Diagnosis Of Acute Cholecystitis Research Articles

Cholelithiasis-diagnostic approach: are clinical presentations in children different?

Cholecystitis has been considered an uncommon entity in children, but it’s incidence is reportedly increasing which may be attributed to widespread use of diagnostic imaging (ultrasonography). A healthy 11-year-old female Indian child presented to the emergency department with a chief complaint of abdominal pain. The pain was at the epigastric region and accompanied with vomiting. As per the complete examination and findings, a diagnosis of constipation colic was made. A month later, the patient presented with the same chief complaint, but general physical examination revealed tenderness at the right hypochondrium, and Murphy’s sign was positive. Upon performing an abdominal ultrasound, multiple small gallstones were noted in an otherwise normal gallbladder. No biliary obstruction was seen. A diagnosis of acute cholecystitis was made. Patient was then admitted and treated with a course of antibiotics. The incidence of cholelithiasis in children has not been sufficiently studied. The incidence of cholecystitis in India was found to be 0.3% with the incidence in age group 0-10 being less than 0.1%. In contrast to adult cholecystitis, it has been found that there is female predominance of cholecystitis in children. In children, 20% to 50% gallstones are radiopaque. Unknown causes are still prevalent in stone formation. Hence, the purpose of this paper was to increase awareness about the diagnosis of cholelithiasis in children. The probability of cholecystitis in children should not be ignored. Cholelithiasis should always be considered as a differential diagnosis when children present with complaints of abdominal pain.

The gallbladder: what's new in 2022?

This review focuses mainly on the imaging diagnosis, treatment, and complications of acute cholecystitis which is the most common benign disease of the gallbladder. The American College of Radiology appropriateness criteria for the imaging evaluation of patients with right upper quadrant pain and the Tokyo Guidelines for evaluating patients with acute cholecystitis and acute cholangitis are presented. The recent articles for using US, CT, MR, and HIDA in the evaluation of patients with suspected acute cholecystitis are reviewed in detail. The clinical management and postoperative complications are described. Because gallbladder polyps and adenomyomatosis can mimic gallbladder malignancies and acute cholecystitis, their imaging findings and management are presented. Finally, due the recent literature reporting better results with CT than US in the diagnosis of acute cholecystitis, a suggested approach for imaging patients with right upper quadrant pain and possible acute cholecystitis is presented in an addendum.

Use of Gallbladder Width Measurement by Computed Tomography in the Diagnosis of Acute Cholecystitis.

This study aimed to evaluate the diagnostic value of gallbladder width measurement with computed tomography (CT) in patients with acute cholecystitis. This retrospective case–control study was conducted between March 2016 and March 2020 at a tertiary emergency department. Of 310 patients, 254 patients with acute cholecystitis confirmed by surgery were compared with 254 patients diagnosed with other diseases (controls). In the acute cholecystitis group, the number of older patients with underlying illnesses was much higher (64% of men). Upon CT, the median (interquartile range [IQR]) gallbladder width was significantly longer in patients with acute cholecystitis (2.26 [1.82–2.78] cm vs. 3.73 [3.32–4.16] cm, p < 0.001). The optimal cut-off value of gallbladder width for differentiating acute cholecystitis was 3.12 cm, showing a sensitivity of 88% and specificity of 86%. In a multivariable analysis using a logistic regression model for diagnosing acute cholecystitis with CT findings (gallbladder width, length, stone, wall thickening, and pericholecystic fluid), a gallbladder width of ≥3.12 cm was significantly meaningful, even when adjusting for other variables (odds ratio 37.9; p < 0.001). Therefore, an increase in gallbladder width (≥3.12 cm) measured with CT can be a simple and sensitive diagnostic sign of acute cholecystitis, supporting the underlying pathophysiology of bile outflow obstruction.

