Complication Of Acute Cholecystitis Research Articles

Hepatobiliary rim sign

The role of a 'rim sign' in increasing specificity for acute cholecystitis and sensitivity for complicated acute cholecystitis has been substantiated in many small retrospective studies. We sought to corroborate this correlation in a large population, as we have encountered doubt among surgeons about the emergent implications of this sign. We performed a small pilot interobserver reliability test with five nuclear medicine physicians from outside institutions. A total of 2881 consecutive hepatobiliary scans performed over 12 years for evaluation of acute cholecystitis were retrospectively reviewed. Available pathological (reference standard) and surgical reports were reviewed for all cases of acute cholecystitis (on scintigraphy) with a rim sign and for an equivalent set without a rim sign. There was no statistically significant interobserver agreement on the presence of a rim sign. There was a 32.4% incidence of acute cholecystitis, based on scintigraphy, and a 10.1% incidence of rim signs. Of 63 pathologic specimens from rim-sign-positive cases, 19 (30.2%) showed acute cholecystitis and 44 (69.8%) showed chronic cholecystitis. Six (9.5%) cases were complicated. Among 55 pathologic specimens from the acute scintigraphy cases without a rim sign, 21 (38.2%) showed acute cholecystitis and 34 (61.8%) showed chronic cholecystitis. There were eight (14.5%) complicated cases. There was no interobserver reliability in the identification of a rim sign. There was almost no difference in the incidence of pathologically acute, chronic, or complicated acute cholecystitis among scintigraphically acute cases with or without a rim sign, approximately two-thirds to three-quarters of which were chronic on pathological evaluation.

Single-incisionvsthree-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis

To compare the clinical outcome of single-incision laparoscopic cholecystectomy (SILC) and three-incision laparoscopic cholecystectomy (3ILC) for acute cholecystitis. From July 2009 to September 2012, 136 patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital. One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes, straight instruments, and conventional ports. Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded. The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings. Patient demography, clinical data, operative results and complications were recorded and analyzed. Fifty patients with gangrenous cholecystitis, gallbladder empyema, or hydrops were classified as the complicated group, and 58 patients with acute cholecystitis were classified as the uncomplicated group. Twenty-three (46.0%) of the patients in the complicated group (n = 50) and 39 (67.2%) of the patients in the uncomplicated group (n = 58) underwent SILC; all others underwent 3ILC. The postoperative length of hospital stay (PLOS) was significantly shorter in the SILC subgroups than the 3ILC subgroups (3.5 ± 1.1 d vs 4.6 ± 1.3 d, P < 0.01 in the complicated group; 2.9 ± 1.1 d vs 3.7 ± 1.4 d, P < 0.05 in the uncomplicated group). The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups, but the difference reached statistical significance only in the uncomplicated group (37.41 ± 0.56 °C vs 37.80 ± 0.72 °C, P < 0.05 on postoperative day 1; 37.10 ± 0.43 °C vs 37.57 ± 0.54 °C, P < 0.01 on postoperative day 2). The operative time, estimated blood loss, postoperative narcotic use, total length of hospital stay, conversion rates, and complication rates were similar in both SILC and 3ILC subgroups. The complicated group had longer operative time (122.2 ± 35.0 min vs 106.6 ± 43.6 min, P < 0.05), longer PLOS (4.1 ± 1.3 d vs 3.2 ± 1.2 d, P < 0.001), and higher conversion rates (36.0% vs 19.0%, P < 0.05) compared with the uncomplicated group. SILC is safe and efficacious for patients with acute cholecystitis. The main benefit is a faster recovery than that achieved with 3ILC.

Spontaneous gall bladder perforation masquerading as a large abdominal lump: An uncommon presentation of a common entity

Gall bladder perforation (GBP) is an uncommon complication of acute cholecystitis. Usually patients with GBP present with localized or diffuse peritonitis defending on their ability to localise the site of perforation. We recently cared for a 65-year-old female with GBP who presented to us with a painful large anterior abdominal lump and jaundice. On investigations, a large subcapsular liver collection was identified along with a perforation at the fundus of gall bladder and a calculus at the lower end of the common bile duct (CBD). The patient underwent pigtail catheter drainage of the collection under ultrasound guidance, endoscopic retrograde cholangiopancreatography, and papillotomy for CBD stone retrieval, followed by elective laparoscopic cholecystectomy with uneventful recovery. This case report highlights the fact that in a patient with gall stone disease presenting with a painful abdominal lump, the possibility of underlying GBP should be considered and the treatment should be individualised based on clinical condition of the patient.

