Cases Of Cholecystitis Research Articles

Progression of Tokyo Guidelines and Japanese Guidelines for Management of Acute Cholangitis and Cholecystitis

The Japanese Guidelines for management of acute cholangitis and cholecystitis were published in 2005 as the first practical guidelines presenting diagnostic and severity assessment criteria for these diseases. After the Japanese version, the Tokyo Guidelines (TG07) were reported in 2007 as the first international practical guidelines. There were some differences between the two guidelines, and some weak points in TG07 were pointed out, such as low sensitivity for diagnosis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. Therefore, revisions were started to not only make them up to date but also concurrent with the same diagnostic and severity assessment criteria. The Revision Committee for the revision of TG07 (TGRC) performed validation studies of TG07 and new diagnostic and severity assessment criteria of acute cholangitis and cholecystitis. These were retrospective multi-institutional studies that collected cases of acute cholangitis, cholecystitis, and non-inflammatory biliary disease. TGRC held 35 meetings as well as international email exchanges with co-authors abroad and held three International Meetings. Through these efforts, TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The world's first management bundles of acute cholangitis and cholecystitis were also presented. The revised Japanese version was published with the same content as TG13. An electronic application of TG13 that can help to diagnose and assess the severity of these diseases using the criteria of TG13 was made for free download.

TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis

In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the Journal of Hepato-Biliary-Pancreatic Surgery. The fundamental policy of TG07 was to achieve the objectives of TG07 through the development of consensus among specialists in this field throughout the world. Considering such a situation, validation and feedback from the clinicians' viewpoints were indispensable. What had been pointed out from clinical practice was the low diagnostic sensitivity of TG07 for acute cholangitis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. In June 2010, we set up the Tokyo Guidelines Revision Committee for the revision of TG07 (TGRC) and started the validation of TG07. We also set up new diagnostic criteria and severity assessment criteria by retrospectively analyzing cases of acute cholangitis and cholecystitis, including cases of non-inflammatory biliary disease, collected from multiple institutions. TGRC held meetings a total of 35 times as well as international email exchanges with co-authors abroad. On June 9 and September 6, 2011, and on April 11, 2012, we held three International Meetings for the Clinical Assessment and Revision of Tokyo Guidelines. Through these meetings, the final draft of the updated Tokyo Guidelines (TG13) was prepared on the basis of the evidence from retrospective multi-center analyses. To be specific, discussion took place involving the revised new diagnostic criteria, and the new severity assessment criteria, new flowcharts of the management of acute cholangitis and cholecystitis, recommended medical care for which new evidence had been added, new recommendations for gallbladder drainage and antimicrobial therapy, and the role of surgical intervention. Management bundles for acute cholangitis and cholecystitis were introduced for effective dissemination with the level of evidence and the grade of recommendations. GRADE systems were utilized to provide the level of evidence and the grade of recommendations. TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The bundles for the management of acute cholangitis and cholecystitis are presented in a separate section in TG13. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

A Case of Acute Cholecystitis Combined with Eosinophilic Pericarditis Caused by Toxocariasis

Correspondence to Hyun Jong Choi, M.D. Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea Tel: +82-32-621-5211, Fax: +82-32-621-5080, E-mail: joseph@schmc.ac.kr Copyrightc 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 개회충증에 의하여 유발된 호산구성 심장막염을 동반한 급성 담낭염 1예

Emphysematous cholecystitis with massive gas in the abdominal cavity

Emphysematous cholecystitis is a rare variant of acute cholecystitis with a high mortality rate. The combination of emphysematous cholecystitis and pneumoperitoneum is also rare. We herein describe a case of emphysematous cholecystitis with massive gas in the abdominal cavity. A 77-year-old male presented with epigastric pain and lassitude lasting for one week. A computed tomography scan demonstrated massive gas in the abdominal cavity. Gas was also detectable inside the gallbladder. Massive ascites as well as a pleural effusion were also detected. Under the diagnosis of perforation of the digestive tract, we performed emergency surgery. Beyond our expectations, the perforation site was not in the alimentary tract, but rather in the gallbladder. We then diagnosed the patient with emphysematous cholecystitis with perforation, and performed cholecystectomy. A pathological examination of the resected gallbladder revealed necrosis in the mucosa and thinning of the wall. Cultures of the ascites detected Clostridium perfringens, a gas-producing microorganism.

