Cholescintigraphy in Acute Acalculous Cholecystitis

Acute acalculous cholecystitis is a relatively rare but potentially lethal condition if not treated promptly. Since stones are not present, diagnostic procedures such as ultrasound or other radiological procedures are frequently not helpful. Tc-99m iminodiacetic acid scan results were analyzed in 11 proven cases of acute acalculous cholecystitis. All had positive tests with nonvisualization of the gallbladder giving a sensitivity of 100%. Tc-99m iminodiacetic acid cholescintigraphy is a highly reliable test and is easily performed even in acutely ill patients and should be the test of choice in all patients predisposed to and suspected of acute acalculous cholecystitis.     

Dengue fever related acalculous cholecystitis in a North Indian tertiary care hospital

BACKGROUND AND AIMS: To document the clinical outcome and prognosis of acalculous cholecystitis in dengue fever. METHODS: Prospective analysis of 27 cases of dengue fever presenting to the medical emergency of a tertiary care referral hospital in Chandigarh, India. RESULTS: All patients with dengue fever presenting with abdominal pain in the year 2003 were studied by ultrasound examination for the presence of acalculous cholecystitis. Five cases presented in October and 22 cases in November. Mean age was 29.8 +/- 9.7 years and there were 21 males and six females. Mean duration of fever was 5.07 +/- 1.8 days and mean duration of body ache was 4.06 +/- 2.6 days. The mean platelet counts for all cases at presentation were 29.41 +/- 18.41 x 10(9)/L and at discharge 95.28 +/- 53.01 x 10(9)/L. The mean duration of in-hospital stay was 3.4 +/- 1.7 days. Fourteen patients presented with pain in the abdomen and were confirmed to have acalculous cholecystitis on ultrasound examination of the abdomen (mean gallbladder wall thickness was 5.2 +/- 1.03 mm). Amongst all variables assessed, the only significant difference seen was that the duration of in-hospital stay was 1.68 days more in the group with acalculous cholecystitis. CONCLUSION: Acalculous cholecystitis should be strongly suspected in patients with dengue fever presenting with abdominal pain. Our study has shown that acalculous cholecystitis occurred in 14 out of 27 patients with dengue fever.     

Dengue fever with acute acalculous cholecystitis

Dengue fever (DF) with acute acalculous cholecystitis is rarely reported. To investigate the incidence, treatment, and prognosis of acute acalculous cholecystitis in DF patients, we retrospectively studied 10 patients with DF and acute acalculous cholecystitis. From October 2001 to July 2002, 131 patients were diagnosed with DF. Ten of 131 DF patients (7.63%) had complications of acute acalculous cholecystitis. Two patients underwent cholecystectomy and one underwent percutaneous transhepatic gallbladder drainage due to poor resolution of acute acalculous cholecystitis. We found acute acalculous cholecystitis in a small proportion of patients with DF. In our experience, closely monitoring vital signs to avoid shock and correct thrombocytopenia to avoid bleeding could be adequate for most patients. In some cases, surgical treatment may be needed for DF fever patients with complications of diffuse peritonitis.     

内镜下逆行胰胆管造影在高龄急性胆囊炎患者中的临床应用

目的探讨内镜下逆行胰胆管造影（ERCP）在高龄（≥75岁）急性胆囊炎患者中的临床应用。方法回顾性分析2008年1月至2012年12月拟行ERCP治疗的75岁以上胆囊炎患者。本次急性发作时间为1～5 d,均经影像学（包括腹部超声、CT及磁共振）确诊为急性胆囊炎。所有手术患者均给予留置鼻-胆囊引流（ENGBD）,术后观察腹部体征、体温、C反应蛋白（CRP）,腹部影像学及记录胆囊引流情况,出院后定期随访。结果共有24名患者,其中男13例,女11例,年龄75～88岁,平均（81.0±3.2）岁接受ERCP检查,其中术前诊断18例为结石性胆囊炎（75.0%）,6例为非结石性胆囊炎（25%）,13例（54.2%）合并胆总管结石。所有患者均成功留置鼻胆引流管,21例（87.5%）于术后腹痛缓解,体温降至正常,CRP于术后6 d内均降至正常。2例（8.3%）术后出现高淀粉酶,3 d后降至正常。无ERCP相关穿孔、出血、术后胰腺炎、死亡等并发症出现。术后随访3～12个月,23例（95.8%）症状长期缓解,1例因症状反复出现行腹腔镜手术。结论对于无法行急诊手术的高龄急性胆囊炎患者,行ERCP留置鼻-胆囊引流管治疗是一种安全、有效的治疗方法。     

Chronic Right Upper Quadrant Pain without Gallstones: Does HIDDA Scan Predict Outcome after Cholecystectomy?

