A case of pericholecystic abscess diagnosed by ultrasonography

Pericholecystic abscess is a serious complication of cholecystitis. Though preoperative diagnosis is easy by gray-scale ultrasonography, there has been no case reported in which the communication between pericholecystic abscess and the gallbladder was demonstrated ultrasonically. We experienced a case in which the communication route between a pericholecystic abscess and the gallbladder was successfully demonstrated by a real-time electric linear scanner. Furthermore, the abscess was successfully treated by percutaneous drainage following ultrasonically guided puncture. This success demonstrates that ultrasonography by a real-time scanner can be effective for diagnosis and treatment of acute cholecystitis and pericholecystic abscess.     

Patient with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas

We report an 84-year-old man with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas. The patient was admitted for abdominal pain, abdominal swelling, and consciousness disorder 18 days after the onset. Abdominal computed tomography (CT) revealed emphysema in the gallbladder and a small amount of intraperitoneal free gas. Intraoperative findings suggested gangrenous cholecystitis. The gallbladder wall was perforated, and an abscess involving the right subphrenic region, the periphery of the liver and gallbladder, and the right paracolonic groove, was detected. The flare on the body surface may have reflected abscess formation in the right abdominal cavity. Emphysematous cholecystitis induces necrosis and perforation in many patients, and immediate strategies such as emergency surgery are important.     

Diagnosis and treatment of gallbladder perforation

INTRODUCTION Gallbladder perforation (GBP) is a rare but life threatening complication of acute cholecystitis. Sometimes GBP may not be different from uncomplicated acute cholecystitis with high morbidity and mortality rates because of delay in diagnosis[…     

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

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

Spontaneous gallbladder perforation, pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease

BACKGROUND:Gallstone disease is common,and complications that are frequently encountered include acute cholecystitis and acute pancreatitis,but rarely gallbladder perforation. METHOD:Data were retrospectively collected from clinical case notes and a literature review is presented. RESULTS:A 72-year-old lady presented with spontaneous gallbladder perforation,pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease.She was previously well and had no abdominal com...     

Can gangrenous cholecystitis be prevented?: a plea against a "wait and see" attitude

BACKGROUND/AIMS: A delay in recognizing and treating an inflamed gallbladder may increase the risk of a necrotic evolution and represent a critical factor affecting the progression of the inflammatory process. Aim of the study is to assess the therapeutic attitude in patients with histologically proved gangrenous cholecystitis, to find out whether it could play a role in the progression of the inflammatory condition. METHODOLOGY: Twenty-seven patients with gangrenous cholecystitis at histology were compared with a matched-control group with phlegmonous cholecystitis. RESULTS: Age, gender, ASA score, and concomitant diseases did not differ significantly in both groups. WBC was significantly higher (P = 0.026) in patients with gangrene. Ultrasounds were unhelpful in identifying the severity of the disease. Patients with gangrenous gallbladder showed a significantly increased (P = 0.0006) admission delay compared with controls (104.3+/-15.3 hours vs. 59.7+/-7.7 hours). Surgeon's delay, morbidity and mortality were not different in both groups. CONCLUSION: Patient's delay before hospitalization may represent a crucial factor in the progression toward a more severe disease in acute cholecystitis. The time between symptoms onset and hospital admission (and consequently surgery) was significantly longer in patients with gangrenous cholecystitis, further emphasizing the need for an early (if not urgent) surgical treatment in acute cholecystitis, even with mild symptoms.     

Omental and extraperitoneal abscesses complicating cholecystocolic fistula

BackgroundAcute cholecystitis resolves with conservative treatment in most patients, but empyema or perforation of an ischaemic area may develop, resulting in a pericholecystic abscess, bile peritonitis or a cholecysto-enteric fistula.Case outlineA 63-year-old man presented with extraperitoneal and omental abscess formation complicating a cholecystocolic fistula secondary to gallbladder disease. Histological examination of the gallbladder and omentum showed xanthogranulomatous inflammation.ConclusionA detailed literature review failed to demonstrate a previous report of this combination of rare complications of gallbladder disease.     