Choque séptico de origen biliar en la Unidad de Cuidados Intensivos

Se presenta un caso de choque séptico de origen biliar en un paciente de sexo masculino de 76 años, con antecedente de colecistitis aguda y su correspondiente resolución quirúrgica. Ingresa a la Unidad de Cuidados Intensivos (UCI) del Hospital General San Vicente de Paúl, de Ibarra, con apoyo de dispositivo de ventilación con presión positiva, RASS -5 con efectos de sedoanalgesia, presencia de acceso venoso central yugular derecho, abdomen con presencia de bolsa de Bogotá y sonda vesical permeable. Luego de 16 días en UCI, a pesar de tratamiento médico, evoluciona tórpidamente y fallece. Cabe recalcar que no se efectuaron exámenes post mortem. En términos generales, la sepsis biliar constituye la disfunción multiorgánica originada en el contexto de infección de la vía biliar principal (VBP) o vía biliar accesoria (VBA). En este caso se revisa la cronología de un paciente con diagnóstico de choque séptico de origen biliar, la clínica y el manejo. En efecto, establecer el diagnóstico tardío de colecistitis aguda determina consecuencias graves como la perforación vesicular, sepsis grave o choque séptico de origen biliar con el mal pronóstico consecuente. El tratamiento es quirúrgico y consiste en colecistectomía, lavado quirúrgico y drenaje, e incluso en la reparación de las complicaciones que se presenten. Gran parte de la mejora en la mortalidad asociada con el shock séptico está relacionada con el reconocimiento precoz combinado con la reanimación con líquidos intravenosos y la administración de antibióticos.

267 An Audit of The Management of Acute Cholecystitis At ELHT

Abstract Aim Acute cholecystitis is a common condition on the surgical take. The evidence shows that the optimal approach is with early laparoscopic cholecystectomy in patients suitable for surgery (Cao, 2015). The aim of this audit was to assess the adherence of the surgical department at ELHT to NICE guidance CG 188 in the management of patients with gallstone disease (NICE, 2014): Offer early laparoscopic cholecystectomy (within 1 week of diagnosis) for acute cholecystitis. Method Retrospective study of all patients with image confirmed diagnosis of acute cholecystitis between 25th January to 1st October 2018. Any unsuitable candidates for surgery were not counted. Results The case notes of 153 patients were reviewed. 109 were included in this study, as the other patients were not likely to be offered surgery due to their comorbidities. Of these 109 patients, 51 (47%) had a laparoscopic cholecystectomy within a week of diagnosis. Conclusions ELHT is not meeting the target of management within 7 days for over half of patients. The modifiable reasons for not meeting the targeted treatment time are a lack of capacity in theatre and Consultants’ decisions to delay treatment. The addition of a dedicated hot gallbladder theatre list can increase the numbers treated within the target time.

Incidence of gall bladder perforation in cases admitted with acute cholecystitis in tertiary care centre, Puducherry

Aim: To present our clinical experience with gallbladder perforation cases in cases admitted with acute cholecystitis.Methods: Records of 75 patients who received medical andor surgical treatment with the diagnosis of acute cholecystitis in Sri Venkateswara medical college hospital and research centre, Ariyur, Puducherry between November 2020 to August 2021 were reviewed retrospectively. Five (6.6%) of those patients had gallbladder perforation. The parameters including age, gender, time from the onset of symptoms to the time of surgery, diagnostic procedures, surgical treatment, morbidity, and mortality were evaluated.Results: One patient had type I gallbladder perforation, 4 type II gallbladder perforation according to Niemeier’s classification. The patients underwent surgery after administration of intravenous fluids, analgesics and antibiotics after admission.Conclusion: Early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance. Upper abdominal computerized tomography for acute cholecystitis patients may contribute to the preoperative diagnosis of gallbladder perforation.

The Role of Neutrophil and Lymphocyte Values in the Diagnosis of Acute Cholecystitis

