Emphysematous Cholecystitis Research Articles

Emphysematous Cholecystitis in a Dog with Damage to the Gallbladder Wall

Emphysematous Cholecystitis in a Dog with Damage to the Gallbladder Wall

A Case of Elective Laparoscopic Cholecystectomy for Emphysematous Cholecystitis with Preoperative Percutaneous Transhepatic Gallbladder Drainage

A Case of Elective Laparoscopic Cholecystectomy for Emphysematous Cholecystitis with Preoperative Percutaneous Transhepatic Gallbladder Drainage

C-reactive Protein Is the Best Biomarker to Predict Advanced Acute Cholecystitis and Conversion to Open Surgery. A Prospective Cohort Study of 556 Cases

BackgroundWhite blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels. MethodsThis was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery. ResultsOn multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3–4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003–1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion. ConclusionCRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter—international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo.

AB161. 182. Emphysematous cholecystitis: case report on a rare, life threatening presentation

: A 78-year-old gentleman with type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and hypertension presented to the emergency department with sudden onset of severe right upper quadrant with associated vomiting. White cell count showed a leukocytosis of 24×10×9/L and a C-reactive protein of 57 mg/L. An ultrasound abdomen revealed no acute gallbladder or biliary pathology. Computed tomography of the abdomen revealed pericholecystic fat stranding, an air-liquid level within the gallbladder and gas dissecting along a significant portion of the gallbladder wall—findings consistent with emphysematous cholecystitis, grade 3 with associated perforation and small volume of portal venous gas. Our patient underwent an emergency laparotomy with cholecystectomy. Pathology examination revealed acute acalculous gangrenous cholecystitis. Our patient required a 5-day admission to intensive care unit post-operatively. Emphysematous cholecystitis was first described at autopsy in 1901 by Stolz, who characterized emphysematous cholecystitis by the presence of air within the gallbladder and/or the biliary tree in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. Emphysematous cholecystitis is a potentially life-threatening anaerobic infection, is a variant of acute cholecystitis. The mortality rate for acute emphysematous cholecystitis however is 15–50%. Despite the high mortality associated with gangrene and gallbladder perforation, patients with emphysematous cholecystitis do not exhibit alarming clinical signs of sepsis, and the presenting symptoms are often nonspecific and initially indistinguishable from those of uncomplicated acute cholecystitis. Patients with diabetic neuropathy may not experience typical right upper quadrant pain and maybe present with a paucity of symptoms.

A Case of Perforated Emphysematous Cholecystitis with Intraabdominal Free Air

A Case of Perforated Emphysematous Cholecystitis with Intraabdominal Free Air

A Case of Emphysematous Cholecystitis Treated by Laparoscopic Cholecystectomy

A Case of Emphysematous Cholecystitis Treated by Laparoscopic Cholecystectomy

Emphysematous Cholecystitis: Rare Scenario Revisited

Emphysematous cholecystitis (EC) is a rare form of acute cholecystitis caused by gas-forming organisms. This entity is characterized radiologically by presence of air within the lumen or in the wall and carries a high morbidity and mortality. The following article pictorially exemplifies this uncommon presentation managed by laparoscopy.

Emphysematous cholecystitis and cholecystocolic fistula

Emphysematous cholecystitis and cholecystocolic fistula

Abdominal Pain, Hypotension With Rectal Bleeding: A Unique Presentation of Emphysematous Cholecystitis From Squamous Cell Carcinoma of Gallbladder (GB)

