Role of Procalcitonin in Evaluation of the Severity of Acute Cholecystitis

Neutrophil to lymphocyte ratio and serum procalcitonin level as a predictor of spontaneous ureteral stone passage: A prospective study

BACKGROUND

Ureteric stone is responsible for around 20% of urinary tract stones and among them 70% of these are located in distal portion of the ureter. Stone causing ureter obstruction produce inflammatory changes in ureteric wall and prevent spontaneous passage of stone. The objective of the study is to compare the predictive role of procalcitonin and Neutrophil-to-lymphocyte ratio (NLR) for spontaneous passage of stone.

MATERIALS AND METHODOLOGY

Total 150 participants having ureteric stone of 4-8 mm, were included in prospective observational study. The patients were followed up for 4 weeks. Spontaneous Stone Passage (SSP) was confirmed with either the patient collecting the stone during urination or by Non-Contrast CT performed at 4 weeks. Blood samples of the patients were analysed and White blood cells, sedimentation, Neutrophile to Lymphocyte (NLR), procalcitonin level compared to analyse predictors of future SSP.

RESULT

The procalcitonin levels of the Spontaneous stone passing SSP (-ve) group (209.05 ± 78.45 pg/ml) were significantly higher than the not passing the SSP (+ve) group (130.76 ± 24.18) (p < 0.001). NLR is significantly higher in the SSP -ve (3.84 ± 0.41) than the SSP +ve (2.18 ± 0.38) group (p < 0.001). In single and multivariate analysis, significant activity was found for procalcitonin in SP +ve group.

CONCLUSION

The findings of the study suggests that high level of procalcitonin, and high NLR have a negative effect on passage of stone. So early intervention can be planned to these patients to prevent complications.

The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

A case of granulocyte-colony-stimulating factor-producing gallbladder cancer with lymph node metastasis together with a literature review

The granulocyte-colony-stimulating factor (G-CSF) glycoprotein stimulates precursor cell proliferation and differentiation in the bone marrow. Various G-CSF-producing tumors have been reported; they showed early progression and an extremely poor prognosis. Here, we report a case of G-CSF-producing gallbladder cancer with lymph node metastasis. In addition, we reviewed 30 previous case reports of G-CSF-producing gallbladder cancers to elucidate the characteristics and most appropriate treatment. During a routine visit to her local doctor for monitoring of diabetes and hypertension, a 68-year-old female was found to have an elevated white-blood-cell (WBC) count and C-reactive protein (CRP) level, and a gallbladder mass. Laboratory tests revealed a high serum G-CSF level, and imaging revealed a tumor of the gallbladder with regional lymphadenopathy. We diagnosed a G-CSF-producing gallbladder cancer and performed liver resection of segment IVa/V: regional lymph node dissection with extrahepatic bile duct resection. Pathologically, the tumor was a poorly differentiated squamous cell carcinoma. G-CSF immunostaining for tumor cells was positive. She is alive without recurrence at 16 months after surgery. If a patient exhibits a gallbladder tumor, with an elevated WBC count and CRP level but no symptoms of infection, a G-CSF-producing gallbladder cancer should be suspected; radical resection should be performed immediately after diagnosis.

Value of monocyte distribution width for predicting severe cholecystitis: a retrospective cohort study

OBJECTIVES

Acute cholecystitis is a gallbladder inflammation, and the Tokyo Guidelines 2018 (TG18) can be used to predict its presence and severity with high sensitivity and specificity. However, TG18 grading require the collection of excessive parameters. Monocyte distribution width (MDW) is a parameter used to detect sepsis early. Therefore, we investigated the correlation between MDW and cholecystitis severity.

METHODS

We conducted a retrospective study of patients with cholecystitis admitted to our hospital from November 1, 2020, to August 31, 2021. The primary outcome was severe cholecystitis analyzed as a composite of intensive care unit (ICU) admission and mortality. The secondary outcomes were length of hospital stay, ICU stay, and TG18 grade.

