Advanced gallbladder inflammation is a risk factor for gallbladder perforation in patients with acute cholecystitis

Gallbladder perforation: Diagnostic accuracy of new CT difficulty score in predicting complicated laparoscopic cholecystectomy

PURPOSE

To formulate and evaluate the diagnostic performance and utility of a new CT difficulty score in predicting difficult laparoscopic surgery in cases of gallbladder (GB) perforation.

METHODS

This prospective single centre study included a total of 48 diagnosed cases of GB perforation on CT between December 2021 and June 2023, out of which 24 patients were operated. A new 6-point CT difficulty scoring system was devised to predict difficult laparoscopic approach, based on patterns of inflammation around the perforated GB that were found to be surgically relevant. The pre-operative imaging findings on CT were studied in detail and correlation coefficients of various imaging findings were calculated to predict difficult surgery.

RESULTS

On CECT, the type of perforation, according to the revised Niemeier's classification could be exactly delineated in all 48 patients. A CT difficulty score of ≥ 3 was found to a good predictor difficult laparoscopic approach, with statistical significance (p = 0.001), sensitivity of 94.44%, specificity of 83.33%, PPV of 94.44% and NPV of 83.33%. Inflammatory changes around duodenum showed maximum correlation coefficient of 0.744 (p = 0.0001), around colon showed a correlation coefficient of 0.657 (p = 0.0005), and in the omentum had a correlation coefficient of 0.5 (p = 0.013)). Inter-observer agreement was also calculated for various findings and it was found to have moderate to strong agreement (κ value 0.5-1.0).

CONCLUSION

The CT difficulty scoring system can be an effective tool in predicting difficult laparoscopic surgery in cases of GB perforation in an emergency setting which can help in decision making and improved patient outcome.

A Case Report of Sepsis Secondary to Perforated Cholecystitis in the Presence of Severe Aortic Stenosis: Diagnosis and Management

Gallbladder perforation is a rare complication of acute cholecystitis that is associated with significant morbidity and mortality. Many cases of gallbladder perforation are not diagnosed until surgery, as the physical symptoms closely mimic acute cholecystitis. Gallbladder perforation is most common among older males with associated comorbidities, and preoperative assessment of comorbidities, particularly cardiac, is critical to determine the appropriate clinical course. We report a case of a 77-year-old male who presented initially with low blood pressure and right upper quadrant pain (RUQ) after not feeling well for five days. CT of the abdomen/pelvis with IV contrast demonstrated acute perforated cholecystitis, and general surgery was consulted for a cholecystectomy. Due to the patient's past medical history of severe aortic stenosis (AS), cholecystectomy was deferred and a cholecystostomy tube was placed by interventional radiology. This report aims to provide an example of a case of perforated cholecystitis with sepsis and how it can be diagnosed and managed non-surgically in the presence of pre-existing severe AS.

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Peritonitis by perforation of the gall bladder of typhoid origin in children

Peritonitis by perforation of the gall bladder of typhic origin is a rare condition. In Côte d'Ivoire, no studies to our knowledge have addressed the vesicular complications of typhoid fever in children. The aim of this work was to describe the epidemic-clinical, therapeutic and evolutionary aspects of the perforation of the gall bladder of typhic origin in subjects under 15 years of age. In 6 years, five children showed a vesicular perforation of typhic origin or 9.4% of peritonites of typhic origin. They were 5 boys with an average age of 07.4 years 5-11 years. The children were from low socioeconomic backgrounds. No history was noted. Clinical examination revealed peritoneal syndrome. X-ray of the abdomen without preparation carried out in all children had objectified a diffuse greyness. Leucocytosis was present in all cases. Treatment in all children initially consisted of resuscitation and antibiotic therapy with the 3^rd generation cephalosporin and an imidazole. Surgical exploration revealed gangrene and perforated gallbladder without damage to other organs or the presence of stones. A cholecystectomy was performed. The following procedures were simple in 4 patients. A patient died of sepsis following postoperative peritonitis by biliary fistula. Perforation of the gall bladder of typhic origin is rare in children. It is usually discovered at the stage of peritonitis. The treatment combines antibiotic therapy and cholecystectomy. Systematic screening should reduce the progression to this complication.