Patients with chronic right upper quadrant pain who do not have gallstones on ultrasound or cholecystography are often referred for surgery for presumed acalculous chronic cholecystitis. We followed 26 patients who had cholecystokinin (CCK) cholescintigraphy for evaluation of chronic right upper quadrant pain without demonstrable gallstones on ultrasound who underwent cholecystectomy so that it could be determined whether there was any relation between a low ejection fraction (EF), morphological features of chronic cholecystitis, and clinical outcome. Eighteen patients (69%) were considered therapeutic successes, whereas eight (31%) were failures after an average 2-yr follow-up. Both patient groups had significantly reduced EF: the successful group at 0.39 and the failures at 0.25. Thus, a low EF did not predict clinical outcome, since the failure group had an even lower EF than the success group. Seven gallbladders demonstrated chronic acalculous cholecystitis; the average EF of this group was 0.35. The remaining 19 gallbladders were normal, yet also had an EF of 0.35. Thus, decreased EF does not predict the histologic features of chronic cholecystitis without gallstones. The diagnostic value of cholescintigraphy in patients with acalculous right upper quadrant pain is low, probably because this entity represents a variety of processes, including inflammation, gallbladder dysmotility, and the irritable bowel syndrome.     

The role of prostaglandins E and F in acalculous gallbladder disease

Prostaglandins have been postulated to be involved in the formation of gallstones and the pain and inflammation of calculous gallbladder disease. This report evaluated prostaglandin E and F levels in patients with acalculous gallbladder disease. Control gallbladders were obtained from patients undergoing cholecystectomy during insertion of hepatic artery catheters for regional, hepatic chemotherapy. Patients without gallstones and with long-standing post-prandial biliary colic with abnormal cholecystokinin administration underwent cholecystectomy for chronic acalculous cholecystitis. A third group of patients underwent cholecystectomy for acute acalculous cholecystitis. Gallbladder mucosa and muscle were separated, and prostaglandin E and F concentrations in mucosal and muscle or mucosa were identified in gallbladders from patients with chronic acalculous cholecystitis compared to gallbladders from patients without biliary tract symptoms. In gallbladders from patients with acute acalculous cholecystitis a seven-fold increase in PGE production by muscle tissue and mucosal cells was found. The more histologically inflamed gallbladders had higher mucosal and muscle prostaglandin E concentrations than were found in less inflamed gallbladders. Prostaglandin F levels were not significantly changed or were decreased, resulting in a significant increase in the ratio of PGE/PGF in acutely diseased gallbladders when compared to normal gallbladders. Prostaglandin E may be a manipulatable intermediary in the sequence of events that results in the development of acute acalculous cholecystitis.     

Post-stress nonlithiasic acute cholecystitis. Contribution of ultrasonics to the diagnosis and treatment in 50 cases

Fifty cases of post-stress acute acalculous cholecystitis were observed during the past 9 years, mainly after major surgery or trauma. The apparently increasing incidence over the last 4 years (42 cases) could probably be explained by a better diagnostic approach of this condition by routine use of ultrasonography. No specific etiological factor could be found; however total parenteral nutrition and/or sepsis and/or use of narcotics could possibly play a role in the appearance of this complication. Although diagnosis can occasionally be suspected in the basis of abdominal and infectious signs, diagnosis was made primarily on the following ultrasonographic signs: enlarged gallbladder with thickened wall, sludge, and occasionally a double-wall aspect and a pericholecystic collection. In this series, most of the patients were treated by cholecystectomy, but a new therapeutic approach was used in 10 cases: percutaneous transhepatic drainage under sonographic control. Outcome is still poor, with a 50 p. 100 mortality rate.     

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.     