SPONTANEOUS PERFORATION OF THE GALL BLADDER: A CASE REPORT

Gall bladder perforation is a rare but life-threatening complication of acute cholecystitis.1 Two per cent of patients undergoing cholecystectomy are found to have perforation of the gall bladder. It occurs in 10% of patients who are being treated conservatively.2 Most studies in which the patients are generally aged 60 or more. Studies reported a mortality rate of 42%, others have reported mortality to be between 12 and 16%.3,4,5 Due to the high mortality that can be caused by a delay in the correct diagnosis and following adequate surgical treatment, gallbladder perforation represents a special diagnostic and surgical challenge.6 Most cases can only be diagnosed during surgery7,8,9. We report one such case which was diagnosed as gall bladder perforation.

Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.

Backgrounds/AimsIn the treatment of complicated cholecystitis, laparoscopic cholecystectomy (LC) has limited efficacy due to its substantial post-operative complications. In addition, the clinical characteristics of complicated cholecystitis (CC) patients were suspected as advanced age with highly risky comorbidity. Percutaneous transhepatic gall bladder (PTGBD) drainage could be an alternative option for successful LC. Hence, this study evaluated the outcome of PTGBD for CC within and after 5 days.MethodsThe medical records of 109 consecutive CC patients who had undergone an LC between January 2007 and December 2011 were retrospectively reviewed and compared with the medical records of CC patients who had undergone an LC within 72 hours of (group I, n=63) or 5 days after PTGBD (group II, n=40). In addition, group I was divided into group Ia (n=46) and group Ib (n=17), according to the patients' development of open-conversion or post-operative complications. The clinical outcomes of the four groups were analyzed.ResultsThere was a significantly higher reference to age, the ASA score grading, and predominant comorbidities in group II than in group I. The peri-operative results of group II showed lower blood loss and relatively shorter operating times than those of group I. In the cases of early LC within 72 hours (group Ia vs. group Ib), the difference was statistically insignificant.ConclusionsThe delayed LC after PTGBD for complicated cholecystitis with high clinical risk had better results in this study, although it prolonged the patient's hospital stay.

Spontaneous healing of gallbladder perforation: Report of a case

Gallbladder perforation is a serious complication of acute cholecystitis. Spontaneous healing is very rare, and only three cases have been reported in the English literature. In this study, we present a 73-year-old female patient who underwent a laparoscopic cholecystectomy years after a gallbladder perforation and spontaneous healing.

急性胆嚢炎に合併した高度溶血を伴うClostridium perfringens 敗血症の1例

急性胆嚢炎に合併した高度溶血を伴うClostridium perfringens 敗血症の1例

CT Findings of Acute Cholecystitis and Its Complications

The purpose of this article is to describe and illustrate the CT findings of acute cholecystitis and its complications. CT findings suggesting acute cholecystitis should be interpreted with caution and should probably serve as justification for further investigation with abdominal ultrasound. CT has a relatively high negative predictive value, and acute cholecystitis is unlikely in the setting of a negative CT. Complications of acute cholecystitis have a characteristic CT appearance and include necrosis, perforation, abscess formation, intraluminal hemorrhage, and wall emphysema.

Gallstone Liver Abscess Secondary to Gallbladder Perforation

We present an unusual case of a pyogenic liver abscess containing gallstones caused by perforation from an inflamed gallbladder and spread of the infection into the liver. It was manifested by right upper quadrant abdominal pain, nausea, and vomiting for approximately 1 month. Ultrasound and computerized tomography demonstrated the finding however unappreciated, and the diagnosis was confirmed by laparoscopy. Open drainage and cholecystectomy were done, with good outcome. There have been very few reports in the literature of intrahepatic perforation of the gallbladder resulting in formation of hepatic abscess. The presentation, diagnosis, and management of liver abscesses, as well as the complications of acute cholecystitis are discussed.