Amaç: Bu çalışmada kolesistektomi geçirecek hastaların preoperative akut kolesistit tanısında nötrofil/lenfosit oranının prediktif değerinin olup olmadığının ortaya konulması amaçlanmıştır.Gereç ve Yöntemler: Araştırma kapsamında 2018-2020 yılları arasında akut kolesistektomi ve elektif kolesistektomi yapılan kura ile seçilen toplam 100 hasta değerlendirildi. Hastaların dosyalarından yaş, cinsiyet, operasyon yöntemi (laparoskopik veya açık), yatış süresi, operasyon öncesi son bakılan nötrofil ve lenfosit sayıları kaydedildi. Histopatolojik olarak akut kolesistit ve kolelitiyazis tanısının doğrulandığı hastalar nötrofil lenfosit sayılarının oranları açısından karşılaştırılarak bu verilerin tanısal değeri ROC eğrileri ve çapraz tablolar ile belirlendi. p&amp;lt;0.05 değeri istatistiksel olarak anlamlı kabul edildi.Bulgular: Akut kolesistektomi grubunda yer alan hastaların Nötrofil/lenfosit oranının elektif kolesistektomi grubunda yer alan hastalara göre istatistiksel olarak daha anlamlı yüksek olduğu saptandı (p=0.001). Lökosit ve platelet/lenfosit oranının da benzer şekilde akut kolesistektomi yapılan hastalarda elektif kolesistektomi yapılan hastalara göre belirgin olarak daha yüksek düzeyde olduğu saptandı (p=0.001).Sonuç: Çalışmamızdan elde ettiğimiz veriler doğrultusunda nötrofil/lenfosit oranının akut kolesistit vakalarında prediktif değerinin olduğu görülmektedir.

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy

BackgroundWhile percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis. MethodsPatients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment. ResultsA total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001). ConclusionAlthough patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.

The Accuracy of Point-of-Care Ultrasound in the Diagnosis of Acute Cholecystitis.

Acute cholecystitis (AC) affects 50-200000 patients per year. Early surgery is the treatment of choice for AC. Therefore, timely diagnosis is important to begin proper management. Recently, emergency departments have adopted point-of-care ultrasound (POCUS) for the initial evaluation of AC. The accuracy of POCUS for AC has not been well studied. Patients receiving POCUS for evaluation of AC in the emergency department at our tertiary care institution for 2years were considered. Patients with previous biliary diagnoses were excluded. Patients were deemed to have AC from a recorded POCUS result or 2/3 of the following POCUS findings: pericholecystic fluid, gallbladder wall hyperemia, and sonographic Murphy's sign. Formal ultrasound and final diagnosis from surgical and pathology reports were used as gold standards for comparison. In total, 147 patients met inclusion criteria. POCUS had a sensitivity and specificity of .4 (95% CI: .1216-.7376) and .99 (.9483-.9982), respectively, when compared to a final diagnosis and .33 (.0749-.7007) and .94 (.8134-.9932) when compared to formal US. The modified Tokyo guidelines for suspicion of AC had a sensitivity of .2 (.0252-.5561) and specificity of .88 (.8173-.931) compared to the final diagnosis. Point-of-care ultrasound was not a better screening test than the modified Tokyo guidelines. We recommend a simplified screening approach for AC using clinical findings and laboratory data, followed by confirmatory formal imaging. This strategy could prevent unnecessary delays in surgical management and use of physician resources.

An investigation into the predictive role of serum inflammatory parameters in the diagnosis of complicated acute cholecystitis.

Gallbladder gangrene and perforation are an important complication of acute calculous cholecystitis and are dif-ficult to detect preoperatively. Therefore, in this study, we aimed to evaluate whether serum inflammatory parameters are predictive factors for complicated cholecystitis (CC). In the present study, histopathological findings of 250 patients who were operated on with the diagnosis of acute chole-cystitis (AC) in the emergency department between 2014 and 2019 were evaluated and the cases were divided into two groups as AC and CC. Parameters, including age, gender, body mass index, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil-to-lym-phocyte ratio (NLR), mean platelet volume (MPV), and platelet distribution width (PDW), were examined for their ability to predict CC. The findings obtained in this study showed that WBC, CRP, and NLR were significantly higher in the CC group (p<0.05). WBC >9.000 cells/ml, CRP >29.0, and NLR >4.3 were the factors that could predict CC. There was no significant difference between the two groups concerning MPV and PDW (p>0.05). CC was observed more frequently in patients over 65 years of age, but there was not a statistically significant difference (p=0468). WBC, CRP, and NLR are valuable biochemical markers in predicting complicated AC. Advanced age may be a help-ful predictive factor for CC. These factors may be helpful in making an early cholecystectomy decision.

