALP+2.7078·PCF]), where P = predicted value; DM = diabetes mellitus; WBC = white blood cell count; ALT = alanine aminotransferase; AST = aspartate aminotransferase; and PCF = pericholecystic fluid. Results Ninety-eight patients presented with AC and 18% had GC (18 of 98). Using a cutoff of P = 0.724, our equation had a specificity of 93%, sensitivity of 83%, PPV of 71%, and NPV of 96%, P <0.001 for the detection of GC. Conclusions Our study demonstrates the equation may be useful in detecting the subset of AC patients who have GC.

Diagnosis of acute cholecystitis in patients with liver cirrhosis: waveform analysis of the cystic artery by color Doppler imaging.

The aim of this study was to investigate the possibility of diagnosing acute cholecystitis in patients with liver cirrhosis using color Doppler imaging to demonstrate the hemodynamics. Color Doppler imaging was used to analyze the waveform of the cystic artery in 28 cirrhotic subjects with thickened gallbladder walls and 56 normal controls. The cirrhotic group was further divided into the cholecystitis group, containing 6 cirrhotic patients with acute cholecystitis, and the liver cirrhosis group, containing 22 cirrhotic patients without acute cholecystitis. Maximum velocity (Vmax) was significantly higher in the cholecystitis group (31.6 ± 23.0 cm/s) than in the normal controls (16.1 ± 5.9 cm/s) (P < 0.01). The resistance index (RI) was higher in the liver cirrhosis group (0.84 ± 0.04) than in either the normal controls (0.70 ± 0.06) (P < 0.01) or the cholecystitis group (0.72 ± 0.09) (P < 0.01). Sensitivity and specificity were 100% when the diagnostic criteria of acute cholecystitis were a maximum velocity of more than 40 cm/s, a resistance index of more than 0.75, or both. A pulsatile signal with a maximum velocity of more than 40 cm/s, a resistance index lower than 0.75, or both indicated the presence of acute cholecystitis in patients with liver cirrhosis and a thickened gallbladder wall.

Acute Cholecystitis: Delayed Surgery or Observation. A Randomized Clinical Trial

Background: The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients randomly allocated to delayed operation or conservative treatment. Methods: One-hundred-and-eighty patients were considered for participation in the study; 71 were excluded according to predefined criteria and 45 did not join for other reasons. The remaining 64 patients were randomized to cholecystectomy ( n r = r 31) or observation ( n r = r 33). Randomized patients were contacted regularly and followed up for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. Results: Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group (19%; 95% CI 5%-33%) and in 12 patients (36%; 9% CI 20%-53%) in the observation group. Twenty-seven of 31 patients randomized to cholecystectomy had a cholecystectomy at a median of 3.6 months after randomization, and, of these, 3 (11%; 95% CI 0%-23%) suffered a major and 7 (26%; 95% CI 9%-42%) a minor complication. Ten patients randomized to observation later had their gallbladders removed, 1 (10%; 95% CI 0%-29%) patient had a major and 1 (10%; 95% CI 0%-29%) a minor complication. We found no mortality after cholecystectomy. Conclusions: We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis, but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis.

Risk Factors for Conversion of Laparoscopic to Open Cholecystectomy

Background. Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic gallstones; however conversion to open cholecystectomy (OC) remains a possibility. Unfortunately, preoperative factors indicating risk of conversion are unclear. Therefore, we aimed to identify risk factors associated with conversion of LC to OC.Patients and materials. Records of 564 patients undergoing LC in 1995 and 1996 were reviewed. Patients were assigned to one of two groups: (1) acute cholecystitis defined by the presence of gallstones, fever, leukocyte count >104, and inflammation on ultrasound or histology; (2) chronic cholecystitis that included all other symptomatic patients. Demographics, history, and physical, laboratory, and radiology data, operative note, and the pathology report were reviewed.Results. 161 of 564 patients, had acute and 403 patients had chronic cholecystitis; 16 acute cholecystitis patients (10%) were converted from LC to OC and 17 chronic cholecystitis patients (4%) had LC converted to OC. Patients having open conversion were significantly older, had greater prevalence of cardiovascular disease, and were more likely to be males. LC conversion to OC in acute cholecystitis patients was associated with a greater leukocyte count; in gangrenous cholecystitis patients, 29% had open conversion.Conclusions. Importantly, these risk factors—older men, presence of cardiovascular disease, male gender, acute cholecystitis, and severe inflammation—are determined preoperatively, permitting the surgeon to better inform patients about the conversion risk from LC to OC. While acute cholecystitis was associated with more than a twofold increased conversion rate, only 10% of these patients could not be completed laparoscopically. Therefore, acute cholecystitis alone should not preclude an attempt at laparoscopic cholecystectomy.