A Case of Gallbladder Perforation in Which the Developmental Pattern was Demonstrated by Laparoscopy

Abstract: A 58-year-old man with diabetes mellitus was referred to our clinic because of epigastric colicky pain of sudden onset with fever. An ultrasonography (US) and endoscopic ultrasonography (EUS) demonstrated marked thickening of the gallbladder wall and a pericholecystic echo-free space. A laparoscopy showed tight adhesion between the greater omenturn and the parietal peritoneum, and pooling of bile on the liver surface, the greater omenturn, and in the perisplenic area. The gallbladder itself could not be seen. A surgical laparotomy revealed perforation of the gallbladder with a pericholecystic abscess. No laparoscopic observation of free bile has been reported in cases of gallbladder perforation. In the present case, US, EUS and laparoscopy were useful for early diagnosis of gallbladder perforation. In addition, laparoscopy played an important role in determining the type of gallbladder perforation.     

Factors effecting the complications in the natural history of acute cholecystitis.

BACKGROUND/AIMS: Gangrenous cholecystitis, empyema, gallbladder perforation, and biliary peritonitis are severe complications of acute cholecystitis associated with increased morbidity and mortality. This study aimed to evaluate perioperative factors associated with complications of acute cholecystitis. METHODOLOGY: Between January 1993 and October 2000, we performed cholecystectomy in 368 patients with acute cholecystitis. All perioperative data were collected on age, sex, medical history, symptoms, laboratory tests, ultrasound, operative and microbiological findings, morbidity and mortality. RESULTS: There were 305 cases (83%) of acute uncomplicated cholecystitis, 26 (7.1%) of gangrenous cholecystitis, 23 (6.3%) of empyema of the gallbladder, 12 (3.3%) of gallblader perforation, and 2 (0.5%) emphysematous cholecystitis. Risk factors for complicated cholecystitis included male gender, advanced age, associated diseases, temperature above 38 degrees C, and white blood cell count on admission greater than 18,000. Laparoscopic cholecystectomy was attempted on 36 patients (11.8%) with uncomplicated and seven patients (11.1%) with complicated acute cholecystitis. The conversion rate to open cholecystectomy was 19.4% for uncomplicated cases, 28.6% for complicated cases. There were no differences in operative complications between complicated and uncomplicated cases, however, length of hospital stay, postoperative morbidity and mortality were significantly higher in complicated cases. CONCLUSIONS: Sex (male), advanced age, presence of associated disease, high temperature (> 38 degrees C) and leukocytosis are all remarkable risk factors inducing complications in acute cholecystitis. Laparoscopic cholecystectomy can be performed with success in uncomplicated cases.     

The significance of magnetic resonance cholangiopancreatography in acute cholecystitis]

To clarify the significance of magnetic renonance cholangiopancreatography (MRCP) in the acute phase of acute cholecystitis, MRCP was carried out in forty-five patients with acute cholecystitis in their acute phase. The MR pericholecystic high signal was observed in 38 of the 45 patients (84%). Enlargement of the gallbladder, presence of gallstones, and impacted stones was seen in 71%, 53%, and 18%, respectively. The MR pericholecystic high signal was classified into four categories: type 0, not observed; type 1, a liner high signal; type 2, a band-like high signal; type 3, a radiating high signal. In patients who showed a type 3 MR pericholecystic high signal, 91% required percutaneous transhepatic gallbladder drainage, and most of the gallbladders were diagnosed as necrotic cholecystitis by histology. The accuracy of MRCP for the diagnosis of choledocholithiasis was 96%. It was suggested that MRCP for patients with acute cholecystitis in the acute phase provides useful information for planning the treatment.     

