Cases Of Acute Cholecystitis Research Articles

A case of acute calculous cholecystitis with sudden deterioration in the absence of signs of peritonitis: A case report

A case of acute calculous cholecystitis with sudden deterioration in the absence of signs of peritonitis: A case report

SP3.1.7 Performance of ultrasound in the diagnosis of cholecystitis and prediction of the “difficult cholecystectomy”

Abstract Aims Ultrasound has long been the radiological investigation of choice for right upper quadrant pain for the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 793 patients. Methods All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. The ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. Results In our large patient series, sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest where the interval between ultrasound and cholecystectomy is less than 27 days. Conclusions We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder on ultrasound can predict a “difficult cholecystectomy” and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.

S1601 An Unusual Case of Acute Cholecystitis and Bradycardia (Cope's Sign)

Introduction: Patients with acute cholecystitis present with right upper quadrant or epigastrium pain, nausea, and vomiting. Fever, leukocytosis, and a positive Murphy's sign support the diagnosis. Oftentimes, acute cholecystitis may mimic cardiovascular disease. Bradycardia is one of the rare presentations of cholecystitis and is called the "Cope's sign." Sir Zachary Cope was the first patient who presented with cardio-biliary reflex in 1970. Very few cases have been reported. Case Description/Methods: A 55-year-old male presented with retrosternal chest pain, diaphoresis, and vomiting followed by epigastric pain. Symptoms started one night prior to admission and he thought they were attributed to the raw chicken he ate for dinner. Examination showed a diaphoretic man with abdominal tenderness and bradycardia. His symptoms were concerning because the chest pain and bradycardia were compatible with inferior-wall Ml. However, troponins were negative. EKG showed sinus bradycardia with 42 beats/min (Figure 1). To further aid investigation, abdominal US was ordered which revealed gallstones, pericholecystic fluid and gallbladder wall thickening. He was diagnosed as a case of acute cholecystitis which presented as a cardio-biliary reflex and bradyarrthythmia. He was treated with IV fluids, pain control, and antibiotics. Surgery recommended urgent cholecystectomy. Discussion: Cardio-biliary reflex exists and can result in serious consequences. Bradyarrhythmia is the most common presentation of cardio-biliary reflex. Cardio-biliary reflex is believed to be vagally mediated and notably has been triggered by pain in the gallbladder via autonomic vagal innervations. A case-control study by Kaufman and Lubera reported that the increased vagal tone caused by the gallbladder could mimic myocardial infarction or cause bradyarrhythmia and even complete heart block. Patients with acute cholecystitis having abnormal ECG changes should be managed cautiously to avoid possible complications. This case highlights the rare case of acute cholecystitis with cope sign. Clinicians should have a high suspicion and order appropriate studies since these patietns can present as myocardial infarction.Figure 1.: EKG showed sinus bradycardia with 42 beats/min.

S1622 Acute Acalculous Cholecystitis: An Unusual First Manifestation of COVID-19

Introduction: COVID-19 pandemic has become a major global health challenge, with more than 178 million confirmed cases and over 3.86 million deaths to date. While general and respiratory symptoms are common, it may have atypical GI involvement. We chronicle here an extremely rare case of acute acalculous cholecystitis (AAC) in a patient with COVID-19. Case Description/Methods: A previously healthy 35-year-old male presented to the emergency room with abdominal pain and non-biliary vomiting. He was nonsmoker, nonalcoholic, and drug-free. His vitals revealed: temperature 37.1°C, heart rate 82 bpm, blood pressure 114/72 mm Hg, respiratory rate 16/minute, and an oxygen saturation of 99% in room air. Physical examination revealed a positive Murphy's sign. Laboratory parameters revealed leukocytosis and high CRP level. Abdominal ultrasound showed marked gallbladder wall thickening, normal CBD, with no cholelithiasis or sludge formation. EUS also ruled out stones in the gallbladder. Therein, coronavirus rRT-PCR came back positive. CT chest revealed bilateral patchy peripheral ground-glass opacities in the lungs, consistent with COVID-19. Based on these findings and exclusion of probable causes of AAC, COVID-19-related AAC was diagnosed. The patient was initiated on standard COVID-19 treatment for the mild disease and conservative treatment for AAC. His hospital course remained unremarkable, except for fever and dyspnea on day 4 of admission. He remained hemodynamically stable. On day 7 of admission, his abdominal pain, vomiting, and fever disappeared with treatment. On day 9 of admission, he was afebrile, dyspnea had resolved, and had no abdominal pain. He was then discharged home in a stable condition. He continues to do well for 2 months now. Discussion: Published medical literature is bereft of reports on the association between AAC and COVID-19. A PubMed search was conducted for all case reports of AAC amidst COVID-19 till June 2021. Search terms included ‘’acalculus cholecystitis’’ and ‘’COVID-19’’. The search resulted in only 4 case reports to date. This case highlights that the GI symptoms may precede the pulmonary manifestations of COVID-19. It further provides the clinical evidence behind a causal relationship between SARS-CoV-2 infection and biliary involvement. The extrapulmonary symptomology of this infection has not been extensively studied, warranting a high index of suspicion for rare manifestations like AAC. Thus, new-onset GI symptoms may indicate COVID-19, requiring prompt testing for SARS-CoV-2.