Laparoscopic cholecystectomy in the elderly

Methods We conducted a retrospective study evaluating the medical records of 40 consecutive patients age 70 or older who underwent laparoscopic cholecystectomy at the Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, Oncology Surgery Unit, University of Catania, Italy. Data included age and gender, American Society of Anaesthesiologists (ASA) score, comorbid illness, prior abdominal surgery, presentation, operative time, conversion rate and reasons for conversion, postoperative morbidity and mortality rates, pathologic diagnosis, and length of hospital stay. Patients were classified as having complicated (acute cholecystitis, biliary pancreatitis, obstructive jaundice, and cholangitis) or uncomplicated (biliary pain) gallstone disease. Ultrasonography evidence of a dilated common duct or presence of common duct stones, serum elevations in alkaline phosphatase, transaminase, or bilirubin were indications for preoperative magnetic resonance cholangiography. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with removal of possible common duct stones was performed in the patients suspected of having choledocholithiasis. The timing for LC in patients with acute cholecystitis was 24–72 hours from admission. Patients with acute pancreatitis related to gallstone disease underwent surgery after resolution of clinical and biochemical symptoms. The supportive treatment during the acute phase consisted of intravenous infusion, antibiotics, and nasogastric suction when necessary. Early surgery was defined as laparoscopic cholecystectomy during the initial hospitalization usually within 5 days, whereas patients undergoing delayed surgery were treated conservatively, discharged, and readmitted for elective operation. Patients were included if surgery was performed primarily for symptomatic gallstone disease and excluded if cholecystectomy was performed incidentally or secondary to another procedure. Laparoscopic cholecystectomy was performed using a standard four-trocars technique. An open technique was used in all cases to introduce the subumbilical cannula as previously described by our group. Dissection of the gallbladder from the liver was accomplished using monopolar electrocautery. Intraoperative cholangiography was performed selectively to assist in defining the anatomy or intraoperative abnormalities. A closed suction drainage was used in all procedures.

Impact of Delayed Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage for Patients With Complicated Acute Cholecystitis

Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis is associated with high rates of complications and conversion to open cholecystectomy. Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe and effective treatment for acute inflammation of the gallbladder. This study was a retrospective analysis of patients who underwent an LC with or without PTGBD for complicated acute cholecystitis at our hospital between January 2002 and January 2007. Patients were classified into 3 groups: group 1, patients who underwent an LC without preoperative PTGBD (n=60); group 2, patients who underwent an early scheduled LC within 7 days of PTGBD (n=35); and group 3, patients in whom the LC was delayed for a mean of 19.9 days (range, 14 to 39 d) after PTGBD (n=38). The conversion rate to open cholecystectomy and the postoperative complication rate were lower in group 3 than in group 1 (P<0.05). Elective delayed LC after PTGBD may lower the conversion and complication rates of patients with complicated acute cholecystitis.

Beneficial Effect of Cholecystography following PGBD for Complicated Acute Cholecystitis: Detection of Unsuspected CBD Stone

Purpose: Frequency of combined CBD stones on cholelithiasis has been known to range 520% in several reports, and diagnostic tools are USG, MDCT, MRCP and ERCP. Predictive factors of CBD stone for cholelithiasis were diameter of CBD, elevated liver enzyme, multiple small sized GB stones and concurrent pancreatitis. However, unsuspected CBD stone for acute cholecystitis is troublesome for patients and surgeons. Methods: We retrospectively reviewed Percutaneous gallbladder drainage (PGBD) for acute complicated cholecystitis from October 1996 to October 2006. Indications for PGBD are clinical symptoms (sepsis) & signs of peritonitis and radiologic findings such as GB empyema, gangrenous cholecystitis and pericholecystic fluid collection. Total laparoscopic cholecystectomy was 1,357 cases, and PGBD for acute complicated cholecystitis was 13.8%. Results: Combined CBD stone rate was 13.6%. Whereas, unsuspected CBD stone was 0.5% (9 cases), 7 in calculous and 2 in acalculous cholecystitis. No. of stone was 1 in 7 cases, 2 in 1 case and 3 in 1 case. Size of stone was less than 5 mm in all cases. Diameter of CBD was not increased in all cases (less than 1 cm) and liver enzymes showed no elevation in all cases. Management for unsuspected CBD stone was preoperative endoscopic lithotripsy in 8 cases and postoperative fluoroscopic lithotripsy in 1 case. Conclusion: Cholecystography following PGBD for acute complicated cholecystitis is a useful diagnostic modality for detection of unsuspected CBD stone.

The association between body mass index and the severity of cholecystitis

Background Severe cholecystitis occurs more frequently in males, and the cause of this discrepancy is unknown. Methods A retrospective study was performed on 910 consecutive patients who underwent laparoscopic cholecystectomy for cholecystitis. The patients were classified according to body mass index (BMI) as obese (n = 354, BMI ≥25 kg/m 2) and nonobese (n = 556; BMI <25). Results In males, there was a significant negative correlation between the BMI and the severity of cholecystitis; the proportion of complicated acute cholecystitis was higher in the nonobese patients (21.5%) compared with the obese patients (8.1%) ( P = .007) but not for the females ( P = .80). A BMI <25 (odds ratio [OR] = 1.92, P = .01), advanced age (OR = 2.52, P < .001), male sex (OR = 1.74, P = .022), and leukocytosis (OR = 1.92, P = .024) were independent predictors for the development of complicated acute cholecystitis. Conclusion There is a negative association between BMI and the inflammation severity of cholecystitis in males, which resulted in a higher incidence of severe cholecystitis in the nonobese male patients.

