Diagnosis Of Acute Calculous Cholecystitis Research Articles

Outcome of Early Versus Delayed Laparoscopic Cholecystectomy in Acute Calculus Cholecystitis

Background: The timing of cholecystectomy for acute cholecystitis has been debated with most studies favoring early cholecystectomy. However, most surgeons in Bangladesh prefer to delay surgery in the acute phase. The study aimed to compare between early Laparoscopic Cholecystectomy (LC) with that of delayed laparoscopic cholecystectomy in the management of acute calculus cholecystitis. Materials and methods: This quasi-experimental study included a total of 74 patients with a diagnosis of acute calculous cholecystitis as per Tokyo guideline from the Surgery Department, Chittagong Medical College Hospital, during August 2019 to July 2020. Thirty-seven patients underwent early cholecystectomy (Within 7 days of onset of symptoms) and 37 patients underwent elective or delayed cholecystectomy (After a gap of 6-8 weeks from the acute attack). Peroperative events, postoperative complications, length of hospital stay and days needed to return to full activity were compared between two groups. Results: Both early and delayed groups were similar in-terms of their baseline demographic and clinical characteristics. Significantly higher number of patients in the early group had difficult Callot’s triangle dissection (59.4% vs. 27.1%, p<0.01) and lower number of patients had difficult gallbladder bed dissection (5.4% vs. 37.8%, p<0.001) than the delayed group. The proportion of the patients required conversion to open surgery was 10.8% and 6.1%, respectively in early and delayed group (p=0.691). Total hospital stay was shorter in the early surgery group than the delayed surgery group (6.05±0.52 vs. 12.03±1.46 days, p=0.001). Wound infection, duration of hospital stays following surgery, and days need to return to full activity after surgery was similar between two groups. Conclusion: Early cholecystectomy is feasible and safe for acute cholecystitis and is better method of treatment because of its shorter hospital stay, which is a major economic benefit to both the patient and health care system. IAHS Medical Journal Vol 5(2), Dec 2022; 11-14

Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study

BackgroundLess invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.MethodThe S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models—POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade—receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.ResultsA 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a ‘Chole-POSSUM’ score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96–97% negative predictive value for major complications.ConclusionsThe Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.Trial Registration: ClinicalTrial.gov NCT04995380.

THROMBOEMBOLIC COMPLICATIONS IN PATIENTS WITH ACUTE CALCULOUS CHOLECYSTITIS

The aim is the analysis of clinical and anamnestic, biochemical and hemostasiological parameters in thromboembolic complications in patients with acute calculous cholecystitis (ACC).&#x0D; Materials and Methods. A retrospective analysis of clinical information was performed regarding 206 patients with a diagnosis of acute calculous cholecystitis, who were hospitalized in the Emergency Medical Care Hospital of Lviv (current name: St. Panteleimon Hospital of the First Territorial Medical Association of the City of Lviv) in the period from 2014 to 2018.&#x0D; Results and Discussion. It was established that 2.91% of patients with ACC had thromboembolic complications, which were manifested in the form of deep vein thrombosis and PE of small branches and were more often diagnosed in patients with significantly older age (on average, 72.67±11.13 years of age). Thromboembolic complications in patients with ACC developed reliably more often in people who had concomitant pathology (hypertensive disease, IHD, COPD, liver cirrhosis, stroke). Patients with a complicated thrombotic diagnosis were also diagnosed with final non-thrombotic complications: local and general peritonitis, perivesical abscess, perforation, abdominal sepsis and subhepatic abscess. The average duration of laparoscopic cholecystectomy (LCE) in patients without complications was 60.00 [45.0-70.0] minutes, in patients with non-thrombotic complications - 62.50 [38.5-85.0] minutes, and in patients with thrombotic complications it was significantly longer - 95.0 [95.0-95.0] minutes (p&lt;0.05).&#x0D; Conclusions. In patients with complicated acute cholecystitis, thromboembolic complications with local and general peritonitis, perivesical abscess were diagnosed more often (p&lt;0.05). Patients with complicated acute calculous cholecystitis underwent cholecystectomy (83.33% [46.48-99.96]) reliably more often than patients with uncomplicated acute cholecystitis, whereas LCE was performed only in 16.67% [0.04-53.52] of cases. Therefore, cholecystectomy lasted for more than 1 hour in 80% [38,45-99,94] of cases.