391 Routine Hatobiliary Iminodiacetic Acid Scan of All Suspected Cases of Acute Cholecystitis

Cholecystitis is the second-most common surgical admission from emergency departments and represents a large health burden. Different imaging modalities are utilized to evaluate this disease while hepatobiliary iminodiacetic acid (HIDA) scans are reported to be more sensitive and specific for acute cholecystitis because it is a functional evaluation of the gallbladder and can demonstrate cystic duct obstruction. Most emergency departments obtain a HIDA scan when the clinical diagnosis is equivalent. At our center, the primary general surgery group requires routine HIDA scans on all suspected cases of acute cholecystitis before deciding operative management. The purpose of this study was to perform a retrospective review of all HIDA scans performed in 2018 among emergency department cases of suspected cholecystitis. The specific aim was to evaluate the agreement between ultrasound (US) and HIDA scan findings and their association with operative decision-making. Secondary objectives were to evaluate discrepancies, insurance status, age, sex, ED length-of-stay, operative outcomes, and costs. HIDA scans were identified from our imaging record system from January 1, 2018 to December 31, 2018. An abnormal US (US+) was defined as the presence of gallstones plus either of the following: gallbladder wall thickening, pericholecystic fluid, sonographic Murphy’s, or common bile duct dilatation. An abnormal HIDA (HIDA+) scan was defined as cystic duct obstruction and/or failure to visualize the gallbladder. Qualitative reviews of specific cases were summarized. STATA (College Station, TX) was used for statistical analysis. N = 550 patients who received both HIDA scan and gallbladder US. There were 348 cases of US+ and 234 cases of HIDA+. There was a 59.3% agreement between US and HIDA findings. n = 169 of US+ and HIDA- and n = 55 of US- and HIDA+. Pairwise correlation 0.236 (p<0.001). There was a net decrease in operative care of 114 cases by adding HIDA. 550 HIDA scans have an estimated aggregate charge of $773,300 whereas 114 fewer laparoscopic cholecystectomies would have an aggregate savings of $2,101,932. This is the largest single-center study of comparison between HIDA and US in emergency department patients. The use of HIDA scans suggested 49% of patients with US+ findings may not require urgent surgery whereas 27% of patients with non-diagnostic US demonstrated the need for surgical intervention. The routine use of HIDA scans may have a significant impact on costs and reimbursements for this common etiology. The clinical suspicion is the main driver of resource utilization and routine HIDA scans increase immediate costs, ED length-of-stay, and can result in a net decrease of costs for urgent operative care.