RESULTS

A total of 331 patients with cholecystitis were enrolled in this study. The average MDWs for TG18 grades 1, 2, and 3 were 20.21 ± 3.99, 20.34 ± 3.68, and 25.77 ± 6.61, respectively. For patients with severe cholecystitis, the average MDW was 25.42 ± 6.83. Using the Youden J statistic, we set a cutoff MDW of 21.6. Multivariate logistic regression revealed that patients with an MDW≥21.6 had a higher risk of severe cholecystitis (odds ratio=4.94; 95 % CI, 1.71-14.21; p=0.003). The Cox model revealed that patients with an MDW≥21.6 were more likely to have a prolonged hospital stay.

CONCLUSIONS

MDW is a reliable indicator of severe cholecystitis and prolonged length of stay. Additional MDW testing and a complete blood count may provide simple information for predicting severe cholecystitis early.

Management of Intra-Abdominal Infections: The Role of Procalcitonin

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.

Comparison of monocyte distribution width and Procalcitonin as diagnostic markers for sepsis: Meta-analysis of diagnostic test accuracy studies

AIM

We aimed to perform a meta-analysis to find out whether PCT and MDW could be used as accurate diagnostic markers for sepsis.

METHODS

We searched PUBMED, WOS, and SCOPUS databases. Inclusion criteria were any observational or clinical trials that compared monocyte Distribution Width [MDW] with Procalcitonin [PCT] as diagnostic markers in a patient with sepsis. Case reports, editorials, conference abstracts, and animal studies were excluded. RevMan software [5.4] was used to perform the meta-analysis.

RESULTS

After the complete screening, 5 observational studies were included in the meta-analysis. The total number of patients included in the meta-analysis in the sepsis group is 565 and 781 in the control group. The pooled analysis between the sepsis group and controls showed a statistically significant association between sepsis and increased levels of MDW and PCT [MD = 3.94, 95% CI = 2.53 to 5.36, p-value < 0.00001] and [MD = 9.29, 95% CI = 0.67 to 17.91, p-value = 0.03] respectively. Moreover, the subgroup analysis showed that the p-value of MDW levels [< 0.00001] is more significant than the p-value of PCT levels = 0.03, the p-value between the two subgroups [< 0.00001]. Additionally, the overall ROC Area for MDW [0.790] > the overall ROC Area for PCT [0.760].

CONCLUSION

Our study revealed a statistically significant association between sepsis and increased MDW and PCT levels compared with controls and the overall ROC Area for MDW is higher than the overall ROC Area for PCT, indicating that the diagnostic accuracy of MDW is higher than PCT.MDW can be used as a diagnostic marker for sepsis patients in the emergency department. More multicenter studies are needed to support our findings.

Should Procalcitonin Be Included in Acute Cholecystitis Guidelines? A Systematic Review

Background and Objectives: Acute cholecystitis (AC) is a common surgical emergency. Recent evidence suggests that serum procalcitonin (PCT) is superior to leukocytosis and serum C-reactive protein in the diagnosis and severity stratification of acute infections. This review evaluates the role of PCT in AC diagnosis, severity stratification, and management. Materials and Methods: PubMed, Embase, and Scopus were searched from inception till 21 August 2022 for studies reporting the role of PCT in AC. A qualitative analysis of the existing literature was conducted. Results: Five articles, including 688 patients, were included. PCT ≤ 0.52 ng/mL had fair discriminative ability (Area under the curve (AUC) 0.721, p < 0.001) to differentiate Grade 1 from Grade 2-3 AC, and PCT > 0.8 ng/mL had good discriminatory ability to differentiate Grade 3 from 1-2 AC (AUC 0.813, p < 0.001). PCT cut-off ≥ 1.50 ng/mL predicted difficult laparoscopic cholecystectomy (sensitivity 91.3%, specificity 76.8%). The incidence of open conversion was higher with PCT ≥ 1 ng/mL (32.4% vs. 14.6%, p = 0.013). A PCT value of >0.09 ng/mL could predict major complications (defined as open conversion, mechanical ventilation, and death). Conclusions: Current evidence is plagued by the heterogeneity of small sample studies. Though PCT has some role in assessing severity and predicting difficult cholecystectomy, and postoperative complications in AC patients, more evidence is necessary to validate its use.