The role of laparoscopic cholecystectomy in the management of acute cholecystitis in patients with sickle cell disease.

As emergency surgery in sickle cell disease patients is associated with high morbidity, the aim of the study was to assess the safety of laparoscopic cholecystectomy in the acute state for these patients. Over a 5-year period, April 1994 till December 1998, 35 sickle cell patients with acute cholecystitis had laparoscopic cholecystectomy within the first 5 days of presentation. A retrospective study of these was undertaken. Thirty-five patients were diagnosed as having acute cholecystitis with sickle cell disease. There were 26 female and 9 male patients; 5 patients needed preoperative and 1 patient needed postoperative endoscopic retrograde cholangiopancreatography. Twenty-seven patients needed simple transfusion and 8 needed partial exchange; conversion was necessary in two cases (5.7%). The mean hospital stay was 5.3 days and the complication rate was 17.5%. Because of the lack of significant complications, we believe that laparoscopic cholecystectomy for acute cholecystitis is safe and recommended in experienced hands with adequate preoperative preparation for patients with sickle cell disease.

Laparoscopic Cholecystectomy for Gallstones: A Comparison of Outcome between Acute and Chronic Cholecystitis

Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results. Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC). There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC. LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

Percutaneous Cholecystoduodenostomy: A Case Report

TREATMENT of acute cholecystitis via cholecystectomy, in patients who have associated debilitating conditions, is associated with high mortality and morbidity rates, reaching 30% and 55%, respectively, for open surgical procedures (1), although a laparoscopic approach may reduce the risks (2). Therefore, percutaneous cholecystostomy (PC) as a safe, minimally invasive procedure remains a commonly accepted method of treatment of acute cholecystitis in patients who have contraindications to surgery (3).

Cholecystostomy: a review of recent experience.

Operative (OC) and percutaneous cholecystostomy (PC) are rarely undertaken for severe acute cholecystitis in patients in whom cholecystectomy is technically difficult or those with significant comorbidity. A retrospective review was undertaken of the clinical, radiological and audit records of patients who were treated by cholecystostomy between 1988 and 1997 at Auckland Hospital. During the 10-year period 19 patients (eight male, 11 female; median age: 70 years, range: 35-90 years) had a cholecystostomy (OC: n = 8; PC: n = 11). The main indication for PC was high anaesthetic risk (10 cases). The main indication for OC was failed cholecystectomy (six cases). The patients undergoing PC tended to have a higher American Society of Anesthesiologists (ASA) grade than patients undergoing OC. The median delay from presentation to cholecystostomy was 3 days. More than half (11/19) were done during the 3 years (1992-94) after the introduction of laparoscopic cholecystectomy. The number of tube-related complications was significantly higher in PC patients (10/11 vs 3/8; P = 0.04), and the number of systemic complications was higher in the OC patients (4/8 vs 0/11; P = 0.018). The median duration of tube drainage was 17 days (range: 0-82 days) for OC and 24 days (range: 5-93 days) for PC. Four patients had stone extraction at the time of OC, including two who also had a partial cholecystectomy. One OC patient had stone extraction via the cholecystostomy tract. A cholecystectomy was performed in four patients. The data indicate that PC is a safe approach for high-risk patients. Operative cholecystostomy had a role following failed cholecystectomy. But PC might be safer in these patients if they could be identified pre-operatively.