Acute Cholecystitis: A comparative study of hematological and ultrasonography findings among middle aged and elderly

Aim: To determine the differences in-between hematological and ultrasonography findings of acute cholecystitis (AC) among middle-aged versus elderly patients. Methodology: This retrospective study was carried out after ethical approval. Patients diagnosed as case of acute cholecystitis was included and patients without findings consistent with acute cholecystitis or with pancreatitic gall stones, co-existing hepato-biliary or intestinal malignancy or with autoimmune biliary disease were excluded. Patients were divided into two groups, one being patients between 30 to 59 years and other group 60 and above year olds. Results: From total of 153 patients included, 87 patients were between 30 and 59 years (middle aged) while 66 patients were 60 years and older (elderly). In both the groups, higher ratios of females persisted (p-0.03). A significant differences between the values were observed only in WBC count (p-0.005) and CRP levels (p&lt;0.001) between middle aged and older age group while all other laboratory variables were found to have an insignificant difference between both the groups. Conclusion: WBC count and CRP level which were observed to be higher among older age patients, compared with middle aged patients. Such alterations in older aged patients ought to be considered when deciding treatment protocols which will have major influence on the prognosis. Keywords: Acute Cholecystitis, C-reactive protein, Systemic Inflammatory Response, Aging Physiology

Diabetes and Hypertension as Risk Factor for Conversion to Open Cholecystectomy

Introduction: Laparoscopic cholecystectomy is the gold standard procedure for gall stone disease. Few cases of acute calculous cholecystitis require conversion to open procedure. Patients with diabetes and hypertension are at increased risk of failure of laparoscopic cholecystectomy. Aims and Objectives: To evaluate the risk of failure of laparoscopic cholecystectomy in type 2 diabetes patients with patients without diabetes. Materials and methods: A prospective study was conducted at a tertiary care hospital. Study was conducted after obtaining ethical committee clearance and informed consent from patients. 90 patients were included in the study. Results: 90 patients of acute calculous cholecystitis were taken for laparoscopic cholecystectomy of which 38 patients had to undergo conversion to open procedure. Among these 17 where having diabetes and hypertension and 14 had type 2 diabetes alone. Conclusion: It is important to evaluate in detail before taking the patients with commodities like diabetes and hypertension for laparoscopic cholecystectomy and prevent morbidity

Clinical application of gelatin sponge microparticles combined with pirarubicin for hepatic transcatheter arterial chemoembolization in breast cancer liver metastasis treatment: results of a single-center long-term study

ObjectiveTo retrospectively analyze the safety and long-term clinical efficacy of gelatin sponge microparticles combined with the chemotherapy drug pirarubicin for hepatic transcatheter arterial chemoembolization (GSMs-TACE) in order to treat breast cancer liver metastasis (BCLM).MethodsTwenty-seven BCLM patients who underwent GSMs-TACE from July 2010 to July 2016 were enrolled. Tumor target blood vessels were slowly and regionally embolized with absorbable gelatin sponge particles and pirarubicin injections. Plain computed tomography (CT) scans and biochemical indexes were re-examined at 4 days after treatment, and enhanced CT scans or magnetic resonance images and biochemical indexes, 1 month later. For patients with stable tumors, the follow-up period was 2 to 3 months, and the tumor response was evaluated using Modified Response Evaluation Criteria in Solid Tumors. Adverse reactions, survival time, and prognostic factors were assessed.ResultsBy October 2019, 27 patients with BCLM had undergone GSMs-TACE, with an average of 2.44 ± 1.58 treatments. The 1-, 3-, and 5-year survival rates were 62.96%, 22.22%, and 14.81%, respectively, and the mOS was 22.0 months. No serious complications, such as acute liver failure and liver abscess, had occurred. There were two cases of acute cholecystitis that recovered after symptomatic treatment. Multivariate analysis of the prognosis showed that the primary tumor size, number of metastatic lymph nodes, estrogen receptor/progesterone receptor (ER/PR) status, and time to postoperative liver metastasis and combination therapy were statistically significant.ConclusionsThe overall prognosis of BCLM was poor. GSMs-TACE was safe and effective for BCLM treatment and could prolong the median survival time of patients. Therefore, it is worthy of widespread clinical application.

