Massive intraperitoneal bleeding due to hemorrhagic cholecystitis and gallbladder rupture: CT findings

Hemorrhagic cholecystitis with subsequent gallbladder rupture and torrential bleeding is a very rare but life-threatening complication of acute biliary tract diseases. Its clinical presentation may be dubious and therefore Computed Tomography (CT) imaging plays a crucial role in a prompt and accurate diagnosis. We present a case of a 64 year-old male who was admitted to the emergency department with clinical findings of acute cholecystitis. During the following hours the patient became hemodynamically unstable and an emergency abdominal CT scan was performed. CT revealed massive hemoperitoneum containing free gallstones. In addition, active extravasation of iv contrast material inside the gallbladder lumen was demonstrated. Based on these findings hemorrhagic cholecystitis with gallbladder rupture was suspected and the patient underwent urgent laparotomy. We describe specific CT findings of this rare condition, thus emphasizing the role of imaging in facilitating urgent surgical treatment.     

Ultrasonography by emergency physicians in patients with suspected cholecystitis

This article investigates the use of bedside abdominal ultrasonography (BAU) performed by emergency physicians (EPs) to screen patients for cholelithiasis and cholecystitis. In this prospective study EPs performed BAU on 116 patients. Agreement between BAU and formal abdominal ultrasound (FUS) performed in the radiology department for detecting cholelithiasis and cholecystitis was determined using Kappa statistics. Test characteristics of BAU for detecting cholelithiasis and acute cholecystitis were calculated. Agreement between BAU and FUS was 0.71 for cholelithiasis and 0.46 for acute cholecystitis. Test characteristics of BAU for cholelithiasis were sensitivity 92%, specificity 78%, positive predictive value (PPV) 86%, negative predictive value (NPV) 88%. Test characteristics of BAU for acute cholecystitis compared with clinical follow-up were sensitivity 91%, specificity 66%, PPV 70%, NPV 90%. BAU may be used to exclude cholelithiasis and is sensitive for cholecystitis. However, when EPs with limited experience identify cholecystitis a confirmatory test is warranted before cholecystectomy.     

Emphysematous cholecystitis: an insidious variant of acute cholecystitis

Emphysematous cholecystitis is an insidious and rapidly progressing disease that requires prompt surgical intervention. As the majority of the patients contracting this disease initially present to the emergency department with complaints of abdominal pain and often mild constitutional symptoms, it is important for the emergency physician to be aware of this clinical entity. Didactic cases have been presented that, in many ways, illustrate classic examples of emphysematous cholecystitis, the diagnosis of which can often be made in the emergency department using an upright abdominal radiograph.     

Relationship between serum Pentraxin 3 and pro-adrenomedullin levels with acute cholecystitis

ObjectivesThe perforation of the gallbladder (GP) is one of the most significant complications of acute cholecystitis. A biochemical marker indicating the GP has not been determined fully to date. Pentraxin 3 and pro-adrenomedullin (Pro-ADM) proteins are novel acute phase reactants. We aimed to investigate the relationship between serum Pentraxin 3 and Pro-ADM and the GP in patients with acute cholecystitis. Methods: This prospective cross-sectional study was conducted on patients with acute cholecystitis in a tertiary care emergency department during the six-month period. The acute cholecystitis patients were divided into two groups as with GP, and without GP. Additionally, patients with GP were evaluated according to pericholecystic fluid and gallbladder wall thickness. Serum levels of pro-ADM and pentraxin 3, WBC, CRP and sedimentation rate were measured in all patients.ResultsA total of 60 patients with acute cholecystitis were included in the study. Pro-ADM and pentraxin 3 levels were significantly higher in patients with GP and the with pericholecystic free fluid (p < 0.0001). There was no significant relationship between serum pentraxin 3 and pro-ADM with gallbladder wall thickness (p > 0.05) According to the ROC analysis, serum Pentraxin 3 levels of ≥4.9 ng/mL could predict GP with a sensitivity of 75% and a specificity of 85% and serum pro-ADM levels of ≥97 nmol/L with sensitivity and specificity of 100% and 95%.ConclusionOur study results reveal that serum Pentraxin 3 and pro-ADM may be novel biochemical parameters in the detection of GP in acute cholecystitis cases.     

Omental torsion: CT features

A 33-year-old male presented to the emergency department complaining of right upper quadrant pain and was initially diagnosed with acute cholecystitis. Abdominal computed tomography showed a whirling pattern of fatty streaks and vessels within the greater omentum, and surgery confirmed infarction of the omentum secondary to torsion. We report a case of surgically and pathologically proven omental torsion that demonstrated the typical whirling appearance on computed tomography.     