Open and laparoscopic cholecystectomy in acquired immunodeficiency syndrome: Indications and results in fifty-three patients

Background: Although acute cholecystitis is one of the most common indications for abdominal surgery in patients with acquired immunodeficiency syndrome (AIDS), previous studies have reported disappointingly high morbidity and mortality among those patients who have undergone cholecystectomy. The aims of this study were to analyze the indications for and the outcome of cholecystectomy performed for acute cholecystitis in patients with AIDS. Methods: We retrospectively reviewed the hospital charts of 53 patients with AIDS who underwent open or laparoscopic cholecystectomy from 1992 to 1997. Statistical analysis using the chi-square, Student's t, and Fisher exact tests was conducted to determine whether cause of cholecystitis, type of surgical approach, and CD4+ T-lymphocyte count influenced outcome. Results: The clinical findings and imaging by ultrasonography were always reliable in establishing diagnosis and guiding treatment of acute cholecystitis. Open cholecystectomy was performed in 24 patients (45%). The procedure was begun laparoscopically in 29 patients (55%) and converted to open in 4 (14%). The pathologic findings showed acalculous cholecystitis in 19 patients (36%) and cholelithiasis in 32 (60%). Morbidity was 34% and mortality was 2%. Type of operative approach, cause of cholecystitis, and CD4+ T-lymphocyte count (greater or less than 50 cells/mm 3) did not significantly affect morbidity and mortality. The length of hospital stay was significantly influenced by the CD4+ T-lymphocyte count. Conclusions: These findings suggest that in most patients with AIDS, laparoscopic or open cholecystectomy may be performed with significant but acceptable morbidity and low mortality. (Surgery 1999;125:172-7.)

Acute cholecystitis after autologous bone marrow transplantation for acute myeloid leukemia

We investigated the incidence of acute cholecystitis in patients with acute myeloid leukemia (AML) undergoing autologous bone marrow transplantation in complete remission. Thirty-five consecutive acute myeloid leukemia patients were given oral busulfan 4 mg/kg/day for 4 days and IV cyclophosphamide 50 mg/kg/day for 4 days followed by reinfusion of autologous bone marrow purged with 4-hydroperoxycyclophosphamide. Five of 35 patients developed clinical evidence of acute cholecystitis, manifested by fever, nausea, vomiting, right-upper-quadrant pain, and abdominal guarding, within 18 days after autologous bone marrow infusion. Ultrasonography and CT scans of the abdomen supported the diagnosis of cholecystitis. Three patients underwent cholecystectomy, while two patients were treated medically; all recovered uneventfully. A review of 338 consecutive bone marrow transplant patients who underwent marrow transplantation for a variety of diseases and were treated with other high-dose cytotoxic regimens during the same time period revealed significantly fewer cases of cholecystitis, i.e. two, (p < 0.0001). Five of 35 AML patients undergoing autologous bone marrow transplant using busulfan, cyclophosphamide, and purged bone marrow developed evidence of acute cholecystitis. These findings suggest that the busulfan/cyclophosphamide preparative regimen may be associated with acute cholecystitis. The true incidence of this injury and its pathogenesis remain to be elucidated.

Laparoscopic Cholecystectomy in Critically Ill Cardiac Patients

CARROLL, BRENDAN J.; CHANDRA, MUDJIANTO; PHILLIPS, EDWARD H.; MARGULIES, DANIEL R. Author Information

Morphine cholescintigraphy in the evaluation of hospitalized patients with suspected acute cholecystitis.

The authors determined if the diagnosis of acute cholecystitis can be accurately made or reliably eliminated by the use of morphine-augmented radionuclide cholescintigraphy (morphine cholescintigraphy [MC]) in hospitalized patients in whom the diagnosis is in doubt. SUMMARY/BACKGROUND DATA: Diagnosis of acute cholecystitis, calculous or acalculous, may be difficult in patients hospitalized for abdominal pain or other illnesses. Clinical signs often are obscure, and routine imaging studies are nonspecific or associated with a high incidence of false-positive tests. The authors report the use of MC in the evaluation of 163 hospitalized patients for acute cholecystitis over an 8-year period. All patients suspected to have acute cholecystitis initially had standard cholescintigraphy performed, which showed nonvisualization of the gallbladder, and then were given morphine sulfate (0.05-0.1 mg/kg, intravenously). Patients were divided into the following three groups: I--acute abdominal pain (N = 53); II--hospitalized for associated illness (N = 49); and III--critically ill (N = 61). Overall, MC confirmed the diagnosis of acute cholecystitis in 75 patients (46%), including 23 cases of acalculous cholecystitis. Visualization of the gallbladder occurred within 60 minutes of intravenous administration of morphine sulfate in all patients. Cystic duct obstruction and, presumably, the diagnosis of acute cholecystitis was excluded in 79 patients, including 38 who were critically ill. There were eight false-positive and one false-negative studies. Morphine cholescintigraphy had a sensitivity of 99%, a specificity of 91%, a positive predictive value of 0.9, a negative predictive value of 0.99, and an overall accuracy of 94%. In hospitalized patients with nonvisualization of the gallbladder after standard cholescintigraphy, MC is highly accurate, especially in predicting the absence of acute cholecystitis in patients with known risk factors.