Delayed laparoscopic cholecystectomy for a patient with coronavirus disease 2019 who developed gangrenous cholecystitis: a case report

Background

Gangrenous cholecystitis has a high risk of perforation and sepsis; therefore, cholecystectomy in the early stage of the disease is recommended. However, during the novel coronavirus disease 2019 (COVID-19) pandemic, the management of emergent surgeries changed to avoid contagion exposure among medical workers and poor postoperative outcomes.

Case presentation

A 56-year-old man presented to our hospital with abdominal pain. Computed tomography revealed intraluminal membranes, an irregular or absent wall, and an abscess of the gallbladder, indicating acute gangrenous cholecystitis. Early laparoscopic cholecystectomy seemed to be indicated; however, a COVID-19 antigen test was positive despite no obvious pneumonia on chest computed tomography and no symptoms. After discussion among the multidisciplinary team, antibiotic therapy was started and percutaneous transhepatic gallbladder drainage (PTGBD) was planned for the following day because the patient’s vital signs were stable and his abdominal pain was localized. Fortunately, the antibiotic therapy was very effective, and PTGBD was not needed. The cholecystitis improved and the patient was discharged from the hospital on day 10. One month later, laparoscopic delayed cholecystectomy was performed after confirming a negative COVID-19 polymerase chain reaction test result. The postoperative course was uneventful, and the patient was discharged on postoperative day 2 in satisfactory condition.

Conclusion

We have reported a case of acute gangrenous cholecystitis in a patient with asymptomatic COVID-19 disease. This report can help to determine treatment strategies for patients with gangrenous cholecystitis during future pandemics.

[Creatine phosphokinase as a predictor of acute destructive cholecystitis]

OBJECTIVE

To analyze creatine phosphokinase as a predictor of destructive cholecystitis.

MATERIAL AND METHODS

We analyzed 105 patients with various clinical variants of acute calculous cholecystitis (catarrhal, phlegmonous, gangrenous), and comparable age, gender and comorbidities. The study included patients with gallstone disease and gallbladder inflammation aged 30-7 years who underwent laparoscopic cholecystectomy, open cholecystectomy, cholecystectomy through mini-laparotomy. We excluded patients with gallstone disease complicated by mechanical jaundice aged under 30 years and over 70 years old. Control group consisted of 35 patients with exacerbation of chronic calculous cholecystitis. Creatinine phosphokinase (CPK) was analyzed at admission by standard kinetic colorimetric method in all patients with suspected acute cholecystitis. Statistical analysis of data was carried out using the SPSS Statistics 7.0 software in compliance with the principles of statistical analysis adopted for research in biology and medicine.

RESULTS

CPK level was 257.7±27.9 U/L (p<0.05) in patients with acute calculous cholecystitis that is 3.5 times higher than in the control group. We found an increase of concentration of this enzyme depending on severity of gallbladder wall destruction.

CONCLUSION

Analysis of serum creatine phosphokinase can be included in the algorithm of preoperative examination to study the prospects of this approach for predicting severity of acute cholecystitis.

Value of nonenhanced CT combined with laboratory examinations in the diagnosis of acute suppurative cholecystitis treated with percutaneous cholecystostomy: a retrospective study

PURPOSES

In this study, we aimed to identify the distribution of presenting laboratory and nonenhanced computed tomography (CT) imaging features within 48 h before percutaneous cholecystostomy (PC) and create a model to appropriately guide the diagnosis of acute suppurative cholecystitis (ASC).

METHODS

The study population included 204 acute cholecystitis patients who underwent PC. Based on the timing of the last laboratory and CT examinations before PC, the patients were divided into two groups: within 48 h before PC (Group 1, n = 138) and over 48 h before PC (Group 2, n = 63). The clinical features of the ASC patients in the two groups were compared. A multivariable model for the diagnosis of ASC in the patients in Group 1 was developed.