Carcinoma of GB is a rare tumor which presents significant diagnostic challenges. We present a case of an elderly woman who presented with abdominal pain and hematochezia was found to have septic shock from emphysematous cholecystitis in the setting of squamous cell carcinoma of the gallbladder. A 70 year old woman with past medical history of hypertension, anemia, CKD Stage III and DVT on warfarin presented with diffuse abdominal pain and bright red rectal bleeding. Her initial blood pressure was 74/38 mm hg with significant epigastric tenderness on exam. Rectal exam revealed hematochezia. Labs revealed hemoglobin of 9.7 g/dL. Initially believed to have lower GI bleed in the setting of supratherapeutic INR (3.1) she was transfused fresh frozen plasma and packed red blood cells. In view of significant epigastric tenderness CT scan of abdomen was done which revealed a markedly distended stone-containing GB with wall thickening, fat stranding and gas anteriorly dependent within the GB concerning for emphysematous cholecystitis. She was treated with IV antibiotics with emergent cholecystectomy. Pathology of the GB was significant for poorly-differentiated squamous cell carcinoma with positive cystic duct lymph node and acute cholecystitis with cholelithiasis. Cancer of the GB is an uncommon malignancy comprising just 0.6% of all new cancer diagnoses, and just 3.7% of all new digestive system cancer diagnoses in 20161. Histologic subtypes include adenocarcinoma, and squamous/adenosquamous carcinoma with an incidence of 90% and 1.7-12% respectively. Occurring primarily in the elderly with a 3:1 predominance in women3,4, GB carcinoma is a highly aggressive disease entity. Due to the lack of typical presenting symptoms GB cancer is usually diagnosed in advanced stages. In certain instances, patients may present with complaints of abdominal pain, nausea and vomiting and are eventually diagnosed with cholecystitis as the tumor obstructs outflow of bile. Aim of treatment is surgical resection when possible. Our case was clinically challenging as the initial presentation was consistent with massive lower GI bleeding but the CT scan of the abdomen helped us reach to the correct diagnosis and treatment. It is important for physicians to think of a broad differential diagnosis as sometimes the disease presentation is not straight forward like in our case where in the presenting complaint of rectal bleeding eventually led to a diagnosis of squamous cell cancer of GB.1241_A.tif Figure 1: Axial view of emphysematous gallbladder with foci of anteriorly dependent air.1241_B.tif Figure 2: Coronal view of markedly distended gallbladder with multiple stones, irregularly thickened wall and pericholecystic fluid.

Acalculous Cholecystitis Presenting as Small Bowel Obstruction

Acalculous cholecystitis (AAC) is an inflammatory disease of the gallbladder which occurs in the absence of gallstones or biliary obstruction. Though the etiology of AAC remains unclear, multiple factors are responsible for its pathogenesis including biliary stasis, sepsis and ischemia. AAC is seen in 0.2% - 0.4% of hospitalized and critically ill patients and represents about 10% of all cases of acute cholecystitis. ACC is associated with a morbidity and mortality rate of 10% - 50%. Herein, we report a 78 year old male with a history of hypertension, hyperlipidemia, diabetes mellitus, and chronic obstructive pulmonary disease who was admitted for an infected left foot ulcer complicated by acute osteomyelitis. During his hospital stay he developed abdominal distention with bilious emesis. A nasogastric tube was placed and drained 2 liters of bilious fluid. Computer tomography (CT) scan of the abdomen and pelvis with contrast showed marked dilatation of the distal esophagus and stomach without evidence of gastric outlet, small or large bowel obstructions. The gallbladder was noted to be massively distended (figure 1) with no evidence of cholelithiasis. Abdominal ultrasound was also negative for cholelithiasis. A hepatobiliary iminodiacetic acid (HIDA) scan was unable to visualize the gallbladder. Liver chemistries remained normal during this time. Successful percutaneous transhepatic biliary drainage (PTBD) was performed for gallbladder decompression. The patient was no longer symptomatic. On subsequent imaging, normalization of the dilated stomach, esophagus and gallbladder was appreciated. An esophagogastroduodenoscopy (EGD) was performed noting a patent pylorus and no signs of obstruction. AAC may be complicated by perforation, gangrene, extra biliary abscess formation, and emphysematous cholecystitis [3]. Our case describes small bowel obstruction secondary to extrinsic compression from a massively distended gallbladder as a rare complication of AAC. A review of the literature shows that our report is the first to highlight this unusual finding. In conclusion, clinicians should bear the differential diagnosis of small bowel obstruction as a corollary to acalculous cholecystitis in the appropriate clinical context.2533 Figure 1. Computed tomography (CT) scan showing distended gallbladder.

Accuracy of ultrasound in diagnosis of cholecystitis

Background: Acute cholecystitis- inflammation of the gall bladder- is most usually brought on by gall stones. Gall stones are one of the most typical problems of the gastrointestinal system, impacting regarding 10% of individuals in Western world. Aim of the study: In this review we discussed background of cholecystitis, symptoms and possible complications. As well we highlighted importance and use of ultrasound in diagnosis of cholecystitis and other diagnoses possibilities and their efficiency. Materials: Articles search was performed in MEDLINE, EMBASE, and CINAHL databases up to May 2018 to identify studies about evaluation ultrasound in diagnosis of cholecystitis and other diagnoses possibilities and their efficiency. Conclusion: CT is debatably the most effective technique for imaging of challenging gallbladder condition, especially for straight imaging of emphysematous cholecystitis, gallstone ileus, and verification of presumed gallbladder perforation. Cholescintigraphy may assist ultrasound and CT for differentiating acute from chronic cholecystitis and for the diagnosis of acalculous cholecystitis.