Current Management of Acute Calculous Cholecystitis

Provide a comprehensive review of the latest reports on management of acute calculous cholecystitis and our current practices The diagnosis of acute calculous cholecystitis (ACC) should be driven by a combination of clinical, laboratory, and imaging findings. The use of grading scales to classify the severity of ACC has successfully predicted the morbidity of surgical management of this disease. Surgical management has shifted from open cholecystectomy or delayed laparoscopic cholecystectomy to early laparoscopic cholecystectomy. If the critical view of safety (CVS) cannot safely be obtained, a change in surgical strategy with either conversion to open or a subtotal laparoscopic cholecystectomy should be considered. For patients that are not surgical candidates, treatment includes antibiotics and biliary drainage with percutaneous cholecystostomy tube. Early laparoscopic cholecystectomy is the gold standard for the treatment of ACC. The use of grading scales to guide operative management should be employed.

Role of percutaneous cholecystostomy in all-comers with acute cholecystitis according to current guidelines in a general surgical unit.

Acute calculous cholecystitis (ACC) is a very common complication of gallstone-related disease. Its currently recommended management changes according to severity of disease and fitness for surgery. The aim of this observational study is to assess the short- and long-term outcomes in all-comers admitted with diagnosis of ACC, treated according to 2013 Tokyo Guidelines (TG13). A retrospective analysis was conducted ona prospectively maintained database of125 patients with diagnosis of ACC consecutively admitted between January 2017 and September 2019, subdivided in three groups according to TG13: percutaneous cholecystostomy (PC group), cholecystectomy (CH group), and conservative medical treatment (MT group). The primary end point was a composite of morbidity and/or mortality rates; the secondary end points were ACC recurrence, readmission, need for cholecystectomy rates and overall length of hospital stay (LOS). After a median follow-up of 639days, overall morbidity rate was 20.8% and mortality rate was 6.4%. Death was directly related to AC during the index admission in two out of eight cases. There were no significant differences in primary end point according to the treatment group. Concerning secondary end points, ACC recurrence rate was not significantly different after PC (10.0%) or MT (9.1%); the readmission rates were significantly higher (p < 0.0001) in the MT group (48.5%) and in the PC group (25.0%) than in the CH group (5.8%); need for cholecystectomy rates was significantly higher (p < 0.0001) in the MT group (42.4%) than in the PC group (20.0%); median overall LOS was significantly higher in the PC (16days) than in the MT (9days) and than in the CH group (5days). PC is an effective and safe rescue procedure in high-risk patients with ACC, representing a definitive treatment in 80% of cases of this specific subgroup.

A Retrospective Study Comparing Radiological to Histopathological Diagnosis After Laparoscopic Cholecystectomy for Suspected Cholecystitis.

IntroductionAcute calculus cholecystitis is one of the most common causes of acute abdominal pain in patients presenting to the emergency department, representing a third of all surgical emergency hospital admissions. Laparoscopic surgery is typically performed within 24 to 48 hours of hospital admission. Due to similarities in presentation, it is often difficult to differentiate between biliary colic and acute cholecystitis. Currently, it is not clear how the clinical and radiological diagnosis of acute calculus cholecystitis correlates with the histopathological diagnosis. MethodsWe performed a retrospective analysis of 350 patients who underwent laparoscopic cholecystectomy in our community hospital for acute calculus cholecystitis. The aim was to compare pre-operative radiological diagnoses of acute calculous cholecystitis to post-operative histopathological diagnosis. Four radiographic modalities were used for diagnosis of acute calculous cholecystitis: ultrasound, computerized tomography, MRI, and hepatobiliary scintigraphy (HIDA scan). A correlation was found between both the clinical pain of biliary origin and radiological diagnosis with subsequent histopathological diagnosis after laparoscopic surgery.ResultsWhen the four commonly used imaging modalities were compared, HIDA scan had the highest sensitivity and ultrasound had the highest specificity in successfully diagnosing acute calculus cholecystitis that had been confirmed with histopathological analysis.ConclusionNo absolute correlation was found between any of the imaging modalities when compared to the pathological diagnosis. The ultrasound had maximum specificity, while the HIDA scan had maximum sensitivity when radiological imaging was compared to histopathology.