Artificial intelligence-based automated laparoscopic cholecystectomy surgical phase recognition and analysis

Artificial intelligence and computer vision have revolutionized laparoscopic surgical video analysis. However, there is no multi-center study focused on deep learning-based laparoscopic cholecystectomy phases recognizing. This work aims to apply artificial intelligence in recognizing and analyzing phases in laparoscopic cholecystectomy videos from multiple centers. This observational cohort-study included 163 laparoscopic cholecystectomy videos collected from four medical centers. Videos were labeled by surgeons and a deep-learning model was developed based on 90 videos. Thereafter, the performance of the model was tested in additional ten videos by comparing it with the annotated ground truth of the surgeon. Deep-learning models were trained to identify laparoscopic cholecystectomy phases. The performance of models was measured using precision, recall, F1 score, and overall accuracy. With a high overall accuracy of the model, additional 63 videos as an analysis set were analyzed by the model to identify different phases. Mean concordance correlation coefficient for annotations of the surgeons across all operative phases was 92.38%. Also, the overall phase recognition accuracy of laparoscopic cholecystectomy by the model was 91.05%. In the analysis set, there was an average surgery time of 2195 ± 896s, with a huge individual variance of different surgical phases. Notably, laparoscopic cholecystectomy in acute cholecystitis cases had prolonged overall durations, and the surgeon would spend more time in mobilizing the hepatocystic triangle phase. A deep-learning model based on multiple centers data can identify phases of laparoscopic cholecystectomy with a high degree of accuracy. With continued refinements, artificial intelligence could be utilized in huge data surgery analysis to achieve clinically relevant future applications.

An unusual case of acute cholecystitis following anterior lumbar interbody fusion

Abstract Introduction: Acute acalculous cholecystitis is also likely to occur in critical systemic conditions, such as trauma, burns, and postoperative situations. Here, we report a rare case of acute cholecystitis after anterior lumbar interbody fusion (ALIF). Patient concerns: A 75-year-old female experienced low-grade fever (&lt; 38.3°C), following ALIF of L4–5. On postoperative day 3, the patient exhibited acute jaundice without abdominal discomfort. Diagnosis: Laboratory investigations revealed elevated values for liver function tests and bilirubin levels (aspartate aminotransferase, 79 IU/L; alanine aminotransferase, 56 IU/L; total bilirubin, 7.6 mg/dL; and direct bilirubin 4.1 mg/dL), with no prominent abnormalities, such as stones or dilatation of the hepatobiliary tract, on abdominal computed tomography. However, endoscopic ultrasound revealed diffuse thickening of the gallbladder (GB) wall and large amounts of echogenic material in the GB lumen, suggesting acute cholecystitis with GB sludge. Interventions: Emergency endoscopic retrograde cholangiopancreatography and biliary drainage were performed by inserting a single-tail catheter through the biliary tract. Outcomes: Clinical symptoms, including skin jaundice and icteric sclera, gradually improved, and the patient was discharged 13 days after the surgery. Liver function tests and bilirubin levels were normalized in the final laboratory investigations during the hospitalization period (aspartate aminotransferase. 26 IU/L; alanine aminotransferase. 16 IU/L; total bilirubin, 2.1 mg/dL; direct bilirubin, 0.9 mg/dL; and C-reactive protein, 0.21 mg/dL). Conclusion: Spinal surgeons should be aware of the possibility of biliary complications after ALIF. In particular, postoperative cholecystitis in elderly patients has a poor prognosis; therefore, early diagnosis and intervention are the only ways to improve the prognosis.

COMPARISON OF OUTCOMES BETWEEN EARLY AND DELAYED LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS

Objective: To compare early versus delayed laparoscopic cholecystectomy in acute calculous cholecystitis in terms of mean operative time, hospital stay, conversion rate to open surgery and post-operative complications.&#x0D; Study Design: Quasi experimental study.&#x0D; Place and Duration of Study: Army Liver Transplant Unit, Department of Surgery, Pak-Emirates Military Hospital Rawalpindi, from Jul to Dec 2018.&#x0D; Methodology: A total of 170 patients (85 in each group) diagnosed as a case of acute calculous cholecystitis who met the sample selection criteria were included. Group A patients underwent early laparoscopic cholecystectomy within 72 hours of admission while group B patients underwent conservative management followed by delayed laparoscopic cholecystectomy after 6 weeks. All patients were followed for operative time, hospital stay, per-operative difficulties encountered and post-operative complications.&#x0D; Results: Group A had a mean operation time of 43.9 ± 11.1 minutes, while group B had a mean operation time of 45.8 ± 10.1 minutes (p=0.83). The mean duration of hospitalization was 2.8 ± 1.1 days in group A and 5.3 ± 0.8 days in group B (p&lt;0.001). Complications were measured at a frequency of 14.1% in group A and 5.9% in group B (p=0.07).&#x0D; Conclusion: Early laparoscopic cholecystectomy is better than delayed laparoscopic cholecystectomy in acute calculous cholecystitis in terms of hospital stay and per-operative difficulties faced. The post-operative complications between the two groups are comparable.

