Risk assessment scales and predictors for simple versus severe cholecystitis in performing laparoscopic cholecystectomy

Pericholecystic Fat Stranding as a Predictive Factor of Length of Stays of Patients with Acute Cholecystitis: A Novel Scoring Model

Background: The 2018 Tokyo Guidelines (TG18) are used to classify the severity of acute cholecystitis (AC) but insufficient to predict the length of hospital stay (LOS). Methods: For patients with AC, clinical factors and computed tomography features, including our proposed grading system of pericholecystic fat stranding were used for predicting an LOS of ≥7 days in the logistic regression models. Results: Our multivariable model showed age ≥ 65 years (OR: 2.56, p < 0.001), C-reactive protein (CRP) ≥ 2 mg/dL (OR: 1.97, p = 0.013), gamma-glutamyltransferase levels (OR: 2.460, p = 0.001), TG18 grade (OR: 2.89 per grade, p < 0.001), and moderate to severe pericholecystic fat stranding (OR: 2.14, p = 0.012) exhibited prolonged LOS ≥ 7 days. Conclusions: We developed a scoring model, including TG18 grades (score of 1-3 per grade), our grading system of fat stranding (score of 1), CRP (score of 1), and gamma-glutamyltransferase (score of 1), and a cutoff of >3 had highest diagnostic performance.

Multidetector Computed Tomography (MDCT) Findings of Complications of Acute Cholecystitis. A Pictorial Essay

Acute cholecystitis stands out as one of the most common surgical pathologies that should always be considered in a right-upper abdominal pain emergency. For this, the importance of a correct diagnosis is well described. However, it has been demonstrated that the simple combination of clinical (pain, Murphy’s sign) and laboratory (leukocytosis) parameters alone does not provide for ruling in or ruling out the diagnosis of this condition, unless accompanied by a radiological exam. For a long time, and still today, ultrasonography (US) is by far the first-to-proceed radiologic exam to perform, thanks to its rapidity and very high sensibility and specificity for the diagnosis of simple acute cholecystitis. However, acute cholecystitis can undergo some complications that US struggles to find. In addition to that, studies suggest that multidetector computed tomography (MDCT) is superior in showing complicated forms of cholecystitis in relation to sensibility and specificity and for its capability of reformatting multiplanar (MPR) reconstructions that give a more detailed view of complications. They have shown to be useful for a precise evaluation of vascular complications, the anatomy of the biliary tree, and the extension of inflammation to surrounding structures (i.e., colitis). Therefore, based also on our experience, in patients with atypical presentation, or in cases with high suspicion for a complicated form, a MDCT abdomen scan is performed. In this review, the principal findings are listed and described to create a CT classification of acute complications based on anatomical and topographic criteria.

Complications of cholecystitis: a comprehensive contemporary imaging review

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

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.

Usefulness of the Geriatric Nutritional Risk Index to predict the severity of cholecystitis among older patients in the emergency department

AIM

We sought to investigate whether the Geriatric Nutritional Risk Index is associated with systemic organ dysfunction among older patients who present with cholecystitis to the emergency department.

METHODS

This was an observational retrospective study among consecutive older patients with cholecystitis in the emergency department from 2012 to 2018. We collected baseline characteristics and laboratory data, and re-categorized the Geriatric Nutritional Risk Index into three risk groups. We carried out univariate and multivariate analyses to identify factors associated with systemic organ dysfunction. Logistic regression was used for statistical analysis.

RESULTS

A total of 303 patients were included in this study. The median age of participants was 74 years (interquartile range 68-79 years). The overall proportion of systemic organ dysfunction was 26.4%. The Geriatric Nutritional Risk Index was stratified as: ≥98 (n = 183, systemic organ dysfunction 15.3%), 87 to <98 (n = 90, systemic organ dysfunction 38.9%) and <87 (n = 30, systemic organ dysfunction 56.7%). Multivariate analysis using a logistic regression model showed that age, respiratory rate, temperature, geriatric nutritional risk index and quick Sepsis-related Organ Failure Assessment score in the emergency department were independently associated with systemic organ dysfunction in patients with cholecystitis.

CONCLUSIONS

The Geriatric Nutritional Risk Index was recognized as an independent factor associated with systemic organ dysfunction in older patients in the emergency department who presented with cholecystitis. This index might be helpful in screening patient risk and deciding whether to carry out further tests. Geriatr Gerontol Int 2020; 20: 455-460.

Frequency-selective non-linear blending for the computed tomography diagnosis of acute gangrenous cholecystitis: Pilot retrospective evaluation

Purpose

To compare the diagnostic performance of frequency-selective non-linear blending and conventional linear blending contrast-enhanced CT for the diagnosis of acute (AC) and gangrenous (GC) cholecystitis.

Materials and methods

Following local ethics committee approval for retrospective data analysis, a database search derived 39 patients (26 men, mean age 67.8 ± 14.6 years) with clinical signs of acute cholecystitis, contrast enhanced CT (CECT) evaluation, cholecystectomy, and pathological examination of the resected specimen. The interval between CECT and surgery was 4.7 ± 4.1 days. Pathological gross examination was used to categorize the cases into AC and GC. Subsequently, two radiologists categorized the CECT studies in a blinded and independent fashion into AC and GC, during two different reading sessions using linear blending and frequency-selective non-linear blending CECT.

Results

Histologic analysis diagnosed 31/39 (79.4%) cases of GC and 8/39 (20.6%) cases of AC. Image interpretation of linear blending CECT resulted in classification of 7/39 (17.9%) patients as GC and 32/39 (82.1%) as AC, whereas image interpretation of frequency-selective non-linear blending CECT resulted in classification of 29/39 (74.3%) patients as GC and 10/39 (25.7%) as AC. Sensitivity/specificity/PPV/NPV for detection of GC were 22.6%/100%/100%/25% with linear blending CECT and 80.6%/50%/86.2%/40% with frequency-selective non-linear blending CECT, respectively. Based on the histopathologic diagnosis frequency-selective non-linear blending had a significant improvement (p > 0.0001) in the diagnostic accuracy of gangrenous cholecystitis compared with linear blending.

Conclusion

Frequency-selective non-linear blending post-processing increases the diagnostic accuracy of gangrenous cholecystitis owing to improved visualization of absence of focal enhancement and mural ulcerations.