Gangrenous cholecystitis: Analysis of imaging findings in histopathologically confirmed cases

Purpose:

To study the imaging findings in gangrenous acute cholecystitis.

Materials and Methods:

Retrospective analysis of imaging findings in 31 histopathologically confirmed cases of gangrenous cholecystitis was done. The following imaging findings were analyzed: wall thickness, gallbladder distension, intraluminal membranes, mural striation, edema, wall enhancement, gallstones, gas, pericholecystic fluid, stranding, hemorrhage, hyperaemia in adjacent liver, mucosal/wall irregularity, complications.

Statistical Analysis:

Appropriate statistical tests were used using SPSS.22.0 software. The two proportions were compared using Chi-square or Fisher exact test and two means were compared using student t test.

Results:

Mean gallbladder wall thickening was 6 ± 1.93 mm. Gallstones, mural edema, mural striation, pericholecystic fluid, intraluminal membranes, gas were seen in 30, 27, 18, 20, 14 and 3 cases respectively. The mean short-axis distension of gallbladder lumen was 4.24 ± 0.91 cm. Gallbladder wall enhancement was studied in only 10 cases. Complete absence of enhancement was seen in 1, focal decreased enhancement in 8 cases. Mucosal/wall irregularity was seen in 28 cases. 74.2% cases had ≥4 cm gallbladder distension. Intraluminal membranes were present in 14 cases with mean short-axis distension of 4.6 cm and absent in 17 (P = 0.041), in 11 cases with mural striation (P = 0.036). Mean wall thickening was 6.69mm in patients with intraluminal membranes and 5.46 mm with absence of membranes (P = .078).

Conclusion:

Presence of more than one of these findings - gallbladder distension (short axis diameter of ≥4 cm), intraluminal membranes, mural striation, absent or decreased enhancement of gallbladder wall suggest high probability of gangrenous change in acute cholecystitis.

Diagnosis and surgical management of congenital intestinal malrotation presenting with midgut volvulus in an adult: high index of suspicion (case report)

Congenital intestinal malrotation is a gastrointestinal anomaly whose most serious complication is midgut volvulus. More commonly, it presents as an incidental finding at laparotomy, or as a finding on diagnostic imaging (Ultrasound, CT, Upper GI contrast study). Most patients are diagnosed in childhood. Laparoscopic Ladd's procedure is an accepted alternative to Laparotomy in children but has not been well-studied in adult. We present the case of this unexpected finding in a patient 38 years old, during emergency laparotomy for mechanical intestinal obstruction. Intra-operative findings included intestinal malrotation with small bowel volvulus. The terminal ilea and cecum were gangrenous on the basis of ischemic necrosis. A limited right hemycolectomy and primary end-to- end anastomosis was performed.

Sonography of gangrenous cholecystitis

Gangrenous cholecystitis is an acute surgical emergency, which requires early cholecystectomy. Differentiation of patients with gangrenous cholecystitis from those with non-gangrenous cholecystitis can be difficult, both clinically and with imaging. Careful attention to the following sonographic signs suggests the presence of gangrenous cholecystitis decreased focal wall perfusion on Color Doppler, irregular gall bladder mucosal outline, gall bladder wall thickening with signs of de-lamination, gas within the gall bladder, absence of calculi, and large peri-cholecystic collections. Both sonogram with color flow imaging and contrast-enhanced Computed tomography are complementary investigations to establish this important diagnosis in critically ill patients.

Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study

Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.

Perforated Gangrenous Gallbladder in an Asymptomatic Patient

Acute cholecystitis or inflammation of the gallbladder is a common cause of hospitalizations. A percentage of those patients will progress to gangrenous cholecystitis and perforation. This medical emergency can lead to peritonitis, which has increased morbidity and mortality. The first-line modality for the diagnosis of acute cholecystitis is an ultrasound, but if it is inconclusive, then a computed tomography (CT) scan may be beneficial. Gangrenous cholecystitis and perforation have been reported in asymptomatic diabetic patients secondary to diabetic neuropathy and/or gallbladder ischemia leading to nerve denervation. Yet, here we present the case of an asymptomatic non-diabetic patient with gangrenous gallbladder perforation that was treated with antibiotics and drain placements. Diagnosis and treatment involve the collaboration between primary care, interventional, and diagnostic services to appropriately manage these patients. This case demonstrates that clinicians should have a low threshold to conduct CT scan of the abdomen, especially when there is a sudden resolution of pain.

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.

Risk Factors for Gangrenous Cholecystitis and the Outcomes of Early Cholecystectomy: A Retrospective Study of a Single-Center City General Hospital

Gangrenous cholecystitis (GC) is classified as moderate acute cholecystitis according to the Tokyo Guidelines from 2018 (TG18). We evaluated the risk factors for GC and the outcomes of early cholecystectomy. A total of 136 patients who underwent emergency cholecystectomy for acute cholecystitis were retrospectively analyzed; 58 of these patients (42.6%) were diagnosed with GC (GC group) based on our retrospective pathologic diagnosis. We comparatively evaluated the patient backgrounds and surgical outcomes between the GC group and non-GC group. The GC group was significantly older and included more hypertensive patients than the non-GC group. The GC group was prescribed more antibiotics as initial treatment than the non-GC group, and they had more days between onset and surgery. The preoperative white blood cell count and C-reactive protein values were significantly higher in the GC group than in the non-GC group, and these values were predictive factors for GC. Cholecystectomy required a longer operation time and caused greater blood loss in the GC group. The GC group also had longer hospitalization times than the non-GC group; however, no significant differences were observed in terms of postoperative complications. In conclusion, gangrenous changes should be assessed when diagnosing cholecystitis, and appropriate treatment, such as surgery or drainage, should be undertaken.