A validated score predicting common bile duct stone in patients hospitalized with acute calculus cholecystitis: a multi-center retrospective study

Concomitant common bile duct (CBD) stone in the setting of acute calculous cholecystitis (ACC) should be suspected once abnormal liver indices are noticed. We aimed to identify predictors of CBD stone in patients hospitalized with ACC. We performed a retrospective multi-center, case-controlled, study from 1st of January 2016 until the 31th of December 2018. Inclusion criteria included patients with an established diagnosis of ACC based on clinical, laboratory and radiological criteria and who had an endoscopic ultrasound (EUS) for suspected CBD stone. One-hundred and twelve patients were included, of these fifty-three patients (47.3%) were diagnosed with CBD stone by EUS. In univariate analysis, Age (OR 1.038, P = 0.001), total bilirubin (mg/dl) (OR 1.429, P = 0.02) and CBD width (mm) by US (OR 1.314, P = 0.01) were statistically significant in predicting CBD stone and remained significant in multivariate regression analysis. We developed a diagnostic score that included these three parameters, with assignment of weights for each variable according to the coefficient estimate. A low cut-off score of 0 was associated with sensitivity of 100% for CBD stone, whereas a high cut-off score of 3 was associated with sensitivity of 10% and specificity of 96.6% with a positive predictive value of 67% (ROC of 0.7558). We validated this score with an independent cohort (ROC of 0.7416) with a sensitivity of 46.6%, a specificity of 91.5% and a PPV of 87.1%. We recommend incorporating this score as an aid for stratifying patients with ACC into low or high probability for concomitant CBD stone.

Magnetic resonance imaging in guiding choice of treatment pathway in patients with cholecystolithiasis and diffuse inflammatory thickening of gallbladder wall

Objective To investigate the use of conventional MR imaging to guide treatment in patients with cholecystolithiasis and diffuse inflammatory thickening of gallbladder wall. Methods The clinical data of patients who were treated in the Ningbo Huamei Hospital, University of the Chinese Academy of Sciences between January 2017 and January 2018 were analyzed. These patients were divided into two groups: patients with acute cholecystitis (n=139) and patients with viral hepatitis combined with cholecystolithiasis (n=67). Differences in the imaging signs in standardized upper abdominal contrast enhanced MRI examinations were retrospectively analyzed. Results The imaging signs, including stone location, continuity of gallbladder mucosa, exudation in peri-gallbladder space, edema of intrahepatic portal area showed significant differences between the two groups (all P<0.05). On stratification analysis, the type of thickened gallbladder wall, background of liver parenchyma and extent of edema in intrahepatic catchment area also showed significant differences (all P<0.05). The imaging signs, including non-gallbladder neck ductal stones, concentric thickening of gallbladder wall, continuous mucous membrane in gallbladder and no peri-gallbladder space exudation but diffuse edema of intrahepatic catchment area supported the diagnosis of viral hepatitis combined with gallstones. The imaging signs, including discontinuity of gallbladder mucosa, exudation of peri-gallbladder space, diffuse edema of gallbladder wall without a cirrhotic background and edema in intrahepatic portal area supported the diagnosis of acute calculous cholecystitis of gallbladder. Conclusions Routine upper abdominal contrast enhanced MRI plays an important role in demonstrating the underlying cause of gallbladder wall diffuse edema thickening in patients with gallstones. It provides an important reference for the choice of clinical treatment pathway. Key words: Cholecystolithiasis; Clinical protocols; Cholecystitis; Hepatitis B; Magnetic resonance imaging

Main right hepatic duct entering the cystic duct: a case report

BackgroundRisk factors for bile duct injury in laparoscopic cholecystectomy include severe inflammation at Calot’s triangle and aberrant bile duct variations. Knowledge of the various biliary anomalies and early identification may therefore assist in decreasing the rate of bile duct injury.Case presentationA 65-year-old woman was admitted with right hypochondrial pain and high fever. A diagnosis of acute calculous cholecystitis was made by radiological imaging. Magnetic resonance cholangiopancreatography revealed that the confluence of the right and left hepatic duct was unclear. Intraoperatively, the procedure was converted from a laparoscopic cholecystectomy to laparotomy because of unclear anatomy of the cystic duct with severe inflammation at Calot’s triangle. Furthermore, intraoperative cholangiography from Hartmann’s pouch showed the main right hepatic duct entering the cystic duct. Subtotal cholecystectomy was performed to avoid injuring the right hepatic duct.ConclusionAlthough an aberrant hepatic duct entering the cystic duct is not uncommon, the main right hepatic duct infiltrating the cystic duct is extremely rare. Preoperative and intraoperative evaluation of the biliary duct and awareness of aberrant biliary duct variations is important in preventing bile duct injury.