A retrospective assessment of the complications and associated risk factors of laparoscopic cholecystectomy

Aim: The aim of the present study to assess the risk factors and complications of Laparoscopic Cholecystectomy. Material and Methods: This was a retrospectively analysed study conducted in the Department of General Surgery, Shri Shankaracharya Institute of Medical Sciences, Bhilai, Chhattisgarh, India, from December 2018 to November 2019. 100 patients who were diagnosed with cholelithiasis and had laparoscopic cholecystectomy were included in this study. We analysed the type and frequency of intraoperative and postoperative complications, as well as factors that increase the risk for development of complications. We noted causes and incidence of conversions and the way they resolved. We noted gender, age, body mass index (BMI), white blood cell count, and level of C-reactive protein (CRP), preoperative ultrasonographic findings, Patho histological findings of the surgically removed gallbladder, as well as their correlation with the occurrence of complications. Results: Out of the 100 patients in the study, 68 were female (68%), and 32 were male (32%). The most common complications noted were: iatrogenic perforations of the gallbladder- 5 (5%), bleeding from the tissues adjacent to the gallbladder 3 (3%), gallstones spilt into the peritoneal cavity 2 (2%). Intraoperative bleeding from the cystic artery occurred in 1 (1%), bleeding from the port in 1 (1%) and bleeding from the ligaments of the liver in 1 patients (1%). The transection of the common bile duct, a major complication, occurred in only one patient (1%). The most common postoperative complications were: bleeding from the abdominal cavity more than 100 ml/24h (in 3 patients or 3%), bile leaks through the drain > 50-100 ml/24h (2 patients, or 2%). In addition, the ultrasonographic findings of empyema, gangrene of the gallbladder wall, and increased gallbladder wall thickness > 3 mm (group II) is a significant predictor of complications and conversion (OR = 4.92, 95% CI 1.61-18.13, p< 0.001). Patho histologic analysis of the surgically extracted gallbladder with the diagnosis of acute cholecystitis was also the significant predictor for complications and conversion (OR 1.82, 95% CI 2.52-16.66, P< 0.001). Conclusion: the laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay.

What is the Treatment Role of Transpapillary Cholecystostomy for Delayed Cholecystectomy in the Coexistence of Acute Cholecystitis and Cholangitis.

This study aims to investigate the role of main bile duct drainage and gallbladder transpapillary drainage in the treatment of patients who diagnosed with acute cholecystitis and acute cholangitis because of choledocholithiasis. Patients who were admitted to the hospital with the diagnosis of acute cholecystitis between January 2018 and December 2019, have hyperbilirubinemia in their laboratory tests, and who were diagnosed with choledochal stone by magnetic resonance imaging and magnetic resonance cholangiopancreatography imaging because of the findings of cholangitis were included in this study. These patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and choledochus stone extraction procedure and gallbladder drainage with the transpapillary pigtail. The demographic data, success rates, and complications of the patients were evaluated. A total of 19 patients were included in the study. Choledochus was cannulated in all patients, but gallbladder drainage could not be achieved in 2 patients. These 2 patients were recorded under the unsuccessful method use. Although 2 patients could not be operated because of high comorbidity (American Society of Anesthesiologists IV), they underwent percutaneous cholecystostomy because of the development of cholecystitis arising from an obstruction in the pigtail catheter in the 11th and 12th weeks. Treatments of the remaining 15 patients and subsequent cholecystectomy procedures were successful. The mean age of the patients was 54.52 years. Of the patients, 9 were female and 6 were male. In the 6th week of follow-up, 15 patients underwent laparoscopic cholecystectomy with ERCP 1 day after removal of the stent and pigtail catheter. Transpapillary cholecystectomy with ERCP is a successful method of treatment in patients with acute cholecystitis with the symptoms of cholangitis because of choledochal stone.

