Acute Cholecystitis

Acute abdomen in pregnancy remains one of the most challenging diagnostic and therapeutic dilemmas today. The incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies. Despite advancements in medical technology, preoperative diagnosis of acute abdominal conditions is still inaccurate. Laboratory parameters are not specific and often altered as a physiologic consequence of pregnancy. Use of laparoscopic procedures as diagnostic tools makes diagnosis of such conditions earlier, more accurate, and safer. Appendicitis is the most common cause of the acute abdomen during pregnancy, occurring with a usual frequency of 1 in 500-2000 pregnancies, which amounts to 25% of operative indications for non-obstetric surgery during pregnancy. Surgical treatment is indicated in most cases, as in nonpregnant women. Laparoscopic procedures in the treatment of acute abdomen in pregnancy proved safe and accurate, and in selected groups of patients are becoming the procedures of choice with a perspective for the widening of such indications with more frequent use and subsequent optimal results. Despite these advances, laparotomy still remains the procedure of choice in complicated and uncertain cases. #

Results: Of a total of 106 patients, positive bile cultures were positive in 49.1% and blood cultures were studied in 19% of patients. Most isolates were: Escherichia coli (51.42%), Klebsiella pneumoniae (17%) and other Gram-positive organisms.

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy is still inevitable in certain cases. Knowledge of the rate and impact of the underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decided to review the rate and causes of conversion from laparoscopic to open cholecystectomy. METHOD: This study included all laparoscopic cholecystectomies due to gallstone disease undertaken from May 1999 to June 2010. The exclusion criteria were malignancy and/or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rate of conversion to open cholecystectomy, the underlying reasons for conversion, and postoperative complications were also analyzed. RESULTS: Of 5382 patients for whom LC was attempted, 5164 were included this study. The overall rate of conversion to open cholecystectomy was 3.16% (163 patients). There were 84 male and 79 female patients; the mean age was 52.04 years (range: 26-85). The conversion rates in male and female patients were 5.6% and 2.2%, respectively (p,0.001). The most common reasons for conversion were severe adhesions caused by tissue inflammation (97 patients) and fibrosis of Calot's triangle (12 patients). The overall postoperative morbidity rate was found to be 16.3% in patients who were converted to open surgery. CONCLUSION: Male gender was found to be the only statistically significant risk factor for conversion in our series. LC can be safely performed with a conversion rate of less than 5% in all patient groups.

Acute abdomen in pregnancy remains one of the most challenging diagnostic and therapeutic dilemmas today. The incidence of acute
abdomen during pregnancy is 1 in 500–635 pregnancies. Despite advancements in medical technology, preoperative diagnosis of acute
abdominal conditions is still inaccurate. Laboratory parameters are not specific and often altered as a physiologic consequence of pregnancy.
Use of laparoscopic procedures as diagnostic tools makes diagnosis of such conditions earlier, more accurate, and safer. Appendicitis is the
most common cause of the acute abdomen during pregnancy, occurring with a usual frequency of 1 in 500–2000 pregnancies, which amounts
to 25% of operative indications for non-obstetric surgery during pregnancy. Surgical treatment is indicated in most cases, as in nonpregnant
women. Laparoscopic procedures in the treatment of acute abdomen in pregnancy proved safe and accurate, and in selected groups of patients
are becoming the procedures of choice with a perspective for the widening of such indications with more frequent use and subsequent optimal
results. Despite these advances, laparotomy still remains the procedure of choice in complicated and uncertain cases.

Background: The third most common healthcare-associated infection is surgical site infection (SSI), accounting for 14%-16% of infections. These SSIs are associated with high morbidity, numerous deaths, and greater costs. Methods: A prospective study was conducted to assess the incidence of SSI in a single university hospital in Croatia. We used the Hospital in Europe Link for Infection Control through Surveillance (HELICS) protocol for surveillance. The SSIs were classified using the standard definition of the National Nosocomial Infections Surveillance (NNIS) system. Results: The overall incidence of SSI was 1.44%. The incidence of infection in the open cholecystectomy group was 6.06%, whereas in the laparoscopic group, it was only 0.60%. The incidence density of in-hospital SSIs per 1,000 post-operative days was 5.76. Patients who underwent a laparoscopic cholecystectomy were significantly younger (53.65-14.65 vs. 64.42-14.17 years; p < 0.001), spent roughly a third as many days in the hospital (2.40-1.72 vs. 8.13-4.78; p < 0.001), and had significantly shorter operations by nearly 26 min (60.34-28.34 vs. 85.80-37.17 min; p < 0.001). Procedures that started as laparoscopic cholecystectomies and were converted to open procedures (n = 28) were reviewed separately. The incidence of SSI in this group was 17.9%. The majority of procedures (71.4%) were elective, and the operating time was significantly longer than in other two groups (109.64-85.36 min). Conclusion: The HELICS protocol has a good concept in monitoring SSI, but in case of cholecystectomy, additional factors such as antibiotic appropriateness, gallbladder entry, empyema of the gallbladder, and obstructive jaundice must be considered.