English

BACKGROUND Acute cholecystitis is a pathology of inflammatory origin, usually associated with cholelithiasis, with a high incidence in the world. Its treatment involves an important socioeconomic impact. There are two surgical therapeutic options: early laparoscopic cholecystectomy (ELC) done within 72 hours of onset of pain or delayed laparoscopic cholecystectomy (DLC) done after 6 weeks of conservative treatment. The present study intends to compare between the effectiveness of ELC vs DLC in the management of acute cholecystitis in a tertiary care setup. METHODS The study sample included 65 patients who were clearly documented and radiologically proven cases of acute calculous cholecystitis, met the inclusion criteria, admitted to the surgery department of MKCG MCH, Berhampur, between August 2018 and July 2020. Out of 65 patients, 33 and 32 patients were selected randomly for ELC and DLC respectively. In ELC group surgery was done within 72 hours of the onset of pain while in DLC group surgery was done after 6 weeks of initial conservative treatment. The study was conducted using a case record proforma, prepared in their local language. The questionnaire included timing of cholecystectomy, duration of antibiotic coverage, mean duration of hospital stay, number of intraoperative and postoperative complications, conversion to open cholecystectomy, and follow-up. The data was compiled and tabulated in MS ® Excel and statistically analysed using IBM ® SPSS 22.0. RESULTS The overall morbidity and mortality were less in ELC compared to DLC. The mean duration of surgery was less in ELC (47.36 minutes) compared to DLC (65.75 minutes). The mean duration of antibiotic coverage was lesser in ELC (3.58 days) compared to DLC (5.50 days).The mean hospital stay was less in ELC (4.67 days) to DLC (6.50 days). The overall morbidity and mortality were less in ELC. CONCLUSIONS ELC is considered to be a safe modality of treatment in patients with acute cholecystitis and leads to an economical treatment. KEYWORDS Acute Calculus Cholecystitis, Early Laparoscopic Cholecystectomy, Delayed Laparoscopic Cholecystectomy

A case of acute calculous cholecystitis with contained gall bladder perforation with pericholecystic collections extending to liver parenchyma

Gall bladder perforation is a serious complication of acute cholecystitis and represents an advanced stage of the disease. Its clinical presentation is varied and can range from non-specific symptoms to acute generalized peritonitis. In many cases, GB perforation in diagnosis during exploratory laparotomy for peritonitis and with no definite source identified. The presentation of gall bladder perforation can be indistinguishable from uncomplicated acute cholecystitis. A 60 yrs. old male with no known comorbidities presented to a tertiary care hospital with diffuse pain abdomen associated with vomiting and constipation of 04 days’ duration. Clinical evaluation revealed icterus and tenderness in right hypochondrium and generalized peritonitis. Lab investigations revealed conjugated type hyperbilirubinemia and elevated serum Lipase levels and normal Amylase levels. Initial USG revealed Acute acalculous cholecystitis with normal IHBR and normal CBD. Later NCCT abdomen and MRCP were done which revealed calculous cholecystitis with sealed off GB perforation IHBR, CBD, and normal pancreas. The patient was managed non-operatively and responded well. The inflammatory reaction of the peritoneum in bile peritonitis increases the absorption of the spilled conjugated bile from the peritoneal cavity. The conjugated type hyperbilirubinemia without dilatation of the bile duct on imaging examination was the sign of bile leakage into the peritoneal cavity.