Ultrasonographic findings in acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is usually seen as a complication of major surgery or trauma. Although this entity is well-known in the surgical literature, little has been written about it in the radiologic literature. A review of patient records from 1975 through 1982 revealed 16 patients with pathologically confirmed AAC on whom at least 1 sonographic study had been performed. Thickening of the gallbladder wall, a subserosal "halo" of edema, pericholecystic abscess, and marked gallbladder distention were consistent findings in AAC. In the proper clinical setting, these otherwise nonspecific findings allow a prompt and accurate diagnosis.     

Ultrasound in postoperative acalculous cholecystitis

Eleven patients were examined by ultrasound before undergoing cholecystectomy (n = 9) or cholecystostomy (n = 2) for acalculous cholecystitis after abdominal surgery. The ultrasound images were analyzed retrospectively and compared with the surgical and histologic findings. The results indicate several established ultrasound criteria of cholecystitis to be less reliable than usual. Although 10 of 11 patients were on parenteral hyperalimentation, gross distention of the gallbladder was observed in only 3. In 4 of 7 patients, in whom pericholecystic fluid was observed, no gallbladder perforation was found at surgery. However, thickening of the gallbladder wall was displayed in 10 of 11 cases, combined with a sonolucent intramural layer in 6. Furthermore, intraluminal nonshadowing echogenic densities correlated with empyema or hemorrhage in 5 of 8 cases. In conclusion, despite several limitations, ultrasound can be of considerable help when one is deciding to perform repeat laparotomy when acalculous cholecystitis is suspected.     

Acute emphysematous cholecystitis. Report of twenty cases.

BACKGROUND/AIMS: Our aim is to present our experience with acute emphysematous cholecystitis (AEC), a severe variety of acute cholecystitis characterized by early gangrene and perforation of the gallbladder. METHODOLOGY: We reviewed the clinical records of 20 patients with AEC, analyzing age, sex, past medical history, symptoms, laboratory tests, X-rays, ultrasounds, operative and microbiological findings, morbidity and mortality. RESULTS: Our study included 13 men and 7 women (mean age 59 years). Associated factors were diabetes mellitus (11 cases) and gallstones (6 cases, 3 of them with common bile duct stones). Clinical symptom presentation included: right hypochondrial pain and fever in all cases, vomiting in 9, septic shock in 3, jaundice in 7, and peritonitis in 8. Hyperbilirubinemia was present in 7 cases. Plain abdominal X-rays or ultrasounds led to diagnosis in 95% of the cases. Surgical findings were AEC in all cases, pericholecystic abscess in 8, gallbladder necrosis in 7 and bile peritonitis in 3. C perfringens, E coli and B fragilis were the most frequent pathogens. Mortality rate was 25%, and morbidity 50%. CONCLUSIONS: AEC predominantly affects elderly diabetic men. Abdominal X-rays or ultrasounds are good diagnostic techniques, and emergency surgery is needed due to the high incidence of gangrene and perforation Despite all the efforts made, morbidity and mortality are still high.     

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

Background

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.

Methods

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.

Results

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.

Conclusion

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.     

Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis

AIM: To evaluate the relationship between clinical information (including age, laboratory data, and sonographic findings) and severe complications, such as gangrene, perforation, or abscess, in patients with acute acalculous cholecystitis (AAC). METHODS: The medical records of patients hospitalized from January 1997 to December 2002 with a diagnosis of acute cholecystitis were retrospectively reviewed to find those with AAC, confirmed at operation or by histologic examination. Data collected included age, sex, white blood cell count, AST, total bilirubin, alkaline phosphatase, bacteriology, mortality, and sonographic findings. The sonographic findings were recorded on a 3-point scale with 1 point each for gallbladder distention, gallbladder wall thickness >3.5 mm, and sludge. The patients were divided into 2 groups based on the presence (group A) or absence (group B) of severe gallbladder complications, defined as perforation, gangrene, or abscess. RESULTS: There were 52 cases of AAC, accounting for 3.7% of all cases of acute cholecystitis. Males predominated. Most patients were diagnosed by ultrasonography (48 of 52) or computed tomography (17 of 52). Severe gallbladder complications were present in 27 patients (52%, group A) and absent in 25 (group B). Six patients died with a mortality of 12%. Four of the 6 who died were in group A. Patients in group A were significantly older than those in group B (mean 60.88 y vs. 54.12 y, P=0.04) and had a significantly higher white blood cell count (mean 15,885.19 vs. 9,948.40, P=0.0005). All the 6 patients who died had normal white blood cell counts with an elevated percentage of band forms. The most commonly cultured bacteria in both blood and bile were E. coli and Klebsiella pneumoniae. The cumulative sonographic points did not reliably distinguish between groups A and B, even though group A tended to have more points. CONCLUSION: Older patients with a high white cell count are more likely to have severe gallbladder complications. In these patients, earlier surgical intervention should be considered if the sonographic findings support the diagnosis of AAC.     

