Concurrent primary carcinoma of the gallbladder and acute cholecystitis

BACKGROUND/AIMS: Primary carcinoma of the gallbladder is rare and associated with a late diagnosis and poor prognosis. Concurrent acute cholecystitis frequently obscures the presence of carcinoma. The information regarding gallbladder carcinoma with acute cholecystitis is limited. In order to better understand the presentation of gallbladder carcinoma with acute cholecystitis, we retrospectively reviewed the data of patients with primary carcinoma of the gallbladder. METHODOLOGY: The data of 86 patients with primary carcinoma of the gallbladder treated between 1979 and 1994 were compiled and reviewed. The patients were divided into 2 groups: Group 1 (with acute cholecystitis, 21 patients) and Group 2 (without cholecystitis, 65 patients). Clinicopathological comparisons were made and evaluated between these two groups RESULTS: The average age of Group 1 patients was older than that of Group 2 patients (75+/-2 years vs. 63+/-2 years; p<0.05). Three Group 1 patients presented with sepsis. The interval between the onset of symptoms and hospital admission in Group 2 patients was significantly (p<0.05) longer than that in Group 1 patients (243+/-95 days vs. 20+/-11 days). Leukocytosis (>11,000/mm3) was more common in Group 1 patients than in Group 2 patients (47.6% vs. 15.4%). Jaundice was more common in Group 2, and fever was common in Group 1. The majority of Group 2 gallbladder cancers were stage V (75.4%). In contrast, 52.4% of Group 1 gallbladder cancers were stage III and 38.1% were stage V. The 30-day postoperative mortality rate in Group 1 and Group 2 patients was 9.5% and 7.7%, respectively. The cumulative survival of Group 1 patients was not different from that of Group 2 patients (log-rank test, p>0.05). CONCLUSIONS: Age, the interval of symptoms prior to admission, the location of abdominal pain, fever, leukocytosis, and the absence of jaundice suggested the presence of acute cholecystitis in gallbladder carcinoma. A high index of suspicion of the disease, intraoperative examination of gallbladder specimens, and more aggressive surgical treatment may improve patient survival.     

Endoscopic drainage of acute obstructive cholecystitis in patients with increased operative risk

Emergency biliary surgery for acute obstructive cholecystitis in the elderly is associated with an increased hospital mortality. We therefore attempted to drain the obstructed gallbladder via the transpapillary route in 18 patients (mean age: 67 years) who had cystic duct obstruction on ERC and who were at an increased surgical risk. A cholecystonasal catheter was successfully introduced after a small EPT in sixteen of them (89%). This resulted in effective bile drainage, obviating the need for emergency surgery in all patients. No procedure-associated morbidity or mortality was found. Following clinical remission, elective treatment consisted of ESWL/direct stone dissolution (n = 10) or elective surgery (n = 3). Three patients received no further therapy. Our results show that endoscopic gallbladder drainage may be a valuable alternative to emergency surgery in high risk patients with acute obstructive cholecystitis.     

Acute cholecystitis in the intensive care unit

The development of acute cholecystitis in the ICU is now a well-recognized complication of many acute illnesses that precipitate ICU admission and may also result as a complication of the subsequent treatment. The etiology of the disease remains obscure and, unlike acute cholecystitis outside the ICU setting, most cases are acalculous and not associated with gallstones. The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems. Clinical examination is often unhelpful, as many patients are receiving mechanical ventilation and have decreased mental awareness. Biochemical markers are nonspecific and contribute to the delay in diagnosis and treatment. Early diagnosis is essential to avoid the high rates of associated morbidity and mortality. The diagnosis is usually made by radiologic tests, most often by sonographic examination of the gallbladder, which can be performed at the bedside. However, radiologic findings may also be nonspecific. The treatment involves gallbladder drainage by percutaneous cholecystostomy, which is usually curative in acalculous cholecystitis. Interval cholecystectomy is indicated for the remaining patients with gallstone-associated cholecystitis.     

Acute inoperable cholecystitis treated by endoscopic naso-vesicular drainage. Study of 15 patients

OBJECTIVES: Cystic duct cannulation during endoscopic retrograde cholangiography is now possible, due to advances in endoscopic equipment and methodology. The aim of this study was to assess the role of endoscopic transpapillary cholecystostomy in inoperable patients with acute cholecystitis. METHODS: Between October 1993 and February 1996, cystic duct cannulation was performed in 15 patients with acute cholecystitis (9 men and 6 women; mean age 74.8 years. Acute calculous cholecystitis was associated with cholangitis in 4 cases, with pancreatitis in 2 cases, and with perforation of the gallbladder in 1 case. RESULTS: Cystic duct cannulation was successful in 13 patients (86.6%), and resulted in remission of cholecystitis by nasovesicular drainage associated with antibiotherapy in all cases. No morbidity and mortality due to this method was observed at one month. No recurrence was observed after a mean follow-up of 8 months (range: 6 weeks-14 months). CONCLUSION: This study suggests that endoscopic nasovesicular drainage is a good alternative treatment to percutaneous cholecystostomy in inoperable patients.     