Clinical Value of Neutrophil CD64 Index, PCT, and CRP in Acute Pancreatitis Complicated with Abdominal Infection

Objective: To study the clinical diagnostic value of neutrophil CD64 index, PCT, and CRP in patients with acute pancreatitis with abdominal infection. Methods: A number of patients with acute pancreatitis (n = 234) participated in the study. According to the infection and health conditions, they were further divided into the non-infection group (n = 122), infection group (n = 78), and sepsis group (n = 34), and 40 healthy subjects were selected in the control group (n = 40). Expression levels of infection indexes, such as CD64 index, PCT, and CRP, were detected and compared. ROC curves were drawn to compare the efficacy of each index in the diagnosis of acute pancreatitis with abdominal infection and sepsis. The study was retrospectively registered under the China Clinical Trial Registry as a trial number ChiCTR2100054308. Results: All indexes were significantly higher in three clinical groups than the healthy control group (p < 0.05). The CD64 index, CD64 positive rate, and PCT in the infected group were significantly higher than those in the uninfected group (ALL p < 0.05). The PCT of patients infected with Gram-negative bacteria was significantly higher than that of Gram-positive bacteria-infected patients (p < 0.05). CD64 index had the best diagnostic efficiency for acute pancreatitis infection, with 82.14% sensitivity, 88.51% specificity, and 0.707 Youden indexes. The CD64 Youden index (0.780) for sepsis diagnosis was the highest, while the AUC of PCT was the highest (0.897). Conclusion: CD64 index combined with PCT has good sensitivity and specificity in diagnosing acute pancreatitis infection and sepsis.

Role of serum procalcitonin in predicting the surgical outcomes of acute calculous cholecystitis

BACKGROUND

Acute calculous cholecystitis (AC) is a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation. In the preoperative planning, the severity of AC should be considered as well as time of onset of symptoms and patient comorbidities. The aim of the present study was to investigate the role of an early PCT assessment in the emergency department in predicting the outcomes of laparoscopic surgery for AC.

STUDY DESIGN

Retrospective, mono-centric study conducted in a teaching urban hospital. We evaluated all patients admitted to our ED from January 1st, 2015, to December 31st, 2019, underwent laparoscopic cholecystectomy for AC having a preoperative PCT determination in ED.

RESULTS

A total of 2285 patients in our ED were admitted for AC. Among them 822 patients were treated surgically, 174 had a PCT determination in ED. Median age was 63 [50-74]. Overall, 33 patients (19.0%) had major complications (MC): 32 needed an open surgery conversion, and 3 among them deceased. Multivariate analysis demonstrated that PCT, WBC, BUN, and CCI were significantly associated to MC in our cohort. When we calculated the area under the ROC curve with regard to MC, a procalcitonin value > 0.09 at admission had sensitivity = 84.8% [68.1-94.9] and specificity = 51.8% [43.2-60.3] for the occurrence of MC.

CONCLUSION

Our results, suggest that a PCT > 0.09 ng/mL at ED admission, could be associated to a poor surgical outcome in patients treated by laparoscopic surgery for AC.

Diagnostic value of neutrophil CD64, procalcitonin, and interleukin-6 in sepsis: a meta-analysis

Background

The aim of the study was to conduct a meta-analysis to evaluate the accuracy of neutrophil CD64, procalcitonin (PCT), and interleukin-6 (IL-6) as markers for the diagnosis of sepsis in adult patients.

Methods

Various databases were searched to collect published studies on the diagnosis of sepsis in adult patients using neutrophil CD64, PCT, and IL-6 levels. Utilizing the Stata SE 15.0 software, forest plots and the area under the summary receiver operating characteristic curves were drawn. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve (AUC) were calculated.

Results

Fifty-four articles were included in the study. The pooled sensitivity, specificity, and AUC of neutrophil CD64 for the diagnosis of sepsis were 0.88 (95% confidence interval [CI], 0.81–0.92), 0.88 (95% CI, 0.83–0.91), and 0.94 (95% CI, 0.91–0.96), respectively. The pooled sensitivity, specificity, and AUC of PCT for the diagnosis of sepsis were 0.82 (95% CI, 0.78–0.85), 0.78 (95% CI, 0.74–0.82), and 0.87 (95% CI, 0.83–0.89), respectively. Subgroup analysis showed that the AUC for PCT diagnosis of intensive care unit (ICU) sepsis was 0.86 (95% CI, 0.83–0.89) and the AUC for PCT diagnosis of non-ICU sepsis was 0.82 (95% CI, 0.78–0.85). The pooled sensitivity, specificity, and AUC of IL-6 for the diagnosis of sepsis were 0.72 (95% CI, 0.65–0.78), 0.70 (95% CI, 0.62–0.76), and 0.77 (95% CI, 0.73–0.80), respectively.