Empyema with giant dilatation of the gallbladder

INTRODUCTION: Gallbladder empyema is a serious complication of acute cholecystitis being peritonitis and sepsis it's main clinical consequences. Organ giant volume is rare specially with no relevant symptoms. CASE REPORT: Man 56-year-old with mild abdominal pain on the right hypochondrium, palpable gallbladder and ultrasound images revealing cholelithiasis. At surgery, there was a giant dilatation of the gallbladder with 580 mL of purulent bile. Cholecystectomy was carried out without post-operative complications. CONCLUSION: Early cholecystectomy should always be realized in patients presenting symptoms of gallbladder empyema no matter the size of it.

Early operation for acute gallbladder as a therapeutic principle

Between 1 January 1969 and 30 June 1984 904 patients with acute cholecystitis were treated as inpatients. Including 1976, initial treatment was conservative, and interval operation was recommended after 6-8 weeks. Commencing in 1977 early operation was preferred. Immediate operation within a few hours after admission and preparation for operation was done only in threatening or demonstrable complications of acute cholecystitis. Multimorbidity was highest (39%) in conservatively treated patients (n = 204), it was 26% in immediately operated patients (n = 201) and 23% in patients operated in the interval (n = 199). Early operation (n = 300) was associated with a multimorbidity of only 13%. Postoperative complications occurred most frequently (33%) after immediate operation, and in only 11% after early operation. Exploration of the choledochus was required in 27% of immediately operated cases and in only 19% of early and interval operations. Mortality after exclusively conservative treatment was 3%, after immediate operation 16%, after interval operation 3% and after early operation only 1.3%. Follow-up assessment of 137 primarily non-operated patients (7-15 years) showed a mortality of 48% on subsequently necessary immediate operation (16 out of 33 patients). No symptoms were seen in 14 out of 32 patients, only two of them had no gallstones. The high reliability of establishing the diagnosis (98% correct diagnosis) justifies early operation as preferred concept of treatment. Primary conservative treatment of acute cholecystitis and subsequently planned interval operation should be limited to justifiable exceptions.

A rare complication of acute cholecystitis: transhepatic perforation associated with massive intraperitoneal hemorrhage

A 2 to 11% of the patients with acute cholecystitis that will develop gallbladder perforation and massive intraperitoneal hemorrhage as a result of perforation will rarely be seen. Massive intraperitoneal hemorrhage associated with the transhepatic perforation is very uncommon. By this article, we anticipate presenting clinical and radiological findings in a case that has acute cholecystitis with massive intraperitoneal hemorrhage associated with transhepatic perforation.

Partial Cholecystectomy as a Safe and Viable Option in the Emergency Treatment of Complex Acute Cholecystitis: A Case Series and Review of the Literature

Partial cholecystectomy (PC) is an alternative choice to standard cholecystectomy in situations with increased risk of Calot's components injury. We reported our experience with the patients treated with PC and reviewed the literature. Fifty-four patients with complex acute cholecystitis underwent PC, including conventional partial cholecystectomy (CPC; n = 48) and laparoscopic partial cholecystectomy (LPC; n = 6). The clinical diagnosis was verified by ultrasonography. In addition, we reviewed 1190 published cases (1972-2005) who underwent a "nonconventional" surgery for severe cholecystitis, including cholecystostomy, CPC, or LPC. Review of the literature, including our cases, showed a male:female ratio of 1.3:1. The major operative indication was severe acute cholecystitis. Procedures included cholecystostomy (65.8%) and PC (34.2%). In the follow-up (n = 1190), biliary leak (4.8%), retained stones (4.6%), recurrent symptoms (2.3%), wound infections (1.9%), persistent biliary fistula (0.9%), and prolonged biliary drainage (0.2%) were found, with an overall mortality rate of 9.4 per cent. In 133 patients, because of postoperative complications (e.g., recurrent symptoms, remaining common bile duct stones, or persistence of bile fistula), reoperation was necessary, including 121 cases (90.1%) of cholecystectomy, whereas the other 11 patients underwent other procedures such as common bile duct exploration or closure of the fistula. The surgical trend for complex acute cholecystitis treatment has been changed from only cholecystostomy to a spectrum of cholecystostomy, CPC, and LPC with the progressive increase of PC. The proportion of the LPC compared with CPC has also increased during recent years. It seems that PC is a safe procedure for treating complicated acute cholecystitis. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies.