First case of bacteremia caused by Cetobacterium somerae following necrotizing cholecystitis

Cetobacterium somerae, a gram-negative anaerobic rod, first identified in the feces of children with autism, also colonize freshwater fish intestinal tract. However there have been no reports of human C. somerae infection. Here, we describe the first case of C. somerae bacteremia in a patient with necrotizing cholecystitis. A 72-year-old male presented to the emergency department with chills, vomiting, and fever and was diagnosed with acute necrotizing cholecystitis. An emergency cholecystectomy was performed and the following day, two sets of blood culture were positive for gram-negative bacilli. Identification of C. somerae from the biochemical profile was difficult but possible by mass spectrometry and 16s rRNA sequence.     

B超在急腹症诊断中的应用价值

目的：探讨B超检查对急腹症的临床应用价值。方法：回顾性分析326例急腹症的超声表现并与手术后、病理诊断以及随访结果进行对照。结果：326例急腹症中以急性胆囊炎、输尿管结石、急性阑尾炎以及妇科急症常见,共289例,占88％,其他急腹症37例,占12％。经手术和病理证实217例,109例临床随访证实。超声符台率89．9％。结论：B超检查对急腹症的早期诊断以及鉴别诊断具有重要临床意义,是急腹症首选的诊断方法。     

Emergent Right Upper Quadrant Sonography

Objective. The purpose of this presentation is to review the sonographic spectrum of disease entities evaluated by right upper quadrant (RUQ) sonography on an emergent basis. Methods. Right upper quadrant sonography was performed on an emergent basis in patients who came to the emergency department with signs and symptoms suspicious for or simulating acute cholecystitis or diseases of the liver and biliary tree. Results. A wide gamut of acute and chronic cholecystitis and diseases of the liver and biliary tree were visualized on RUQ sonography. Several other entities in addition to hepatic and biliary disease were also suspected on sonography and further evaluated by computed tomography. Conclusions. Right upper quadrant sonography is the first line of imaging in patients with signs and symptoms of hepatic, gallbladder, or biliary disease as well as RUQ pain. Patient triage or additional imaging may be obtained on the basis of emergent RUQ sonographic findings.     

Torsion of the gallbladder: a rare cause of acute cholecystitis

We present a case of acute torsion of the gallbladder in a young woman. Approximately 400 cases have been reported since 1898, mostly in elderly women, and the incidence appears to be increasing. The anatomy and pathophysiology that predispose patients to this rare surgical emergency are discussed. Several clinical and imaging findings can be used to distinguish gallbladder torsion from typical acute cholecystitis. By recognizing and treating gallbladder torsion early in its course, a low surgical morbidity and mortality can be achieved. The case presented highlights for emergency physicians some of the considerations in identification of patients with acute cholecystitis who are at highest risk of gangrene and perforation, their emergency treatment, and the timing of surgery.     

Gonococcal perihepatitis in a surgical ward.

Within a three-year period six female patients with gonococcal perihepatitis were encountered. In the acute stage they had clinical symptoms indistinguishable from acute cholecystitis. In all six patients the diagnosis was established by positive growth of Neisseria gonorrhoeae from cervix specimens. Evidence of previous gonococcal pelvic infection was disclosed in three of the patients. In two patients the gonococcal aetiology of the disease was suggested by papular skin lesion and arthritis. Of the annual mean number of patients admitted to the emergency ward with suspicion of acute cholecystitis within the same three year period, 2.6% presented with gonococcal perihepatitis. As the incidence of gonorrhoea is increasing, complications such as perihepatitis are seen more frequently among young female patients admitted to surgical emergency wards because of acute abdominal pains.     

Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED

Objective

The diagnosis of cholecystitis or biliary tract disease in children and adolescents is an uncommon occurrence in the emergency department and other acute care settings. Misdiagnosis and delays in diagnosing children with cholecystitis or biliary tract disease of up to months and years have been reported in the literature. We discuss the technique and potential utility of point-of-care ultrasound evaluation in a series of pediatric patients with suspected cholecystitis or biliary tract disease.

Methods

We present a nonconsecutive case series of pediatric and adolescent patients with abdominal pain diagnosed with cholecystitis or biliary tract disease using point-of-care ultrasound. The published sonographic criteria is 3 mm or less for the upper limits of normal gallbladder wall thickness and is 3 mm or less for normal common bile duct diameter (measured from inner wall to inner wall) in children. Measurements above these limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy's sign.