Two Cases of Acute Cholecystitis Developing After Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery

Two Cases of Acute Cholecystitis Developing After Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery

A Case of Acute Cholecystitis after Colonoscopy

A 43-year-old man, who received total gastrectomy five years ago for advanced gastric cancer, underwent a screening colonoscopy and abdominal CT scan. Abdominal CT scan revealed no abnormal findings. Colonoscopy revealed polyps at the rectum, which were removed by polypectomy. The patient did not complain of abdominal pain or discomfort throughout the procedure. But, he developed right upper quadrant abdominal pain on the next day after colonoscopy. Abdominal CT scan revealed the distended gallbladder with mild wall thickening and suspicious sandy stones or sludge in the gallbladder. The patient underwent an open cholecystectomy. Pathology was compatible with acute cholecystitis. We should be aware of and consider cholecystitis in the differential diagnosis for patients with abdominal pain after colonoscopy.

The Correlation between Ultrasonography and Histopathology in the Management of Gall Bladder Polyps

Introduction : The diagnosis of gall bladder polyps has increased greatly due to widespread implementation of abdominal ultrasound.Patients and methods : Between February 2005 and February 2010 a total of 39 laparoscopic cholecystectomies were performed for suspected gall bladder polyps. We retrospectively analysed these patients pre-operative ultrasound and histopathology report.Results : The study comprised 10 male and 29 female symptomatic patients with a mean age of 51.4 years. Histo-pathology demonstrated seven true polyps and 23 pseudopolyps. There were no cases of malignant specimens and nine cases of chronic cholecystitis. The positive predictive value (PPV) of ultrasonography for gall bladder polyps was 0.77 and the PPV for true polyps 0.18.Conclusion : PPV for the identification of true gallbladder polyps using ultrasound remains very low at 0.18. We suggest that more advanced imaging modalities are required to improve this figure and enhance patient management.

門脈血栓症を伴った急性胆嚢炎の1例

門脈血栓症を伴った急性胆嚢炎の1例

Acute Acalculous Cholecystitis in a 10-Year-Old Girl With Cystic Fibrosis

Acute acalculous cholecystitis is uncommon in pediatrics and more likely to be encountered in adult patients. Signs and symptoms of acute cholecystitis are similar to other causes of acute abdominal pain such as pancreatitis, gastritis, and acute appendicitis, further making diagnosis difficult. We present a case of acute acalculous cholecystitis in a child with cystic fibrosis and discuss the role of emergency physician bedside sonography in the evaluation of right-upper-quadrant pain.

Lactobacillus fermentum, a pathogen in documented cholecystitis

INTRODUCTIONLactobacillus species are probiotics proven to exhibit various preventative as well as therapeutic properties. While lactobacillus species have been implicated in the formation of dental caries, endocarditis and bacteremia, their role as pathogens in cholecystitis has not been reported. We present a rare case of Lactobacillus fermentum working as a pathogen in cholecystitis. PRESENTATION OF CASEAn 81-year old male was admitted with right upper quadrant abdominal pain. His signs, symptoms, laboratory values and imaging were consistent with a diagnosis of cholecystitis with ascending cholangitis. In view of his co-morbidity and severe sepsis, the patient was treated non-operatively with antibiotics and cholecystostomy. L. fermentum, which was vancomycin resistant, was identified from the cholecystostomy aspirate and from anaerobic blood culture. The patient went into septic shock, developed multi-organ dysfunction syndrome and eventually died. DISCUSSIONCommensal bacteria such as L. fermentum are known to modulate immunity, reduce the pathogenicity of gastrointestinal organisms and play a therapeutic role in various disease processes. We isolated L. fermentum as a pathogen in a documented case of cholecystitis with ascending cholangitis. CONCLUSIONWhile the routine use lactobacillus species as a probiotic is supported in the literature, understanding its potential role as a pathogen may allow more judicious use of these bacteria and encourage research to elucidate the pathogenicity of lactobacillus species.

