Cholecystitis After Trauma

Surgical management of complex duodenal trauma using laterolateral duodenum enteroanastomosis: A case report

Introduction and importance

Duodenal trauma is rare, however, it has high morbidity and mortality rates. Surgical treatment modalities are employed depending on severity, ranging from simple sutures to complex pancreaticoduodenectomy cases.

Case presentation

A male patient had a circular saw accident, leading to evisceration in an extensive wound from the thoracoabdominal transition to the inguinal region, with 75% laceration of the second duodenal portion circumference, laceration in hepatic segments, section from right mesocolon to transverse colon, and multiple perforations in small bowel loops between 70 and 90 cm from the angle of Treitz. Laterolateral duodenum enteroanastomosis was performed with proximal jejunum and gastroenteroanastomosis with the distal loop of the small intestine at 90 cm from the Treitz angle, and a termino lateral enteroanastomosis between food and the biliary loop at 20 cm from the gastroenteroanastomosis.

Clinical discussion

This report presents a new surgical technique for patients with penetrating duodenal trauma associated with liver and intestinal injuries, to avoid the need for more complex procedures. In addition, it demonstrates postoperative management of complications, including confection of the enteroatmospheric fistula for feeding.

Conclusion

The technique described in this article proved to be a good option for treating these lesions, as evidenced by optimal postoperative results.

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Duodenal lesions are challenging to repair due to presentation heterogeneity.

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The use of this new technique proved to be a safe alternative.

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Despite the complex trauma, the patient evolved well.

[The intensive care gallbladder as shock organ: symptoms and therapy]

Acute acalculous cholecystitis (AAC) represents a severe disease in critically ill patients. The pathogenesis of acute necroinflammatory gallbladder disease is multifactorial and intensive care unit (ICU) patients show multiple risk factors. In addition AAC is difficult to diagnose because of the vague physical and non-specific technical findings. Only the combination of clinical and technical findings including the challenging physical examination of critically ill patients, laboratory results and ultrasound or computed tomography (CT) scan, will lead to the diagnosis. The condition of AAC has a rapid progress to gallbladder necrosis, gangrene and perforation and these complications are reflected in the high morbidity and mortality rates, therefore, therapy should be promptly initiated. If there are no clinical contraindications for an operative approach cholecystectomy is the definitive treatment and both open and laparoscopic procedures have been used. In unstable, critically ill patients percutaneous cholecystostomy should be immediately performed. In addition, transpapillary endoscopic drainage is also possible if there are contraindications for percutaneous cholecystostomy. Patients who fail to improve or deteriorate following interventional drainage should be reconsidered for cholecystectomy. Due to the fact that more than 90 % of patients treated with percutaneous cholecystostomy showed no recurrence of symptoms during a period of more than 1 year, it is still unclear if percutaneous cholecystostomy is the definitive treatment of AAC for unstable patients or if delayed cholecystectomy is still necessary.

Percutaneous cholecystostomy: the radiologist's role in treating acute cholecystitis

Acute cholecystitis is a common condition, with laparoscopic cholecystectomy considered the gold-standard for surgical management. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant. Percutaneous cholecystostomy (PC) is an image-guided intervention, used to decompress the gallbladder, reducing patient's symptoms and the systemic inflammatory response. PC has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery. This review aims to develop a broader understanding of PC, discussing its specific indications, patient management, technical factors, imaging guidance, and outcomes following the procedure.

Bedside diagnostic laparoscopy for critically ill patients: a retrospective study of 62 patients

BACKGROUND

Bedside diagnostic laparoscopy has an important role of diagnosing acute abdomen in critically ill patients hospitalized in the intensive care unit (ICU). Delayed diagnosis of intraabdominal pathology increases the morbidity and mortality rates for these patients, whose clinical signs often are absent due to analgesic medication and sedation.

METHODS

In this retrospective study performed from January 2007 to December 2009, 62 consecutive ICU patients whose blood test results showed them to be hemodynamically unstable underwent bedside diagnostic laparoscopy. The inclusion criteria specified clinically suspected acute cholecystitis, unknown sepsis, acidosis with a high level of lactate, elevated lab tests (white blood cell count, bilirubin, lactic dehydrogenase, creatine phosphokinase, gamma glutamyl transferase [γGT]), and acute anemia with suspected intraabdominal bleeding. The major contraindications to bedside diagnostic laparoscopy were coagulopathy, endocranic hypertension, and heart failure. Patients with a clear indication for an open surgical procedure were excluded from the study.