Mini-cholecystectomy: a personal series in acute and chronic cholecystitis

BackgroundMinimally invasive techniques in the surgical treatment of gallbladder disease include laparoscopic cholecystectomy (LC) and mini-cholecystectomy (MC). Reports of LC in acute or chronic inflammation of the gallbladder are common, but those of MC are much more limited, particularly in complicated cases.MethodsThirty-six consecutive patients with gallstone disease who underwent mini-cholecystectomy (MC) were included in this study. Twenty-four were female, median age 62 years (range 23–82) and median body mass index (BMI) was 23.4 (range 17.0–28.4). Seventeen of 36 patients had an acutely inflamed gallbladder, one with septicaemia, and six had gangrenous cholecystitis. Three patients presented with acute pancreatitis. MC was performed by a standardised technique. Operative time, frequency of postoperative analgesic injections, time to start oral diet after operation and length of postoperative hospital stay were compared between patients with chronic and acute cholecystitis.ResultsThe median operative time was 92.5 minutes (range 35–130). There was no difference in operative time between patients with chronic and acute cholecystitis: 80 minutes (range 35–120) vs 95 minutes (range 60–130). The frequency of postoperative analgesic injections was also similar in the two groups. Oral diet could be started within 24 h of operation in all except one patient with chronic cholecystitis but in only 8 of 17 with acute cholecystitis. Postoperative hospital stay was shorter in patients with chronic cholecystitis: 2 days (range 2–5) vs 4 days (range 2–14), p =0.0009.ConclusionsMC is an effective surgical procedure for an inflamed gallbladder regardless of the degree and type of inflammation. Patients with chronic cholecystitis recover more quickly and have a shorter hospital stay.     

Prognostic parameters for the prediction of acute gangrenous cholecystitis

Background/Purpose

The aim of this study was to identify preoperative prognostic parameters for gangrenous cholecystitis to differentiate this subgroup of patients with acute cholecystitis in order to provide immediate surgical therapy.

Methods

The medical records of patients who had an emergency cholecystectomy with the diagnosis of acute cholecystitis between January 2002 and June 2005 were reviewed retrospectively. Univariate and multivariate analysis were performed on the data.

Results

Out of 203 individuals with the clinical diagnosis of acute cholecystitis, 21 (10.3%) patients had a histological diagnosis of gangrenous cholecystitis. Multivariate analysis demonstrated an independent association of male sex, diabetes mellitus and white blood cell (WBC) count with the development of acute gangrenous cholecystitis.

Conclusions

The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14?900/mm³. Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.     