Acute Acalculous Cholecystitis due to Viral Hepatitis A

Inflammation of the gallbladder without evidence of calculi is known as acute acalculous cholecystitis (AAC). AAC is frequently associated with gangrene, perforation, and empyema. Due to these associated complications, AAC can be associated with high morbidity and mortality. Medical or surgical treatments can be chosen according to the general condition of the patient, underlying disease and agent. Particularly in acute acalculous cholecystitis cases, early diagnosis and early medical treatment have a positive effect on the patient and protect them from surgical trauma. ACC is a rare complication of acute viral hepatitis A. Herein, we present an adult patient of acalculous cholecystitis due to acute viral hepatitis A. She responded to the conservative management.

A Case of Pantoea species Cholangitis with Bacteremia

Pantoea infections are rare in humans and an unusual cause for sepsis in immunocompetent patient. It is a gram-nagative bacillus of the family Enterobacteriaceae. Infections are usually associated with plant thorn injury or outbreak traced to comtaminated par enteral nutrition. We experienced a case of pantoea species cholecystitis and cholangitis with bacteremia. The patient was adminis trated intravenous antibiotics, and then patient was improved.

PERINEURAL LYMPHOID INFILTRATION IN CHRONIC PANCREATITIS, PANCREATIC ADENOCARCINOMA AND CHRONIC CHOLECYSTITIS

Objective: to study the quantitative and qualitative composition of perineural lymphoid infiltration in chronic pancreatitis and pancreatic cancer. Methods. The histological specimens of 28 patients with chronic pancreatitis, 12 patients with pancreatic cancer and 1 patient with chronic cholecystitis who had undergone the surgery of the head of pancreas were studied. Immunohistochemical expression of CD-45, CD-20, CD-5, CD-3 and CD-79 was studied in 14 cases (10 cases of chronic pancreatitis, 3 cases of pancreatic adenocarcinoma in chronic pancreatitis background disease and 1 case of chronic cholecystitis). Results. Hyperplasia and hypertrophy of nerve trunks in the pancreas and parapancreatic adipose tissue were detected in 26 of 28 cases of chronic pancreatitis, in 9 of 12 cases of pancreatic cancer and in 1 case of chronic cholecystitis. The perineural lymphoid infiltration was revealed in more than a half of the revealed cases. The considerable variability of qualitative and quantitative cell composition of perineural infiltrate was determined in chronic pancreatitis. Conclusion. The reparative hyperplasia and hypertrophy of nervous tissue is the consequence of primary enzymatic damage of myelin sheaths of nerves in pancreas during acute conditions of chronic pancreatitis. These changes of nerve trunks are accompanied by the development of an autoimmune response which is probably the cause of pancreatic pain in the period between exacerbations of chronic pancreatitis. The ratio of T-cells and B-cells in perineural infiltrate is probably caused by different duration of pathological process.

First Report of Human Acute Acalculous Cholecystitis Caused by the Fish Pathogen Lactococcus garvieae

We report herein the first case of acute acalculous cholecystitis caused by Lactococcus garvieae, which is known as a fish pathogen. A 69-year-old fisherman underwent laparoscopic cholecystectomy due to severe inflammation in the gallbladder. The isolate obtained from the gallbladder was identified as L. garvieae by 16S rRNA and manganese-dependent superoxide dismutase (sodA) gene sequence analysis.

Obesity, dyslipidemia and cholesterol gallstone disease during one year of Antarctic residence

Age, gender, ethnicity, geographic location, diet, obesity, diabetes mellitus and dyslipidemia are known risk factors for development of gallstone disease (GD). We describe the development of four cases of symptomatic GD including a case of acute cholecystitis in Indian Antarctic expedition members during 1 year of polar residence and their response to 6 months of ursodeoxycholic acid (UDCA) therapy. Twenty subjects were evaluated at baseline and at serial intervals using clinical history, dietary assessment, anthropometry, blood investigations and ultrasonography for development of gallstone disease. Ursodeoxycholic acid and lipid lowering agents were prescribed as indicated and response to therapy measured over a period of 1 year in Antarctica. Four cases of cholesterol GD and two cases of biliary sludge were detected after 4 months. Dyslipidemia including hypertriglyceridemia in four of 20 cases (20%), hypercholesterolemia in nine of 20 cases (45%) and low high density lipoprotein (HDL) cholesterol in six of 20 cases (30%) was seen to develop after 3 months of polar residence. Impaired glucose tolerance was found in three of 20 cases (15%), two of whom developed gallstones. Ursodeoxycholic acid therapy completely dissolved gallstones in three cases and led to partial resolution in one case at 6 months. A trial of lipid lowering agents and 1 month of UDCA led to resolution of biliary sludge in both cases. Obesity, dyslipidemia, impaired glucose tolerance and high fat and caloric intake were found to increase the risk of developing cholesterol GD during the Antarctic expedition. Ursodeoxycholic acid therapy was found to be efficacious in dissolution of gallstones and prevention of formation of larger stones in cases with gall bladder sludge. The effect of geographical factors such as exposure to colder environments on the development of GD needs further research.