Results of cholescintigraphy in a VA hospital.

In a review of 200 hepatobiliary imaging studies done in a VA hospital over a 5-year period, a sensitivity of 96% and a specificity of 88% were obtained. In a subgroup of 40 patients with alcoholic liver disease, the specificity dropped to 60% although the sensitivity remained high (100%). These data indicated that in patients with alcoholic liver disease a positive DISIDA scan is not diagnostic of acute cholecystitis and cannot be interpreted as an indication for cholecystectomy. Possible modifications of imaging techniques, including delayed imaging and morphine-augmented cholescintigraphy, may prove to increase the specificity of cholescintigraphy in these patients. A prospective study using these modifications would help in determining the current role of cholescintigraphy in the diagnosis of acute cholecystitis in patients with alcoholic liver disease.

Asymptomatic Gallstones in Diabetic Persons

Letters and Corrections1 December 1987Asymptomatic Gallstones in Diabetic PersonsDAVID HOCH, M.D., BETH SCHORR-LESNICK, M.D., PAUL MARANTZ, M.D., M.P.H.DAVID HOCH, M.D.Search for more papers by this author, BETH SCHORR-LESNICK, M.D.Search for more papers by this author, PAUL MARANTZ, M.D., M.P.H.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-107-6-942_1 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the editor: Ransohoff and colleagues (1) have provided an interesting reexamination of the clinical dogma that surgery should be considered for diabetic patients with asymptomatic gallstones. There is, however, a methodologic problem we feel should be addressed before this approach is abandoned.To arrive at the final sample of 311 patients, 1978 charts were reviewed. Among the exclusion criteria was acute pancreatitis, accounting for 87 patients. No rationale was given for this exclusion, and if there is a relation between development of pancreatitis and diabetes, this could lead to significant confounding.The importance of this factor can be examined...Reference1. RANSOHOFFMILLERFORSYTHEHERMANN DGSR. Outcome of acute cholecystitis in patients with diabetes mellitus. Ann Intern Med. 1987;106:829-32. LinkGoogle Scholar1. RANSOHOFFMILLERFORSYTHEHERMAN DGSR. Outcome of acute cholecystitis in patients with diabetes mellitus. Ann Intern Med. 1987;106:829-32. LinkGoogle Scholar2. TANWARREN EK. Diseases of the gallbladder and bile ducts. In: SCHIFF L, SCHIFF ER, eds. Diseases of the Liver. Philadelphia: J.B. Lippincott Company; 1982:1507-59. Google Scholar3. SOLOWAY R. Asymptomatic gallstones. In: WYNGAARDEN JB, SMITH LH JR. Cecil Textbook of Medicine. 17th ed. Philadelphia: W.B. Saunders Company; 1985:855. Google Scholar4. FROMMBAZZOLI HF. Medical dissolution of cholesterol gallstones. In: COHEN S, SOLOWAY RD, eds. Gallstones. New York: Churchill Livingstone: 1985:167-78. Google Scholar5. SOERGEL K. Acute pancreatitis. In: SLEISENGER MH, FORDTRAN JS, eds. Gastrointestinal Disease. Philadelphia: W.B. Saunders Company, 1983:1462-85. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Montefiore Medical Center Bronx, NY 10467 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 December 1987Volume 107, Issue 6Page: 942-942KeywordsAcute pancreatitisChartsPancreatitisSurgery Issue Published: 1 December 1987 PDF DownloadLoading ...