Conclusions

Of the three biomarkers studied, neutrophil CD64 showed the highest diagnostic value for sepsis, followed by PCT, and IL-6. On the other hand, PCT showed a better diagnostic potential for the diagnosis of sepsis in patients with severe conditions compared with that in patients with non-severe conditions.

Plasma Procalcitonin Is Useful for Predicting the Severity of Acute Cholecystitis

Background

Acute cholecystitis is a common complication of cholelithiasis. Delayed diagnosis may constitute morbidity and mortality; therefore, early diagnosis and determining the severity of acute cholecystitis are crucial.

Objectives

This study aimed to determine the validity of blood procalcitonin (PCT) levels in assessing the severity of acute cholecystitis.

Methods

The Emergency Department (ED) patients diagnosed as acute cholecystitis were included in the study. Patients were allocated into three severity grades according to the Tokyo Guidelines 2013. PCT level was measured after the clinical and radiological diagnosis of acute cholecystitis in the ED.

Results

Ninety-five patients diagnosed with acute cholecystitis, among them 48 of were male. Forty patients (42.1%) were allocated to grade 1, 19 (20%) to grade 2, and 36 (37.9%) to grade 3. The median values of PCT were 0.104 ng/ml, 0.353 ng/ml, and 1.466 ng/ml for grade 1, 2, and 3 patients, respectively (p < 0.001).

Conclusion

Blood procalcitonin levels can be used to determine the severity of acute cholecystitis effectively.

Can serum procalcitonin levels be useful in predicting spontaneous ureteral stone passage?

Background

Medical expulsive therapy (MET) is recommended for ureteral stones when there is no indication for interventional treatment. Spontaneous passage (SP) may not always be perceived in patients undergoing MET. We aimed to demonstrate the effects of inflammatory factors on spontaneous ureteral stone passage in patients undergoing MET.

Methods

Our study was conducted between August and November, 2016, in healthy volunteers and patients with a single distal ureteral stone between 5 and 10 mm in diameter and no indications for interventional therapy. Blood and urine samples from all patients and healthy volunteers were tested. The patients were followed up every 2 weeks for 1 month unless emergency situations appeared. Patients with stone-free status at follow-up were concluded to have achieved complete stone passage [SP(+)], and failure [SP(−)] was concluded if the patient had not passed the stone by the end of the study. Blood samples of the patients and the control group were analyzed, recording WBC (white blood cell), CRP (c-reactive protein), SED (sedimentation), MPV (mean platelet volume), NLR (neutrophil-to-lymphocyte ratio), and serum procalcitonin levels. Abnormalities in urine samples were recorded. All patients received diclofenac sodium 75 mg/day, tamsulosin 0.4 mg/day, and at least 3 l/day fluid intake. Patients were followed for a month with kidney, ureter, bladder (KUB) plain films, ultrasonography (USG), and unenhanced abdominal CT scans while undergoing MET. Comparative statistical analyses were performed between the SP(+) and SP(−) groups.

Results

The procalcitonin levels of the SP(−) group were significantly higher (207 ± 145.1 pg/ml) than in the SP(+) group (132.7 ± 28.1 pg/ml) (p = 0.000). The leucocyturia rate of the SP(−) group was significantly higher than in the SP(+) group (p = 0.004). Based on the ROC curve analysis, 160 pg/ml (86.7% sensitivity, 70.8% specificity, p < 0.001; AUC: 0.788 95% CI (0.658–0.917) was identified as the optimal cut-off value for procalcitonin. In logistic regression analysis, a significant efficacy of procalcitonin and leucocyturia was observed in the univariate analysis on spontaneous passage. In the multivariate analysis, significant independent activity was observed with procalcitonin. (p < 0.05).

Conclusion

Our findings suggest that high procalcitonin levels and the presence of leucocyturia have a strong negative effect on SP of ureteral stones between 5 and 10 mm in diameter. This relationship can be explained by stone impaction, possibly caused by increased mucosal inflammation.