Association of laboratory and radiologic parameters in the diagnosis of acute cholecystitis

Introduction and objectivesThere is currently more evidence suggesting that early surgery should be the treatment of choice for acute calculous cholecystitis, although initial conservative treatment is also reported to be safe. Treatment decision depends on the conditions of the patient, surgical experience, and hospital infrastructure, given that early surgery cannot always be carried out. The aim of the present study was to correlate C-reactive protein values with other variables to determine those situations in which surgery cannot be delayed. Materials and methodsA retrospective study was conducted on patients admitted to the hospital from the emergency service with the diagnosis of acute calculous cholecystitis. The patients were divided into 2groups: 1) patients that required urgent cholecystectomy and 2) patients that responded well to conservative medical treatment and later underwent deferred cholecystectomy. ResultsA total of 238 patients (♂ 54.6%, ♀ 45.4%) were analyzed. Urgent surgery was performed on 158 patients, whereas the remaining 80 patients were released from the hospital following conservative treatment. The odds ratio of gangrenous cholecystitis presenting in acute cholecystitis for C-reactive protein was calculated in the logistic regression analysis, obtaining an OR of 1.088 and a 95% CI of 1.031-1.121. ConclusionIn patients diagnosed with acute calculous cholecystitis, the combination of elevated values of C-reactive protein levels, gallbladder wall thickness, and number of leukocytes was correlated with less favorable clinical and gallbladder histologic states, resulting in a greater need for urgent surgical treatment.

Percutaneous cholecystostomy-tube for high-risk patients with acute cholecystitis: current practice and implications for future research.

While cholecystectomy (CCY) is the standard of care for gallstone-related acute cholecystitis, percutaneous cholecystostomy-tube (CCYT-tube) is an alternative option in patients with significant comorbid conditions. We sought to identify immediate and longitudinal hospital outcomes of patients who underwent CCYT-tube placement and determine predictors of CCYT-tube placement and eventual CCY on a national level in the US. We identified all adults (age ≥ 18years) with a primary diagnosis of acute calculous cholecystitis from January to November 2013 in the Nationwide Readmissions Database (NRD). The NRD allows longitudinal follow-up of a patient for one calendar year. Outcomes of patients undergoing CCY and CCYT-tube were compared. Separate univariable and multivariable regression analyses were performed to identify predictors of CCYT-tube placement and failure to undergo subsequent CCY. A total of 181,262 patients had an index hospitalization with acute cholecystitis where 178,095 (98.3%) patients underwent only CCY and 3167 (1.7%) patients were managed with CCYT-tubes. Among patients with CCYT-tube, 1196 (37.8%) underwent eventual CCY in 2013, while 1971 (62.2%) did not. One in five patients with CCYT-tube were readmitted within 30 days of hospital discharge. Multivariable analysis demonstrated that increasing age, male gender, coronary artery disease, cirrhosis, atrial fibrillation, diastolic congestive heart failure, and sepsis were associated with CCYT-tube placement. Longitudinal follow-up revealed that older age (OR 1.16, 95%CI 1.09-1.23), Elixhauser comorbidity score 3-4 (OR 1.94, 95% CI 1.03-3.63), cirrhosis (OR 3.28, 95% CI 1.59-6.79), and diastolic congestive heart failure (OR 2.47, 95% CI 1.33-4.60) were associated with failure to undergo subsequent CCY. In this national survey, nearly two in three patients who receive CCYT-tube for acute cholecystitis do not get CCY during longitudinal data capture within the same calendar year. Future research needs to target novel options for drainage of the gallbladder in high-risk patient populations.

Ultrasound for the Diagnosis of Acute Calculous Cholecystitis, and the Impact of Analgesics: A Retrospective Cohort Study

Ultrasound for the Diagnosis of Acute Calculous Cholecystitis, and the Impact of Analgesics: A Retrospective Cohort Study

PHARMACOECONOMIC ANALYSIS OF EFFICACY OF DIFFERENT MODES OF ANTIBIOTIC PROPHYLAXIS IN CHOLECYSTECTOMY

Pharmacoeconomic assessment of efficacy of different modes of antibiotic prophylaxis was made in 27 patients with diagnosis of acute calculous cholecystitis using method of «cost-efficacy». Patients have taken ampicillin/sulbactam intravenously in the dose of 1,5 g or cephazolin intravenously in the dose 2,0 g. Medicine should be taken in 30 min. before the operation. The most expensive was antibiotic prophylaxis by cephazolin. The coefficient of «cost-efficacy» was 774,2 rubles on 1 unit of efficacy in case of cephazolin and it was 506,1 rubles on 1 unit of efficacy in other group with antibiotic prophylaxis by ampicillin/sulbactam. The authors noted the economical and clinical advantage of antibiotic prophylaxis by ampicillin /sulbactam.

