Predictive factors for the diagnosis of severe acute cholecystitis in an emergency setting

Association of biliary distention with a diagnosis of acute cholecystitis

BACKGROUND

Gallbladder distention has been described in radiology literature but its value on point-of-care ultrasound (PoCUS) performed by emergency physicians is unclear. We sought to determine the test characteristics of gallbladder distention on PoCUS for cholecystitis (acute or chronic), and secondarily whether distention was associated with an obstructing stone-in-neck (SIN), acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times.

METHODS

This was a dual-site retrospective cohort study of all Emergency Department (ED) patients that underwent diagnostic biliary PoCUS and were subsequently admitted from 11/1/2020 to 10/31/2022. Patients with pregnancy, liver failure, ascites, hepatobiliary cancer, prior cholecystectomy, or known cholecystitis were excluded. Gallbladder distention was defined as a width ≥4 cm or a length ≥10 cm. Saved ultrasound images were reviewed by three independent reviewers who obtained measurements during the review. Test characteristics, Cohen's kappa (κ), and strength of association between distention and our variables (acute cholecystitis on pathology report and SIN on PoCUS) were calculated using a Chi Square analysis, where intervention (cholecystectomy, percutaneous cholecystostomy, or intravenous antibiotics) was used as the reference standard for AC. A one-tail two sample t-test was calculated for mean operative times.

RESULTS

Of 280 admitted patients who underwent ED biliary PoCUS, 53 were excluded, and 227 were analyzed. Of the 227 patients, 113 (49.8%) had cholecystitis according to our reference standard, and 68 (30.0%) had distention on PoCUS: 32 distended by both width and length, 16 distended by width alone, and 20 distended by length alone. Agreement between investigators was substantial for width (κ 0.630) and length (κ 0.676). Distention was 85.09% (95% CI 77.20-91.07%) specific and 45.1% (95% CI 35.8-54.8%) sensitive for cholecystitis. There was an association between distention and SIN; odds ratio (OR) 2.76 (95% CI 1.54-4.97). Distention of both length and width was associated with acute over chronic cholecystitis; OR 4.32 (95% CI 1.42-13.14). Among patients with acute cholecystitis, mean operative times were 114 min in patients with distention and 89 min in patients without distention (p = 0.03).

CONCLUSION

Gallbladder distention on PoCUS was specific for cholecystitis (acute or chronic), and associated with SIN, acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times. Measurement of gallbladder dimensions as part of the assessment of cholecystitis may be advantageous.

[Cholecystectomy in acute cholecystitis-a surgical emergency or elective in the next day's program?]

BACKGROUND

The treatment of acute cholecystitis is based on the German S3 guidelines on "Prophylaxis, diagnosis and treatment of gallstones", which was updated in 2018. If the patient has no contraindications for surgery, early laparoscopic cholecystectomy is the treatment of choice.

OBJECTIVE

Current meta-analyses and studies confirm that for most patients the optimal period of time for surgical treatment is the first 24 h after hospitalization; however, there is an ongoing controversial discussion on how strictly the 24 h rule should be adhered to and under which circumstances it may be valid to deviate from it.

MATERIAL AND METHOD

A systematic analysis of the current literature and a clinical evaluation were carried out.

RESULTS

For the diagnosis of an acute cholecystitis, laparoscopic cholecystectomy should be carried out within the first 24 h after hospitalization regardless of the age and comorbidities of the patient as well as the severity of inflammation. If there is no special emergency situation, under certain circumstances surgery can be performed in the next day's program.

DISCUSSION

This recommendation for early surgery for high-risk patients has so far been controversially discussed; however, current studies confirm that the advantages of early surgery outweigh the disadvantages also for this group of patients. The surgical risk should be individually assessed and be included in the treatment decision.

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.

Accuracy of pre-operative parameters in predicting severe cholecystitis-A systematic review

INTRODUCTION

Severity of cholecystitis can be defined by the presence of histopathological changes such as gangrene, perforation, and empyema. Severe cholecystitis correlates with higher morbidity and longer hospital stay. The present review aimed to identify the predictors of severe cholecystitis.

METHODS

Electronic databases including PubMed, Scopus, and Cochrane library were searched in the period of January 1980 to March 2019. The main outcome of this review was to assess the predictability of pre-operative parameters such as Leukocytosis, fever, tachycardia, gallbladder wall edema, gallbladder distension, serum platelet count, and gallbladder mural striation. The role of patients' characteristics including age, gender, and diabetes mellitus in predicting severe cholecystitis was also assessed.

