Acute acalculous cholecystitis immediately after gastric operation: Case report and literatures review

Current status and therapeutic strategy of acute acalculous cholecystitis: Japanese nationwide survey in the era of the Tokyo guidelines

PURPOSE

This study aimed to clarify the incidence, therapeutic modality, and prognosis of acute acalculous cholecystitis and to reveal its optimal treatment strategy.

METHODS

As a project study of the Japanese Society for Abdominal Emergency Medicine, we performed a questionnaire survey of demographic data and perioperative outcomes of acute acalculous cholecystitis treated between January 2018 and December 2020 from 42 institutions.

RESULTS

In this study, 432 patients of acute acalculous cholecystitis, which accounts for 7.04% of acute cholecystitis, were collected. According to the Tokyo guidelines severity grade, 167 (38.6%), 202 (46.8%), and 63 (14.6%) cases were classified as Grade I, II, and III, respectively. A total of 11 (2.5%) patients died and myocardial infarction/congestive heart failure was the only independent risk factor for in-hospital death. Cholecystectomy, especially the laparoscopic approach, had more preferable outcomes compared to their counterparts. The Tokyo guidelines flow charts were useful for Grade I and II severity, but in the cases with Grade III, upfront cholecystectomy could be suitable in some patients.

CONCLUSIONS

The proportions of severity grade and mortality of acute acalculous cholecystitis were found to be similar to those of acute cholecystitis, and laparoscopic cholecystectomy is recommended as an effective treatment option. (UMIN000047631).

Clinical characteristics and prognosis of patients with healthcare-associated cholecystitis receiving percutaneous cholecystostomy

PURPOSE

Acute cholecystitis occurring outside the hospital setting is categorized as community-acquired cholecystitis (CAC). In contrast, it would be classified as a healthcare-associated cholecystitis (HAC) when it is associated with healthcare risk factors. This study aimed to compare the clinical characteristics of HAC to those of CAC and analyze their difference in prognosis after percutaneous cholecystostomy (PC).

METHODS

A retrospective study was conducted for patients with acute cholecystitis who underwent PC between January 1, 2017, and June 30, 2020, in our hospital. Patients with HAC and CAC were compared in terms of demographics, laboratory tests, isolated pathogens, treatment response after PC, mortality, complications, and subsequent management.

RESULTS

A total of 247 patients with a mean age of 68 years were enrolled, among whom 131 patients (53.0%) were male. Twenty patients (8.1%) had HAC, and 227 patients (91.9%) had CAC. Patients with HAC were more likely to present with the following: fever (65.0% vs 35.7%; p = 0.010), acalculous cholecystitis (50.0% vs 20.3%; p = 0.002), and a history of malignancy (50.0% vs 15.4%; p < 0.001), poorer clinical responses to PC treatment (75.0% vs 93.0%; p = 0.006), longer length of stay (14.15 days vs 7.62 days; p < 0.001), and higher all-cause mortality (30.0% vs 9.7%; p = 0.006). In addition, a relatively small number of patients with HAC underwent cholecystectomy in subsequent management (35.0% vs 69.2%; p = 0.002).

CONCLUSIONS

In conclusion, compared to patients with CAC, those with HAC had more atypical symptoms, poorer clinical response to PC, longer hospital stay, and higher all-cause mortality, which makes the acceptability of PC treatment questionable.

Acute cholecystitis after urological surgery: A report of 11 cases in our department and a review of the literature

Objective:

Postoperative acute cholecystitis (PAC) after gastrointestinal surgery is considered to be a relatively common complication. However, PAC after urological surgery is extremely rare.

Patients and methods:

We conducted a retrospective review of 2583 patients who underwent urological surgery in our department from 2006 to 2014 to identify those who developed acute cholecystitis in the postoperative period.

Results:

Of the 2583 patients, 11 (0.4%) were diagnosed with PAC. The study population consisted of 10 (91%) men and one (9%) woman. Among them, five (45%) patients had acalculous cholecystitis. The median interval between the preceding urological surgery and the onset of PAC was 16 days (range, 3–39 days). Emergent cholecystectomy and/or gallbladder drainage was performed in eight (73%) cases. Although four (36%) patients developed septic shock and were treated in the intensive care unit, cholecystitis improved in all cases. One patient died of her underlying disease (adrenal cancer) two months after PAC.

Conclusion:

Most routinely performed urological surgeries can cause PAC. The symptoms of PAC may be masked in the postoperative period. Urologists must be aware of PAC and should not hesitate to perform further inspection and consultation with a gastroenterologist in cases in which it is suspected.

Another Report of Acalculous Cholecystitis in a Greek Patient with Infectious Mononucleosis: A Matter of Luck or Genetic Predisposition?

We here report a case of a young, male patient who presented with jaundice and was diagnosed with acalculous cholecystitis during the course of a primary Epstein-Barr Virus (EBV) infection. The coexistence of cholestatic hepatitis and acalculous cholecystitis in patients with infectious mononucleosis is extremely uncommon and only few cases can be found in the literature. Moreover, almost one-fourth of the total reports of this rare entity are coming from Greece. Whether this is a result of physicians' high index of suspicion due to previous reports or a consequence of genetic predisposition is an issue that deserves further investigation in the future. More studies are required in order to clarify the pathophysiological and genetic backgrounds that connect acalculous cholecystitis and EBV infection.

Gallbladder perforation: a rare complication of postoperative chemotherapy of gastric cancer

A middle-aged man presented 1 day after being discharged from hospital with completing the first course of postoperative chemotherapy. He suffered a sudden persistent high fever and chills. It was noted that he had a history of a total gastrectomy (with D2 lymphadenectomy) 1 month ago. His admission bloods revealed total bilirubin was 142.2umol/L , indirect bilirubin of 107.6umol/L and white cell count of 20.05×10⁹/L. A color doppler ultrasound scan confirmed fluid and gas around liver and hilus lienis while the gallbladder cannot be detected. During Computed Tomography (CT) guided puncture positioning technology and setting a three-channel tube, about 400 ml of foul smell hazel turbid liquid was drained out. He was diagnosed as gallbladder perforation and he was underwent conservative treatment consist of drainage, banning diet, total parenteral nutrition and intravenous antibiotics. Then he recovered well within the subsequent 10 days and was discharged.

Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies

PURPOSE

Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database.

MATERIALS AND METHODS

This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database.

RESULTS

LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients.

CONCLUSIONS

We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.