Acute acalculous cholecystitis complicating trauma: a prospective sonographic study

Part 1: Current Concepts in Radiologic Imaging and Intervention in Acute Cholecystitis

Acute calculous cholecystitis and acute acalculous cholecystitis are encountered commonly among critically ill, often elderly, patients. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, infectious disease physicians, gastroenterologists, and endoscopists able to contribute to patient care. In this article intended predominantly for intensivists, we will review the imaging findings and radiologic treatment of critically ill patients with acute calculous cholecystitis and acute acalculous cholecystitis.

Effectiveness of ultrasound screening in right upper quadrant pain: A comparative study in a basic emergency service

Background and Aims

The use of ultrasound screening is primarily facilitated by point-of-care ultrasound (POCUS) and its integration into healthcare systems is a result of the versatility of this imaging technique. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with that of radiologists at referral hospital (RH) in Portugal.

Methods

Twenty patients with right upper quadrant (RUQ) pain and suspected cholecystitis or biliary pathology underwent sonography screening using POCUS in the BES. They were then forwarded to the RH where a radiologist performed a conventional ultrasound exam on the same patients. The results of both exams were compared to determine if the findings obtained in the BES were confirmed by the radiologist in the RH.

Results

In our sample, 60% of cases were related to biliary pathology, 20% were liver-related, 10% had hepatopancreatic biliary etiology, and 10% had unknown etiology. A strong association between the sonographic findings in the BES and the RH was found in the variables "Sonographic Murphy sign" (V = 0.859; p = 0.001), "Cholelithiasis/Gallbladder sludge" (V = 0.840; p = 0.001), and "Intrahepatic biliary tract dilatation" (V = 0.717; p = 0.006). Adequate measures of agreement between the findings of the radiographer and radiologist were obtained for the "Sonographic Murphy sign" (k = 0.664; p = 0.001) and the presence of "Cholelithiasis/Gallbladder sludge" (k = 0.712; p = 0.000).

Conclusion

Major biliary abnormalities were detected in patients with RUQ pain in BES using sonography. The correlation between the sonographic findings obtained by the sonographers at BES and those obtained by radiologists at the RH in Portugal was strong, showing that POCUS screening could be extended to other similar settings; however, more studies are needed.

Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature

The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time.

Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis.

AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability.

Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD.

In addition, emergency physicians are not always familiar with transient ECG changes with AAC.

The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD.

Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC.

US – Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC.

Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC.

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AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery.

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ECG changes in absence of significant laboratory data for IMA could be related to a misdiagnosed AAC.

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Cholecystectomy is an only definitive treatment for AAC.

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The first report on this theme after 20 years.

Acute Acalculous Cholecystitis in Hospitalized Patients With Hematologic Malignancies and Prognostic Importance of Gallbladder Ultrasound Findings

OBJECTIVES

Patients with hematologic malignancies, especially those with acute disease or those receiving intense chemotherapy, are known to develop acute acalculous cholecystitis (AAC). The aim of this study was to evaluate the diagnostic and prognostic value of the established ultrasound (US) diagnostic criteria for AAC in patients with acute hematologic malignancies who were clinically suspected to have AAC.

METHODS

We retrospectively studied the US findings of the gallbladder in patients with hematologic malignancies and correlated these findings with the duration of clinical symptoms, complications, and gallbladder-specific mortality. The major criteria were a 3.5-mm or thicker wall, pericholecystic fluid, intramural gas, and a sloughed mucosal membrane. The minor criteria were echogenic bile and hydrops (gallbladder distension > 4 cm). Ultrasound findings were considered positive if they included 2 major criteria or 1 major and 2 minor criteria.

RESULTS

Ninety-four (25.5%) of 368 patients with hematologic malignancies had clinical signs of AAC during their acute phase of illness or during intense chemotherapy. Forty-three (45.7%) of these 94 patients had AAC-positive test results based on US criteria. The mean duration of symptoms was significantly longer (7.8 days) in this group than among the patients with negative test results (3.9 days; P < .001). Patients with positive test results had a higher rate of complications or mortality (20.9%) than those with negative test results (0%; P < .001).

CONCLUSIONS

Symptomatic patients who meet the US criteria for the diagnosis of AAC have a poor prognosis. Other patients require a close follow-up US examination within 1 week to detect early progression.

Risk factors for poor outcomes of children with acute acalculous cholecystitis

BACKGROUND

Acute acalculous cholecystitis (AAC) is generally considered to be a mild disease in children; however, if left untreated or treated without caution, AAC can lead to severe outcomes, such as death. The objectives of this study were to present the clinical features and identify the predictors of mortality in pediatric AAC.

METHODS

Patients diagnosed with AAC between 2005 and 2012 were enrolled. AAC was defined by the presence of fever and an echo-proven thickened gallbladder wall exceeding 4 mm. A poor health outcome was defined as death. Further information related to the demographics, clinical manifestations, laboratory results, ultrasound findings, and pathogens present in the AAC patients was also collected. Predictors of mortality were identified by association analyses and confirmed by multivariate logistic regression.

RESULTS

A total of 147 pediatric AAC patients (male/female = 1.01, mean age = 5.2 years) were included in this retrospective study. The most common clinical presentation was an elevated C-reactive protein level (84%) followed by hepatomegaly (80%) and anorexia (78%). AAC in children was associated with various diseases, including infectious diseases (70%), systemic diseases (13%), and malignancy (11%). Fourteen of the 147 (9.25%) patients died during the study period. The presences of thrombocytopenia, anemia, gallbladder sludge, hepatitis, and/or sepsis plus hepatitis were found to be the important predictors of AAC mortality.

CONCLUSIONS

The factors associated with AAC mortality were anemia, thrombocytopenia, gallbladder sludge, hepatitis, and sepsis plus hepatitis. These predictors are likely to help clinicians identify patients who are at a high risk of poor prognoses and make appropriate clinical decisions.

Spontaneous rupture of the gall bladder: an unusual forensic diagnosis

Peritonitis secondary to spontaneous rupture/perforation of the gall bladder is a rare condition overall and is even less common in the forensic population. We report the case of a middle-aged man who died from generalized peritonitis from gall bladder perforation due to acute acalculous cholecystitis. This condition usually occurs in critical patients with systemic illness, and although the exact pathogenesis remains unclear, the development of acalculous cholecystitis appears to be multifactorial. Antemortem diagnosis is reliant upon clinical presentation, laboratory data, and radiologic studies. Surgery and appropriate antibiotics are mainstays of treatment; however, there is an emerging role for minimally invasive procedures. Histopathologic features show significant overlap with the calculous type. Although increasing numbers of acalculous cholecystitis have been diagnosed in the critically ill, the fatal presentation of a perforated gall bladder following an undiagnosed case of acute acalculous cholecystitis is unusual in a nonhospitalized and ambulatory man.

Epstein-barr virus infection with acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder in the absence of demonstrated stones. AAC is frequently associated with severe systemic inflammation. However, the exact etiology and pathogenesis of AAC still remain unclear. Acute infection with Epstein Barr virus (EBV) in childhood is usually aymptomatic, whereas it often presents as typical infectious mononucleosis symptoms such as fever, cervical lymphadenopathy, and hepatosplenomegaly. AAC may occur during the course of acute EBV infection, which is rarely encountered in the pediatric population. AAC complicating the course of a primary EBV infection is usually associated with a favorable outcome. Most of the patients recover without any surgical treatment. Therefore, the detection of EBV in AAC would be important for prediction of better prognosis. We describe the case of a 10-year-old child who presented with AAC during the course of primary EBV infection, the first in Korea, and review the relevant literature.

Liver function test abnormalities after traumatic brain injury: is hepato-biliary ultrasound a sensitive diagnostic tool?

BACKGROUND

This study was to evaluate the usefulness of hepato-biliary ultrasound (HBUS) for the investigation of isolated liver function tests (LFTs) abnormalities.

METHODS

We retrospectively reviewed HBUS reports in traumatic brain injury (TBI) patients admitted to our tertiary neuro-critical care unit (NCCU; January 2005-June 2011). We included patients receiving an HBUS for isolated LFTs derangement, excluding pre-existing hepato-biliary diseases or trauma. We assessed the temporal profile of alanine aminotransferase (ALT), bilirubin (Bil), and alkaline phosphatase (ALP).

RESULTS

Of 511 patients, 58 received an HBUS. Of these, 47 were investigated for isolated LFTs derangement; HBUS always failed to identify a cause for these abnormalities. The HBUS was performed on day 18 (range 6-51) with the following mean values: 246 IU litre(-1) [ALT, 95% confidence interval (CI) 183-308], 24 μmol litre(-1) (Bil, 95% CI 8-40), and 329 IU litre(-1) (ALP, 95% CI 267-390); only ALT (72, 95% CI 36-107) and ALP (73, 95% CI 65-81) were deranged from admission values (both P<0.01). At NCCU discharge, both ALT (160, 95% CI 118-202) and ALP (300, 95% CI 240-360) were higher than at admission (P<0.01). Compared with HBUS-day value, only ALT improved by NCCU discharge (P<0.05), while both were recovering by hospital discharge (ALT 83, 95% CI 59-107; ALP 216, 95% CI 181-251; P<0.01). At hospital discharge, ALP remained higher than at admission (P<0.01).

CONCLUSIONS

In TBI patients, HBUS did not appear sensitive in detecting causes for isolated LFT abnormalities. Both ALT and ALP worsened and gradually recovered. Their abnormalities did not prevent NCCU discharge. ALP recovered more slowly than ALT. TBI and its complications, critical illness, and pharmacological strategies may explain the LFTs derangement.

Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature

Background

To evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities.

Methods

The authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) computed tomography, (4) magnetic resonance cholangiopancreatography and (5) cholescintigraphy. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.

Results

Sonography is still used as the initial imaging technique for evaluating patients with suspected acute calculous cholecystitis because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability. Cholescintigraphy still has the highest sensitivity and specificity in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern the use of cholescintigraphy is limited in clinical practice. CT is particularly useful for evaluating the many complications of acute calculous cholecystitis. The lack of widespread availability of MRI and the relatively high cost prohibits its primary use in patients with acute calculous cholecystitis.

Conclusions

US is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis.

Septic shock and hypofibrinogenemia predict a fatal outcome in childhood acute acalculous cholecystitis

OBJECTIVES

The aim of the study was to investigate the etiology, clinical presentation, and risk factors for poor prognosis of acute acalculous cholecystitis (AAC) in children.

PATIENTS AND METHODS

Children younger than 18 years diagnosed as having AAC were analyzed retrospectively from 2000 to 2009. The demographic and clinical characteristics, etiology, and outcomes were recorded. AAC was defined as a gallbladder wall thickness of >3.5 mm in sonogram with a duration of symptoms <1 month. The severity of sonographic findings was scored, with 1 point each given for wall thickness >3.5 mm, gallbladder distention, sludge, and pericholecystic fluid.

RESULTS

A total of 109 children (boys:girls 1:2, median age 4.9 years) were diagnosed. The most common clinical presentation was fever (88%), followed by hepatomegaly (72%). The rates of elevated alanine aminotransferase and thrombocytopenia were 72% and 65%, respectively. The most common causative etiology was infectious diseases (74%). All of the patients were treated nonoperatively. Sixteen (15%) patients died. Children with mortality had a significantly higher rate of septic shock (P < 0.001), anemia (P = 0.01), thrombocytopenia (P = 0.04), hypofibrinogenemia (P = 0.002), the presence of pericholecystic fluid (P = 0.04), and higher sonographic scores (P = 0.04) than those with survival. Multiple logistic regression analysis confirmed that the presence of septic shock (P = 0.004) and hypofibrinogenemia (P = 0.014) were independent risk factors that predict mortality.

CONCLUSIONS

Childhood AAC is usually secondary to a variety of etiologies, especially during the course of infectious diseases. The presence of septic shock and a low value of fibrinogen determine a fatal outcome in childhood AAC.

Acute acalculous cholecystitis: a review

Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.

Acute acalculous cholecystitis after trauma: a prospective study

OBJECTIVE

The purpose of this study was to identify risk factors for the development of acute acalculous cholecystitis (AAC) and useful criteria to facilitate the decision to perform cholecystectomy.

METHODS

This was a prospective study of patients with an Injury Severity Score (ISS) > or = 12 requiring intensive care for > 4 days (n = 255), divided into three groups by ultrasound: AAC (n = 27), hydropic gallbladder (n = 37), and normal gallbladder (n = 191). Multivariate analysis was conducted for trauma scores and laboratory and intensive care unit (ICU) data and complemented by logistic regression analysis.

RESULTS

Three factors sufficiently define the risk for AAC: ISS, heart rate, and units of packed red blood cells required at ICU admission. All patients who underwent cholecystectomy (n = 21) had both highly pathologic ultrasound and major clinical symptoms, and all had histologically verified AAC. There was no significant difference in daily laboratory data between patients with and without AAC.

CONCLUSION

Patients with a high ISS who are tachycardic and have required several units of packed red blood cells at ICU admission should be monitored early by ultrasound. When ultrasound is highly pathologic together with major clinical symptoms, cholecystectomy should be performed. Daily laboratory data are of no additional value regarding the decision to perform cholecystectomy.

Gastrointestinal problems in the chronically critically ill patient

In summary, a variety of gastrointestinal processes may occur in the chronically critically ill patient population, usually as consequence of the primary systemic process. The clinical presentation is frequently nonclassic and there often is a substantial delay in diagnosis, resulting in increased morbidity and mortality.

Application of trocar technique in ultrasound-guided drainage of the gallbladder

OBJECTIVE

The ultrasound-guided drainage of the gallbladder (USDGB) is mainly performed by Seldinger technique. We aim to evaluate the use of the easier performable trocar technique in draining critically ill patients with acute calculous or acalculous cholecystitis.

PATIENTS AND METHODS

Critically ill patients with acute acalculous (AAC; n=29) or calculous cholecystitis (ACC; n=7) underwent trocar technique application of USD. Technical problems, complications and patients' further courses were recorded.

RESULTS

In group 1 (AAC) 29/29 patients could be drained without problems or complications. Three dislocations of the USDGB were seen. In group 2 (CAC) only four out of seven could be drained by this technique, in these four patients (a) major bleeding and (b) pericholecystic fluid collections were observed. In both groups no further complications during USDGB or its removal were seen.

CONCLUSIONS

In acute acalculous cholecystitis the use of trocar technique in applying the USDGB is easy and bedside performable, in acute calculous cholecystitis the USD should be done by Seldinger technique.

The approach to common abdominal diagnosis in infants and children

This article focuses on salient points in the evaluation of abdominal pain in infants and children. Specifically, the authors address appendicitis and abdominal pain associated with either vomiting, constipation, or gastrointestinal bleeding. A discussion of common abdominal masses, urologic, and gynecologic problems, and considerations in the evaluation of immunologically suppressed or neurologically impaired children, and children with recurrent abdominal pain is also presented. The authors establish logical, focused approaches to the initial evaluation and management of abdominal pain and suggest criteria for timely surgical referral.

Trends in management of gallbladder disorders in children

Gallbladder disorders have been recognized with increasing frequency in pediatric patients. This study aimed to identify recent trends in management and compare the effectiveness of laparoscopic (LC) over open cholecystectomy (OC) by a retrospective chart analysis of all cholecystectomies from 1990 through 1995. Information obtained included demographics, symptoms, predisposing conditions, associated illnesses, family history, imaging studies, type of cholecystectomy, complications, operative time, pain medication, diet recommencement, pathologic findings, and length of hospital stay. The type of cholecystectomy (OC vs. LC) was compared with the clinical variables using standard statistics. Eighty-three patients between 21 months and 18 years of age were identified; their mean age was 14.8 years. Females (76%) with classic biliary symptoms predominated;12% of the patients developed gallstone pancreatitis and 7% jaundice. Abnormal liver chemistry values, obesity, and elevated triglyceride levels comprised the most significant predisposing factors. Indications for surgery were cholelithiasis in 71 patients (86%), gallbladder dyskinesia in 10 (12%), and sludge/polyp in 2. Fifty-nine cholecystectomies (71%) were done laparoscopically and 24 (29%) open. Choledocholithiasis in 6 children (7%) was managed by open extraction with t-tube placement or endoscopic papillotomy followed by LC. No major ductal complication was identified. The predominant pathologic finding was chronic cholecystitis, including the subgroup with biliary dyskinesia. Statistical comparison showed that LC is superior to OC in regard to length of stay, diet resumption, use of pain medication, operating time, and cosmetic results. It is concluded that a contemporary diet, obesity, and abnormal liver chemistry are the main predisposing conditions of gallbladder disease in children in this decade. Females in their teenage years with typical symptoms continue to be the most commonly affected group. Persistent biliary symptoms associated with low gallbladder ejection fractions during hepatobiliary cholecystokinin-stimulated scans can be caused by dyskinesia. The method of choice to remove the diseased gallbladder in children is LC, which is safe, efficient, and superior to the conventional method. Common duct stones can be managed by simultaneous endoscopic papillotomy. The costs of LC are reduced by employing reusable equipment and selective cholangiographic indications.

Acalculous cholecystitis in children

Acalculous cholecystitis (AC) is a rare disease in children, and its spectrum has not been well established. Twenty-five children with AC were identified (treated between 1970 and 1994) by retrospective clinical and pathological review. The authors recognized two distinct forms of this disease: acute (duration of symptoms < 1 month) and chronic (duration > 3 months). Thirteen children had acute AC. Seventy-five percent were males; the age range was from 2 months to 20 years. Of these cases, six occurred in the immediate postoperative period, five were in association with a systemic medical illness, and two had an infectious cause (Salmonella). The mean time of onset of symptoms ranged from 4 to 30 days after surgery or hospitalization (mean, 16 days). All children presented with fever, right-upper-quadrant pain, and vomiting. Other manifestations included jaundice (38%) and right-upper-quadrant mass (23%). Most had leukocytosis (76%) and abnormal liver function test results (62%). Ultrasonography was the most commonly used radiological test, and all 10 cases tested met the ultrasonographic criteria for acute AC. Cholecystectomy was performed in nine children, and pathological examination confirmed cholecystitis. No postoperative complications occurred. The other four children were managed nonoperatively with intravenous antibiotics. One died, but the other three recovered fully. Twelve children had chronic AC. Sixty-seven percent were females; the age range was 7 to 18 years. All presented with chronic symptoms of right-upper-quadrant pain and nausea or vomiting. The leukocyte count and results of liver function tests were normal. Seventy-five percent had evidence of abnormal gallbladder function (noted by a radionuclide hepatobiliary scan or cholecystography). All children in this group underwent cholecystectomy, with pathological confirmation of chronic inflammation. No complications occurred, and all patients had complete resolution of symptoms. The authors conclude that AC in children occurs in two distinct patterns. The acute and chronic forms differ in their clinical setting and presentation. Cholecystectomy is effective treatment of AC, although there may be a role for nonoperative management in selected cases.