RESULTS

A total of 8823 patients were analysed. The mean age of patients was 67.14 ± 4.17. The parameters that had the highest Odds ratio in predicting severe cholecystitis were all findings on CT scanning and included attenuation of arterial phase, mural striation of the gallbladder, and decreased gallbladder wall enhancement.

CONCLUSION

We conclude that CT findings were the most significant predictors of severe cholecystitis. Patients with clinical and laboratory predictors of severe cholecystitis should be urgently evaluated with contrast CT scan to rule out any severe complications.

Gangrenous cholecystitis in male patients: A study of prevalence and predictive risk factors

Backgrounds/Aims

The prevalence and risk factors of gangrenous cholecystitis in male are unknown.

Objective

To verify the prevalence and risk factors of gangrenous cholecystitis in males.

Methods

This cross-sectional study includes 95 patients (59.5±17.1 years), with clinical and histopathological diagnosis, operated laparoscopically on 2012–2016. Eligibility was decided based on the variables of age; tachycardia (>100 bpm); leukocytosis (>10,000/mm³); Murphy's sign; gallbladder wall thickness (>4 mm); biochemical tests, morbidities (diabetes, alcoholism, smoking) and mortality. Multivariate regression, the chi-squared and Prevalent Chances Ratio (PCR) were used to define a few parameters.

Results

The prevalence of gangrenous cholecystitis in men older than 50 years was 29.3%. The risk factors for the disease were as follows: diabetes mellitus (p=0.006, RCP=4.191), leukocytosis (p=0.003), gallbladder thickness greater than 4 mm (p=0.035, RCP=3.818), which increased mortality [(p=0.04) (RCP=8.001)]. Murphy's sign showed a negative association (p=0.002, RCP=0.204). Values close to significance were observed in relation to gamma glutamyl transferase (p=0.083, RCP=3.125) and hospital stay (p=0.061, RCP=2.765).

Conclusions

Male gender, and age older than 50 years, were correlated with a high prevalence of necrosis, higher than that reported in females. The risk factors for developing necrosis are the same as those described for female patients.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Can we predict severity of acute cholecystitis at admission?

Background and Objective

Acute cholecystitis (AC) is an inflammation of the gallbladder. Tokyo Guidelines (TGs) for the diagnosis of AC classified this condition according to severity as mild, moderate and severe. Therapeutic intervention regulated according to the type of severity. This study aimed to determine laboratory parameters that predict the severity of AC at hospital admission.

Methods

One-hundred and ten patients with AC were retrospectively reviewed. These patients were treated in our department of surgery within a one-year period (2015-2016). Three patient groups were formed depending on the severity of Acute cholecystitis.

Results

The baseline mean values for white blood cell count (WBC), blood urea nitrogen (BUN), creatinine and international normalized ratio (INR) were higher in the severe patient group at a significant level compared to the mild patient group. The WBC level was also significantly higher in the moderate group than the mild group. However, none of the laboratory parameters differentiated the severe group from the moderate group.

Conclusion

Acute cholecystitis patients with high WBC, BUN, creatinine and INR levels at admission should be referred to an advanced care center for management.

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.

The utility of hepatic artery velocity in diagnosing patients with acute cholecystitis

PURPOSE

To test the diagnostic performance of elevated peak systolic hepatic arterial velocity (HAv) in the diagnosis of acute cholecystitis.

METHODS

229 patients with an ultrasound (US) performed for right upper quadrant (RUQ) pain were retrospectively reviewed. 35 had cholecystectomy within 10 days of ultrasound and were included as test subjects. 47 had normal US and serology and were included as controls. Each test patient US was reviewed for the presence of gallstones, gallbladder distention, sludge, echogenic pericholecystic fat, pericholecystic fluid, gallbladder wall thickening, gallbladder wall hyperemia, and reported sonographic Murphy sign. Demographic, clinical, and hepatic artery parameters at time of original imaging were recorded. Acute cholecystitis at pathology was the primary outcome variable.

