A 72-year-old female without abdominal symptoms visited our hospital for routine follow-up while undergoing pancreatic cancer treatment (using TS-1). Her vital signs were normal, and her abdomen was ...soft and non-tender. Blood test revealed elevated C-reactive protein levels with normal white blood cell count. Computed tomography was performed for follow-up of pancreatic cancer. Contrast-enhanced computed tomography showed partial discontinuity and irregular thickness of the gallbladder wall; however, a definitive diagnosis was not obtained due to unclear imaging. Contrast-enhanced transabdominal ultrasonography revealed intraluminal membranes in the gallbladder and a perfusion defect at the bottom, indicating gangrenous cholecystitis. Surgical resection was performed, and pathological examination showed severe necrosis of the gallbladder wall, consistent with the findings of contrast-enhanced transabdominal ultrasonography.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
It is difficult to differentiate between non-complicated acute cholecystitis (NCAC) and complicated acute cholecystitis (CAC) preoperatively, which are two separate pathologies with different ...management. The aim of this study was to create an algorithm that distinguishes between CAC and NCAC using the decision tree method, which includes simple examinations. In this retrospective study, the patients were divided into 2 groups: CAC (149 patients) and NCAC (885 patients). Parameters such as patient demographic data, American Society of Anesthesiologists (ASA) score, Tokyo grade, comorbidity findings, white blood cell (WBC) count, neutrophil/lymphocyte ratio, C-reactive protein (CRP) level, albumin level, CRP/albumin ratio (CAR), and gallbladder wall thickness (GBWT) were evaluated. In this algorithm, the CRP value became a very important parameter in the distinction between NCAC and CAC. Age was an important predictive factor in patients with CRP levels >57 mg/L, and the critical value for age was 42. After the age factor, the important parameters in the decision tree were WBC and GBWT. In patients with a CRP value of ≤57 mg/L, GBWT is decisive and the critical value is 4.85 mm. Age, neutrophil/lymphocyte ratio, and WBC count were among the other important factors after GBWT. Sex, ASA score, Tokyo grade, comorbidity, CAR, and albumin value did not have an effect on the distinction between NCAC and CAC. In statistical analysis, significant differences were found groups in terms of gender (34.8% vs 51.7% male), ASA score (P < .001), Tokyo grade (P < .001), comorbidity (P < .001), albumin (4 vs 3.4 g/dL), and CAR (2.4 vs 38.4). By means of this algorithm, which includes low-cost examinations, NCAC and CAC distinction can be made easily and quickly within limited possibilities. Preoperative prediction of pathologies that are difficult to manage, such as CAC, can minimize patient morbidity and mortality.
Emphysematous cholecystitis is a potentially life-threatening variant of acute cholecystitis, characterized by the presence of gas in the gallbladder wall/lumen due to the proliferation of ...gas-producing bacteria. Symptoms include upper right quadrant pain, fever, nausea, and vomiting. Laboratory tests may show nonspecific indications of systemic infection, and radiological assessment, especially CT scanning, is crucial for diagnosis. This case underscores the significance of early diagnosis and intervention in managing emphysematous cholecystitis to prevent serious complications and reduce the higher mortality rate compared to acute cholecystitis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
ABSTRACTRim sign is assumed as an ominous sign of gangrenous cholecystitis and mandates an urgent surgery. The main mechanism by which this phenomenon arises is increased regional blood flow as a ...result of an inflammatory process. Therefore, it is expected that this finding be visualized in varieties of scans with various radiopharmaceuticals, including myocardial perfusion scan with Tc-MIBI as an extracardiac finding. Herein, we present a case of acute cholecystitis with a rim sign on preoperative myocardial perfusion SPECT using Tc-MIBI, which posed the possibility of gangrene and perforation and thus the need for urgent surgical intervention.