BIOCHEMICAL STUDIES RELATED TO ACUTE CHOLECYSTITIS IN LIBYAN SUBJECTS

Acute cholecystitis and cholelithiasis are one of common health problems of Libyans. [1] Acute cholecystitis or bile gallbladder stones are one of the major surgical problems in the Libyan population and account for many hospital admissions and surgical interventions. This study was done to estimate causes and risk factors of AC among general population of Benghazi city in Libya. Reflux of pancreatic secretions into the biliary duct due to a defect in motility of gallbladder or biliary tree or spastic episodes of Sphincter Oddi may cause injury to gallbladder mucosa and biliary tract which may precipitate acute cholecystitis. Pancreatic biliary reflux (PBR) therefore may cause such reflux of pancreatic juice into gallbladder and biliary tract. This problem is probably related to obesity, cardiovascular disorders (CVD), metabolic syndrome, and dietary habits. Studies on gallstone composition carried out a close link with dietary habits and ethnicity. The biliary composition has been demonstrated by many researches for several years. Gallstone formation is relatively increased with consumption of dietary fats, age and gender.2-3 Estimation of pancreatic amylase in gallbladder bile as well as in serum of patients with acute cholecystitis (AC) may be considered as a biomarker of PB reflux. Serum and bile pancreatic amylase levels as marker for diagnosis of acute cholecystitis" by investigate biliary composition especial alpha amylase pancreatic, total amylase, liver enzymes estimation the correlation between (AST, ALT, ALP and Bilirubin total, C-RP and lipid profile in gallstone disease patients and estimate the correlation between (Cholesterol, HDL, LDL, VLDL) concentration in serum and biliary gallbladder, presence of gallstones, age, in both gender patient with gallbladder diseases.

Surgical treatment of acute cholecystitis in obese patients.

&lt;b&gt;Introduction:&lt;/b&gt; In today's technological climate, science and medicine have entered a new era. At the level of technological progress, we have identified millennia of "new" problems and diseases. If earlier diseases had a certain individuality then, in the third millennium, we face compliance and synergistic influence of diseases. Obesity is a problem of the third millennium. It is known that obesity is the main factor in the development of various chronic diseases [1-3]. With excess weight and obesity, bile is oversaturated with cholesterol, resulting in an increase of its lipogenicity index. As a result, frequency of gallstone disease increases; findings from this study document an increase of disease frequency as high as 50% to 60% [4]. In 20% of patients, housing concerns are combined with obesity [5]. Thus, obesity is one of the factors in the development of cholelithiasis and cholecystitis [6]. The presence of acute cholecystitis represents the most difficult situation for patients with gallstones. When obesity is also present, the patient's risk of surgical complications increases due to altered homeostasis and reduced reserve capacity [7]. A retrospective study of this issue [8] posed a number of questions about the possibility of influencing the course of disease in the preoperative period as well as the improvement and impact of surgical technicalities in patients with acute cholecystitis and obesity. Addressing these and additional questions is the main goal of this study. &lt;br&gt;&lt;b&gt;Aim: &lt;/b&gt;The aim of the study was to study and select the optimal method of surgery in patients with acute cholecystitis and obesity. &lt;br&gt;&lt;b&gt;Materials and methods:&lt;/b&gt; In our study, a prospective analysis was used. We analyzed 67 cases with diagnosis of acute cholecystitis and obesity; all were treated at Kyiv Regional Clinical Hospital in the period from September 2018 to March 2020. Patients with acute cholecystitis and obesity received either traditional or modified laparoscopic cholecystectomy. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; Retrospective analysis indicates traditional laparoscopic cholecystectomy is technically difficult and costly in patients with acute cholecystitis and obesity. A modified laparoscopic cholecystectomy has been proposed to improve and enhance surgery in patients with acute cholecystitis and obesity. Surgical duration was shortened by 9.01 ± 0.41 minutes (p = 0.001; αα= 0.05) when a modified laparoscopic cholecystectomy was performed. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Performing a modified laparoscopic cholecystectomy reduced the duration of surgery by 9.01 ± 0.41 minutes (p = 0.001; α = 0.05), prevents development of metabolic acidosis pH 7.39 ± 0.03 vs 7.30 ± 0.005 = 0.001; αα= 0.05, pCO2 5.05 ± 0.36 vs 6.03 ± 0.38 (p = 0.02; αα= 0.05), reducing the risk of hypercoagulation. Modified laparoscopic cholecystectomy (LHE) is effective in II and III degrees of obesity (p = 0.001; α = 0.05).