Soft Tissue Gas Gangrene: A Severe Complication of Emphysematous Cholecystitis

Soft tissue gas gangrene with myonecrosis is a severe complication of traumatic and non-traumatic conditions with a potentially lethal outcome. Emphysematous cholecystitis is a complication of acute cholecystitis, which is characterized by air accumulation in the gallbladder wall and is reported in the literature as a rare causative factor of soft tissue gas gangrene. Here we report 4 patients who developed soft tissue gas gangrene as a complication of emphysematous cholecystitis. Two patients were female octogenarians (one with a history of diabetes mellitus), and underwent percutaneous trans-gallbladder drainage and fascia incisions of the affected soft tissue with prompt administration of antibiotics. Finally, both of them died. The other two patients were male (32 years old diabetic and 47 years old with a history of chronic alcoholism). They underwent open cholecystectomy. Fascia incisions of the gangrenous areas and antibiotic therapy administration were also performed. Both of them were discharged from the hospital and are currently in excellent clinical status. We also present the ultrasonographic and/or radiologic images of these four patients. Soft tissue gas gangrene may complicate emphysematous cholecystitis, and clinicians should be aware of the coexistence of these two clinical conditions, since immediate management is needed in order to prevent fatal outcome.

Valutazione ecografica e TC–spirale delle colecistiti acute semplici e complicate: definizione dell'iter diagnostico attraverso una esperienza personale e la revisione della letteratura

The aim of this study was to identify and classify the ultrasonographic and computed tomography (CT) signs of simple and complicated acute cholecystitis and to define the correct diagnostic protocol. We retrospectively reviewed 35 patients (23 men and 12 women; mean age 66.6 years) presenting with acute cholecystitis who were assessed by emergency ultrasonography (US) (30/35 cases) and spiral CT (12/35 cases); all patients underwent emergency surgery. The US signs were analysed and classified as major criteria (wall thickening and stratification, distension, Murphy's sign), minor criteria (bile stones, sludge, and biliary tract dilatation), and complication signs (gas collections, aerobilia, fluid collection, difficult or missed identification of the gallbladder). Imaging results were compared with histological findings (gold standard), and accuracy, sensitivity, specificity, and positive and negative predictive values (PPVs and NPVs) were assessed for each modality. Concordance between the US and CT findings was also evaluated for cases undergoing both examinations; additional findings provided by one or the other modality were also assessed. US had an accuracy of 66.6%, a sensitivity of 37.5%, a specificity of 70%, a PPV of 100%, and an NPV of 58.3%. CT had 100% accuracy, sensitivity, and specificity. Concordance between US and CT was observed for diagnosis of complications, but CT provided additional findings in all cases. The majority of complicated cases undergoing US examination (68.7%) revealed more than two major criteria and one minor criterion or at least one sign of complication. If more than two major signs associated with one minor sign or at least one sign of complication are present at US, CT is mandatory to recognise and thoroughly evaluate the type of complication and indicate appropriate treatment.

Factors Affecting Morbidity and Mortality in Gangrenous Cholecystitis

Introduction: Gangrenous cholecystitis is a serious complication of acute cholecystitis. Male gender, older age, leukocytosis, cardio-vascular diseases and diabetes were reported as factors that increase the risk of gangrenous cholecystitis. The aim our study was to determine variables affecting morbidity and mortality as well as to define the independent risk factors in Gangrenous Cholecystitis.Methods: Fifty three patients who had been treated for Gangrenous Cholecystitis were reviewed. The variables are defined as follows: age, gender, systemic diseases, Mannheim Peritonitis index, aspartate aminotransferase, alanine aminotransferase, white blood cell count and type of surgery. In order to determine the independent risk factors that might affect morbidity and mortality in Gangrenous Cholecystitis, we made use of multivariate logistic regression analysis. Results: The independent risk factors affecting on morbidity were age (P = 0.037), existing systemic disease (P = 0.047) and > 29 Mannheim Peritonitis index (P = 0.008), and the independent risk factors affecting on mortality were age (P = 0.046), white blood cell count (P = 0.035). Pre-operative and post-operative third day aspartate aminotransferase and alanine aminotransferase average values were compared, there was a significant difference (P < 0.0001, P < 0.0001 respectively).Conclusions: We found that older age, > 29 Mannheim Peritonitis index and existence of systemic diseases were independent risk factors affecting morbidity. Older age and lower of white blood cell count were independent risk factors affecting mortality. We believe that further comprehensive studies, involving prospective, multi-center and a large number of patients, are needed.