RESULTS

Of the 62 patients who underwent bedside diagnostic laparoscopy, 43 (69.3%) had positive findings and 29 (46.7%) had acute acalculous cholecystitis. The mean operation time was 38 min, and no procedure-related deaths occurred. The procedure was performed for postsurgery patients, especially after cardiac operations, and for trauma or septic patients. Respiratory and hemodynamic parameters were monitored before, during, and after the procedure.

CONCLUSIONS

As a minimally invasive procedure, bedside diagnostic laparoscopy can be performed in the ICU for hemodynamically unstable patients. It is safe procedure with high diagnostic accuracy for acute intraabdominal conditions that avoids negative laparotomies for unstable patients. The bedside diagnostic laparoscopy procedure is not performed widely, and prospective studies are needed to better evaluate outcome and advantages for critically ill patients.

Is routine ultrasound examination of the gallbladder justified in critical care patients?

Objective. We evaluated whether routine ultrasound examination may illustrate gallbladder abnormalities, including acute acalculous cholecystitis (AAC) in the intensive care unit (ICU). Patients and Methods. Ultrasound monitoring of the GB was performed by two blinded radiologists in mechanically ventilated patients irrespective of clinical and laboratory findings. We evaluated major (gallbladder wall thickening and edema, sonographic Murphy's sign, pericholecystic fluid) and minor (gallbladder distention and sludge) ultrasound criteria. Measurements and Results. We included 53 patients (42 males; mean age 57.6 ± 2.8 years; APACHE II score 21.3 ± 0.9; mean ICU stay 35.9 ± 4.8 days). Twenty-five patients (47.2%) exhibited at least one abnormal imaging finding, while only six out of them had hepatic dysfunction. No correlation existed between liver biochemistry and ultrasound results in the total population. Three male patients (5.7%), on the grounds of unexplained sepsis, were diagnosed with AAC as incited by ultrasound, and surgical intervention was lifesaving. Patients who exhibited ≥2 ultrasound findings (30.2%) were managed successfully under the guidance of evolving ultrasound, clinical, and laboratory findings. Conclusions. Ultrasound gallbladder monitoring guided lifesaving surgical treatment in 3 cases of AAC; however, its routine application is questionable and still entails high levels of clinical suspicion.

Acute acalculous cholecystitis-like phenotype in scavenger receptor A knock-out mice

BACKGROUND

Sepsis is a major health problem in the United States that affects more than three-quarters of a million people every year. Previous studies have shown that scavenger receptor A (Sra), also known as macrophage scavenger receptor 1 (Msr1), is a modifier of interleukin 10 (IL-10) expression after injection of bacterial lipopolysaccharide (LPS). Therefore, we investigated the response to sepsis in Sra knock out mice.

MATERIALS AND METHODS

C57BL/6J (B6) (n = 88) and Sra (-/-) mice (n = 88) were subjected to cecal ligation and puncture (CLP) using 18G or 16G needles, sham operation, or non-operated controls. At the end, mice were autopsied for the determination of abnormalities after the procedure. Cytokine gene expression was examined in lung and liver samples by quantitative RT-PCR (qRT-PCR), and circulating cholesterol levels were also measured.

RESULTS

Sra (-/-) mice displayed an enlargement of the gallbladder after CLP that was not detected in sham or non-operated mice or in B6 mice (wild-type) after CLP. The enlarged gallbladder resembles a condition of acute acalculous cholecystitis observed in humans. Sra (-/-) mice presented high cholesterol levels in circulation as opposed to wild type B6 mice. Moreover, Sra (-/-) mice exhibited a reduction in IL-10 mRNA levels in lungs compared to wild-type B6 mice after CLP.

CONCLUSIONS

The development of acute acalculous cholecystitis may be the combination of pre-existing conditions, such as hypercholesterolemia associated with a defect in Sra (Msr1) and a robust inflammation induced by sepsis.

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.