Percutaneous cholecystostomy in acute acalculous cholecystitis

Percutaneous cholecystostomy was performed in 8 poor-surgical-risk patients with acute acalculous cholecystitis. Seven patients had had previous laparotomy, 1 patient a coronary bypass operation. A transhepatic approach was used in all patients. Insertion of the drainage catheters was guided by ultrasound and fluoroscopy. Percutaneous drainage was successful in all patients, with no need for further surgical intervention. Two patients died, for reasons unrelated to the gallbladder disease. Percutaneous cholecystostomy may be definitive treatment for acute acalculous cholecystitis in the critically ill patient.     

Acute acalculous cholecystitis

Opinion statement Acute acalculous cholecystitis is defined as acute inflammation of the gallbladder in the absence of gallstones. Patients are usually critically ill with atherosclerotic heart disease, recent trauma, burn injury, surgery, or hemodynamic instability. The presentation of acute acalculous cholecystitis may be insidious, characterized by unexplained fever, leukocytosis, hyperamylasemia, or abnormal aminotransferases, and patients often lack right upper quadrant tenderness. Diagnostic evaluation includes ultrasonography, computerized tomography, and cholescintigraphy. Given the high mortality of untreated disease, definitive treatment consists of cholecystectomy or, in poor surgical candidates, cholecystostomy. Endoscopic therapy with nasobiliary drainage and lavage is an effective treatment option in patients unable to tolerate surgery or cholecystostomy.     

Acute acalculous cholecystitis

Acute cholecystitis can develop without gallstones in critically ill or injured patients. However, the development of acute acalculous cholecystitis is not limited to surgical or injured patients, or even to the intensive care unit. Diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, and shock or cardiac arrest have been associated with acute acalculous cholecystitis. Children may also be affected, especially after a viral illness. The pathogenesis of acute acalculous cholecystitis is a paradigm of complexity. Ischemia and reperfusion injury, or the effects of eicosanoid proinflammatory mediators, appear to be the central mechanisms, but bile stasis, opioid therapy, positive-pressure ventilation, and total parenteral nutrition have all been implicated. Ultrasound of the gallbladder is the most accurate diagnostic modality in the critically ill patient, with gallbladder wall thickness of 3.5 mm or greater and pericholecystic fluid being the two most reliable criteria. The historical treatment of choice for acute acalculous cholecystitis has been cholecystectomy, but percutaneous cholecystostomy is now the mainstay of therapy, controlling the disease in about 85% of patients. Rapid improvement can be expected when the procedure is performed properly. The mortality rates (historically about 30%) for percutaneous and open cholecystostomy appear to be similar, reflecting the severity of illness, but improved resuscitation and critical care may portend a decreased risk of death. Interval cholecystectomy is usually not indicated after acute acalculous cholecystitis in survivors; if the absence of gallstones is confirmed and the precipitating disorder has been controlled, the cholecystostomy tube can be pulled out after the patient has recovered.     

Utility and accuracy of ultrasonically measured gallbladder wall as a diagnostic criteria in biliary tract disease

Biliary tract sonography has achieved wide acceptance as a screening test for chronic calculous disease. However, the clinical usefullness of biliary sonography is limited by the inability of this test to identify patients with acalculous cholecystitis or to separate patients with calculous cholecystitis from those with asymptomatic calculi. A prospective blinded study of 106 patients undergoing cholecystectomy was performed to determine if, cholecystosonography could visualize the gallbladder wall accurately and to evaluate gallbladder wall thickening as a predictor of disease. Of these patients, 88 had a sonographically visible gallbladder wall and in 95% of the patients the ultrasonic and direct surgical measurements of the gallbladder wall agreed within 1 mm. To determine the sonographic size range of gallbladder wall thickness in the normal population, the width of the gallbladder wall in the fasting state was measured in 100 patients without biliary tract disease. One percent of the normal population had thickened gallbladder walls, in contrast to 96% of the patients with acute calculous or acalculous cholecystitis. Gallbladder wall thickness appears to be an accurate noninvasive technique for diagnosing patients with acute calculous and acalculous cholecystitis in the absence of other entities which thicken the gallbladder wall such as ascites and hypoproteinemic states.     