RESULTS

Thirty-nine patients in Group 1 had ASC (28.3%). Gallbladder stones, common bile duct stones, gallbladder wall thickness > 2.85 mm, and neutrophil granulocytes > 82.55% were confirmed to be independent risk factors for ASC. The receiver operating characteristic curve of the recurrence prediction model verified its accuracy (area under the curve: 0.803). Compared with the ASC patients in Group 2, the ASC patients in Group 1 had a higher proportion of pericholecystic exudation or fluid (P = 0.013) and thicker gallbladder walls (P = 0.033).

CONCLUSIONS

Using nonenhanced CT imaging features and cutoffs for neutrophil granulocytes, we were able to identify a simple algorithm to discriminate ASC. The degree of local inflammation of the gallbladder in ASC patients progressively increases over time, and these changes can be observed on nonenhanced CT images. However, the symptoms of abdominal pain are of little help in estimating the disease duration in elderly patients.

Current management of incidental gallbladder cancer: A review

Early-stage gallbladder cancer (GBC) is mostly discovered incidentally by the pathologist after cholecystectomy for a presumed benign disease. It is the most common malignancy of the biliary tract with a variable incidence rate all over the World. The majority of patients with GBC remain asymptomatic for a long time and diagnosis is usually late when the disease is at an advanced stage. Radical surgery consisting in resection of the gallbladder liver bed and regional lymph nodes seems to be the best treatment option for incidental GBC. However, recurrence rates after salvage surgery are still high and the addition of neoadjuvant/adjuvant chemotherapy may improve outcomes. The aim of the present review is to evaluate current literature for advances in management of incidental GBC, with particular focus on staging techniques and surgical options.

Access to Surgery and Quality of Care for Acute Cholecystitis During the COVID-19 Pandemic in 2020 and 2021 - an Analysis of 12,545 Patients from a German-Wide Hospital Network

PURPOSE

To determine effects on admission, treatment, and outcome for acute cholecystitis during the course of the COVID-19 pandemic in 2020 and 2021.

METHODS

Retrospective analysis of claims data from 74 German hospitals. Study periods were defined from March 5, 2020 (start of first wave) to June 20, 2021 (end of third wave) and compared to corresponding control periods (March 2018 to February 2020). All in-patients with acute cholecystitis were included. Distribution of cases, type of surgery, comorbidities, surgical outcome, and length of stay of all cases with acute cholecystitis and cholecystectomy were compared. In addition, we analyzed the type of treatment (non-surgical, cholecystostomy, or cholecystectomy) for all cases with main diagnosis of acute cholecystitis.

RESULTS

We could not demonstrate differences in daily admissions over the course of the pandemic (11.2-12.7 patients vs. 11.9-12.6 patients for control periods). Proportion of patients with non-surgical treatment was low and not increased (11.7-17.3% vs. 14.5-18.4%). Cholecystostomy was rare throughout all periods (0-0.5% of all patients). We did not observe an increase in open surgery (proportion of open cholecystectomies 3.4-5.5%). Mortality was generally low (1.5-1.9%) with no differences between periods. Median length of stay was 4 days throughout all periods.

CONCLUSION

The numerous restrictions during the COVID-19 pandemic did not result in an increase of admissions or surgery for acute cholecystitis. Laparoscopic cholecystectomy has been safely applied during the pandemic. Our results may assure the ability to maintain high quality of surgical care even in times of disruptions to the health care system.

Perforated gallbladder in a parastomal hernia

We present an 87-year-old woman who presented to the emergency department with a 7-day history of severe abdominal pain at her ileostomy parastomal hernia site. Prior to presentation, her general practitioner had started her on a reducing steroid dose for suspected Crohn's disease exacerbation. On examination, she had a distended abdomen with localised guarding and tenderness over her hernia site. A CT scan demonstrated an incarcerated perforated gallbladder within her parastomal hernia. Successful surgical management was performed involving an enterotomy, refashioning her ileostomy and an open cholecystectomy. The patient recovered well with a short postoperative stay. This report is intended as a guide for clinicians in the differential diagnoses for acute abdominal pain and an unusual presentation of a gallbladder perforation.

