Diagnosis Of Acute Acalculous Cholecystitis Research Articles

The Diagnosis and Treatment of Acute Cholecystitis

Acute cholecystitis (AC), defined as inflammation of the gallbladder, is mainly caused by gallstones. Over 90% of AC results from obstruction of the cystic duct by stones or sludge, which subsequently increases the intraluminal pressure within the gallbladder and, in conjunction with the presence of bile supersaturated with cholesterol, activates an acute inflammatory cascade. Clinical features play an important role in the diagnosis of AC. The Tokyo Guidelines 2018 for acute cholecystitis designates the presence of local inflammatory signs and systemic inflammatory signs for a suspected diagnosis. It requires confirmation by radiological imaging along with these two factors for a definitive diagnosis. Thanks to less invasiveness, easy availability, ease of use, and cost-effectiveness, ultrasound (US) is usually accepted as the first choice in suspicious AC patients. A meta-analysis comparing methods of diagnosis for AC reported that the US has 81% of sensitivity and 83% of specificity. Abdominal computed tomography is recommended for diagnosing emphysematous or gangrenous cholecystitis. Meanwhile, acute acalculous cholecystitis (AAC) is a life-threatening disease mainly in severely ill patients. It usually affects the patients hospitalized for multiple trauma, burns, cardiopulmonary bypass surgery, long-term total parenteral nutrition or sepsis. The diagnosis of AAC is quite challenging and requires a high index of suspicion. Currently, cholecystectomy is the treatment of choice for AC, although the optimal time for surgery is still controversial. Due to high morbidity and mortality in high surgical risk groups, percutaneous gallbladder drainage can be a safe and feasible alternative to cholecystectomy, particularly for patients unfit for the surgery.

Fatal reversal of the cholecystocardiac link

Abstract Patients presenting to the emergency department with right upper quadrant pain are usually placed on a list of critical, yet limited differential diagnoses. Of these diagnoses, cholecystitis is fairly common. Although most cases of cholecystitis are relatively straight-forward, there are numerous extracholecystic conditions which have been known to cause acute acalculous cholecystitis. Examples include systemic infections, acute and chronic renal failure, systemic lupus erythematosus, and congestive heart failure. These conditions lead may lead to diffuse gallbladder wall thickening through a number of hypothesized mechanisms, including an increase in portal venous pressure, and a decrease in plasma oncotic pressure. The right upper quadrant pain caused by this gallbladder wall thickening however, is usually a late complaint, after the primary etiology has made itself clear. We report the case of a 6 year old female who presented to the emergency department with acute right upper quadrant pain and vomiting. Apart from the gastrointestinal system, examination of all other systems (including cardiovascular) was negative. An ultrasound was done and the diagnosis of acute acalculous cholecystitis was made. The patient did not respond to treatment, and after additional investigations, evidence of congestive heart failure with bilateral pulmonary effusions was seen. It was concluded that the patient's heart failure, although not apparent on initial examinations, was the etiology behind her initial gallbladder thickening and abdominal pain. This case reports an important etiology to be aware of in patients presenting with right upper quadrant pain which is unresponsive to treatment methods. Multiple extracholecystic disease entities such as congestive heart failure, must be placed in the list of differential diagnoses by the caring physician.

Acute acalculous cholecystitis in patients with systemic lupus erythematosus: A unique form of disease flare.

Objective We aimed to investigate the clinical features of acute acalculous cholecystitis (AAC) in patients with systemic lupus erythematosus (SLE). Methods SLE patients with AAC hospitalized in the Peking Union Medical College Hospital (PUMCH) from January 2001 to September 2015 were retrospectively analyzed. Their medical records were systematically reviewed. The diagnosis of AAC was based on clinical manifestations and confirmed by radiologic findings including a distended gallbladder with thickened wall, pericholecystic fluid and absence of gallstones. Results Among the 8411 hospitalized SLE patients in PUMCH, 13 (0.15%) were identified to have SLE-AAC. Eleven (84.6%) of them were female, with a mean age of 30.1 ± 8.6 years. AAC was the initial manifestation of SLE in four (30.8%) cases. Eleven (84.6%) patients complained of fever and abdominal pain, four (30.8%) had positive Murphy's sign and six (46.2%) had elevated liver enzymes. The median SLE Disease Activity Index was 8.0 (range 0-20.0) at the time of AAC. Other affected organs in SLE-AAC included kidney (11, 84.6%) and hematologic system (11, 84.6%), followed by mucocutaneous (seven, 53.8%), musculoskeletal (seven, 53.8%) and neuropsychiatric (two, 15.4%) systems. All patients received treatment of glucocorticoids and immunosuppressants but none underwent surgical intervention. During a median follow-up of 28 months (range, 2-320 months), 12 cases (92.4%) responded to treatment with no relapse and one patient (7.6%) died of septic shock. Conclusion Our study suggests that AAC is a relatively uncommon and underestimated gastrointestinal involvement of SLE that is often associated with active disease. For patients with AAC in SLE, treatment with aggressive glucocorticoids could result in a good prognosis.