Experience with 1904 laparoscopic cholecystectomies at a private hospital

The purpose of this paper is to describe our recent experience in performing laparoscopic cholecystectomies of which we performed 1904, from January 1991 to May 1997, at our private hospital, mainly to treat cholecystolithiasis. The patients included 1563 with gallbladder stones (82.0%), 82 with cholecystocholedocholithiasis (4.3%), 104 with adenomyomatosis (5.5%), 132 with polyps (6.9%), and 23 with gallbladder cancer (1.3%). A difficult pericholecystic dissection led to conversion to open surgery in 61 patients. The average operation time was 63 min. Bile duct injury or cystic artery bleeding occurred in 3 patients with acute cholecystitis, and small intestine injury occurred in 1 patient, while bile leakage or a right subphrenic abscess occurred in 6 patients postoperatively. Although this series included 69 patients with previous upper abdominal surgery, 14 with liver cirrhosis, 267 with a nonvisualized gallbladder, and 148 with acute cholecystitis, the overall conversion rate was only 3.2% and morbidity only 0.5%. Although almost all patients with cholelithiasis are now considered potential candidates for a laparoscopic cholecystectomy, difficulties during cholecystectomy have been encountered in patients with acute cholecystitis. Surgeons should thus be fully prepared to convert to open surgery whenever difficulties are encountered, in order to avoid complication.     

Omental abscess due to a spilled gallstone after laparoscopic cholecystectomy

Omental abscess due to a spilled gallstone is extremely rare after laparoscopic cholecystectomy. Herein, we report a 68-year-old man who presented with left upper abdominal pain after laparoscopic cholecystectomy for gangrenous cholecystitis. Seven months prior to admission, gallbladder perforation with spillage of pigment gallstones and bile occurred during laparoscopic cholecystectomy. The spilled gallstones were retrieved through vigorous peritoneal lavage. Abdominal computed tomography showed a 3?×?2.5 cm intra-abdominal heterogeneous mass, suspected to be an omental abscess, and ascites around the spleen. Exploratory laparoscopy revealed an inflammatory mass within the greater omentum. Laparoscopic partial omentectomy and abscess drainage were performed, and a small black pigment gallstone was unexpectedly found in the whitish abscess fluid. Abscess fluid culture results were positive for extended-spectrum β-lactamase-producing Escherichia coli and Streptococcus salivarius, which were previously detected in the gangrenous gallbladder abscess. The histopathological diagnosis was abscess in the greater omentum. Postoperative course was uneventful, and the patient was discharged 13 days later. In conclusion, we report a successful case of laparoscopic management of an omental abscess due to a spilled gallstone after LC. It is important to attempt to retrieve spilled gallstones during LC because they may occasionally result in serious complications.     

A local imbalance between MMP and TIMP may have an implication on the severity and course of appendicitis

Background Matrix metalloproteinases (MMPs) and the tissue inhibitors of MMPs (TIMPs) have been demonstrated to be involved in inflammatory conditions in the intestine. The purpose of this study was to investigate whether the alterations of the MMP/TIMP balance might reflect the course of the inflammatory process in acute appendicitis and if the expression and localisation of MMPs and TIMP is variable in the various clinical manifestations of appendicitis. Materials and methods The study comprises 40 patients (26 men and 14 women) having emergency appendectomy and a control group constituting of 10 patients (5 men and 5 women) having a hemicolectomy for other reasons. MMP and TIMP expressions were assessed and compared in tissue specimens from phlegmonous (n = 15), gangrenous (n = 7), perforated appendicitis (n = 11) and controls with noninflamed appendices (n = 10) by means of enzyme-linked immunosorbent assay technique. Localisation of the enzymes was performed by immunohistochemistry. Results MMP-1 was significantly higher in gangrenous and perforated appendicitis compared with phlegmonous appendicitis and controls (p < 0.05) while MMP-2 was significantly lower in gangrenous appendicitis compared with phlegmonous appendicitis and controls. MMP-2 was also lower in perforated appendicitis when compared with controls (p < 0.01). Elevated expression of MMP-9 was demonstrated in all groups of appendicitis compared with the controls (p < 0.001). Conclusions MMP-9 is the most abundantly expressed MMP of those investigated in inflamed appendix. We postulate that a local imbalance between MMP-9 and TIMP-1 may trigger a perforation. These results suggest that MMPs might be useful as biomarkers of appendices prone to perforation.