Concealed gallbladder perforation: a rare case report

Acute acalculous cholecystitis remains an elusive clinical diagnosis possibly due to complex clinical setting in which this entity develops, lack of large prospective controlled trials that evaluate various diagnostic modalities, thus dependence on a small database for clinical decision making. Concealed gallbladder perforation is rare. Herein, we report an 82-year-old female who presented with a right upper quadrant pain and features of local peritonitis. Abdominal ultrasound was suggestive of cholecystitis while computed tomography (CT) scan reported a perforated gallbladder with pericholecystic fluid collection. The patient underwent successful cholecystectomy; and intra-operatively, similar findings as those reported on imaging were seen. Unfortunately, she succumbed shortly post-operatively due to pulmonary embolism. Our report highlights the importance CT scan in patients with vague abdominal symptoms followed by sudden resolution. It also reminds the importance of considering the diagnosis of concealed gallbladder perforation as a differential in patients with peritonitis, as it may be missed by routine radiological investigations.

Occult Perforated Gangrenous Gallbladder Found on Magnetic Resonance Cholangiopancreatography

Acute gangrenous cholecystitis is a life-threatening disease that is most often diagnosed intraoperatively and can be missed on mildly symptomatic patients without the proper imaging modality. We present a case of a 69-year-old male with a history of hypertension, hyperlipidemia, and type 2 diabetes, and a recent right pontine infarct that arrived with 3 out of 10 right-sided abdominal pain. His liver ultrasound and computed tomography (CT) with contrast demonstrated acute cholecystitis. He was initially worked up conservatively and was scheduled for an elective cholecystectomy per surgery recommendation. However erring on the side of caution, the medical team had ordered a magnetic resonance cholangiopancreatography (MRCP), which demonstrated perforated gangrenous cholecystitis. Of note, the imaging modalities were ordered within a 24-hour window. The patient's antibiotics were promptly broadened, and he was emergently sent to the operating room. Moving forward, we will identify atypical clinical presentations of gangrenous cholecystitis and consider ordering an MRCP when clinical suspicion remains high and initial imaging is inconclusive. Perforated gangrenous cholecystitis is a severe disease and can cause rapid demise if not identified and treated early.

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.

Uncommon but valuable for diagnosis: Green deposits on peritoneal fluid cytospins

When ascites fluids are observed under the microscope, unshaped greenish deposits should not be considered as artifacts but should rather prompt to bile leakage assessment.

Postoperative Outcomes after Index vs Interval Cholecystectomy for Perforated Cholecystitis

BACKGROUND

Gallbladder perforation is a known morbid sequela of acute cholecystitis, yet evidence for its optimal management remains conflicting. This study compares outcomes in patients with perforated cholecystitis who underwent cholecystectomy at the time of index hospital admission with those in patients who underwent interval cholecystectomy.

STUDY DESIGN

A retrospective analysis was conducted of 654 patients from the American College of Surgeons NSQIP database who underwent cholecystectomy for perforated cholecystitis (2006-2018). Primary outcomes were 30-day postoperative major and minor morbidity, 30-day mortality, and need for prolonged hospitalization. Patient and procedure characteristics and outcomes were compared using Mann-Whitney rank sum test for continuous variables and Pearson chi-square tests for categorical variables. A subset analysis was conducted of patients matched on propensity for undergoing interval cholecystectomy.

RESULTS

The 30-day postoperative mortality rate of matched cohort patients undergoing index cholecystectomy was 7% vs 0% of patients undergoing interval cholecystectomy (p = 0.01). The 30-day minor morbidity rates were 2% for index and 8% for interval patients (p = 0.06), and the major morbidity rates were 33% for index and 14% for interval patients (p = 0.003). Of the index patients, 27% required prolonged hospitalization compared with 6% of interval patients (p < 0.001). Results showed similar trends in the unmatched analysis.