Acute Acalculous Cholecystitis in Severe Trauma Patients: A Single Center Experience

J Acute Care Surg Vol. 5 No. 2, October 2015 52 Correspondence to: Yun Su Mun, M.D. Department of Surgery, Eulji University Hospital, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: +82-42-611-1134 Fax: +82-42-611-3261 E-mail: mdearnest@naver.com Purpose: Early diagnosis and prompt treatment of acute acalculous cholecystitis is important, because it is associated with high mortality. In major trauma patients, besides the direct damage the trauma itself causes, many complications can occur due to trauma. The purpose of this study was to evaluate the prevalence and risk factors for development of acute acalculous cholecystitis in patients with severe traumatic injuries. Methods: In this retrospective study, we reviewed the trauma registry data of 629 major trauma patients (injury severity score>15) of Eulji University Hospital seen between May 2012 and March 2015. Of the 629 patients, twelve were diagnosed with acute acalculous cholecystitis. Information collected from the medical record review included demographic data, clinical characteristics, laboratory findings, and diagnostic and therapeutic outcomes. Results: Twelve patients of 629 patients (1.9%) were diagnosed with acute acalculous cholecystitis, and while nine patients survived, three patients died. The clinical and laboratory findings at the initial emergency room visit and at diagnosis of acute acalculous cholecystitis were compared, and there were significant differences in the body temperature (p=0.002), C-reactive protein (CRP) (p=0.002), alkaline phosphatase (ALP) (p=0.008), total bilirubin (p=0.015), and lactate (p=0.046). Conclusion: Early diagnosis and proper treatment is important in acute acalculous cholecystitis after major trauma. If the patients after major trauma have elevated body temperature, lactate, CRP, ALP, and total bilirubin, one should keep in mind of the possibility of acute acalculous cholecystitis. (J Acute Care Surg 2015;5:52-58)

Acute acalculous cholecystitis with gallbladder perforation in children – case report

Although relatively common in adult pathology, acute acalculous cholecystitis with gallbladder perforation is a rather infrequent entity in pediatric practice. In many cases, its unspecific clinical symptoms and the often inconclusive medical imagining results lead to the diagnosis of acute acalculous cholecystitis being set intraoperatively. Nevertheless, this condition should be considered when setting the differential diagnosis of a peritonitis syndrome in children.