Should Delayed Cholecystectomy Following Acute Calculous Cholecystitis Be Discouraged in a Resource-restricted Setting?

Early cholecystectomy for acute calculous cholecystitis (ACC) reduces hospital stay and complications during the waiting period. The purpose of this study is to establish the patterns of management of ACC at the University Hospital of the West Indies (UHWI) and to evaluate the advantages of early versus delayed cholecystectomy. This was a retrospective chart review of patients admitted with a diagnosis of ACC. Data collection included demographics, management strategy, timing to cholecystectomy, significant events while awaiting cholecystectomy and duration of hospital stay. Mann-Whitney U and Chi-squared tests were used for analysis. P-value of < 0.05 was considered significant. A total of 102 patient charts were extracted, 59 of which were managed conservatively and 43 managed with early cholecystectomy. The mean time to surgery after conservative management was 173 days. About 30% of persons managed conservatively had significant attacks while awaiting surgery, which included need for re-admission and earlier intervention. There was a trend toward longer mean total hospital stay in the conservative group (xsx = 5.03, xCons = 6.12; p = 0.054). Conservative management of ACC results in significant delays in definitive management and risks of complications during the waiting period. Early cholecystectomy should be encouraged even in a resource-restricted setting.

Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature

BackgroundTo evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities.MethodsThe authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) computed tomography, (4) magnetic resonance cholangiopancreatography and (5) cholescintigraphy. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.ResultsSonography is still used as the initial imaging technique for evaluating patients with suspected acute calculous cholecystitis because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability. Cholescintigraphy still has the highest sensitivity and specificity in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern the use of cholescintigraphy is limited in clinical practice. CT is particularly useful for evaluating the many complications of acute calculous cholecystitis. The lack of widespread availability of MRI and the relatively high cost prohibits its primary use in patients with acute calculous cholecystitis.ConclusionsUS is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis.

Laparoscopic Resection for the Treatment of Symptomatic Remnant Huge Cystic Duct with Stone after Laparoscopic Cholecystectomy

During laparoscopic cholecystectomy, the cystic duct is frequently divided closer to the gallbladder to avoid iatrogenic injury to the common bile duct. Postcholecystectomy syndrome can be considered if the patient complains of right upper abdominal discomfort after cholecystectomy. We report a case of a laparoscopic resection for the treatment of a symptomatic remnant huge cystic duct with stones after a previous laparoscopic cholecystectomy. A 46-year-old male was admitted to our hospital due to right upper quadrant abdominal pain. Five years earlier, the patient had undergone a laparoscopic cholecystectomy under the diagnosis of acute calculous cholecystitis but he subsequently suffered from intermittent right upper abdominal pain and fever. An abdominal computed tomography scan revealed a stone in a dilated remnant cystic duct. A laparoscopic remnant cystic duct resection was performed and apathologic diagnosis was made with chronic calculus cystic duct inflammation. The patient was discharged without complications and has been doing well without recurrent symptoms.

The role of the Tokyo guidelines in the diagnosis of acute calculous cholecystitis