Covering the Cover

Covering the Cover

Short-term effectiveness of radiochemoembolization for selected hepatic metastases with a combination protocol.

To introduce the combination method of radiochemoembolization for the treatment of selected hepatic metastases. Twenty patients with biopsy proven hepatic metastases were selected from those who underwent transarterial radiochemoembolization, a novel combination protocol, between January 2009 and July 2010. Patients had different sources of liver metastasis. The treatment included transarterial administration of three chemotherapeutic drugs (mitomycin, doxorubicin and cisplatin), followed by embolization with large (50-150 μm) radioisotope particles of chromic 32P. Multiphasic computer tomography or computer tomography studies, with and without contrast medium injections, were performed for all patients for a short-term period before and after the treatment sessions. The short-term effectiveness of this procedure was evaluated by modified response evaluation criteria in solid tumors (mRECIST), which also takes necrosis into account. The subjective percentage of necrosis was also assessed. The response evaluation methods were based on the changes in size, number, and the enhancement patterns of the lesions between the pre- and post-treatment imaging studies. Patients had liver metastasis from colorectal carcinomas, breast cancer, lung cancer and carcinoid tumors. The response rate based on the mRECIST criteria was 5% for complete response, 60% for partial response, 10% for stable disease, and 25% for progressive disease. Regarding the subjective necrosis percentage, 5% of patients had complete response, 50% had partial response, 25% had stable disease, and 20% had progressive disease. Based on traditional RECIST criteria, 3 patients (15%) had partial response, 13 patients (65%) had stable disease, and 4 patients (20%) had disease progression. In most patients, colorectal carcinoma was the source of metastasis (13 patients). Based on the mRECIST criteria, 8 out of these 13 patients had partial responses, while one remained stable, and 5 showed progressive disease. We also had 5 cases of breast cancer metastasis which mostly remained stable (4 cases), with only one partial response after the procedure. Six patients had bilobar involvement; three of them received two courses of radiochemoembolization. The follow up imaging study of these patients was performed after the second session. In the studied patients there was no evidence of extrahepatic occurrence, including pulmonary radioactive deposition, which was proven by Bremsstrahlung scintigraphy performed after the treatment sessions. For the short-term follow-ups for the 2 mo after the therapy, no treatment related death was reported. The mostly common side effect was post-embolization syndrome, presented as vomiting, abdominal pain, and fever. Nineteen (95%) patients experienced this syndrome in different severities. Two patient had ascites (with pleural effusion in one patient) not related to hepatic failure. Moreover, no cases of acute liver failure, hepatic infarction, hepatic abscess, biliary necrosis, tumor rupture, surgical cholecystitis, or non-targeted gut embolization were reported. Systemic toxicities such as alopecia, marrow suppression, renal toxicity, or cardiac failure did not occur in our study group. Radiochemoembolization is safe and effective for selected hepatic metastases in a short-term follow-up. Further studies are required to show the long-term effects and possible complications of this approach.

Analysis of Factors Which Reduce Operation Time in Performance of Single Incision Laparoscopic Cholecystectomy