Mo1143 Risk Factors and Therapeutic Outcomes of Acute Acalculous Cholecystitis

Background and aims: Acute acalculous cholecystitis (AAC) is traditionally known to occur in critically ill patients and to have a worse prognosis compared to acute calculous cholecystitis (ACC). Although cholecystectomy is usually recommended for the treatment of AAC, non-surgical treatment may be a good alternative treatment especially in high risk patients. The objective of this study was to review the incidence, risk factors, treatment modality and therapeutic outcome of AAC. Methods: The data of 69 AAC patients and 415 ACC patients between January 2007 and August 2011 were collected from hospital records. The diagnostic criteria for acute cholecystitis were right upper quadrant abdominal pain or tenderness with characteristic image findings compatible to acute cholecystitis. AAC was defined when there were no stones or sludge in the biliary tree on imaging study. The demographic characteristics, clinicopathologic features, and therapeutic modality and outcomes were analyzed and compared between AAC and ACC patients. Results: sixty-nine cases of the total 484 patients with acute cholecystitis fulfilled the criteria for the diagnosis of AAC. Age was not significantly different between AAC and ACC group (67 vs. 63 years). There was male predominance in the AAC group compared to ACC group. Cerebrovascular accidents were significantly more frequent in patients with AAC than those with ACC (15.9% vs. 6.7%, p<0.05, OR 2.621, 95% CI, 1.238-5.550). There was higher incidence of gangrenous cholecystitis in AAC group than ACC group (31.2% vs. 5.6%, p=0.000, OR 7.647, 95% CI, 3.130-18.685). Of the 69 AAC patients, 32 patients (46.4%) underwent cholecystectomy, 12 patients (17.4%) were treated with percutaneous cholecystostomy, and 25 patients (36.2%) received antibiotics only. The overall therapeutic outcomes of AAC were not statistically different from patients with ACC. Conclusions: The risk of AAC increases in patients with advanced age and cerebrovascular accidents. Cholecystectomy is recommended because of higher incidence of gangrenous cholecystitis in AAC patients. However, non-surgical treatment such as percutaneous cholecystostomy or antibiotics only might be effective especially in high risk patients.

A rare complication of acute acalculous cholecystitis following abuse of transdermal fentanyl for the treatment of failed back surgery syndrome

A 65-year-old man presented with uncontrolled severe low back pain and both leg pain (VAS 9) due to failed back surgery syndrome confirmed by magnetic resonance imaging. We prescribed transdermal fentanyl patch (25 μg/h) for pain relief, and at 2 weeks later, symptom was lessened (VAS 4). But after 1 month, he was admitted to our emergency department for nausea, vomiting, and right upper quadrant (RUQ) pain occurring 3 days and aggravating 4 h before arrival. He used 2 patches (50 μg/h) without prescription for the purpose of relieving breakthrough pain for 2 weeks. After subsidence of pain, he applied TDF with same dose. On physical examination and radiologic assessment, he was diagnosed as acute acalculous cholecystitis. To the best of authors’ knowledge, there have been no reports about acute acalculous cholecystitis after abuse of TDF. On the diagnosis of acute acalculous cholecystitis (AAC), laparoscopic cholecystectomy was performed. Gangrenous change of GB was found on pathologic specimen. Severe abdominal pain was relieved after surgery. Acute acalculous cholecystitis can occur as a rare complication after abuse of TDF.

Acute acalculous cholecystitis revealing hepatitis A virus infection in children

Sir, Acute hepatitis A virus (HAV) infection is frequently encountered in developing countries, especially in children. The occurrence of acute acalculous cholecystitis (AAC) during HAV infection is uncommon and it has been exceptionally described in the literature.[1,2] An 11-year old boy, with an unremarkable medical history, was admitted to the pediatric emergency department with a 4-day history of fever, asthenia, vomiting and abdominal pain. At presentation, the patient had myalgia, jaundice associated with dark urine and pale stool. Physical examination showed body temperature of 38.8°C, scleral and cutaneous icterus and a painful hepatomegaly without associated splenomegaly. Laboratory studies revealed the following: Hemoglobin, 11.4 mg/dL; white blood cell, 6300/mm3; alanine aminotransferase, 1918 U/L (Normal: 7-40 U/L); aspartate aminotransferase, 2953 U/L (Normal: 7-40 U/L); total serum bilirubin, 48 mg/L; with a direct fraction of 27 mg/L, alkaline phosphates 573 U/L (Normal: 38-155 U/L); gamma-glutamyl-transpeptidase, 214 U/L (15-60 U/L); albumin, 3.3 g/dl; prothrombin rate at 62%; C-reactive protein, 66 mg/L (0-5 mg/L). Abdomen ultrasonography showed a marked thickness of the gallbladder wall evaluated at 11 mm (Normal: ≤2 mm), with a pericholecystic fluid collection and heterogeneous hydrops with no calculi or sludge. The intrahepatic and extrahepatic biliary tracts were normal. Sepsis was suspected and intravenous antibiotics associating clavulanic acid combined with amoxicillin and gentamicin were administered. The serologic tests showed specific IgM anti-HAV. Viral hepatitis B and C and typhoid diseases were excluded serologically. Bacteriological and parasitological examinations of stools also yielded negative results. During follow-up, the child remained febrile for three days. At the fifth day, the jaundice and abdominal tenderness regressed. Four days later, the patient was discharged in a stable condition. After one month, abdominal ultrasonography was normal and a significant improvement was also seen in biochemical test results. HAV infection symbolizes an asymptomatic and benign disease. Cholestasis, relapse and fulminant hepatitis are the three major complications.[3] Pathophysiology of the gallbladder wall thickness remains unclear. Hypoalbuminemia, local extension of the hepatic inflammatory process and direct lesions of the biliary epithelium caused by the virus are the main suggested hypotheses.[4] Clinical symptoms include fever, jaundice, pain and guarding in the right hypochondrium. Homogeneous or stratified gallbladder wall thickness, greater than 10 mm, noted in ultrasonography examination without any calculous or sludge, confirm the diagnosis of acute acalculous cholecystitis. The diagnosis of AAC due to HAV infection can be established in the presence of important cytolysis with positive specific IgM anti-HAV. Other possible etiologies of AAC such as salmonellosis, parasitosis of the digestive tract, Kawasaki syndrome and sepsis must be excluded.[2] AAC as a result of HAV infection is transient and gradually disappears when viremia becomes low. Concurrently, gallbladder wall thickness returns to normal size within a few days. Therefore, patients do not require surgical intervention. The occurrence of AAC during HAV infection is exceptional. It usually manifests as abdominal pain associated with fever and icterus. This diagnosis should be kept in mind by paediatricians and gastroenterologists to avoid unnecessary invasive procedures.