Validity of the Glasgow prognostic score and modified systemic inflamma-tion score in predicting complicated cholecystitis

BACKGROUND

Complicated cholecystitis (CC) is the severe form of acute cholecystitis (AC). Clinical, radiological, inflammatory, or biochemical parameters are used to predict presence of CC. We aimed to evaluate the Glasgow prognostic (GPS) and modified systemic inflammation scores (mSIS) that are used to predict presence of CC.

METHODS

We retrospectively analyzed data from patients who underwent AC surgery from January 2014 to August 2019. Collected information included age, gender, length of stay (LOS), pathology [as CC or uncomplicated (UCC)], albumin, C-reactive protein (CRP), white blood cells (WBC), and neutrophils (NEU) results. The lymphocyte-to-monocyte ratio (LMR) was calculated. The GPS was calculated using CRP and albumin levels, and mSIS was calculated using LMR and albumin levels, and it was scored from 0 to 2.

RESULTS

Among the 593 hospitalized patients, 217 patients underwent AC surgery and were included in the study. Among them, 40.1 % of the patients had CC, 53.4 % were male, and the mean age was 51.76 ± 13.8 years. LOS was significantly longer for CC compared to UCC (p =0.018). Four patients died from CC (1.8 %). The mean CRP, WBC, and NEU levels were not different CC compared to UCC (p =0.821, p =0.84, and p =0.196, respectively). The cut-off values for CC were 103.54 mg/L, 15.18 ×10⁶/μL, and 11.79 ×10³/μL, respectively. GPS and mSIS were significantly higher in CC compared to UCC (p =0.008, p =0.022, respectively).

CONCLUSION

CRP, WBC, and NEU could be used to predict presence of CC. The combination of CRP or LMR with albumin could be a positive but weak predictor of CC, and it is quick, easy to use, and reliable. HIPPOKRATIA 2020, 24(1): 15-20.

Utility of leucocytes, inflammatory markers and pancreatic enzymes as indicators of gangrenous cholecystitis

BACKGROUND

Acute cholecystitis is an emergency condition. If not promptly diagnosed and properly managed, the complication of gangrenous cholecystitis may develop, which may be a life-threatening complication.

OBJECTIVES

The study aims to examine various characteristics and physiological parameters in patients diagnosed with acute cholecystitis to evaluate if significant predictive factors exist for the differential diagnosis of gangrenous cholecystitis.

MATERIALS AND METHODS

This was a retrospective study included patients with acute cholecystitis diagnosis, who presented to 'blinded for peer review' from 1 January 2010 to 1 January 2017. Parameters evaluated included liver function tests, complete cell count, C reactive protein, erythrocyte sedimentation rate (ESR), amylase and lipase levels, as well as medical history, and presenting clinical signs. Cases were divided according to whether or not there was a histopathological diagnosis of gangrenous cholecystitis.

RESULTS

A total of 186 (54.5%) female and 155 (45.5%) male cases were examined. Patients with gangrenous cholecystitis tended to be male, showed a significantly higher white cell count, higher neutrophil percentage, lower lymphocyte percentage and higher ESR compared with patients without gangrenous cholecystitis. However, serum amylase and lipase demonstrated no differential diagnostic utility CONCLUSION: Male patients with a high ESR level, high total leucocyte count with a relative high proportion of neutrophils and a low proportion of lymphocytes were found to be at increased risk of the presence of gangrenous cholecystitis.

Role of procalcitonin as a predictor in difficult laparoscopic cholecystectomy for acute cholecystitis case: A retrospective study based on the TG18 criteria

Difficult laparoscopic cholecystectomy (DLC) is difficult to precisely predict before operation. This observational cohort study aimed to evaluate the predictive value of procalcitonin (PCT) for DLC in patients with acute cholecystitis (AC). A total of 115 patients were included in the study from January 2017 to April 2018. Multiple logistic regression and receiver-operating characteristic (ROC) were performed to evaluate the predictive value of PCT levels in DLC. Patients with DLC had significantly higher Tokyo Guidelines 2018 (TG18) grade (P = 0.002) and levels of C-reactive protein (CRP) (P = 0.007) and PCT (P < 0.001). The cut-off value of PCT for predicting DLC was 1.50 ng/ml. The sensitivity and specificity were 91.3% (95% CI 78.3–97.1) and 76.8% (95% CI 64.8–85.8), respectively. The area under ROC curve was 92.7% (95% CI 88.2–97.3, P < 0.001). Our results suggested that PCT was a good predictor for DLC in the AC patients, but further research is necessary. Monitoring of PCT trends in AC patients may be useful for preoperative risk assessment.