CONCLUSIONS

Patients who underwent index cholecystectomy had significantly longer postoperative hospitalizations and higher 30-day postoperative major morbidity and mortality. There were no differences in 30-day minor morbidity. Selected patients with perforated cholecystitis can benefit from operative management on an interval, rather than urgent, basis.

An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis

PURPOSE

The Tokyo Guidelines 2018 (TG18) were developed to aid diagnosis and treatment for acute cholecystitis. The benefits of being treated in an acute general surgical unit (AGSU) include earlier diagnosis and treatment. This study aims to define the usefulness of TG18 before and after the introduction of AGSU.

METHODOLOGY

Patients who underwent cholecystectomy at Northern Health were audited retrospectively and assessed for TG18 diagnostic criteria and outcomes between 1 February 2012 and 1 February 2014 (one-year pre- and post-AGSU).

RESULTS

Five hundred and eighty-seven patients underwent emergency cholecystectomy with 203 (34.6%) patients having a suspected diagnosis, and 234 (39.9%) patients with a definitive diagnosis of acute cholecystitis using TG18 diagnostic criteria. After the introduction of AGSU, time from imaging to operation improved from 2.5 to 1.7 days (p = 0.012). There were more operations occurring during in-hours following AGSU implementation (75.8% vs. 62.7%, p < 0.001). Maximum pre-operative CRP of >26.6 mg/L had a higher likelihood of Clavien-Dindo complication grade 3 or 4 (OR 3.86, 95%CI 1.18-12.63, p = 0.027) compared with TG18 definitive diagnosis criteria (OR 1.50, 95%CI 0.46-4.91, p = 0.501). Surprisingly, there was a trend towards higher complications and readmissions for patients operated within 24 h, although this trend was not significant.

CONCLUSION

Patients with suspected acute cholecystitis should be stratified clinically and with CRP in an AGSU with TG18 adding little value in a busy metropolitan unit.

Systematic review of management of incidental gallbladder cancer after cholecystectomy

BACKGROUND

Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer.

METHODS

A systematic PubMed search of the English literature to May 2018 was conducted.

RESULTS

The search identified 12 systematic reviews and meta-analyses, in addition to several consensus reports, multi-institutional series and national audits. Some 0·25-0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one-third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5-year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross-sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET-avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port-site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused.

CONCLUSION

Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.

Gallbladder Perforation Secondary to Enteric Fever: An Interesting Case of Acute Abdomen

Enteric fever is a common infectious disease, especially in countries with poor sanitation and in the tropics. It is caused mainly by Salmonella typhi and accounts for nearly 27 million cases worldwide and 200,000 deaths annually. Enteric fever involves the reticuloendothelial system such as bone marrow, spleen, and liver. As it mostly involves the Peyer’s patches of the terminal ileum, enteric perforation occurs commonly. However, gallbladder perforation can also occur, though not very often. Ultrasound as well as computerized tomography (CT) abdomen and pelvis lack specificity for detecting gallbladder perforations in enteric fever. Diagnosis is usually confirmed intraoperatively when the gallbladder is visualized and perforation is seen. Gallbladder perforation is usually seen in acute cholecystitis when the gallbladder becomes necrotic and gangrenous. In acalculous cholecystitis, perforation is rare. Enteric fever is one of the rarest causes of acalculous cholecystitis, leading to perforation. Here, we present the case of a 20-year-old man who presented with fever for 10 days along with loose stools, vomiting, and acute abdomen. Labs showed leukopenia, positive Typhidot test but X-ray erect abdomen and ultrasound abdomen and pelvis were nonspecific. Only after resuscitation and exploration of the abdomen was it found that the gallbladder had multiple perforations. The patient was improved after eight days of postoperative intravenous antibiotics. This is a unique and rare presentation of such a common infectious disease.