Acute acalculous cholecystitis in children

Acute acalculous cholecystitis(AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. AAC is estimated to represent at least 50% to 70% of all cases of acute cholecystitis during childhood. Although this pathology was originally described in critically ill or post-surgical patients, most pediatric cases have been observed during several infectious diseases. In addition to cases caused by bacterial and parasitic infections, most pediatric reports after 2000 described children developing AAC during viral illnesses(such as Epstein-Barr virus and hepatitis A virus infections). Moreover, some pediatric cases have been associated with several underlying chronic diseases and, in particular, with immune-mediated disorders. Here, we review the epidemiological aspects of pediatric AAC, and we discuss etiology, pathophysiology and clinical management, according to the cases reported in the medical literature.     

Cholesterol crystal embolization to liver,gallbladder, and pancreas

We retrospectively studied the clinical features of all 44 patients (35 men, 9 women, mean age 74.5 years) registered with a diagnosis of hepatic, biliary, and/or pancreatic cholesterol crystal embolization (CCE) in the Dutch National Pathology Information System (DNPIS) from 1973 through 1994. Liver CCE was found in 12 (11 autopsies and 1 biopsy), gallbladder CCE in 2 (resection specimens), pancreas CCE in 19 (18 autopsies and 1 biopsy), and both liver and pancreas CCE in 11 (all autopsies) patients. Five patients presented with focal liver cell necrosis, 1 with acalculous necrotizing cholecystitis, 1 with chronic cholecystitis, 10 with necrotizing pancreatitis, and 1 with chronic fibrosating pancreatitis. Four patients died of CCE-induced pancreatitis. Nineteen patients died as a consequence of other CCE sites. These were reported in 37 patients. All patients had a history of atherosclerotic vascular disease. In half the patients a possibly CCE provoking factor (vascular surgery and/or cannulation, anticoagulant treatment) was present. We conclude that liver cell necrosis, cholecystitis, and pancreatitis may be caused by CCE, particularly in elderly male patients with a history of atherosclerosis.     

Endoscopic ultrasound‐guided endoluminal drainage of the gallbladder

For patients with acute cholecystitis who are not suitable for surgery, endoscopic ultrasound‐guided endoluminal drainage of the gallbladder (EUS‐GBD) has been developed to overcome the limitations of percutaneous transhepatic gallbladder drainage when endoscopic transpapillary gallbladder drainage is not feasible. In the present review we have summarized the studies describing EUS‐GBD. Indications, techniques, accessories, endoprostheses, limitations and complications reported in the different studies are discussed. There were 90 documented cases in the literature. The overall reported technical success rate was 87/90 (96.7%). All patients with technical success were clinically successful. A total of 11/90 (12.2%) patients had complications including pneumoperitoneum, bile peritonitis and stent migration. The advantage of EUS‐GBD is its ability to provide gallbladder drainage especially in situations where percutaneous or transpapillary drainage is not feasible or is technically challenging. It also provides the option of internal drainage and the ability to carry out therapeutic maneuvers via cholecystoscopy.     

Acute acalculous cholecystitis during the course of primary Epstein-Barr virus infection: a new case and a review of the literature.

OBJECTIVE: The aim of this study was to describe a case of acute acalculous cholecystitis occurring in the course of primary Epstein-Barr virus (EBV) infection. METHODS: The clinical features of the case were analyzed and compared to those of three other similar cases reported in the international literature. RESULTS: All cases occurred in European females with cholestatic hepatitis, presented with gallbladder wall thickening, and recovered uneventfully without the need for surgical intervention. CONCLUSIONS: Acute acalculous cholecystitis may occur during the course of acute EBV infection, especially in patients with cholestatic hepatitis. Clinicians should be aware of the possible involvement of the gallbladder during EBV infection to avoid unnecessary invasive procedures or the overuse of antibiotics.     