Acute Acalculous Cholecystitis Complicating Major Trauma: A Report of Five Cases

The purpose of this study was to identify the clinical characteristics of the patients in our institution who developed acute acalculous cholecystitis (AAC) after major trauma. Data of all trauma patients who developed AAC from January 2001 through June 2006 were analyzed. Five out of 1386 (0.3%) major trauma patients were diagnosed with AAC. One out of five patients had hypotension and shock and received vasopressor treatment. Prior to the diagnosis of AAC, all patients received ventilatory support, intravenous opioid analgesia, had pneumonia, and experienced tachycardia. No specific clinical characteristic was identified in patients with AAC; however, prolonged ventilatory support, pneumonia, use of opioids, and new onset arrhythmias were seen in the majority of patients.

Acute acalculous cholecystitis of viral etiology—a rare condition in children?

Acute acalculous cholecystitis (AAC) comprises 5% to 10% of all cases of acute cholecystitis in adults and appears to be even less frequently diagnosed in children. The diagnosis of AAC is established upon some clinical, laboratory, and ultrasonographic findings, which may sometimes be ambiguous and confusing especially in children. Diagnostic difficulties may result in either delayed diagnosis or unnecessary surgical intervention. Acute cholecystitis owing to viral infectious factors is reported to be extremely rare. The aim of the article is to demonstrate 2 cases of AAC as a clinical presentation of both Epstein-Barr virus and cytomegalovirus infection in children.

Acute acalculous cholecystitis as the initial presentation of primary Epstein-Barr virus infection

The case of a 13-year-old girl with primary Epstein-Barr virus (EBV) infection and concomitant cholestatic hepatitis, which initially presented as acute acalculous cholecystitis (AAC), is described. The diagnosis of AAC was documented by clinical and ultrasonographic criteria, whereas acute EBV infection was confirmed serologically. AAC may develop during the course of acute EBV infection, especially in patients with cholestatic hepatitis.

Ultrasonography and color Doppler contrast-enhanced imaging of the gallbladder in intensive care unit patients: an early diagnosis of acute acalculous cholecystitis

Patients in the ICU are at risk of developing acute acalculous cholecystitis (AAC). The disease carries high morbidity and mortality rates partly because of the difficulties of diagnosis.