Results

Point-of care ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty over a 5-year period. Diagnoses were confirmed by radiology imaging or at surgery and surgical pathology.

Conclusions

Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain.     

Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients

BackgroundAcute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients.MethodThis was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points.Results153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%–96.9%), and a specificity of 67.5% (95% CI 58.2%–75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%–100%) and specificity of 35% (95% CI 26.5%–44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%–61.9%) and specificity of 95.7% (95% CI 90.3%–98.6%).ConclusionA bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.     

My patient has got abdominal pain: identifying biliary problems

Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient’s right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4–92.5%) and specificity of 88.0% (83.7–91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.     

Treatment of acute myocardial infarction in Scottish emergency departments: survey of current practice.

INTRODUCTION: Thrombolysis was rarely given in emergency departments in Scotland when last studied in 1996. This study aimed to review the current practice of Scottish emergency departments with respect to thrombolysis for acute myocardial infarction. METHODS: Postal questionnaires were sent to all emergency departments in Scotland staffed by at least one consultant in emergency medicine, assessing the processes used for thrombolysis of acute myocardial infarction in the emergency department. A reminder letter was sent to non-responders after 1 month. All results were anonymized. RESULTS: The response rate was 77% (23 questionnaires from 30 hospitals). Twenty (87%) emergency departments performed thrombolysis according to protocol. In 13 emergency departments, thrombolysis was initiated by the emergency department staff, in six by on-call physicians and one emergency department had nurse-led thrombolysis. Twelve emergency departments occasionally received patients who had been given prehospital thrombolysis. Six hospitals had on-site primary angioplasty but only two hospitals had a 24-h service. Thirteen respondents thought the emergency department was the most appropriate place for thrombolysis, four felt that prehospital thrombolysis was best and one thought that coronary care was optimal. Four respondents felt that prehospital or the emergency department were the best options. CONCLUSION: Most emergency departments in Scotland are now administering thrombolysis for patients with acute myocardial infarction. Thrombolysis, delivered either in the prehospital arena or in the emergency department, is likely to be the primary option for patients with acute myocardial infarction in Scotland in the foreseeable future.     

Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk

BACKGROUND AND STUDY AIMS: Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure. The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor. It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course. PATIENTS AND METHODS: A prospective unselected series of 105 patients over 65 years of age (52 men, 53 women; mean age 78) suffering from acute cholecystitis were initially treated on a random basis with either conservative methods or endoscopic sphincterotomy. Within the first 72 h after the onset of symptoms, all 52 patients in the endoscopic sphincterotomy group were managed by endoscopic retrograde cholangiopancreatography (ERCP), combined with endoscopic sphincterotomy in 50 cases. The main study parameter was the need for emergency cholecystectomy within the first week after admission. RESULTS: Biliary sepsis requiring emergency surgery occurred in 15 patients in the conservatively treated group, in contrast with none of the 52 patients in the endoscopic sphincterotomy group ( P < 0.001). Iatrogenic complications after endoscopic sphincterotomy occurred in three patients, one of whom required surgery, while two were managed by conservative means. The clinical course improved, avoiding the need for emergency cholecystectomy and other interventions, in 48 patients in the endoscopic sphincterotomy group and in 36 patients in the conservatively treated group ( P < 0.01). CONCLUSIONS: The clinical course after endoscopic sphincterotomy improved in the majority of elderly patients suffering from acute cholecystitis, suggesting that early relief of obstruction at the level of the common channel reduces the risk of developing biliary sepsis. The majority of these patients can undergo surgery electively or can receive further conservative treatment.     

腹腔镜胆囊切除术治疗急性胆囊炎的体会

目的探讨腹腔镜胆囊切除术治疗急性胆囊炎的经验。方法介绍并总结了该科在1997年6月～2006年8月收治的171例急性胆囊炎患者。结果该组171例急性胆囊炎患者10例中转开腹,1例为Mirizzi综合征,9例为胆囊三角结构严重粘连,其余病例行腹腔镜胆囊切除术,1例并发术后出血,二次腹腔镜手术止血,1例术后胆汁漏,保守治疗痊愈。结论术前注意病例选择,术中注意仔细操作,及时正确判断术中情况,腹腔镜胆囊切除术治疗急性胆囊炎是安全可行的。     