RESULTS

21 patients had acute cholecystitis and 14 had chronic cholecystitis by pathology. For patients who went to cholecystectomy, HAv ≥100 cm/s to diagnose acute cholecystitis was more accurate (69%) than the original radiology report (63%), the presence of gallstones (51%), and sonographic Murphy sign (50%). Statistically significant predictors of acute cholecystitis included HAv ≥100 cm/s (p = 0.008), older age (p = 0.012), and elevated WBC (p = 0.002), while gallstones (p = 0.077), hepatic artery resistive index (HARI) (p = 0.199), gallbladder distension (p = 0.252), sludge (p = 0.147), echogenic fat (p = 0.184), pericholecystic fluid (p = 0.357), wall thickening (p = 0.434), hyperemia (p = 0.999), and sonographic Murphy sign (p = 0.765) were not significantly correlated with acute cholecystitis compared to chronic cholecystitis.

CONCLUSION

HAv ≥100 cm/s is a useful objective parameter that may improve the performance of US in the diagnosis of acute cholecystitis.

Evaluation of plasma microRNA-122, high-mobility group box 1 and keratin-18 concentrations to stratify acute gallstone disease: a pilot observational cohort study in an emergency general surgery unit

OBJECTIVE

To obtain pilot data to evaluate the discriminatory power of biomarkers microRNA-122 (miR-122), high-mobility group box 1 (HMGB1), full-length keratin-18 (flk-18) and caspase-cleaved keratin-18 (cck-18) in plasma to identify potential biliary complications that may require acute intervention.

DESIGN

An observational biomarker cohort pilot study.

SETTING

In a Scottish University teaching hospital for 12 months beginning on 3 September 2014.

PARTICIPANTS

Blood samples were collected from adults (≥16 years old) referred with acute biliary-type symptoms who have presented to hospital within 24 hours prior were recruited. Patients unable or refused to give informed consent or were transferred from a hospital outside the National Health Service regional trust were excluded.

PRIMARY OUTCOME MEASURES

To evaluate whether circulating miR-122, HMGB1, flk-18 and cck-18 can discriminate between people with and without gallstone disease and uncomplicated from complicated gallstone disease during the first 24 hours of hospital admission.

RESULTS

300 patients were screened of which 285 patients were included. Plasma miR-122, cck-18 and flk-18 concentrations were increased in patients with gallstones compared with those without (miR-122: median: 2.89×104 copies/mL vs 0.90×104 copies/mL (p<0.001); cck-18: 121.2 U/L vs 103.5 U/L (p=0.031); flk-18: 252.4 U/L vs 145.1 U/L (p<0.001)). Uncomplicated gallstone disease was associated with higher miR-122 and cck-18 concentrations than complicated disease (miR-122: 5.72×104 copies/mL vs 2.26×104 copies/mL (p=0.023); cck-18: 139.7 U/L vs 113.6 U/L (p=0.047)). There was no significant difference in HMGB1 concentration between patients with and without gallstones (p=0.559). Separation between groups for all biomarkers was modest.

CONCLUSION

miR-122 and keratin-18 plasma concentrations are elevated in patients with gallstones. However, this result is confounded by the association between biomarker concentrations, age and gender. In this pilot study, miR-122 and keratin-18 were not sufficiently discriminatory to be progressed as clinically useful biomarkers in this context.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos)

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1^st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression/T2 image fusion for the diagnosis of acute cholecystitis

Prompt and accurate diagnosis is critical in the treatment of acute cholecystitis. Diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression/T2 image fusion (DWIBS/T2) identifies areas with high signal intensity, corresponding to inflammation. In the present study, the records and images of patients with acute cholecystitis who underwent DWIBS/T2 between January 2013 and March 2014 were retrospectively analyzed. A total of 11 patients with acute cholecystitis were enrolled. In one patient, DWIBS/T2 identified a thickened wall and high signal intensity, with high signal intensity in the pericholecystic space that suggested localized peritonitis. Positive DWIBS/T2 results indicating acute cholecystitis were obtained in 10/11 patients, with a sensitivity of 90.9%. In addition, wall thickening and high signal intensity were absent in DWIBS/T2 images when wall thickening was not detected by computed tomography. Wall thickening and high signal intensity was attenuated when patients with acute cholecystitis were clinically treated. These data suggest that a thickened gallbladder wall and high signal intensity are indicative of acute cholecystitis and that DWIBS/T2 may be a useful technique in evaluating the severity of acute cholecystitis.

Validation of TG13 severity grading in acute cholecystitis: Japan-Taiwan collaborative study for acute cholecystitis

BACKGROUND

The collaborative multicenter retrospective study of acute cholecystitis (AC) was performed in Japan and Taiwan. The aim for this study was evaluation of the clinical value of TG13 severity grading for AC.