Medical Image of the Month: Perforated Gangrenous Cholecystitis

No abstract available. Article truncated after 150 words. Clinical Scenario: A 47-year-old lady with a past medical history of hypertension, DVT on Xarelto, and methamphetamine use presented with a 3-day history of progressive right upper quadrant pain. Physical examination demonstrated marked right upper quadrant tenderness with palpation and significant rebound tenderness. A CT of the abdomen and pelvis without intravenous contrast demonstrated findings consistent with acute calculus cholecystitis with evidence of perforation and a pericholecystic abscess. The patient was taken emergently to the operating room where she underwent an open cholecystectomy which demonstrated perforated gangrenous cholecystitis with a large abscess in the gallbladder fossa. She was admitted to the ICU post-operatively due septic shock and did well with fluid resuscitation and antibiotic administration. Discussion: Acute cholecystitis is the most common acute complication of cholelithiasis and accounts for 3-9% of hospital admissions for acute abdominal pain. Eight to 95% of cases of acute cholecystitis are the result of a …

Acute acalculous cholecystitis: an unusual presentation of vitamin B12 deficiency

Paediatric cases of acute acalculous cholecystitis (AAC) are due to infectious diseases or immune mediated disorders. Hereby, we present a case of 6 months old infant who presented with excessive crying with irritability and tenderness over right hypochondrium region with a palpable liver. Investigations revealed AAC and anaemia. In the work-up of anaemia, vitamin B12 deficiency was diagnosed and after giving treatment with vitamin B12, anaemia resolved as well as AAC. Through this case report we intent to emphasize the possibility of vitamin B12 deficiency presenting as AAC.

Which Preoperative Findings Translate to a Positive Intraoperative Cholangiogram?

Background: The most common investigations used in the preoperative diagnosis of choledocholithiasis are ultrasound and liver function tests (LFTs). These modalities have a low sensitivity for detecting common bile duct stones among the intermediate-risk groups. Aim: The aim of the study is to identify preoperative findings which predict choledocholithiasis in intermediate-risk groups. Describe the implications of a positive intraoperative cholangiogram (IOC). Materials and Methods: A retrospective study of all consecutive laparoscopic cholecystectomies with IOC performed. Data were collected over the past 2 years between January 1, 2015, and December 31, 2016. Standard demographic variables, preoperative symptoms, LFTs, IOC findings, abdomen ultrasound, and postoperative symptoms were included in the study. Results: Of 237 laparoscopic cholecystectomies 23 cases were planned for IOC. The median age was 41 years. Seventeen cases were female. Indications were 12 biliary colic, eight gallstone pancreatitis, two cases of acute cholecystitis, and one case was for ascending cholangitis. Four cases had a positive IOC, and in this group, the median age was 44.5 years with one male. The mean common bile duct diameter was 6.5 mm. Two patients had biliary colic, one patient gallstone pancreatitis, and one acute cholecystitis. One patient had a history of jaundice, and all four cases had elevated gamma-glutamyl transferase (GGT) above 40 mmol/l, three cases had alkaline phosphatase (ALP) above 98 mmol/l. Postoperative, out of 23 cases, five cases had an endoscopic retrograde cholangiopancreaticogram, repeated ultrasound in three cases, persistence symptoms in four cases. Conclusions: GGT was the strongest predictor of choledocholithiasis. A normal GGT seems to be quite good at ruling out Cannabidiol stones. ALP was less accurate. Gallstone pancreatitis is not a good predictor, but it is importance to exclude choledocholithiasis before/during cholecystectomy. There is no relation between the IOC and persistent symptoms.

Increased incidence of acute calculous cholecystitis observed during COVID-19 social restrictions.

PurposeIn response to the outbreak of COVID-19 in Ireland, the government implemented a nationwide stay-at-home order, with the closure of all non-essential businesses. During this period, there was a significant increase in supermarket expenditure. It has been shown that stress, anxiety and boredom are triggers for unhealthy eating habits. Fat consumption is a risk factor for both the development of gallstones and, additionally, the development of acute calculous cholecystitis. The aim of this study was to assess the incidence of acute calculous cholecystitis during the nationwide lockdown and compare it to the same period one year prior.MethodsA retrospective review of all emergency abdominal imaging performed during the first 5 weeks of the lockdown was completed using the hospital PACS (picture archiving and communication system). All cases of acute calculous cholecystitis were identified and compared with the same period 1 year prior.ResultsEighteen cases of acute calculous cholecystitis were identified from 24 March to 27 April 2020. Eleven cases were identified during the same period in 2019. This represented an increase of 63%. Non-COVID-19-related emergency presentations decreased during this period, and imaging of emergency presentations decreased by 24%. The rate of scans positive for acute cholecystitis more than doubled (p < 0.037).ConclusionA statistically significant increase in cases of acute calculous cholecystitis was observed during a nationwide lockdown during the COVID-19 pandemic. It is hypothesised that this is due to increased consumption of fatty foods during this period due to stress, anxiety and boredom.