Purpose: Single-incision laparoscopic surgery (SILS) is a rapidly evolving technique which bridges traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). We previously published a study comparing single port laparoscopic cholecystectomy (SPLC) and three port laparoscopic cholecystectomy (TPLC). We concluded that age, sex, diagnosis, body mass index (BMI), length of hospital stay, and mobilization between SPLC and TPLC produced no effect on the surgical requirements or outcomes between the two techniques. However, there were significant differences in operating time and pain scale. Thus, in this study we aimed to analyze those factors which reduced operating time. Methods: This retrospective medical record review enrolled 49 patients who had received SPLC at Presbyterian Medical Center from April 2009 to November 2010. Patient age, sex, BMI, length of hospital stay, operating time, pathological reports, and incidents of iatrogenic gallbladder (GB) perforation and complications were assessed and analyzed. For determining those factors which necessitated long operating times, we assessed the operating times relative to incidents of iatrogenic GB perforation, pathologic report results, surgeon experience and patient BMI. Results: The ratio of men to women in the study population was 1 : 6. The average patient age was 46 years (range of 21 to 93 years). The average BMI was 24.1 (range of 18.5 to 31.5). The mean duration of hospital stay was 5.12 days (range of 2 to 15 days). The average operating time was 118 minutes (range of 75 minutes to 185 minutes). The pathologic report assessments revealed cases of acute calculous cholecystitis (n=4, 8.2%), chronic calculous cholecystitis (n=37, 76.1%) and GB polyp (n=8, 16.3%). Iatrogenic perforation of the GB occurred in 5 cases. Minor complications such as surgical site infection and umbilical skin burn occurred in 6 cases. Longer operating times were required in the GB perforation cases than in the non-perforation cases (155±21.21 minutes versus 113.9±30.71 minutes, p=0.008). Of the cases of acute and chronic calculous cholecystitis and GB polyp, those including acute calculous cholecystitits required the longest operation times. The average operating time for the first 25 cases was 134.6±33.16 minutes and the average operating time for the remainder was 100.8±20.41 minutes (p=0.001). There was no significant difference in operating time between the BMI＞24 and BMI＜24 groups (125.9±35.17 minutes versus 111.2±27.65 minutes, respectively, p=0.112). Conclusion: We found 3 factors related to a reduction in operation time: (i) avoidance of iatrogenic perforation of the GB, (ii) application of treatment to case of chronic calculous cholecystitis and GB polyp, and (iii) accumulation of case experience by the attending surgeon.

Outcomes of patients with histologically proven acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is traditionally described in the setting of critical illness, where the diagnosis is based on clinical assessment and imaging criteria. Very few studies have assessed the features and outcomes of AAC in patients treated by cholecystectomy. Patients with histologically confirmed acute cholecystitis treated in a specialized unit in a tertiary hospital between 2005 and 2011 were identified from prospectively maintained database. Retrospective review of data was undertaken and patients with AAC were compared with those patients with acute cholecystitis and confirmed gallstones. AAC was identified in 35 of 412 (8.5%) patients with acute cholecystitis. These patients were older (69 years versus 61 years; P = 0.004) and were more likely to be febrile (46% versus 21%; P = 0.001) and hypotensive (23% versus 5%; P < 0.001) at initial presentation. There was a higher incidence of chronic obstructive airways disease (COAD) in the AAC group (26% versus 6%; P < 0.001). Other co-morbidities were similar among the groups. Operative outcomes were similar between the groups. There were no overall differences in postoperative complications between AAC and calculous acute cholecystitis patients (17% versus 16%; P = 0.063). However, the postoperative length of stay was higher in the AAC group (5 days versus 3 days; P = 0.026). AAC more commonly occurs in older patients and those with COAD. The operative outcomes and complications of AAC treated by cholecystectomy are similar to cases of acute calculous cholecystitis.

Case of emphysematous cholecystitis in a patient with type2 diabetes mellitus associated with schizophrenia.

Emphysematous cholecystitis is a rare, but life-threatening, form of acute cholecystitis caused by gas-forming organisms in the gallbladder. A 73-year-old male patient with type2 diabetes mellitus complicated with neuropathy associated with schizophrenia was admitted to Okayama University Hospital, Okayama, Japan, because of a high fever and general malaise. On the fourth hospital day, despite normal liver function tests and little abdominal pain, his abdominal computed tomography showed huge gas formation in the gallbladder lumen along with a dilated gallbladder with a thickened wall, consistent with emphysematous cholecystitis. The patient underwent an emergency open cholecystectomy. Few abdominal symptoms appeared because of the hyposensitivity to pain caused by not only diabetic neuropathy, but also antipsychotic agents the patient was taking for schizophrenia. Emphysematous cholecystitis should be taken into consideration for the differential diagnosis of high fever in diabetic patients with schizophrenia, irrespective of the level of liver function tests and clinical symptoms.