難治性上部消化管穿孔症例に対する内視鏡的フィブリン接着剤局注療法の応用(Application of endoscopic local injection of fibrin glue to treat refractory perforation cases in the upper digestive tract)

要旨内視鏡的止血法の1つとして，フィブリン接着剤（fibrin glue: FG）局注療法が報告されている。今回我々は，難治性上部消化管穿孔例に，FG局注療法を応用し，良好な結果を得た。症例1は79歳の女性。上腹部痛を主訴に救急搬送された。壊疽性胆嚢炎，胆石性膵炎の診断にて消炎後，胆嚢摘出術を施行した。その後，膵炎に合併した仮性膵嚢胞と接する胃体後壁に穿孔を認め，内視鏡的にFG局注療法を施行した。結果，約2週間で同部の閉鎖を見た。症例2は82歳の男性。嘔気と腹痛を主訴に救急搬送された。下部食道の特発性食道破裂の診断のもと，食道破裂部単純閉鎖術を施行した。約1か月後，縫合部の再穿孔を認め，内視鏡的にFG局注療法を施行した。その後，上皮形成を認め，閉鎖した。難治性上部消化管穿孔例に対し，内視鏡的FG局注療法は有用な閉鎖術になりうると考えられた。

Clinical study, management and outcome of gall bladder perforation in a tertiary care hospital

Background: The objective of the study was to present our clinical experience with gall bladder perforation cases. This may help in the management and decision making of such cases.Methods: Records of 480 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our hospital between 2007 and 2014 were reviewed retrospectively. Twenty nine (6%) of those patients had gall bladder perforation. Original Niemeier’s classification of gall bladder perforation used to describe the type of perforation. The parameters including age, gender, duration of symptoms, diagnostic procedures, medical or surgical or radiological interventional treatment used, morbidity and mortality were evaluated.Results: Out of the 29 patients, 25 patients had subacute type of gall bladder perforation (Niemeier type II) and 4 patients had chronic (Niemeier type III) perforation. None of the patients encountered had generalized peritonitis (Niemeier type I). The diagnosis in all these patients was established on admission to the hospital by means of abdominal ultrasound and computed tomography. Twelve (43%) patients underwent early surgery. The rest (58.6%) either underwent conservative medical line of management or pigtail catheter insertion in the collection followed by interval cholecystectomy. Three (10.7%) patients died of sepsis and associated comorbid condition.Conclusions: Early diagnosis of gall bladder perforation is of critical importance. Abdominal ultrasound coupled with computerized tomography is useful in diagnosis of gall bladder perforation. Management strategies include early surgery in patients with generalized peritonitis or suspicion of gall bladder necrosis, and initial conservative line of management and/or pigtail insertion in surgically high risk patients which can be followed up by interval cholecystectomy.

Patología quirúrgica abdominal en el paciente de edad avanzada

Abdominal surgical pathology in elderly patient is relevant because of two fundamental factors: life expectancy rises and some features of the elderly patients make the diagnosis and treatment a challenge. The prevalence of acute diverticulitis increases with age and usually is located in bowel sigmoid. Diagnosis relies on clinical history and computed tomography (CT). Treatment is conservative (antibiotics), surgery is required only if complications.The diagnosis of acute cholecystitis is based on clinical history and ultrasound; frequently, treatment is surgical with laparoscopic approach. The early diagnosis of acute intestinal ischemia is based on a high level of clinical suspicion and CT angiography is mandatory. Surgical treatment is based on revascularization and non-viable bowel resection. Sigmoid volvulus is the most frequent. Diagnosis is carried out using CT. Initial treatment is endoscopic decompression accompanied by delayed resection of redundant sigma..