Clinical study of gallbladder cancer associated with acute cholecystitis

The clinical features of gallbladder carcinoma associated with acute cholecystitis and problems in diagnosing this condition by ultrasonography were investigated. Nine cases of gallbladder cancer with acute cholecystitis and 51 cases of gallbladder cancer without acute cholecystitis were reviewed. There were no obvious differences between those two groups as far as depth of invasion, location of cancer, and the prevalence of gallstones were concerned. However, there was a tendency for detection of cancer associated with acute cholecystitis by ultrasound to be more difficult than detection of cancer without acute cholecystitis. Macroscopic examination of resected specimens showed that superficial or flat type cancers tended to occur more often in cases of acute cholecystitis. This is considered to be the main cause of the difficulty in diagnosing such cancer by ultrasound.     

Early surgery in the approach to acute lithiasic cholecystitis (ALC)

The surgical approach to acute cholecystitis has changed through the years. It was extended to all ages. The authors report their 10-year experience with 562 cases of cholecystitis. The mortality rate was 1.5% the morbidity rate was 7.6% The authors propose early surgery (within 72 hours of diagnosis) in the majority of patients with acute cholecystitis.     

Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. METHODS: 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). FINDINGS: The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). INTERPRETATION: Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.     

Clinical experience with heart transplantation in infants

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.     

Blastomycosis as an etiology of acute lung injury

Blastomyces dermatitidis, a dimorphic broad-based budding yeast endemic to the Mississippi River Valley region, is responsible for morbidity in humans via inhalation and dissemination. The response of acute lung injury, which produces an illness with serious morbidity and an approximately 50% mortality, uncommonly occurs. Diagnosis can be difficult, and a high index of suspicion should be maintained in endemic regions for patients with acute lung injury of uncertain etiology, especially if their condition deteriorates on broad-spectrum antimicrobial and antitubercular therapy and they have a previous insidious respiratory complaint and constitutional symptoms. Diagnosis should be aggressively pursued and treatment with amphotericin B (0.6 to 0.8 mg/kg/day) initiated as early as possible.     

Postoperative and post-traumatic acute cholecystitis. Value of ultrasound diagnosis

An often unrecognized but potentially fatal complication, mostly seen in posttraumatic patients under intensive care, is reactive acute cholecystitis. On account of the high specificity of ultrasound diagnosis in the biliary system we decided to examine the ultrasound criteria for early detection of posttraumatic cholecystitis. Ultrasound of the abdomen was performed prospectively, seven times on different days, in each of 40 artificially respirated patients under intensive care conditions over a period of 12 months. The results show that artificial respiration, parenteral feeding and previous trauma can lead to tardive (28/40) wall-thickening or to a three-layered wall of the gallbladder (9/40). In 22.5% of patients (9/40) we found the sonographic signs of acute cholecystitis. In correlation with the clinical signs, cholecystectomy was indicated in only two patients. The preoperative ultrasonographic findings and clinical signs of 23 patients with the diagnosis of acute reactive cholecystitis were analysed retrospectively. We found good correlation between sonographic and clinical signs of acute cholecystitis in 21 of these 23 patients. Our study shows that the morphological correlate of a thickened three-layered gallbladder wall can occur in the context of systemic alterations, even if there is no underlying cholecystitis. The diagnosis of acute reactive cholecystitis and the indication for cholecystectomy should be based on the synopsis of pathologic and clinical findings.     

Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis

BACKGROUND: The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis. METHODS: LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8.5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15.6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6). RESULTS: The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45-130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2-28) days. CONCLUSION: LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.     

Experimental study of the pathogenesis of acute acalculous cholecystitis: role of autonomic denervation

This study was undertaken to elucidate the role of autonomic denervation in the pathogenesis of acute acalculous cholecystitis. In Experiment I, the gallbladder was denervated by performing either celiac neurotomy (sympathetic denervation) or truncal vagotomy (parasympathetic denervation), or both, in dogs. In Experiment II, 45-min ischemia and 90-min reperfusion of the gallbladder with or without autonomic denervation were performed by simultaneously occluding the middle hepatic artery and superior mesenteric vein. Celiac neurotomy, and truncal vagotomy, or both, did not cause cholecystitis. Sympathetic denervation, however, decreased the amount of mucin in the gallbladder mucosa and parasympathetic denervation caused reduction of the tissue blood flow, as well as the accumulation of lipid peroxide and xanthine oxidase in the gallbladder mucosa. These changes were most remarkable 1-2 weeks after denervation and were alleviated 4 weeks after denervation. Ischemia-reperfusion 2 weeks after denervation caused more severe cholecystitis than ischemia-reperfusion alone. The most severe inflammation developed in animals that received both celiac neurotomy and truncal vagotomy. These results suggest that autonomic denervation alone does not induce acute cholecystitis, but that it plays an important role in the progression of the inflammatory process in ischemia-reperfusion injury.     