Thrombotic microangiopathy involving the gallbladder as an unusual manifestation of systemic lupus erythematosus and antiphospholipid syndrome： Case report and review of the literature

INTRODUCTION Gallbladder disease is no more common in patients with systemic lupus erythematosus (SLE) than in the general population[1]. Scarce reports on acalculous cholecystitis (ACC) in SLE or in antiphospholipid syndrome (APS) have been described in …     

Sclerosing cholecystitis associated with autoimmune pancreatitis

AIM: To evaluate the histopathological and radiological findings of the gallbladder in patients with autoimmune pancreatitis (AIP). METHODS: The radiological findings of the gallbladder of 19 AIP patients were retrospectively reviewed. Resected gallbladders of 8 AIP patients were examined histologically and were immunostained with anti- IgG4 antibody. Controls consisted of gallbladders resected for symptomatic gallstones (n = 10) and those removed during pancreatoduodenectomy for pancreatic carcinoma (n = 10), as well as extrahepatic bile ducts and pancreases removed by pancreatoduodenectomy for pancreatic carcinoma (n = 10). RESULTS: Thickening of the gallbladder wall was detected by ultrasound and/or computed tomography in 10 patients with AIP (3 severe and 7 moderate); in these patients severe stenosis of the extrahepatic bile duct was also noted. Histologically, thickening of the gallbladder was detected in 6 of 8 (75%) patients with AIP; 4 cases had transmural lymphoplasmacytic infiltration with fibrosis, and 2 cases had mucosal-based lymphoplasmacytic infiltration. Considerable transmural thickening of the extrahepatic bile duct wall with dense fibrosis and diffuse lymphoplasmacytic infiltration was detected in 7 patients. Immunohistochemically, severe or moderate infiltration of IgG4-positive plasma cells was detected in the gallbladder, bile duct, and pancreas of all 8 patients, but was not detected in controls. CONCLUSION: Gallbladder wall thickening with fibrosis and abundant infiltration of IgG4-positive plasma cells is frequently detected in patients with AIR We propose the use of a new term, sclerosing cholecystitis, for these cases that are induced by the same mechanism as sclerosing pancreatitis or sclerosing cholangitis in AIR     

Acalculous cholecystitis: an uncommon form of presentation of Q fever

Acute acalculous cholecystitis is a very rare clinical presentation of Q fever. We report the case of a 38-year-old man who presented with fever associated with elevation of liver enzyme levels and thickening of the gallbladder wall on abdominal ultrasonography and who was initially diagnosed with acute acalculous cholecystitis. Due to the persistence of fever and transaminase elevation despite antibiotic treatment, a liver biopsy was performed. Characteristic "doughnut" epithelioid granulomas were observed, suggesting a diagnosis of granulomatous hepatitis caused by Q fever, which was confirmed by serological methods. Treatment with doxycycline was commenced and the patient subsequently showed rapid clinical improvement, with disappearance of fever and normalization of liver enzyme levels. We review 8 cases of acute cholecystitis associated with Q fever published in the literature and stress the importance of liver biopsy in the etiological diagnosis of patients with prolonged fever and abnormal liver function tests.     

Infectious factors in acute acalculous cholecystitis

BACKGROUND/AIMS: The infection is shown as a secondary phenomenon in lithiasic acute cholecystitis. However, its importance in acute gallbladder inflammation without lithiasis has not been sufficiently clarified. In this context, we tried to investigate this issue by resorting to animal research. Similarly we studied the repercussions of Diclofenac (NSAID) in bacteriological features of the bile in the operated animals. METHODOLOGY: We provoked acute cholecystitis in pigs by the ligature of biliary pedicle associated to the gallbladder introduction of "Lysophosphatidylcoline". Two series of animals were used: P1 (pigs not treated with Diclofenac) with 17 pigs and P2 (pigs treated with Diclofenac) with 23. In the latter group we associated the administration of Diclofenac given before the production of acute cholecystitis and administered for 4 days. The microbiology of the bile was studied in 34 pigs. The following parameters were valorized: histological gallbladder lesions and microorganisms in bacteriological examination of the bile. RESULTS: Severe lesions of acute cholecystitis were registered in 82.3% of the animals. Positive bile cultures were registered in 64.1% of group P1 and 65.5% in the group P2. The simultaneous administration of Diclofenac in the P2 group did not cause a regression of gallbladder lesions or in microbial agents in the bile in relation to the first group (P = 0.649, and P = 0.781, respectively). CONCLUSIONS: Our investigations allow us to conclude by valorization the infection factor in acute acalculous cholecystitis. On the other hand, the absence of repercussion of Diclofenac in acute acalculous cholecystitis was demonstrated not only in histological gallbladder lesions, but also in bile infection.