Accuracy of ultrasound in diagnosis of cholecystitis

Background: Acute cholecystitis- inflammation of the gall bladder- is most usually brought on by gall stones. Gall stones are one of the most typical problems of the gastrointestinal system, impacting regarding 10% of individuals in Western world. Aim of the study: In this review we discussed background of cholecystitis, symptoms and possible complications. As well we highlighted importance and use of ultrasound in diagnosis of cholecystitis and other diagnoses possibilities and their efficiency. Materials: Articles search was performed in MEDLINE, EMBASE, and CINAHL databases up to May 2018 to identify studies about evaluation ultrasound in diagnosis of cholecystitis and other diagnoses possibilities and their efficiency. Conclusion: CT is debatably the most effective technique for imaging of challenging gallbladder condition, especially for straight imaging of emphysematous cholecystitis, gallstone ileus, and verification of presumed gallbladder perforation. Cholescintigraphy may assist ultrasound and CT for differentiating acute from chronic cholecystitis and for the diagnosis of acalculous cholecystitis.

Validation of a new American Association for the Surgery of Trauma (AAST) anatomic severity grading system for acute cholecystitis.

The American Association for the Surgery of Trauma (AAST) established anatomic grading to facilitate risk stratification and risk-adjusted outcomes in emergency general surgery. Cholecystitis severity was graded based on clinical, imaging, operative, and pathologic criteria. We aimed to validate the AAST anatomic grading system for acute cholecystitis. This is a retrospective cohort study including consecutive patients admitted with acute cholecystitis at an urban, tertiary medical center between 2013 and 2016. Grade 1 is acute cholecystitis, Grade 2 is gangrenous or emphysematous cholecystitis, Grade 3 is localized perforation, and Grades 4 and 5 have regional and systemic peritonitis, respectively. Concordance between the AAST grade and outcome including mortality, length of stay (LOS), ICU use, readmission, and complications were assessed using logistic regression. A total of 315 patients were included. There was very good inter-rater (two independent raters) reliability for anatomic grading, κ = 1.00, p < 0.005. The majority of patients were Grade 1 or Grade 2 (94%). Incidence of complications, LOS, ICU use, and any adverse event increased with increasing anatomic grade. When compared to Grade 1 disease, patients with Grade 2 were more likely to undergo cholecystectomy (OR 4.07 [1.93-8.56]). Grade 3 patients were at higher risk of adverse events (OR 3.83 [1.34-10.94]), longer LOS (OR 1.73 [1.03-2.92]), and ICU use (OR 8.07 [2.43-26.80]). AAST severity scores were independently associated with clinical outcomes in patients with acute cholecystitis. Despite low-grade disease, complications were common, and therefore a refinement of the scoring system may be necessary for more granular prediction. Epidemiologic/prognostic, level III.

4:03 PM Abstract No. 168 Results of percutaneous cholecystostomy tube placement in 324 patients