The utility of an under-distended gallbladder on ultrasound in ruling out acute cholecystitis.

To study the association between gallbladder dimensions and acute cholecystitis and to define a sensitive cutoff for excluding the disease. 456 consecutive patients with an abdominal ultrasound performed for right upper quadrant pain, from 1/2019 to 4/2019, were retrospectively collected. Length and width of the gallbladder were measured by a blinded radiology fellow. Patient charts were examined for prospective sonographic findings, clinical data, and pathology from subsequent cholecystectomy or at least 1month of follow-up with symptom resolution. Univariable and multivariable logistic regression analysis were conducted to define the association of gallbladder dimensions and other sonographic and clinical variables with acute cholecystitis. Optimal and sensitive cutoffs of gallbladder widths were defined. The determined sensitive cutoff was validated with a separate cohort of 501 consecutive patients. 319 patients (median age 48 ± 19years) including 11%, 19%, and 70% with acute, chronic, and no cholecystitis were included in the experimental cohort, respectively, and 298 patients (median age 50 ± 19years) including 10%, 12%, and 79% with acute, chronic, and no cholecystitis were included in the validation cohort, respectively. Of all sonographic findings and clinical data, gallbladder width produced the best univariate ROC curve with an AUC of 0.91 (Odds ratio 5.1, 95% CI 3.1-8.5, p < 0.001). 2.2cm was the gallbladder width cutoff below which there were no cases of acute cholecystitis in the experimental cohort. Multivariable logistic regression analysis using sonographic findings only produced an ROC curve with an AUC of 0.94. Applying the 2.2cm cutoff in the validation cohort resulted in 100% sensitivity. Lack of gallbladder distention, defined as a width less than 2.2cm, has potential to serve as a highly sensitive sign for exclusion of acute cholecystitis, regardless of additional sonographic findings and clinical data.

A Case of Acute Cholecystitis with a Communicating Accessory Bile Duct that was Diagnosed Preoperatively and Safely Underwent Surgery

A Case of Acute Cholecystitis with a Communicating Accessory Bile Duct that was Diagnosed Preoperatively and Safely Underwent Surgery

Bile duct injuries during urgent cholecystectomy: analysis of 1320 acute cholecystitis cohort

Introduction: Bile duct injuries (BDI) are feared and complex complications during cholecystectomies, adding major morbidity to patients. Literature reviews of BDI are based on retrospective small studies, usually in a non-urgent scenario. Furthermore, there is an expected difference of BDI incidence in cholecystectomies performed during acute cholecystitis (AC) episode due to its major surgical complexity. Our aim is to analyze the BDI incidence from our time-continued cohort of patients with AC. Methods: Single institution retrospective cohort study of AC cases, according to Tokyo Guidelines, from June 2010 until January 2021. Results: A total of 1320 patients were studied and 789 (59,8%) cholecystectomies were performed in this context. We found 20 cases (2,53%) of BDI. 95% of these had an ASA score > 2, median age of 66 years-old and most of them were male. 70% of them were operated by non-training staff with a median surgical time of 110 minutes. 90% of cases underwent laparoscopic surgery with a conversion rate of 15,8%. BDI were statistically associated to major severity grading and longer surgical time (p value <0,05). 19 of BDI were Strasberg Type A and there was only 1 Type E injury.Type A BDI were successfully treated with ERCP in 14 patients, 4 required surgeries and 1 patient percutaneous drainage. Type E BDI patient underwent surgery performing right hepatectomy and biliojejunal derivation. Unfortunately, this patient died during postoperative time being the only mortal case. Conclusions: Our BDI rate during AC episodes is lower than usual reports around 5%. ERCP was the definitive treatment in most patients. Prolonged operative time and severe AC cases should alert surgeons to prevent BDI.