Initiation of thrombolytic therapy for patients with acute myocardial infarction by emergency physicians: The Hong Kong experience

Abstract Objectives: To compare door-to-needle time and complications for eligible acute myocardial infarction patients receiving thrombolytic therapy in the emergency department and in the coronary care unit. Methods: A prospective study was performed involving all patients with acute myocardial infarction who received thrombolytic therapy either in the emergency department or the coronary care unit during the period January 1995 to March 1996. Patients’ time interval between registration in ED and receiving thrombolytic therapy (door-to-needle time) was the main audit parameter. Other emergency department information collected included inappropriate administration of thrombolytic therapy and the occurrence and management of complications of thrombolytic therapy. Results: In the United Christian Hospital, Hong Kong, 148 patients with acute myocardial infarction received thrombolysis. Sixty-eight cases (group A) received thrombolysis in the emergency department and 80 cases underwent thrombolysis in the coronary care unit. The 80 cases in the coronary care unit included 47 cases (group B) whose diagnosis of acute myocardial infarction and eligibility for thrombolysis were established in the emergency department, and 33 cases (group C) in which there were difficulties in diagnosis or exclusion of contraindications for thrombolysis. The mean door-to-needle times were 31.3 min in group A (95% CI, 27.6–35.1), 54 min in group B (95% CI, 47.8–60.2) and 171.8 min in group C (95% CI, 121.8–211.8). Inappropriate use of thrombolysis in the emergency department occurred in 2.9% of all cases. The most common complication of thrombolysis in the emergency department was hypotension (4.4%). All cases were successfully managed in the emergency department. There was one case of anaphylaxis during streptokinase infusion that required resuscitation in the emergency department. There were no deaths of patients receiving thrombolysis in the emergency department. Conclusion The initial experience of a regional hospital in Hong Kong supports the view that initiation of thrombolytic therapy in the emergency department can achieve a more favourable door-to-needle time without compromising the care of acute myocardial infarction patients.     

Efficacy of plain abdominal radiography in patients with biliary tract disease

A retrospective review was performed to determine the usefulness of plain abdominal radiographs in patients presenting to the emergency department with gallbladder disease. Patients with the clinical diagnosis of biliary tract disease were divided into two groups: those with confirmed biliary tract disease and those who did not have gall bladder disease. There were no major radiologic findings (pneumoperitoneum, pneumobilia, or bowel obstruction) in any patient with biliary tract disease. No significant difference was noted in the incidence of minor radiologic findings (right upper quadrant calcification, mild ileus and right basilar atelectasis) in patients with biliary colic and acute cholecystitis. Additionally, there was no significant difference in minor findings between patients with biliary tract and nonbiliary tract disease. Plain abdominal radiographic findings were found to be nonspecific in patients with gallbladder disease and not useful in differentiating between patients with biliary colic and acute cholecystitis. Our results also suggest that plain abdominal radiographic findings are not useful in differentiating between patients with and without biliary tract disease, although the selection of patients without biliary tract disease may have biased this finding.     

Acute cholecystitis in cholelithiasis: importance of early surgery (a comparative study)

The results of early surgery (ES) for acute calculous cholecystitis obtained in 74 patients operated on between 3/78 and 12/87 were compared with relevant data obtained in 74 sex- and age-matched patients with a history of acute cholecystitis operated on for biliary colic or jaundice during the same period. Operative procedures, incidence of jaundice and common bile duct calculi, duration of operation, number of patients requiring blood transfusions, surgical and general complications and mortality showed no significant difference. Only operative blood loss was significantly higher in the ES group, but this was of no practical relevance. ES precludes the sequelae of emergency surgery in the delayed surgery group not infrequently necessary for failure of conservative treatment of acute cholecystitis, which necessarily precedes planned delayed surgery, and thus renders a significant reduction of over-all risk. This forms the rationale for ES as treatment concept.     

Hepatobiliary ultrasound

The use of ultrasound technology in the emergency department(ED) is a recent and fast-growing phenomenon. Ultrasound is an extremely valuable tool for the evaluation of gallbladder (GB) dis-ease in the ED for several reasons: this disease is a common medical problem, cholecystitis can present in different ways clinically,the nature of the GB allows it to be well visualized by ultrasound,and ultrasound has many benefits and few complications associated with its use. This article reviews the focused examination of the GB, with specific attention to test characteristics (sensitivity,specificity, positive predictive value, and negative predictive value)when performed by emergency physicians in the ED.