The changing face of emphysematous cholecystitis

Emphysematous cholecystitis is a variant of acute cholecystitis characterized by the presence of gas in the gall bladder lumen, wall or pericholecystic tissues in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. In the past, the diagnosis has relied on the plain abdominal radiograph (AXR), since there are no clinical features to separate this condition from simple acute cholecystitis. The apparently high mortality and morbidity associated with emphysematous cholecystitis has previously emphasized the importance of emergency cholecystectomy. We have reviewed eight cases of emphysematous cholecystitis presenting to this hospital over the last 5 years. The diagnosis was made on AXR in only one of these cases. Ultrasound (US) scans were performed in all eight cases, of which five were positive and three negative, due to non-visualization of the gall bladder. In the three negative cases, the diagnosis was made on subsequent CT scans. On initial clinical examination, only one of the eight patients appeared systemically unwell and conservative management was employed in five of the patients. The remaining three patients underwent cholecystectomy within 3-5 days because of continuing signs or symptoms. It is concluded that the AXR is relatively insensitive in the diagnosis of emphysematous cholecystitis. As a result of the regular use of US in suspected hepatobiliary disease, emphysematous cholecystitis is being diagnosed with increased frequency, uncovering a broad spectrum of disease ranging from mild to severe. Previously, failure to separate milder cases from simple acute cholecystitis may have been responsible for reports of unremitting severity and progression requiring emergency cholecystectomy. Based on clinical assessment, conservative surgical management is possible in a significant proportion of patients.     

Neonatology radiology casebook. Tracheal agenesis

BACKGROUND: Biliary tract diseases are frequent in heart transplant recipients, with significant morbidity and mortality. Since the first presentation of gallstones in this population is often acute cholecystitis, asymptomatic cholelithiasis should not be considered benign. PATIENTS AND METHODS: We retrospectively reviewed 18 heart transplant recipients who underwent cholecystectomy from January 1991 to June 1997. We intentionally chose to perform a straightforward open procedure when acute cholecystitis was suspected (3 patients). A laparoscopic cholecystectomy was performed in all the other cases (15 patients) without conversion to open procedure. CONCLUSION: Since no significant complications were observed in our patients, we believe that transplant recipients with cholelithiasis should undergo laparoscopic cholecystectomy in their posttransplantation course regardless of the symptomatic status of their biliary tract.     

Mirizzi''s syndrome as the cause of intrahepatic lithiasis. A clinical case

The authors report a case of Mirizzi's syndrome that was the cause of intrahepatic lithiasis. The recurrence of acute episodes of cholecystitis may lead to a partial obstruction of hepato-choledochal duct through compression and phlogosis (Type 1 Mirizzi's syndrome); moreover, the compression of calculous material wedged in the cystic duct may also result in ischemic necrosis of the wall, thus causing a cholecystic-choledochal internal biliary fistula (Type 2 Mirizzi's syndrome). The authors analyse problems relating to the complications of gallbladder calculosis with indications for surgery at the first symptomatic manifestation, given that the recurrence of cholecystic inflammatory episodes provokes pathological conditions in the biliary tract that require major surgery with a consequent increase in mortality and morbidity, above all in elderly patients. The authors recommended performing a through intraoperative study to ensure the correct identification of intrahepatic lithiasis, given the difficulty of preoperative diagnosis. The objective of treatment is to suppress the lithogenic focus and ensure good biliary drainage.     

Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ

Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.     

Secondary acute cholecystitis (author's transl)

A case of acute postoperative cholecystitis following subtotal gastrectomy for carcinoma has been observed. The combination of temporary intraoperative shock and probably vagal denervation of the gallbladder initiated secondary acute cholecystitis. After an emergency type cholecystectomy the patient recovered.     

Laparoscopic management of acute cholecystitis with subtotal cholecystectomy

Approximately 20 per cent of laparoscopic cholecystectomies performed for acute cholecystitis require conversion to open cholecystectomy because of severe inflammation. In a retrospective review of 125 consecutive patients undergoing laparoscopic surgery for gallbladder disease from January 1995 through June 1997, 31 had acute cholecystitis. Eight patients underwent a subtotal cholecystectomy because of severe inflammation. There were no conversions to open cholecystectomy and no intraoperative complications. Selected patients were evaluated and treated for common duct stones with preoperative endoscopy to avoid intraoperative cholangiography. One patient had a retained common duct stone successfully managed with postoperative endoscopy. Laparoscopic subtotal cholecystectomy is a safe and effective alternative to conversion to open cholecystectomy for severe inflammation associated with acute cholecystitis. Endoscopic assessment and treatment of common duct stones when indicated either before or after surgery omits the use of intraoperative cholangiography and potential injury to the inflamed ducts.     

Echogenic fetal bowel and calcified meconium in a fetus with trisomy 21

A case of acute cholecystitis in an immunosuppressed patient with hepatocellular dysfunction is reported. The diagnostic dilemmas posed by the lack of specific sonographic findings, the possibility of acute gallbladder disease without early cystic duct obstruction, and the absence of clear guidelines for the interpretation of delayed appearance of the gallbladder on hepatobiliary scintigraphy in this subgroup of patients are discussed.     

Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases.