Use of a predictive equation for diagnosis of acute gangrenous cholecystitis

Ultrasonographic predictors of acute gangrenous cholecystitis in patients treated with laparoscopic cholecystectomy: a single center retrospective study

BACKGROUND

Acute gangrenous cholecystitis, a severe complication of cholecystitis, carries a high risk of morbidity and mortality. Despite its severity, preoperative diagnosis is challenging, often only confirmed during surgery. Therefore, we analyzed various factors that could predict acute gangrenous cholecystitis in patients undergoing cholecystectomy.

METHODS

We retrospectively reviewed patients who underwent laparoscopic cholecystectomy at Bundang Jasaeng General Hospital from January 2018 to December 2021. Only patients who proceeded directly to surgery without radiologic interventions were included, and all underwent trans-abdominal ultrasonography before surgery.

RESULTS

Our study investigated 305 patients diagnosed with acute cholecystitis, identifying 37 with acute gangrenous cholecystitis. Analysis showed that patients with gangrenous cholecystitis were significantly older, more likely to be male, and had a higher prevalence of diabetes mellitus compared to those with uncomplicated cholecystitis. Ultrasound findings revealed a higher incidence of sonographic Murphy's signs, thickened gallbladder walls, gallbladder wall defects, and pericholecystic fluid in gangrenous cases. Multivariate analyses showed that a thickened gallbladder wall and the presence of pericholecystic fluid were significantly associated with gangrenous cholecystitis.

CONCLUSION

Our study showed that ultrasound findings of a thickened gallbladder wall, along with pericholecystic fluid, could be predictors of gangrenous cholecystitis. Additionally, leukocytosis and high CRP values strongly indicate the likelihood of this condition. Therefore, urgent management is recommended due to the high morbidity and mortality associated with gangrenous cholecystitis.

Predictive Factors for the Development of Gallbladder Necrosis

Introduction Acute cholecystitis is a common complication of gallstone disease. Likewise, gallbladder necrosis is a complication of cholecystitis associated with higher risks of morbidity and mortality. Identification of risk factors which portend to gallbladder necrosis is key in prioritizing the management of higher-risk patients. This study aimed to identify such factors that predict the development of gallbladder necrosis. Method A retrospective review of all patients undergoing emergency cholecystectomy in a tertiary hospital over a two-year period was performed. Gallbladder necrosis was diagnosed on histopathological examination of operative specimens. Multivariable logistic regression was performed to determine risk factors for gallbladder necrosis. Results A total of 163 patients underwent acute cholecystectomy and 43 (26%) had proven gallbladder necrosis. Multivariable analysis demonstrated that elevated white cell count (WCC) (OR 1.122, 95%CI 1.031-1.221, p=0.007), elevated C-reactive protein (CRP) (OR 1.004, 95%CI 1.001-1.008, p=0.022) and positive smoking status (OR 5.724, 95%CI 1.323-24.754, p=0.020) were independently predictive of gallbladder necrosis. Notably, advancing age, elevated BMI, diabetes mellitus or American Society of Anesthesiologists (ASA) grade were not found to be associated with developing necrosis. Conclusion Patients at risk of gallbladder necrosis include those with higher WCC, CRP, and active smokers. Given the increased potential complications, these risk factors should be identified early in the management of those admitted with gallstone disease to ensure such patients receive aggressive medical therapy alongside timely and guided surgical intervention.

Evaluation of early sonographic predictors of gangrenous cholecystitis: mucosal discontinuity and echogenic pericholecystic fat

PURPOSE

To identify early sonographic features of gangrenous cholecystitis.

MATERIALS AND METHODS

101 patients with acute cholecystitis and a pre-operative sonogram were retrospectively reviewed by three radiologists in this IRB-approved and HIPAA-compliant study. Imaging data were correlated with histologic findings and compared using the Fisher's exact test or Student t test with p < 0.05 to determine statistical significance.

RESULTS

Forty-eight patients had gangrenous cholecystitis and 53 had non-gangrenous acute cholecystitis. Patients with gangrenous cholecystitis tended to be older (67 ± 17 vs 48 ± 18 years; p = 0.0001), male (ratio of male:female 2:1 vs 0.6:1; p = 0.005), tachycardic (60% vs 28%; p = 0.001), and diabetic (25% vs 8%; p = 0.001). Median time between pre-operative sonogram and surgery was 1 day. On imaging, patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat (p = 0.001), mucosal discontinuity (p = 0.010), and frank perforation (p = 0.004), while no statistically significant differences were seen in the presence of sloughed mucosa (p = 0.104), pericholecystic fluid (p = 0.523) or wall striations (p = 0.839). In patients with gangrenous cholecystitis and echogenic pericholecystic fat, a smaller subset had concurrent mucosal discontinuity (57%), and a smaller subset of those had concurrent frank perforation (58%). The positive likelihood ratios for gangrenous cholecystitis with echogenic fat and mucosal discontinuity were 4.6 (95% confidence interval 1.9-11.3) and 14.4 (2.0-106), respectively.

CONCLUSION

Echogenic pericholecystic fat and mucosal discontinuity are early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation.

Acute cholecystitis: diagnostic value of dual-energy CT-derived iodine map and low-keV virtual monoenergetic images

PURPOSE

To compare conventional and dual-energy CT (DECT) for the diagnosis of acute cholecystitis and gangrene.

METHODS

Fifty-seven consecutive adult patients with abdominal pain who underwent IV contrast-enhanced abdominal DECT on a dual-layer (dlDECT) or rapid-switching (rsDECT) scanner from September, 2018 to April, 2021 with cholecystectomy and pathology-confirmed cholecystitis were retrospectively reviewed, and compared with 57 consecutive adult patients without cholecystitis from the same interval scanned with DECT. Images were reviewed independently by two abdominal radiologists with 12 and 16 years of experience in two sessions 4 weeks apart, blinded to clinical data. Initially, only blended reconstructions (simulating conventional single-energy CT images) were reviewed (CT). Subsequently, CT and DECT reconstructions including low-keV virtual monoenergetic images and iodine maps were reviewed. Gallbladder fossa hyperemia, pericholecystic fluid, subjective presence of gangrene, heterogeneous wall enhancement, sloughed membranes, intramural air, abscess, overall impression of the presence of acute cholecystitis, and intramural iodine density were assessed.

RESULTS

Gallbladder fossa hyperemia was detected with increased sensitivity on DECT (R1, 61.4%; R2, 75.4%) vs. CT (R1, 22.8%; R2, 15.8%). DECT showed increased sensitivity for gangrene (R1, 24.6%; R2, 38.6%) vs. CT (R1, 5.3%; R2, 14%), heterogeneous wall enhancement (DECT: R1, 33.3%; R2, 63.2% vs. CT: R1, 7%; R2, 31.6%), and cholecystitis (DECT: R1, 86%; R2, 89.5% vs. CT: R1, 77.2%; R2, 70.2%). In addition, DECT was more sensitive for the detection of acute cholecystitis (R1, 86%; R2, 89.5%) vs. CT (R1, 77.2%; R2, 70.2%). Iodine density threshold of 1.2 mg/ml, 0.8 mg/mL, and 0.5 mg/mL showed specificity for gangrenous cholecystitis of 78.26%, 86.96%, and 95.65%, respectively, using the rsDECT platform.

CONCLUSION

DECT showed improved sensitivity compared to conventional CT for detection of acute cholecystitis. Iodine density measurements may be helpful to diagnose gangrene.

Gallbladder volvulus: a case report

Background

Gallbladder volvulus is a rare pathology first reported by Wendel in 1898. Although the main pathological process associated with gallbladder volvulus is not known, there is clinical evidence suggesting that lack of gallbladder adhesions to the liver leads to an eventual twisting around the cystic bile duct (a process that seems to favor older female populations).

Case presentation

In this report, an 81-year-old Caucasian elderly female presented to the emergency department with acute/severe right upper quadrant pain, which was also accompanied by an elevated leukocyte count. Relevant imaging showed a distended gallbladder with gallbladder wall thickening and a dilated common bile duct. The patient was subsequently admitted to the hospital for acute cholecystitis and scheduled for surgery the next day. Upon laparoscopic surgery, the gallbladder was black and gangrenous with no visible adhesions to the liver. Further inspection demonstrated that the gallbladder had twisted clockwise around the cystic bile duct.

Conclusions

While many previous cases have been reported since Wendel, further case studies are nevertheless important to help guide proper clinic evaluation and pinpoint the potential for a gallbladder volvulus.

Admission Variables Predictive of Gangrenous Cholecystitis

The objective of the present study was to identify admission clinical factors associated with gangrenous cholecystitis (GC) and factors associated with conversion to open cholecystectomy. We retrospectively evaluated 391 patients over a 17-month period who underwent urgent laparoscopic cholecystectomy for a diagnosis of acute cholecystitis. Eighty-nine patients with pathologically proven GC were compared with 302 patients without GC. On multivariable logistic regression, predictors of GC included male gender, white blood cell count greater than 14,000/mm3, heart rate greater than 90 beats per minute, and sodium 135 mg/dL or less. Conversion rate to open cholecystectomy was 7.9 per cent overall, 4 per cent for non-GC, and 19 per cent for GC (odds ratio, 0.2; 95% confidence interval, 0.1 to 0.4; P < 0.00001). Conversion was predicted by increasing number of days to surgery, total bilirubin, and white blood cell count. Complication rate was higher in the GC group (10.1 vs 3.6% in the acute cholecystitis group, P = 0.01). The increased rate of conversion observed with surgery delay suggests that early laparoscopic cholecystectomy may be preferable in most patients.

Utility of leucocytes, inflammatory markers and pancreatic enzymes as indicators of gangrenous cholecystitis

BACKGROUND

Acute cholecystitis is an emergency condition. If not promptly diagnosed and properly managed, the complication of gangrenous cholecystitis may develop, which may be a life-threatening complication.

OBJECTIVES

The study aims to examine various characteristics and physiological parameters in patients diagnosed with acute cholecystitis to evaluate if significant predictive factors exist for the differential diagnosis of gangrenous cholecystitis.

MATERIALS AND METHODS

This was a retrospective study included patients with acute cholecystitis diagnosis, who presented to 'blinded for peer review' from 1 January 2010 to 1 January 2017. Parameters evaluated included liver function tests, complete cell count, C reactive protein, erythrocyte sedimentation rate (ESR), amylase and lipase levels, as well as medical history, and presenting clinical signs. Cases were divided according to whether or not there was a histopathological diagnosis of gangrenous cholecystitis.

RESULTS

A total of 186 (54.5%) female and 155 (45.5%) male cases were examined. Patients with gangrenous cholecystitis tended to be male, showed a significantly higher white cell count, higher neutrophil percentage, lower lymphocyte percentage and higher ESR compared with patients without gangrenous cholecystitis. However, serum amylase and lipase demonstrated no differential diagnostic utility CONCLUSION: Male patients with a high ESR level, high total leucocyte count with a relative high proportion of neutrophils and a low proportion of lymphocytes were found to be at increased risk of the presence of gangrenous cholecystitis.

Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis

BACKGROUND

Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis.

METHODS

This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created.

RESULTS

Age as a continuous variable, WBC count ≥ 12.4 × 10³/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points.

CONCLUSIONS

Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes.

CT Findings for Detecting the Presence of Gangrenous Ischemia in Cholecystitis

OBJECTIVE

The objective of our study was to evaluate the diagnostic accuracy of CT in differentiating gangrenous cholecystitis from uncomplicated cholecystitis and healthy gallbladders.

MATERIALS AND METHODS

We performed a retrospective review of 308 patients with histologically proven gangrenous cholecystitis who underwent preoperative CT 1 month before gallbladder removal over a 4-year period. Two readers who were blinded to the histologic diagnosis independently recorded CT features of and overall likelihood of gangrenous cholecystitis on a 5-point scale (1, definitely absent; 5, definitely present). Ratings were dichotomized such that a diagnosis was considered present at a rating of 4 or 5 and considered absent at lower ratings. Interobserver variability for individual CT findings was also assessed.

RESULTS

Patients had gangrenous cholecystitis (n = 28), acute cholecystitis (n = 98), chronic cholecystitis (n = 118), or healthy gallbladders (n = 64). Multivariate analysis showed that CT findings of gallbladder distention greater than 4.0 cm (odds ratio [OR], 9.63; p < 0.01), mural striation (OR, 11.39; p < 0.01), and decreased mural enhancement (OR, 3.55; p < 0.05) independently predicted gangrenous cholecystitis. Using these CT features, the diagnosis of gangrenous cholecystitis was made with a specificity of 93.9% and 89.6% for readers 1 and 2, respectively, and accuracy of 90.9% and 87.0%, respectively. Good agreement was seen between the two readers with respect to gallbladder distention greater than 4.0 cm (κ = 0.77) and decreased mural enhancement (κ = 0.64).

CONCLUSION

A markedly distended gallbladder associated with decreased wall enhancement is highly specific for gangrenous cholecystitis.

Usefulness of contrast-enhanced US in the diagnosis of acute gangrenous cholecystitis: A comparative study with surgical and pathological findings

OBJECTIVE

To prospectively determine the usefulness of contrast-enhanced ultrasound (CEUS) in the diagnostic assessment of acute gangrenous cholecystitis, using histopathology as the reference method.

MATERIAL & METHODS

The local institutional review board approved the study protocol, and all patients at enrollment provided a written informed consent. From December 2011 to July 2014, all patients with a clinical-sonographic diagnosis of acute cholecystitis underwent a CEUS examination. We included only patients who underwent cholecystectomies within 24-h of CEUS. Radiologists in the course of routine clinical care interpreted the US and CEUS images at the end of the examination, filling out a questionnaire. Two radiologists, blinded to the final diagnosis, independently reviewed the video CEUS sequences for the presence of defects of the gallbladder wall enhancement. Associations between the sonographic findings and histological gangrenous cholecystitis were evaluated by using univariate and multivariate logistic regression analysis.

RESULTS

A total of 150 patients were analyzed. The histological diagnoses were 41 (27%) nongangrenous cholecystitis and 109 acute gangrenous cholecystitis (73%). Multivariate analysis of the predictive parameters at univariate analysis revealed that only leukocytosis, diabetes mellitus, lithiasis and defects of wall enhancement on CEUS were independent variables related to gangrenous cholecystitis. The presence of enhancement defects on CEUS enabled the diagnosis of the gangrenous form with sensitivity between 85 and 91% and specificity of 67.5-84.8%. Interobserver agreement for CEUS interpretation was good (median k value: 0.664; range, 0.655-0.680).

CONCLUSION

Local or widespread absence of gallbladder wall enhancement on CEUS is associated with the presence of gangrenous acute cholecystitis.

Is gallbladder inflammation more severe in male patients presenting with acute cholecystitis?

BACKGROUND

The male gender is considered a risk factor for complications in patients undergoing laparoscopic cholecystectomy. The reasons for this gender associated risk are not clearly understood. The extent of gallbladder inflammation has been shown to influence surgical outcome. The aim of this study was to investigate whether or not gallbladder inflammation is more severe in male patients presenting with acute cholecystitis.

METHODS

A retrospective gender dependent comparison of the data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a primary care facility within a five-year period was performed.

RESULTS

138 patients, 69 males and 69 females were included for analysis. Severe gallbladder inflammation (gangrenous and necrotizing cholecystitis) was seen in a significant portion of the male population compared to the female population (p = 0.002). The male gender was confirmed in a multivariate analysis as an independent risk factor for severe cholecystits (p = 0.018).

CONCLUSION

The male gender is a risk factor for severe gallbladder inflammation. An early surgical intervention may be needed to prevent complications.

Gangrenous cholecystitis: mortality and risk factors

As a serious complication of cholelithiasis, gangrenous cholecystitis presents greater mortality than noncomplicated cholecystitis. The aim of this study was to specify the risk factors on mortality. 107 consecutive patients who underwent surgery due to gangrenous cholecystitis between January 1997 and October 2011 were investigated retrospectively. The study included 60 (56.1%) females and 47 (43.9%) males, with a mean age of 60.7 ± 16.4 (21-88) years. Cardiovascular diseases were the most frequently accompanying medical issues (24.3%). Thirty-six complications (33.6%) developed in 29 patients, and surgical site infection was proven as the most common. Longer delay time prior to hospital admission, low white blood cell count, presence of diabetes mellitus, higher blood levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and total bilirubin, pericholecystic fluid in abdominal ultrasonography, and conversion from laparoscopic surgery to open surgery were identified as risk factors affecting mortality (P < 0.001, P = 0.001, P = 0.044, P = 0.005, P = 0.049, P = 0.009, P = 0.022, P = 0.011, and P = 0.004, respectively). Longer delay time prior to hospital admission and low white blood cell count were determined as independent risk factors affecting mortality.

Predicting gangrenous cholecystitis

BACKGROUND

Gangrenous cholecystitis (GC) is often challenging to treat. The objectives of this study were to determine the accuracy of pre-operative diagnosis, to assess the rate of post-cholecystectomy complications and to assess models to predict GC.

METHODS

A retrospective single-institution review identified patients undergoing a cholecystectomy. Logistic regression models were used to examine the association of variables with GC and to build risk-assessment models.

RESULTS

Of 5812 patients undergoing a cholecystectomy, 2219 had acute, 4837 chronic and 351 GC. Surgeons diagnosed GC pre-operatively in only 9% of cases. Patients with GC had more complications, including bile-duct injury, increased estimated blood loss (EBL) and more frequent open cholecystectomies. In unadjusted analyses, variables significantly associated with GC included: age >45 years, male gender, heart rate (HR) >90, white blood cell count (WBC) >13,000/mm(3), gallbladder wall thickening (GBWT) ≥ 4 mm, pericholecystic fluid (PCCF) and American Society of Anesthesiology (ASA) >2. In adjusted analyses, age, WBC, GBWT and HR, but not gender, PCCF or ASA remained statistically significant. A 5-point scoring system was created: 0 points gave a 2% probability of GC and 5 points a 63% probability.

CONCLUSION

Using models can improve a diagnosis of GC pre-operatively. A prediction of GC pre-operatively may allow surgeons to be better prepared for a difficult operation.

Clinical features and outcomes of patients with severe acute pancreatitis complicated with gangrenous cholecystitis

BACKGROUND

The effects of gangrenous cholecystitis (GC) and consequent surgical interventions on the clinical outcomes and prognosis of patients with severe acute pancreatitis are not clear. The present study was to characterize the clinical outcomes of patients with severe acute pancreatitis complicated with GC.

METHODS

We retrospectively analyzed 253 consecutive patients hospitalized for acute pancreatitis in intensive care unit. Among them, 68 were diagnosed as having severe acute pancreatitis; 10 out of the 68 patients had GC. We compared these 10 patients with GC and 58 patients without GC. The indices analyzed included sepsis/septic shock, pancreatic encephalopathy, acute respiratory distress syndrome, acute renal failure, multiple organ dysfunction syndrome, and death.

RESULTS

Specific CT images of GC in patients with severe acute pancreatitis included enlarged and high-tensioned gallbladder, wall thickening, lumenal emphysema, discontinuous and/or irregular enhancement of mucosa, and pericholecystic effusion. The rates of severe sepsis/septic shock (70.0% vs 24.1%, P<0.01), pancreatic encephalopathy (50.0% vs 17.2%, P<0.05), acute respiratory distress syndrome (90.0% vs 41.4%, P<0.01), multiple organ dysfunction syndrome (70.0% vs 24.1%, P<0.01), acute renal failure (40.0% vs 27.6%, P<0.05), and death (40.0% vs 13.8%, P<0.05) were significantly higher in patients with GC than in those without GC.

CONCLUSION

CT scans can help to identify early GC in patients with severe acute pancreatitis; early diagnosis and intervention for patients with GC can reduce morbidity and mortality.

TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos)

Since its publication in 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) have been widely adopted. The validation of TG07 conducted in terms of clinical practice has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. Discussion by the Tokyo Guidelines Revision Committee concluded that acute cholecystitis should be suspected when Murphy's sign, local inflammatory findings in the gallbladder such as right upper quadrant abdominal pain and tenderness, and fever and systemic inflammatory reaction findings detected by blood tests are present but that definite diagnosis of acute cholecystitis can be made only on the basis of the imaging of ultrasonography, computed tomography or scintigraphy (HIDA scan). These proposed diagnostic criteria provided better specificity and accuracy rates than the TG07 diagnostic criteria. As for the severity assessment criteria in TG07, there is evidence that TG07 resulted in clarification of the concept of severe acute cholecystitis. Furthermore, there is evidence that severity assessment in TG07 has led to a reduction in the mean duration of hospital stay. As for the factors used to establish a moderate grade of acute cholecystitis, such as leukocytosis, ALP, old age, diabetes, being male, and delay in admission, no new strong evidence has been detected indicating that a change in the criteria used in TG07 is needed. Therefore, it was judged that the severity assessment criteria of TG07 could be applied in the updated Tokyo Guidelines (TG13) with minor changes. TG13 presents new standards for the diagnosis, severity grading and management of acute cholecystitis. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines

BACKGROUND

The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world's first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13).

METHODS AND MATERIALS

We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The "gold standard" for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis.

RESULTS

Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III).

CONCLUSION

The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.

Home treatment of patients with acute cholecystitis

BACKGROUND

Patients with acute cholecystitis are treated in Hospital. The aim of the study was to analyze the security and efficacy of treating not-operated-on patients with acute cholecystitis in Hospital in the Home (HIH).

METHODS

Prospective study from January 2010 to May 2011 including all patients diagnosed with acute cholecystitis, not operated on and without comorbidities admitted to HIH Unit from the Emergency Department Short Stay Unit and Observation Unit. Patients were treated with ertapenem for at least one week. Intravenous treatment was followed by oral therapy to complete 14 days of antibiotic treatment. Patient characteristics, clinical course, need for return to hospital during admission to HIH, and admission to hospital in the month after discharge from HIH are analyzed.

RESULTS

25 patients were included. Mean age was 59 years (34-82). Upon arrival to the Emergency Department, all patients suffered abdominal pain, 60% had fever, and 32% vomiting. 48% of patients had a leukocyte count over 13,000 cells/μl. All patients had cholelithiasis and a distended gallbladder. 56% showed thickening of the gallbladder wall. Fluid accumulation around the gallbladder was noted in 16% of the cases. Murphy's sign proved positive in 44%. All patients showed a favorable course. No patient required hospital readmission during stay in HIH or in the month after discharge. All patients expressed their satisfaction with treatment at home.

CONCLUSIONS

Patients with acute cholecystitis and without comorbidities can be safely and effectively treated in HIH after a short monitoring period in hospital.

Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis

BACKGROUND

Gangrenous cholecystitis (GC) is considered a more severe form of acute cholecystitis. The risk factors associated with this condition and its impact on morbidity and mortality compared with those of non-gangrenous acute cholecystitis (NGAC) are poorly defined and based largely on findings from older studies.

METHODS

Patients with histologically confirmed acute cholecystitis treated in specialized units in a tertiary hospital between 2005 and 2010 were identified from a prospectively maintained database. Data were reviewed retrospectively and patients with GC were compared with those with NGAC.

RESULTS

A total of 184 patients with NGAC and 106 with GC were identified. The risk factors associated with GC included older age (69 years vs. 57 years; P= 0.001), diabetes (19% vs. 10%; P= 0.049), temperature of >38 °C (36% vs. 16%; P < 0.001), tachycardia (31% vs. 15%; P= 0.002), detection of muscle rigidity on examination (27% vs. 12%; P= 0.01) and greater elevations in white cell count (WCC) (13.4 × 10⁹/l vs. 10.7 × 10⁹/l; P < 0.001), C-reactive protein (CRP) (94 mg/l vs. 17 mg/l; P= 0.001), bilirubin (19 µmol/l vs. 17 µmol/l; P= 0.029), urea (5.3 mmol/l vs. 4.7 mmol/l; P= 0.016) and creatinine (82 µmol/l vs. 74 µmol/l; P= 0.001). The time from admission to operation in days was greater in the GC group (median = 1 day, range: 0-14 days vs. median = 1 day, range: 0-10 days; P= 0.029). There was no overall difference in complication rates between the GC and NGAC groups (22% vs. 14%; P= 0.102). There was a lower incidence of common bile duct stones in the GC group (5% vs. 13%; P= 0.017). Gangrenous cholecystitis was associated with increased mortality (4% vs. 0%; P= 0.017), but this was not an independent risk factor on multivariate analysis.

CONCLUSIONS

Gangrenous cholecystitis has certain clinical features and associated laboratory findings that may help to differentiate it from NGAC. It is not associated with an overall increase in complications when treated in a specialized unit.

Prediction of patients with acute cholecystitis requiring emergent cholecystectomy: a simple score

The objective was to develop a score, to stratify patients with acute cholecystitis into high, intermediate, or low probability of gangrenous cholecystitis. The probability of gangrenous cholecystitis (score) was derived from a logistic regression of a clinical and pathological review of 245 patients undergoing urgent cholecystectomy. Sixty-eight patients had gangrenous inflammation, 132 acute, and 45 no inflammation. The score comprised of: age > 45 years (1 point), heart rate > 90 beats/min (1 point), male (2 points), Leucocytosis > 13,000/mm³ (1.5 points), and ultrasound gallbladder wall thickness > 4.5 mm (1 point). The prevalence of gangrenous cholecystitis was 13% in the low-probability (0–2 points), 33% in the intermediate-probability (2–4.5 points), and 87% in the high probability category (>4.5 points). A cutoff score of 2 identified 31 (69%) patients with no acute inflammation (PPV 90%). This scoring system can prioritize patients for emergent cholecystectomy based on their expected pathology.

Prognostic parameters for the prediction of acute gangrenous cholecystitis

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14 900/mm(3). Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.