The patient was an 87-year-old woman diagnosed as having hepatocellular carcinoma in liver segment S6. She had undergone transcatheter arterial chemoembolization (TACE) twice and remained in a stable ...condition during and after the procedures. However, she developed epigastric pain immediately upon injection of lipiodol for the third session of TACE. The following day, abdominal CT revealed a high-density area in the gallbladder wall, suggestive of stagnation of the injected lipiodol and inflammation of the gallbladder wall. She was diagnosed as having acute cholecystitis due to embolization of the cystic artery, and open cholecystectomy was performed. Histopathological examination revealed mollification of the gall bladder wall and full-thickness necrosis, leading to the diagnosis of gangrenous cholecystitis. The patient had a satisfactory postoperative course and was discharged on day 12 after the operation.
Perforation of the gallbladder wall leads to a local perivesical abscess or progression to biliary peritonitis. The study aimed to analyse clinical, laboratory, and imaging indicators that have the ...strongest relationship with the presence of gangrenous cholecystitis and perforation of the wall and to design a predictive scoring system that highlights the risk of developing gangrenous cholecystitis with perforation. We performed a retrospective analysis of a total of 331 patients operated for five years (2016-2020) at the Department of Surgical Diseases” of Medical University - Pleven, with histologically verified chronic cholecystitis (120 patients; 36.4%), acute cholecystitis (100 patients; 30.1%), and destructive cholecystitis (111 patients; 33.5%). The statistical analysis identified nine main factors with the most substantial statistical significance in patients with gangrene and perforation of the gallbladder wall: age >65, male gender, diabetes mellitus, cardiovascular pathology, tachycardia>90 bpm, WBC>14.109, the thickness of gallbladder wall > 4 mm with pericholecystic fluid, ASAT and ALAT > 40 UI, CRP>150 ng/l. The total possible score was 11 points. The positive predictive value of the scale was 96% and identified the cases with micro-perforation and perivesical abbesses among the group with the highest total score.
The utility of the SAND balloon catheter in laparoscopic cholecystectomy for acute cholecystitis (AC) remains unclear.
A retrospective cohort study of patients who underwent emergency cholecystectomy ...at Shinshu University was performed to evaluate the efficacy of the SAND balloon catheter in cases of AC (SAND balloon utilization: Group S, n = 44; non-utilization: Group non-S, n = 47).
The duration of surgery was significantly shorter in Group S than in Group non-S (p = .031). Despite comparable incidences of blood transfusions in the two groups, intraoperative blood loss was significantly less in Group S than in Group non-S (p = .013). The incidence of postoperative intraperitoneal infection tended to be higher in Group non-S (p = .076). Within Group non-S, bile spillage during operation was found in 16 (34.0%) patients. The multivariate analysis revealed that gangrenous AC was the strongest independent risk factor for bile spillage during operation (odds ratio OR: 19.1; 95% confidence interval CI: 2.84-78.4; p = .002), followed by surgeons with ≤10 years of experience (OR: 11.3; 95% CI: 1.81-70.6; p < .010).
Implementation of the SAND balloon catheter in patients with AC is a safe and efficacious surgical option. This catheter is recommended in cases of gangrenous cholecystitis and for surgeons with limited experience.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a ...set protocol and intraoperative steps in LC for complex ACC.
Methods
All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as ‘complex ACC (CACC).’ Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien–Dindo classification.
Results
We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (
p
= 0.0059) and older (
p
= 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2–5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien–Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention.
Conclusion
The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Epigastric pain is a common complaint in patients who present to the emergency department (ED); abdominal pain is the most common chief complaint in older adult patients who request treatment by a ...provider (A. B. Friedman et al., 2022). These patients may experience atypical presentations, which can result in delayed or missed diagnosis altogether, increasing morbidity, and mortality. This is the case of an older adult man who presented with chest and epigastric pain. The clinical presentation, atypical signs, and symptoms of gangrenous gallbladder are presented herein along with the differential diagnoses and diagnostics for this patient. The care for and the "what not to miss" in the management of this patent are also examined in this article. It is imperative that ED providers diagnose gangrenous gallbladder early on, especially in the older adult population, who may present with covert signs and symptoms to prevent complications and avoid poor outcomes including death in this age group.
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