Acute calculous cholecystitis is a condition in which the gallbladder becomes inflamed due to cholelithiasis. Early diagnosis reduces both mortality and morbidity. The aim of this retrospective study was to assess the diagnostic value of the Tokyo guidelines in patients with acute cholecystitis. The medical records of patients admitted for acute calculous cholecystitis proven by pathological findings were collected between January 2007 and June 2008. Exclusion criteria included: acalculous cholecystitis, hepatobiliary malignancy, patients younger than 18 years and mortality unrelated to cholecystitis. A total of 235 patients were classified into three groups according to the severity grading in the Tokyo guidelines. Clinical characteristics among these patients were analyzed for comparison. Among all diagnostic criteria, right upper quarter (RUQ) abdominal pain (97.9%) and thickened gallbladder wall (92.3%) had the highest sensitivity rates, whereas pericholecystic fluid collection (18.3%) and RUQ abdominal mass (0.8%) had the lowest sensitivity rates. Higher sensitivity rates of diagnostic criteria were related to severe cholecystitis, except for Murphy's sign and white blood cell (WBC) count. The presence of both RUQ abdominal pain and elevated C-reactive protein (55.1%), or both RUQ abdominal pain and elevated WBC count (53.7%), accounted for the highest sensitivity rates in making the definite diagnosis of acute cholecystitis. Seventeen patients (7.2%) without comparable typical image findings were prone to be afebrile and had normal C-reactive protein values compared to those with typical image findings. Among all diagnostic criteria in the Tokyo guidelines for acute cholecystitis, RUQ abdominal pain and thickened gallbladder wall had the highest sensitivity rates, and RUQ abdominal mass had the lowest sensitivity rate. A combination of diagnostic criteria with different pathophysiologic findings, as noted in the Tokyo guidelines, can help clinicians make the correct diagnosis for patients with acute calculous cholecystitis.

Prevalência e fatores associados à bacteremia nos portadores de colecistite aguda litiásica

Bacteremia seems to increase the morbidity and mortality in clinical and surgical conditions, however the importance and factors associated with it during acute calculous cholecystitis are not well established. The purpose of this study was to determine pre-operative prevalence, associated factors and prognosis of bacteremia in patients with acute calculous cholecystitis submitted to an emergency cholecystectomy. A prospective study of 51 patients with histological diagnosis of acute calculous cholecystitis was designed. The Bactec System was used to detect bacteremia. Mean results of clinical and laboratory analyses were related to the presence of bacteremia. The pre-operative prevalence of bacteremia was of 15.68%. Age (P=0.024), heart rate (P=0.026), respiratory rate (P=0.028), serum creatinine (P=0.028) and presence of systemic inflammatory response syndrome (P=0.016) were positively associated with bacteremia. Bacteremic patients had statistically higher overall (P=0.045) and infectious (P=0.039) complication rates and longer hospitalization (P<0.005) including one death. Patients with acute calculous cholecystitis have a considerable prevalence of bacteremia in the pre-operative period. It is associated with old age, heart rate, respiratory rate, serum creatinine and systemic inflammatory response syndrome. In patients with acute calculous cholecystitis, presence of bacteremia may be associated to severity of the condition and poor outcome related to pos-operative complications.

Vólvulo da vesícula biliar tratado por colecistectomia laparoscópica

Our objective is to report a case of gallbladder torsion treated by laparoscopic cholecystectomy. A 87 year old patient presented with intense right upper quadrant pain, anorexia, nausea and vomiting. Murphy's sign was present at physical examination. Hemogram showed 9.200 leukocytes/mm3, with six bands. Ultrassonography showed a distended gallbladder, perivesicular fluid collection, wall edema, and sludge with stones inside. At laparoscopic cholecystectomy, there was a complete gallbladder torsion with areas of necrosis. There was no postoperative complication. Pathologic examination confirmed the diagnosis of acute calculous cholecystitis with areas of necrosis.

An extrahepatic bile duct metastasis from a gallbladder cancer mimicking Mirizzi’s syndrome

We report a case of an extrahepatic bile duct metastasis from a gallbladder cancer that mimicked Mirizzi’s syndrome on cholangiography. A 67-yr-old woman was admitted to our hospital with a diagnosis of acute calculous cholecystitis. As obstructive jaundice developed after the admission, percutaneous transhepatic biliary drainage was performed to ameliorate the jaundice and to evaluate the biliary system. Tube cholangiography revealed bile duct obstruction at the hepatic hilus, and extrinsic compression of the lateral aspect of the common hepatic duct, with nonvisualization of the gallbladder. No impacted cystic duct stone was visualized on CT or ultrasonography. Laparotomy revealed a gallbladder tumor as well as an extrahepatic bile duct tumor. We diagnosed that the latter was a metastasis from the gallbladder cancer, based on the histopathological features. This case is unique in that the extrahepatic bile duct metastasis obstructed both the common hepatic duct and the cystic duct, giving the appearance of Mirizzi’s syndrome on cholangiography. Metastatic bile duct tumors that mimic Mirizzi’s syndrome have not been previously reported. The presence of this condition should be suspected in patients with the cholangiographic features of Mirizzi’s syndrome, when the CT or ultrasonographic findings fail to demonstrate an impacted cystic duct stone.