Ultrasound is Not a Useful Screening Tool for Acute Acalculous Cholecystitis in Critically Ill Trauma Patients

Acute acalculous cholecystitis remains a diagnostic challenge in critically ill trauma patients. Laboratory studies are nonspecific and associated injuries or mental status changes may mask clinical signs and symptoms. We conducted a retrospective study to assess the utility of ultrasound in the diagnosis of acute acalculous cholecystitis. We hypothesized that ultrasound is inadequate as a screening tool for acute acalculous cholecystitis. The abdominal ultrasounds of all patients undergoing evaluation for acute acalculous cholecystitis in a 40-month period at our Level I trauma center were reviewed. Thickened gallbladder wall, pericholecystic fluid and emphysematous gallbladder were considered positive sonographic criteria. Sludge, cholelithiasis, and hydrops were considered suggestive. Patients who did not undergo cholecystectomy had their gallbladders evaluated either during subsequent laparotomy or at autopsy or they were discharged from the hospital without need for intervention. Sixty-two patients were included. Twenty-one patients underwent cholecystectomy for presumed acute acalculous cholecystitis. The data revealed a sensitivity of 30 per cent (6/20) and a specificity of 93 per cent (39/42) for ultrasound evaluation. Twenty patients had subsequent hepatobiliary scans [hepato-iminodiacetic acid (HIDA)] with a sensitivity of 100 per cent (12/12) and specificity of 88 per cent (7/8). Our data do not support ultrasound as a reliable routine screening tool for acute acalculous cholecystitis. Despite its convenience as a bedside procedure ultrasound has insufficient sensitivity to justify its use and a more sensitive diagnostic tool should be used.

Contribution of ultrasonography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients.

To assess the respective value of ultrasonography (US) and morphine cholescintigraphy (MC) in the diagnosis of acute acalculous cholecystitis (AAC). Prospective study in an intensive care unit of a university hospital. Twenty-eight patients with clinically and biologically suspected of AAC. US was performed at the bedside and less than 12 h later MC. US was considered positive if three major criteria were present: wall thickness greater than 4 mm, hydrops, sludge; MC results were regarded as positive if the gallbladder could not be visualized. These latter patients underwent cholecystectomy and the diagnosis of AAC was confirmed through histopathological study. Sensitivity of US and MC, respectively, was 50% and 67%, specificity 94% and 100%, positive predictive value 86% and 100%, negative predictive value 71% and 80%, and accuracy 75% and 86%. The correlation between US and MC findings was 71%, with chi = 0.31. By Bayesian analysis the probability of disease if the MC finding was positive was 100% regardless of US results. A positive US finding was associated with a 86% probability of disease, but with a probability of only 66% in case of negative MC results. MC is thus superior to US for confirming AAC in selected critically ill patients. Nevertheless, US is an easy, noninvasive, and effective method of bedside screening. The combination of the two imaging tests improves diagnostic accuracy and reduces false-positive and false-negative rates. Poor agreement between the two tests leads to better diagnostic complementarity.

Gallbladder abnormalities in medical ICU patients: An ultrasonographic study

Patients in the intensive care unit (ICU) have many risks factors for gallbladder stasis or acute acalculous cholecystitis (ACC), including fasting, total parenteral nutrition, sedation, mechanical ventilation, infection and shock. We have performed a prospective study to estimate the prevalence of ultrasonographic gallbladder abnormalities in 30 consecutive medical ICU patients during the first 2 days of their stay in the ICU. Two patients had previously undergone cholecystectomy and were excluded from the study. Seventeen (61%) of the remaining 28 patients presented with gallbladder abnormalities. Considering three major criteria of ACC, 14 patients (50%) presented with either sludge (25%), wall thickening (22%) or hydrops (11%). However, none of the patients needed a surgical procedure during the study because of gallbladder disease. We conclude that an important proportion of ICU patients presented with gallbladder abnormalities shown by ultrasonography and that this may have implications for establishing a diagnosis of ACC using ultrasonographic criteria.