Emotional Support and its Medical and Healthcare Implications: A Mind and Body Approach

High complications and conversion rate associated with laparoscopic treatment for acute cholecystitis was a common sense by surgeons. The optimal time of laparoscopic cholecystectomy for acute cholecystitis remains controversial. Either early or interval elective to undergo laparoscopic cholecystectomy for acute cholecystitis could gain the best cost/beneficial ratio. A prospective randomized study was performed to make it clear. During a 29-month period, 97 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n= 48) or delayed interval surgery after initial medical treatment (delayed group, n=49). Thirteen patients (five in the early group and eight in the delayed group) were excluded because of refusal of operation (n=5), misdiagnosis (n=5), contraindication for laparoscopic surgery (ca. of gallbladder), or loss of follow-up (n=2). Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n=3) and persistent fever (n=5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs.11%; p=0.174) and complication rate (29% vs.13%; p=0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p=0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p＜0.001) and recuperation period (19 days vs.12 days; p＜0.001).We concluded that initial conservative treatment followed by interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early laparoscopic or traditional cholecystectomy within 72 hours may be safer and has definite socioeconomic benefits.

Can we use neutrophil lymphocyte ratio and platelet lymphocyte ratio as a potential biomarker for acute cholecystitis?

Aim : The aim of this study is to determine the effectiveness of the neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) in the diagnosis of acute cholecystitis (AC). Material and method : 452 patients diagnosed with AC and 152 patients who admitted to the clinic with biliary colic and elective cholecystectomy have been included this study. Groups compared according to age, gender, white blood cell count (WBC), mean platelet volume (MPV), platelet distribution width (PDW), red blood cell distribution width (RDW), NLR and PLR. Results : There was no significant difference in age between the two groups (p=0.52). Female patients were significantly higher in both control and AC groups (p=0.006). WBC, CRP, NLR, PLR values of the patients in the study group have been observed significantly higher than the control group (p<0.001). The parameter with the highest sensitivity and specificity was found as NLR. Conclusions: NLR and PLR can be considered as a potential inflammatory biomarker for AC, due it being inexpensive and easy calculated.

Early cholecystectomy (< 72h) is associated with lower rate of complications and bile duct injury: a study of 109,862 cholecystectomies in the state of New York.

The timing of cholecystectomy for acute cholecystitis has been debated with most studies favoring early cholecystectomy (< 72h of onset). However, most reported studies are from single institution studies with only a few population-based studies. The purpose of this study is to compare clinical outcomes of patients undergoing cholecystectomy within 72h of emergency department (ED) presentation to patients undergoing cholecystectomy following 72h in a large statewide database. The New York SPARCS administrative database was used to identify all adult patients presenting to the ED with a diagnosis of acute cholecystitis from 2005 to 2016. Patients aged < 18, missing data, or other biliary diagnoses were excluded from the analysis. Early cholecystectomy was defined as within 72h of presentation to the emergency department. Early vs late groups were compared in terms of overall complications, bile duct injury (BDI), hospital length of stay (LOS), 30-days ED visits and readmissions. The linear trends of yearly early/late cholecystectomies were examined using a log-linear Poisson regression models. Multivariable logistic regression model was used to compare complications, BDI, and 30-day readmission/ED visits after controlling for confounding factors. Multivariable generalized linear regression for a negative binomial distributed count data was used to compare LOS. Following the application of the inclusion/exclusion criteria, there were 109,862 patients who presented to an ED with the diagnosis of acute cholecystitis. The majority of patients underwent early cholecystectomy (n = 93,761, 85.3%), whereas only 16,101 patients underwent late cholecystectomy (14.7%). There was an increasing trend of early cholecystectomy from 2005 (81.1%) to 2016 (87.8%). On multivariable regression, patients with early cholecystectomy were less likely to have complications (OR 0.542, 95% CI 0.518-0.566), had shorter LOS (ratio 0.461, 95% CI 0.458-0.465), were less likely to have 30-day readmission (OR 0.871, 95% CI 0.816-0.928), 30-day ED visits (OR 0.909, 95% CI 0.862-0.959), and bile duct injury (OR 0.654, 95% CI 0.444-0.962) compared to late cholecystectomy patients. Early cholecystectomy (< 72h) is associated with fewer complications, specifically BDI, shorter LOS, and fewer 30-day readmissions and ED visits. For patients presenting to the ED for acute cholecystitis, early cholecystectomy should be preferred.