Clinical and therapeutic features of acute cholecystitis in diabetic patients

Predictors of failure of conservative management of cholecystitis: a systematic review of the literature

OBJECTIVES

While emergency cholecystectomy is the preferred treatment for acute cholecystitis, conservative management can be used as a bridge to definitive surgical management in situations where emergency surgical services are limited. The objective of this systematic review is to identify factors associated with conservative management failure as defined as either failed resolution of symptoms on initial presentation, or the recurrence of symptoms whilst awaiting an elective cholecystectomy. This study aims to allow clinicians to make evidence-based recommendations for conservative versus operative management.

METHODS

A systematic review of the Medline database was conducted in May 2022 to identify studies analysing the success of non-operative management of acute cholecystitis. Two independent reviewers selected studies based on predefined criteria, and the risk of bias was evaluated. Out of the initial 1344 studies retrieved, 12 studies met the inclusion criteria.

RESULTS

Factors significantly associated with persistence of symptoms in at least one study on multivariable analysis included diabetes mellitus, age >70, tachycardia, elevated temperature, elevated white cell count >15 000/uL and a distended gallbladder >5 cm. Factors significantly associated with recurrence of symptoms included Age <40 or >80, male sex, acute cholecystitis grade 2 or 3, elevated creatinine, serum albumin <4 g/dL, thickened gallbladder wall >5 mm.

CONCLUSION

Several factors have been identified which may facilitate future evidence-based recommendations for tailored management strategies for patients with acute cholecystitis.

The surgical management of a diabetic patient with gallbladder duplication complicated by acute cholecystitis: Case report

BACKGROUND

Duplication of the gallbladder is a rare occurrence and seldom detected before surgery but can complicate the procedure, potentially leading to a higher likelihood of converting to open surgery and encountering complications. Symptoms, when present, typically relate to gallstone disease and cholecystitis. We report a unique case of a diabetic patient with duplicate gallbladder complicated by acute cholecystitis, which was effectively treated through laparoscopic cholecystectomy.

PRESENTATION OF CASE

A 51-year-old man with well-managed diabetes presented with right upper quadrant pain worsened by fatty meals. Initially diagnosed with acute acalculous cholecystitis, he was treated conservatively with antibiotics and pain relief. Recurrent symptoms led to cholecystostomy tube insertion, offering temporary relief. Subsequent imaging identified a double gallbladder with inflammatory changes, confirmed by magnetic resonance cholangiopancreatography. Elective laparoscopic cholecystectomy was performed, revealing an inflamed double gallbladder with a unique arterial supply. Histopathology showed inflammation without malignancy, and the procedure was complication-free.

DISCUSSION

Reporting this case of gallbladder duplication in a diabetic patient suffering from acute cholecystitis is important due to its rarity and surgical management challenges it presents. This case offers valuable insights into handling complex biliary anatomies, highlights the necessity for customized surgical techniques and thorough perioperative care, and enriches the medical literature by adding knowledge about uncommon surgical situations.

CONCLUSION

The case presented highlights the successful surgical management of acute cholecystitis in a diabetic patient with gallbladder duplication. Despite the anatomical complexity, laparoscopic techniques proved effective in achieving successful surgical outcomes with minimal invasiveness and reduced postoperative complications.

Developing a Simple Score for Diagnosis of Acute Cholecystitis at the Emergency Department

We aim to develop a diagnostic score for acute cholecystitis that integrates symptoms, physical examinations, and laboratory data to help clinicians for timely detection and early treatment of this disease. We retrospectively collected data from our database from 2010 to 2020. Patients with acute abdominal pain who underwent an ultrasound or computed tomography (CT) scan at the emergency department (ED) were included. Cases were identified by pathological, CT, or ultrasound reports. Non-cases were those who did not fulfill any of these criteria. Multivariable regression analysis was conducted to identify predictors of acute cholecystitis. The model included 244 patients suspected of acute cholecystitis. Eighty-six patients (35.2%) were acute cholecystitis confirmed cases. Five final predictors remained within the reduced logistic model: age < 60, nausea and/or vomiting, right upper quadrant pain, positive Murphy’s sign, and AST ≥ two times upper limit of normal. A practical score diagnostic performance was AuROC 0.74 (95% CI, 0.67−0.81). Patients were categorized with a high probability of acute cholecystitis at score points of 9−12 with a positive likelihood ratio of 3.79 (95% CI, 1.68−8.94). ED Chole Score from these five predictors may aid in diagnosing acute cholecystitis at ED. Patients with an ED Chole Score >8 should be further investigated.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.