Hepatobiliary scintigraphy in children

Hepatobiliary scintigraphy using iminodiacetic (IDA) radiopharmaceuticals provides clinically useful information on the function of the biliary tract in a variety of pathological processes in children, including neonatal jaundice, gallbladder dysfunction, trauma, and liver transplantation. Phenobarbital premedication (5 mg/kg per day for a minimum of 5 days in divided doses) is used in infants who are being examined for neonatal jaundice to increase the accuracy of 99mTc-IDA scintigraphy in differentiating extrahepatic biliary atresia from neonatal hepatitis. Biliary atresia can be ruled out in an infant if a patent biliary tree is shown with passage of activity into the bowel. If no radiopharmaceutical is noted in the bowel on imaging up to 24 hours, distinction between severe hepatocellular disease and biliary atresia cannot be made. The literature reports 91% accuracy, 97% sensitivity, and 82% specificity for hepatobiliary imaging in the diagnosis of biliary atresia. The impairment of both intrahepatic and extrahepatic biliary drainage is an important cause of liver disease in cystic fibrosis. Hepatobiliary scintigraphy in cystic fibrosis has shown characteristic patterns of dilatation of mainly the left hepatic duct, narrowing of the distal common bile duct, gallbladder dysfunction, and delayed bowel transit. Cholecystitis in children may be acalculous. Sensitivity and specificity for the scintigraphic diagnosis of acute acalculous cholecystitis is reported to range from 68% to 93% and 38% to 93%, respectively. Cholescintigraphy in a suspected bile leak provides information generally not available with other techniques, except for direct cholangiography. If the amount of intraperitoneal accumulation of the tracer is greater than that entering the gastrointestinal tract, surgery is usually indicated. Hepatobiliary imaging in children who have undergone liver transplantation will assess graft vascularity, parenchymal function, biliary drainage, presence of a leak, and obstruction.

Value of laparoscopy in trauma ICU patients with suspected acute acalculous cholecystitis

Patients who require prolonged intensive care following traumatic injuries are at risk for developing acute acalculous cholecystitis (AAC). The diagnosis of AAC is often difficult to establish, resulting in increased morbidity and mortality in this critically ill population. We reasoned that diagnostic laparoscopy might provide a more accurate and timely method of diagnosis. Laparoscopy was performed in nine trauma ICU patients with suspected AAC. Four procedures were considered positive and five were negative. There were no false-positive or false-negative laparoscopic exams, and no procedure-related morbidity occurred. Comparison of multiple clinical, laboratory, and radiologic findings showed that only laparoscopy accurately distinguished between those patients with AAC and those without AAC. We conclude that diagnostic laparoscopy is safe and definitive in trauma ICU patients with suspected AAC and should be performed prior to proceeding with laparotomy.

Computed tomography as an adjunct to ultrasound in the diagnosis of acute acalculous cholecystitis

The sonographic and computed tomographic (CT) findings were reviewed in 17 patients with acute acalculous cholecystitis (AAC) over a 6-year period from 1984 to 1989. Of the six patients in whom both ultrasound and CT were performed, CT revealed marked gallbladder (GB) wall abnormalities, including perforation, and pericholecystic fluid collections in five patients not demonstrated by sonography. Of the total group, five patients had GB wall thicknesses of less than or equal to 3 mm (normal) at pathologic examination, which demonstrated a spectrum of disease ranging from acute hemorrhagic/necrotizing, to gangrenous acalculous cholecystitis with perforation. Sonography was falsely negative or significantly underestimated the severity of AAC in seven of the 13 patients examined by sonography. CT because of its superior ability to assess pericholecystic inflammation may provide additional diagnostic information even after a thorough sonographic study in cases of AAC.

The clinical importance of a thickwalled, tender gall-bladder without stones on ultrasonography

Ultrasound examinations of 563 patients with right upper quadrant pain and a clinical suspicion of acute cholecystitis were reviewed. In 31 patients, a tender, dilated gall-bladder with a thick (more than 4 mm) partly hypoechoic wall without any detectable calculi was found on the emergency examination. This was interpreted as due to acute acalculous cholecystitis. None of the patients was critically ill. Twenty-one of the patients had follow-up studies with either oral cholecystography, cholangiography, or ultrasound. Fourteen of the 21 had gall-bladder calculi while seven did not. These seven patients presumably represent the true frequency (1.2%) of acute acalculous cholecystitis in this clinical setting. In five other patients with an initial diagnosis of acute acalculous cholecystitis the gall-bladder wall thickening probably was secondary to concomitant pancreatitis, appendicitis, hepatitis or peptic ulcer disease. A meticulous and careful search for gall-bladder calculi should be performed in the presence of a dilated, tender thick-walled gall-bladder.

Cholecystokinin Sonography: Lack of Utility in Diagnosis of Acute Acalculous Cholecystitis

Cholecystokinin Sonography: Lack of Utility in Diagnosis of Acute Acalculous Cholecystitis