Determine the technical success and clinical outcome of cholecystostomy tube placement along with removal rate after placement. A database search was performed from January 2010 to September 2017 for the term “cholecystostomy tube” yielding 1,160 patients. Patients with no indication for cholecystostomy (n = 625; 53.9%) or an outside hospital placed cholecystostomy (n = 211; 18%) were excluded. 324 (27.9%) patients with cholecystostomy tubes were included in the analysis. 312 (96.2%) tubes were placed by interventional radiology and 12 (3.8%) intraoperatively by surgery. Indication for cholecystostomy tube placement, ultrasound findings, initial lab studies, candidacy for surgery, comorbidities, access route, tube size, dwell time, bile culture results, reason for tube removal, follow-up, and complications were recorded. The indications for cholecystostomy tube placement included: acute cholecystitis (n = 270; 83.3%), perforated cholecystitis (n = 22; 6.8%), and emphysematous cholecystitis (n = 18; 5.6%). Ultrasound findings included: wall thickening (n = 208; 64.2%), calculi (n = 187; 57.7%), and pericholecystic fluid (n = 143; 44.1%). 297 (91.7%) patients were not surgical candidates. The most frequent reason for removal was cholecystectomy (n = 96; 29.6%). 36 (11.1%) had a patent cystic duct on follow-up, 19 (5.9%) had cholecystoscopy and stone removal, 15 (4.6%) underwent double J stent placement, and 3 (0.01%) had liver transplants. 94 patients died (29%), 33 (10.2%) had tubes migrate or fall out. 256 (79%) had transhepatic and 56 (17.2%) had transperitoneal tubes. Mean tube size was 7-French. Mean dwell time was 89 days (range, 0-586 days). 45 (13.9%) patients had tubes at the end of study period, and 19 (4.2%) were lost to follow-up, 13 (28.9%) had ongoing tube changes, 8 (17.8%) scheduled cholecystectomy, and 4 (8.9%) getting downsized with plans for removal. 321 (99%) of patients had no major adverse events, 2 (0.006%) had bile leak, and 1 (0.001%) developed septic shock. Cholecystostomy tube placement was possible in all patients and clinical symptoms resolved after placement in all cases. A majority of patients were able to have their tubes removed.

Percutaneous Cholecystostomy: Long-Term Outcomes in 324 Patients.

To report technical success and clinical outcome of cholecystostomy tube placement along with timing-and method-of tube removal. A retrospective review of cholecystostomy tubes placed from January 2010 to September 2017 was performed at a single academic center. This search yielded 1160 patients. Of these patients, 324 (27.9%) met inclusion criteria for cholecystostomy placement, 199 (61.4%) males and 125 (38.6%) females, with mean age of 67years (range 6-101years). The indication for cholecystostomy tube placement, technical success, surgical candidacy, medical comorbidities, clinical outcome, tube indwelling time, complications, and follow-up were recorded. Indications for cholecystostomy tube placement included: acute cholecystitis (n=270; 83.3%), perforated cholecystitis (n=22; 6.8%), emphysematous cholecystitis (n=18; 5.6%), and other (n=14; 4.3%). Technical success was 100%. Many patients had multiple medical comorbidities including (most commonly): debilitation (n=211; 65.1%), cardiovascular disease (n=194; 59.9%), multisystem disease (n=181; 55.9%), and malignancy (n=131; 40.4%). After tube placement, 96 (29.6%) patients underwent definitive cholecystectomy, 94 expired (29.0%), 36 (11.1%) had a patent cystic duct on follow-up cholangiogram and subsequent cholecystostomy removal, 14 (4.3%) underwent cholecystoscopy with stone removal, and 3 (0.9%) had liver transplantation. Forty-five (13.9%) patients had indwelling tubes at the end of the study period. Mean tube indwelling time was 89days (range 0-586days). Technical success for cholecystostomy tube placement was 100% with all patients having clinical resolution of acute cholecystitis. Many patients were able to have tubes subsequently removed.

Acalculous Perforated Hemorrhagic Emphysematous Cholecystitis Caused byClostridium perfringensin a Patient with Myeloma Taking Daratumumab

Background: Acute calculous cholecystitis is a common disease entity familiar to every surgeon, however, variations such as acalculous cholecystitis, hemorrhagic cholecystitis, and emphysematous or gangrenous cholecystitis are rare. Diagnosis is more difficult and delays increase patient morbidity. Case Presentation: We present the case of a 75-year-old female Caucasian with multiple myeloma, undergoing treatment with daratumumab and dexamethasone, who was diagnosed with acute acalculous, emphysematous, perforated, and hemorrhagic cholecystitis. Active hemorrhage was demonstrated via contrast blush on computed tomography (CT) scan. She was treated expeditiously and recovered well. Cultures demonstrated a polymicrobial infection, including Clostridium perfringens. Conclusion: This is a complex case with unclear initial etiology, likely exacerbated by growth of Clostridium perfringens. It is possible that the patient's immunocompromised state contributed to infection that then lead to gallbladder emphysema, perforation, and hemorrhage. Thus, the clinician should be aware of the possibility of complicated cholecystitis in the immunocompromised patient, even in the absence of neutropenia, to avoid missing devastating complications of perforation or hemorrhage.

Laparoscopic Cholecystectomy in Patients with Emphysematous and Gangrenous Cholecystitis: An Experience at Khwaja Yunus Ali Medical College &amp; Hospital, Enayetpur, Sirajgonj.

