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Unusual cases of acute cholecystitis and cholangitis: Tokyo
Guidelines.J
Hepatobiliary Pancreat Surg.
2007;14(1):98-113.
Unusual cases
of acute cholecystitis and cholangitis include (1) pediatric biliary
tract infections, (2) geriatric biliary tract infections, (3)
acalculous cholecystitis, (4) acute and intrahepatic cholangitis
accompanying hepatolithiasis (5) acute biliary tract infection
accompanying malignant pancreatic-biliary tumor, (6) postoperative
biliary tract infection, (7) acute biliary tract infection
accompanying congenital biliary dilatation and pancreaticobiliary
maljunction, and (8) primary sclerosing cholangitis. Pediatric biliary
tract infection is characterized by great differences in causes from
those of adult acute biliary tract infection, and severe cases should
be immediately referred to a specialist pediatric surgical unit.
Because biliary tract infection in elderly patients, who often have
serious systemic conditions and complications, is likely to progress
to a serious form, early surgery or biliary drainage is necessary.
Acalculous cholangitis, which often occurs in patients with serious
concomitant conditions, such as those in intensive care units (ICUs)
and those with disturbed cardiac, pulmonary, and nephric function, has
a high mortality and poor prognosis. Cholangitis accompanying
hepatolithiasis includes recurrent pyogenic cholangitis, an epidemic
disease in Southeast Asia. Biliary tract infections, which often occur
after a biliary tract operation and treatment of the biliary tract,
may have a fatal outcome, and should be carefully observed. The causes
of acute cholangitis associated with pancreaticobiliary maljunction
differ before and after operation. Direct cholangiography is most
useful in the diagnosis of primary sclerosing cholangitis. If
cholangiography visualizes a typical bile duct, differentiation from
acute pyogenic cholangitis is easy. This article discusses the
individual characteristics, diagnostic criteria, treatment guidelines,
and prognosis of these unusual types of biliary tract infection.
Definitions,
pathophysiology, and epidemiology of acute cholangitis and
cholecystitis: Tokyo Guidelines. J
Hepatobiliary Pancreat Surg.
2007;14(1):15-26.
This article
discusses the definitions, pathophysiology, and epidemiology of acute
cholangitis and cholecystitis. Acute cholangitis and cholecystitis
mostly originate from stones in the bile ducts and gallbladder. Acute
cholecystitis also has other causes, such as ischemia; chemicals that
enter biliary secretions; motility disorders associated with drugs;
infections with microorganisms, protozoa, and parasites; collagen
disease; and allergic reactions. Acute acalculous cholecystitis is
associated with a recent operation, trauma, burns, multisystem organ
failure, and parenteral nutrition. Factors associated with the onset
of cholelithiasis include obesity, age, and drugs such as oral
contraceptives. The reported mortality of less than 10% for acute
cholecystitis gives an impression that it is not a fatal disease,
except for the elderly and/or patients with acalculous disease.
However, there are reports of high mortality for cholangitis, although
the mortality differs greatly depending on the year of the report and
the severity of the disease. Even reports published in and after the
1980s indicate high mortality, ranging from 10% to 30% in the
patients, with multiorgan failure as a major cause of death. Because
many of the reports on acute cholecystitis and cholangitis use
different standards, comparisons are difficult. Variations in
treatment and risk factors influencing the mortality rates indicate
the necessity for standardized diagnostic, treatment, and severity
assessment criteria.
Endoscopic
gallbladder drainage of patients with acute cholecystitis.
Endoscopy. 2007 Apr;39(4):304-8.
BACKGROUND AND
STUDY AIM: The standard treatment for acute cholecystitis is early
laparoscopic cholecystectomy. In cases of increased operative risk
surgery may be postponed or rejected, and instead alternative methods,
such as percutaneous or endoscopic drainage, may be attempted. This
paper is a retrospective assessment of our results with endoscopic
gallbladder drainage (EGBD) by means of endoscopic retrograde
cholangiopancreatography (ERCP). PATIENTS AND METHODS: Over a 9-year
period, data from all patients who underwent attempted EGBD, primarily
referred for diagnosis and treatment of cholestasis by ERCP, were
analyzed. EGBD was attempted in those patients who had concomitant
acute cholecystitis. RESULTS: EGBD was successful in 24 of 34 patients
with acute cholecystitis (70.6%). The success rate rose from 50%
during the first 4-year period to 89% during the subsequent 5-year
period. Of the 24 patients in whom EBGD had been successful, 21 showed
clinical improvement and 10 were finally managed nonoperatively. Of
the 21 clinically improved patients, 14 underwent elective surgery a
median of 24 days later. Of the 10 patients in whom EGBD failed nine
underwent surgery four of whom required surgery within one week.
CONCLUSION: Treatment of acute cholecystitis in patients could be done
successfully by EGBD, and in 70% of cases cholecystectomy could then
be carried out on an elective basis rather than as emergency surgery.
Some patients could be treated with EGBD alone. Future prospective
trials will clarify the role of EGBD in patients with acute
cholecystitis.
Acute
cholecystitis complicating cardiac surgery: case series involving more
than 16,000 patients.Ann
Thorac Surg. 2007 Mar;83(3):1096-101.