METHOD

The study was designed as an international multicenter retrospective study of AC from 2011 to 2013. Based on the data, we investigated the TG13 severity grading by analyzing the correlations between grade and prognosis, surgical procedures, histopathology, and organ dysfunction and prognosis.

RESULTS

An investigation revealed that 30-day overall mortality rate was 1.1% for Grade I, 0.8% for Grade II, 5.4% for Grade III. The mortality rate for Grade III was significantly higher than lower grades (P < 0.001). The greater the number of organ dysfunction, the higher the mortality rate (P < 0.001). However, the mortality rate varied depending on the number of organ dysfunction (3.1-25%). With respect to the surgical procedures, laparoscopic cholecystectomy was performed for Grade I patients (P < 0.001), and the higher the grade, the more likely open surgery would be selected (P < 0.001).

CONCLUSION

TG13 severity grading criteria for AC are providing great benefits in actual clinical settings. From this study, the position of each severity grade was obviously confirmed.

Risk factors for gallbladder contractility after cholecystolithotomy in elderly high-risk surgical patients

Objective

Cholecystolithiasis is a common disease in the elderly patient. The routine therapy is open or laparoscopic cholecystectomy. In the previous study, we designed a minimally invasive cholecystolithotomy based on percutaneous cholecystostomy combined with a choledochoscope (PCCLC) under local anesthesia.

Methods

To investigate the effect of PCCLC on the gallbladder contractility function, PCCLC and laparoscope combined with a choledochoscope were compared in this study.

Results

The preoperational age and American Society of Anesthesiologists (ASA) scores, as well as postoperational lithotrity rate and common biliary duct stone rate in the PCCLC group, were significantly higher than the choledochoscope group. However, the pre- and postoperational gallbladder ejection fraction was not significantly different. Univariable and multivariable logistic regression analyses indicated that the preoperational thickness of gallbladder wall (odds ratio [OR]: 0.540; 95% confidence interval [CI]: 0.317–0.920; P=0.023) and lithotrity (OR: 0.150; 95% CI: 0.023–0.965; P=0.046) were risk factors for postoperational gallbladder ejection fraction. The area under receiver operating characteristics curve was 0.714 (P=0.016; 95% CI: 0.553–0.854).

Conclusion

PCCLC strategy should be carried out cautiously. First, restricted by the diameter of the drainage tube, the PCCLC should be used only for small gallstones in high-risk surgical patients. Second, the usage of lithotrity should be strictly limited to avoid undermining the gallbladder contractility and increasing the risk of secondary common bile duct stones.

Contrast-enhanced ultrasonography to diagnose complicated acute cholecystitis

Gangrenous cholecystitis and perforation are severe complications of acute cholecystitis, which have a challenging preoperative diagnosis. Early identification allows better surgical management. Contrast-enhanced computed tomography (ceCT) is the current diagnostic gold standard. Contrast-enhanced ultrasonography (CEUS) is a promising tool for the diagnosis of gallbladder perforation, but data from the literature concerning efficacy are sparse. The aim of the study was to evaluate CEUS findings in pathologically proven complicated cholecystitis (gangrenous, perforated gallbladder, pericholecystic abscess). A total of 8 patients submitted to preoperative CEUS, and with subsequent proven acute complicated cholecystitis at surgical inspection and pathological analysis, were retrospectively identified. The final diagnosis was gangrenous/phlegmonous cholecystitis (n. 2), phlegmonous/ulcerative changes plus pericholecystic abscess (n. 2), perforated plus pericholecystic abscess (n. 3), or perforated plus pericholecystic biliary collection (n. 1). Conventional US findings revealed irregularly thickened gallbladder walls in all 8 patients, with vaguely defined walls in 7 patients, four of whom also had striated wall thickening. CEUS revealed irregular enhancing gallbladder walls in all patients. A distinct wall defect was seen in six patients, confirmed as gangrenous/phlegmonous cholecystitis at pathology in all six, and in four as perforation at macroscopic surgical inspection. CEUS is a non-invasive easily repeatable technique that can be performed at the bedside, and is able to accurately diagnose complicated/perforated cholecystitis. Despite the limited sample size in the present case series, CEUS appears as a promising tool for the management of patients with the clinical possibility of having an acute complicated 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.