Does surgical difficulty relate to severity of acute cholecystitis? Validation of the parkland grading scale based on intraoperative findings

BACKGROUND

The Parkland grading scale (PGS) was assessed to validate its correlation to severity of acute cholecystitis (AC).

METHODS

This study investigated the correlation between the PGS and Tokyo guidelines (TG) using multinomial logistic regression analysis in 177 patients with AC.

RESULTS

High PGS grades were related to higher C-reactive protein (p < 0.001) and frequent gangrenous cholecystitis (p < 0.001). The PGS and TG grades correlated with statistical significance (p < 0.001). Patients with PGS Grade 4 had a higher risk of moderate AC than those with Grade 3 (odds ratio: 4.4; 95% confidence interval [CI]: 1.2-15.6; p = 0.019). The PGS showed good predictive power for moderate or severe AC (area under the curve: 0.771; 95% CI: 0.700-0.842; p = 0.031).

CONCLUSION

The PGS is helpful to discriminate severity of AC. Patients with PGS Grade 4 or 5 have a high risk of moderate or severe AC.

Relationship between serum Pentraxin 3 and pro-adrenomedullin levels with acute cholecystitis

OBJECTIVES

The perforation of the gallbladder (GP) is one of the most significant complications of acute cholecystitis. A biochemical marker indicating the GP has not been determined fully to date. Pentraxin 3 and pro-adrenomedullin (Pro-ADM) proteins are novel acute phase reactants. We aimed to investigate the relationship between serum Pentraxin 3 and Pro-ADM and the GP in patients with acute cholecystitis.

METHODS

This prospective cross-sectional study was conducted on patients with acute cholecystitis in a tertiary care emergency department during the six-month period. The acute cholecystitis patients were divided into two groups as with GP, and without GP. Additionally, patients with GP were evaluated according to pericholecystic fluid and gallbladder wall thickness. Serum levels of pro-ADM and pentraxin 3, WBC, CRP and sedimentation rate were measured in all patients.

RESULTS

A total of 60 patients with acute cholecystitis were included in the study. Pro-ADM and pentraxin 3 levels were significantly higher in patients with GP and the with pericholecystic free fluid (p < 0.0001). There was no significant relationship between serum pentraxin 3 and pro-ADM with gallbladder wall thickness (p > 0.05) According to the ROC analysis, serum Pentraxin 3 levels of ≥4.9 ng/mL could predict GP with a sensitivity of 75% and a specificity of 85% and serum pro-ADM levels of ≥97 nmol/L with sensitivity and specificity of 100% and 95%.

CONCLUSION

Our study results reveal that serum Pentraxin 3 and pro-ADM may be novel biochemical parameters in the detection of GP in acute cholecystitis cases.

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.

Sepsis and Septic Shock: Current Treatment Strategies and New Approaches

Sepsis is a complex condition characterized by the simultaneous activation of inflammation and coagulation in response to microbial insult. These events manifest as systemic inflammatory response syndrome or sepsis symptoms through the release of proinflammatory cytokines, procoagulants, and adhesion molecules from immune cells and/or damaged endothelium. Today, sepsis is a severe multisystem disease with difficult treatments for its manifestations and high mortality rates. In the last two decades in particular, many studies have been conducted on sepsis that cause shock, multiorgan dysfunction, and organ failure by especially leading to hemodynamic changes. In sepsis, increasing antibiotic resistance and medicine-resistant hemodynamic changes have resulted in further research on new treatment modalities in addition to classical treatments. In the last decade, the sepsis physiopathology has been elucidated. Various therapeutic agents have been used in addition to antibiotherapy, but no satisfactory results have been obtained. This review summarizes the sepsis pathophysiology, current treatment protocols, and new approaches.