Strangulated Bochdalek Hernia in Adults: Timely Recognition and Surgical Intervention Can Prevent a Lethal Outcome

Bochdalek hernias are rare diaphragmatic hernias most commonly seen in pediatric populations. Adults with this condition may be asymptomatic or present with gastrointestinal symptoms such as abdominal pain, pressure, choking, or dysphagia. Computed tomography imaging is a gold standard in diagnosing the condition. The definitive treatment is surgery, recommended and encouraged for asymptomatic patients as well to reduce the risk of future complications. Whilst the approach to surgical management differs on a case-by-case basis, the main goal is to reduce the herniating organ and repair the defect. It is important to note that in severe cases, intestinal obstruction and strangulation may occur. We present a unique case of this very phenomenon in a patient diagnosed and treated as a case of strangulated Bochdalek hernia. We aim to highlight the importance of diagnosing this condition as clinical symptoms may be non-specific, and rapid surgical intervention is necessary.

Discordance in Appendicitis Grading and the Association with Outcomes: A Post-Hoc Analysis of an EAST Multicenter Study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) appendicitis severity grading criteria use independent subscales for radiologists (Rad), surgeons (Surg), and pathologists (Path). We reviewed the EAST Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database to determine rates of discordance and clinical consequences of inaccuracy.

MATERIALS AND METHODS

A confusion matrix was constructed for pairs among Rad, Surg, and Path. Accuracy was reported using chronologically latest diagnosis as gold standard. "Concordance" (C) was achieved when both agreed on the severity grade and "Discordance"(D) when they disagreed. A composite endpoint("COMP"= 30-d incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED[Emergency Department] visit, hospital readmission, and mortality) was compared between C versus D groups via χ² test with Bonferroni correction to define statistical significance(P = 0.05/9 = 0.005).

RESULTS

For each pair and diagnosis, subjects were categorized as C or D and compared for the incidence of COMP. Incidence of COMP for Surg and/or Path in C versus D: 16% versus. 26% (p = 0.006, NS by Bonferroni) for acute (A), 39% versus 33% (p = 0.39) for gangrenous (G), and 48% versus 37% (p = 0.035, NS by Bonferroni) for perforated (P). For Rad and/or Path in C versus. D: 17% versus 42% (p < 0.001) for A, 27% versus 31% (p = 0.95) for G, and 56% versus 48% (p = 0.48) for P. For C versus D: 17% versus 40% (p < 0.001) for A, 36% versus 26% (p = 0.43) for G, and 51% versus 39% (p = 0.29) for P.

CONCLUSIONS

In appendicitis treated by appendectomy, surgeons are most accurate at diagnosing acute appendicitis and least accurate at diagnosing gangrenous. Radiologists are less accurate for all categories. When the surgeon is wrong, clinical outcomes are not significantly worse. However, when the radiologist is wrong about acute appendicitis, patients have worse clinical outcomes.

Pre-operative predictive factors for gangrenous cholecystitis at an Australian quaternary cardiothoracic centre

INTRODUCTION

The aim of this study was to determine associations between pre-operative factors and gangrenous cholecystitis. Gangrenous cholecystitis represents a severe spectrum of cholecystitis and is associated with an increased risk of complications. Early recognition and diagnosis of gangrenous cholecystitis can optimize prioritization for surgery and improve outcomes.

METHODS

A retrospective case-control study was undertaken. Patient demographics, medical comorbidities, pre-operative biochemical and ultrasound findings as well as post-operative outcomes were assessed. Four hundred and fourteen patients who underwent an emergency cholecystectomy between 2018 and 2020 were reviewed.

RESULTS

One hundred and nine (26%) patients who underwent emergency cholecystectomy during this 3-year period had gangrenous cholecystitis. These patients were older (median age 65 versus 45, P < 0.001) and more likely to be male (58.7% versus 32.5%, P < 0.001). Patients with coronary disease (OR 2.55, P < 0.001), hypertension (OR 2.25, P = 0.001), or arrhythmias (OR 3.64, P = 0.001) were two-to-three times more likely to have gangrenous cholecystitis. Patients with renal disease (OR 1.92, P = 0.004) or using antiplatelet medication (OR 2.27, P = 0.003) were twice as likely to have gangrenous cholecystitis. Patients who had gangrenous cholecystitis presented with a higher white cell count (median 13 x 10⁹ /L versus 8 x 10⁹ /L, P < 0.001) and a higher C-reactive protein (median 196 versus 18 mg/L, P < 0.001). Patients with gangrenous cholecystitis had poorer post-operative outcomes.

CONCLUSION

We verified predictive factors from existing literature and identified a number of novel pre-operative predictive factors for gangrenous cholecystitis which could help with development of a scoring system for clinical use.