BACKGROUND:
Acute cholecystitis after cardiac surgery is rare but carries a high
mortality. Its management remains controversial. METHODS: We reviewed
all cases of calculous cholecystitis (CC) and acalculous cholecystitis
(ACC) encountered at our institution over the past 11 years. Data
collection included preoperative variables, details of performed
procedures, postoperative course, and outcome. RESULTS: The overall
incidence was 0.03% for CC and 0.08% for ACC (5 and 13 of 16,576
patients, respectively). Patients in the ACC group appeared to be
sicker patients whereas most patients in the CC group had an
uncomplicated recovery from cardiac surgery. The diagnosis was
straightforward with typical presentation and ultrasonographic
findings in the CC group. In the ACC group, the presentation was less
specific, and although useful as diagnostic tool, ultrasonography
findings were not as consistent as in the CC group. In the CC group, 3
patients underwent surgery, and 2 patients were treated
conservatively. One patient died of cardiac causes after uncomplicated
cholecystectomy. In the ACC group, 7 patients were treated medically
and 6 patients underwent surgery. The overall mortality was 23% (3
patients). All deaths occurred in patients treated surgically.
CONCLUSIONS: Given the low incidence of CC, we do not recommend
preoperative screening or intervention for cholelithiasis. Treatment
should be according to established guidelines. Patients with ACC,
without overt peritonitis, should initially be treated conservatively
with appropriate antibiotics. However, failure of significant
improvement within 48 hours or a worsening clinical picture should
lead to surgical intervention.
Factors effecting
the complications in the natural history of acute cholecystitis.
Hepatogastroenterology. 2001 Sep-Oct;48(41):1275-8.
BACKGROUND/AIMS:
Gangrenous cholecystitis, empyema, gallbladder perforation, and
biliary peritonitis are severe complications of acute cholecystitis
associated with increased morbidity and mortality. This study aimed to
evaluate perioperative factors associated with complications of acute
cholecystitis. METHODOLOGY: Between January 1993 and October 2000, we
performed cholecystectomy in 368 patients with acute cholecystitis.
All perioperative data were collected on age, sex, medical history,
symptoms, laboratory tests, ultrasound, operative and microbiological
findings, morbidity and mortality. RESULTS: There were 305 cases (83%)
of acute uncomplicated cholecystitis, 26 (7.1%) of gangrenous
cholecystitis, 23 (6.3%) of empyema of the gallbladder, 12 (3.3%) of
gallblader perforation, and 2 (0.5%) emphysematous cholecystitis. Risk
factors for complicated cholecystitis included male gender, advanced
age, associated diseases, temperature above 38 degrees C, and white
blood cell count on admission greater than 18,000. Laparoscopic
cholecystectomy was attempted on 36 patients (11.8%) with
uncomplicated and seven patients (11.1%) with complicated acute
cholecystitis. The conversion rate to open cholecystectomy was 19.4%
for uncomplicated cases, 28.6% for complicated cases. There were no
differences in operative complications between complicated and
uncomplicated cases, however, length of hospital stay, postoperative
morbidity and mortality were significantly higher in complicated
cases. CONCLUSIONS: Sex (male), advanced age, presence of associated
disease, high temperature (> 38 degrees C) and leukocytosis are all
remarkable risk factors inducing complications in acute cholecystitis.
Laparoscopic cholecystectomy can be performed with success in
uncomplicated cases.
Acute
cholecystitis: an evaluation of the factors that determine the start
of surgical treatment.Rev
Esp Enferm Dig. 1993 Jan;83(1):26-31.
The authors
studied 100 acute cholecystitis treated between 1984 and 1990. In
71.4% of the cases it was associated with gallstones and 28.6% were
primary acalculous cholecystitis. Two percent were postoperative. 77
patients underwent surgery. 14.3% needed an emergency operation due to
acute abdominal syndrome and sepsis. In the remaining patients, the
surgical procedure was performed days or weeks later according to the
course of the disease, the surgeons criteria, and family and social-labour
conditions. Based on these criteria, 31.7% had surgery during the
first week, 23.8% in the second and 44.5% in the third or later.
Cholecystectomy was the surgical procedure performed in 98.7% of the
cases. Morbidity rate was 11.6% and mortality 3.9%. Analysis of morpho-clinical
grades has been done in relation with the type of cholecystitis, the
clinical symptoms and the course of the disease. Finally the different
factors used to argue for an early or delayed surgical treatment are
discussed.
Acute
cholecystitis in the intensive care unit. New
Horiz. 1993;1(2):246-60.
The
development of acute cholecystitis in the ICU is now a well-recognized
complication of many acute illnesses that precipitate ICU admission
and may also result as a complication of the subsequent treatment. The
etiology of the disease remains obscure and, unlike acute
cholecystitis outside the ICU setting, most cases are acalculous and
not associated with gallstones. The disease may often go unrecognized
due to the complexity of the patient's medical and surgical problems.
Clinical examination is often unhelpful, as many patients are
receiving mechanical ventilation and have decreased mental awareness.
Biochemical markers are nonspecific and contribute to the delay in
diagnosis and treatment. Early diagnosis is essential to avoid the
high rates of associated morbidity and mortality. The diagnosis is
usually made by radiologic tests, most often by sonographic
examination of the gallbladder, which can be performed at the bedside.
However, radiologic findings may also be nonspecific. The treatment
involves gallbladder drainage by percutaneous cholecystostomy, which
is usually curative in acalculous cholecystitis. Interval
cholecystectomy is indicated for the remaining patients with
gallstone-associated cholecystitis.
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