Objective- To look for the feasibility and safety of laparoscopic cholecystectomy in patients with emphysematous and gangrenous cholecystitis.Back ground- Emphysematous and gangrenous cholecystitis are severe form of acute cholecystitis. They are considered as contraindication of laparoscopic cholecystectomy due to peri operative life threatening complications, surgical technical difficulties, frequent conversion to open procedure. This study describe our experience in terms of feasibility and safety with laparoscopic cholecystectomy in patients with emphysematous and gangrenous cholecystitis.Materials and methods- From January 2012 to December 2014,total 37 patients with clinical diagnosis of severe acute cholecystitis under went laparoscopic cholecystectomy within 72 hours of admission. Operative findings and histopathological reports were used to identify patients of emphysematous and gangrenous cholecystitis.Results- 35(94.59%)among 37 patient's laparoscopic cholecystectomy were performed successfully.29 case were emphysematous and 8 cases were gangrenous cholecystitis. Two patient's laparoscopic procedure were converted to open procedure due to various operative difficulties, of which the most common was distorted calot's triangle. Maximum operating time was up to 130 minutes(one case),Post operative major complications occurred in 2 cases(5.40%).maximum patients were discharged by 48 to72 hours. There was no mortality.Conclusion- laparoscopic cholecystectomy is feasible and safe in emphysematous and gangrenous cholecystitis. However the experience of the surgeon and his patience during surgery play key role in over all out come. Based on our experience we recommend an early laparoscopic cholecystectomy for these group of patients, provided expertise &amp; gadgets are available.KYAMC Journal Vol. 5, No.-2, Jan 2015, Page 519-523

Emphysematous Cholecystitis in a patient with Metastatic Pancreatic Neuroendocrine Tumour

Emphysematous Cholecystitis in a patient with Metastatic Pancreatic Neuroendocrine Tumour

Emphysematous cholecystitis in a young patient with no risk factors.

A 43-year-old, otherwise healthy, male patient presented at the emergency department, with a 3-day history of right upper quadrant abdominal pain and fever of 39°C. Physical examination revealed positive Murphy’s sign and jaundice. Laboratory values revealed leukocytosis (18,000/ml), elevated CRP and liver function tests (direct bilirubin, ALP, ³GT). Ultrasound scanning demonstrated distention of the gallbladder, with wall thickening, pericholecystic fluid and a gallstone impacted in cystic duct. The patient was empirically started on broad-spectrum antibiotics. An abdominal CT scan on the following day revealed gas in the gallbladder wall and lumen (A, B). A percutaneous cholecystostomy was placed (C) and his clinical condition improved dramatically over the following hours, with normalisation of inflammatory indices and liver chemistry. He is scheduled to undergo laparoscopic cholecystectomy in 8 weeks. Emphysematous cholecystitis usually begins as a typical case of acute cholecystitis, but ischemia and gangrene soon develop in the gallbladder wall, due to intramural translocation of gas-forming microorganisms ( Clostridium , E. coli , Klebsiella , Streptococci ). Predisposing factors include diabetes mellitus, immunosuppression, peripheral vascular disease, abdominal surgery and trauma. Initial assessment with ultrasound may show reverbation artifacts due to the presence of air. CT scans are considered more specific and sensitive, demonstrating a gaseous halo around the gallbladder as well as air within its lumen. Emphysematous cholecystitis is a surgical emergency. Early intervention with surgery or percutaneous cholecystostomy is the mainstay of therapy. Left untreated, it can progress to perforation, pericholecystic abscess or bile peritonitis. Mortality rate for uncomplicated emphysematous cholecystitis is 1.4%, whereas for complicated cases it can reach up to 25%.

Sonographic Non-Visualization of the Gallbladder: A Pitfall in Diagnosis of Emphysematous Cholecystitis

Emphysematous cholecystitis is an uncommon complication of calculous cholecystitis due to secondary infection of gallbladder wall with gas-forming enteric organisms. It carries high morbidity and mortality to the patients and a rapid and early diagnosis is essential in patient’s clinical outcomes. Ultrasonography is usually the first and foremost test performed in cases of suspected biliary diseases. Herein, we describe a diagnostic pitfall of ultrasound in a patient with emphysematous cholecystitis – non-visualization of gallbladder, caused by reverberations from air in the gallbladder wall.