Background: Acute cholecystitis remains to be a frequent presentation in emergency rooms worldwide. Role of ultrasound in evaluation of acute cholecystitis is well established however, Computed Tomography (CT) is still under evaluated as a diagnostic modality for detection of acute cholecystitis. In this work we describe frequencies of various CT signs in pathologically proven cases of cholecystitis. Methods: Retrospective review of CT images of 120 patients with cholecystitis for identifying signs of cholecystitis and their relative frequencies. Results: Pericholecystic inflammatory changes with or without fluid collection was the most common CT sign followed in order by; gall bladder distention, wall thickening, mucosal enhancement, visualization of calculi, tensile fundus sign and reactive hepatic hyperemia. Conclusion: An understanding of CT signs in diagnosis of cholecystitis will help improve the diagnostic confidence as well as ensure prompt diagnosis of cholecystitis.

In adults presenting to the emergency depart-ment with biliary colic, is treatment with non-steroid anti-in-flammatory  drugs  (NSAIDs)  safer  and  more  effective  thantreatment with other analgesics? The aim of this study was toanswer this clinical question by means of a systematic reviewand meta-analysis of randomized controlled trials (RCT).METHODS:  A  systematic  search  for  RCT  was  performed  inMedline,  Central,  ClinicalTrials.gov,  Lilacs,  Teseo,  andIME.  A  manual  search  was  carried  out  in  the  references  ofretrieved  articles  and  through  contact  with  the  authors  ofthe RCT.All RCT comparing NSAIDs with any other active interven-tion  in  adults  diagnosed  with  uncomplicated  biliary  colicwere included. Outcome  measures  consisted  of  rescue  analgesia,  the  rapi-dity  of  analgesic  effect,  progression  to  acute  cholecystitis,and adverse effects. The RevMan program was used with afixed  effects  model.  The  results  were  expressed  as  odds  ra-tios (OR) with 95% confidence intervals (CI). Heterogeneitywas analyzed with the chi-squared test with a statistical sig-nificance level of p 0.10.RESULTS: Seven RCT were selected, with 349 patients. Com-parison between NSAIDs and all the other analgesics showeda  benefit  in  favor  of  NSAIDs  with  a  lower  need  for  rescueanalgesia (OR = 0.32; 95% CI, 0.16-0.61) and less progressionto acute cholecystitis (OR = 0.19; 95% CI, 0.08-0.44).CONCLUSION: NSAIDs are the analgesics of choice in uncom-plicated  biliary  colic  since  these  drugs  are  more  effectivethan  other  analgesics  and  can  improve  prognosis,  limitingprogression of colic to acute cholecystitis.

Acute abdomen in pregnancy remains one of the most challenging diagnostic and therapeutic dilemmas today. The incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies. Despite advancements in medical technology, preoperative diagnosis of acute abdominal conditions is still inaccurate. Laboratory parameters are not specific and often altered as a physiologic consequence of pregnancy. Use of laparoscopic procedures as diagnostic tools makes diagnosis of such conditions earlier, more accurate, and safer. Appendicitis is the most common cause of the acute abdomen during pregnancy, occurring with a usual frequency of 1 in 500-2000 pregnancies, which amounts to 25% of operative indications for non-obstetric surgery during pregnancy. Surgical treatment is indicated in most cases, as in nonpregnant women. Laparoscopic procedures in the treatment of acute abdomen in pregnancy proved safe and accurate, and in selected groups of patients are becoming the procedures of choice with a perspective for the widening of such indications with more frequent use and subsequent optimal results. Despite these advances, laparotomy still remains the procedure of choice in complicated and uncertain cases.

Introduction: Acute lithiasic cholecystitis is one of the most common gallbladder pathologies. Conservative treatment can hardly be considered as a definitive treatment. The objective of this study is to determine the factors associated with the lack of response of such management in patients with acute cholecystitis with more than 72 hours of disease evolution. Material and methods: An observational, analytical and retrospective case-control study was carried out at the Cayetano Heredia National Hospital. The cases were patients who needed emergency surgery after the start of conservative treatment; and the controls those who had a good response to this treatment. The factors associated with the failure of conservative management were analyzed; and then, through a logistic regression analysis, identify the best predictive model for this poor response was identified. Results: A total of 136 patients were included, being the cases 44. The factors that had a greater degree of association with the lack of response to conservative management were advanced age (OR=2.34 CI=1.05-5.28), thickened gallbladder wall (OR=7.38 CI=3.22-16.96), gallbladder distention (OR=6.38 CI=2.56-15.92), persistent fever (OR=3.55 CI=1.57-8.04), leukocytosis at admission (OR=2.20, CI=1.04-4.64) and at 48 hours (OR=2.73 CI=1.26-5.94), tachycardia at admission (OR=3.11 CI=1.29-7.48) and obesity (OR=2.45 CI=1.08-5.60). A predictive model was developed, which predicts 96.78% failure to conservative management. Conclusions: There are several factors associated with the failure in the conservative management of acute cholecystitis with more than 72 hours of disease evolution. Considering these factors might allow early identification of patients who have a high probability of failure to such treatment.

Acute abdominal pain is a common symptom and often inconsequential. It can represent a wide spectrum of conditions from benign to surgical emergencies. The association of two diseases as a cause of acute abdominal pain is uncommon. It may cause a delay in the diagnosis. Here we are reporting an unusual coexistence of herpes zoster and acute cholecystitis in a previously healthy 55-year-old female patient.

The most common casues of acute abdomen during pregnancy are acute appendicitis followed by acute
cholecystitis. The case presented is a 33-year-old patient in 16 weeks’ in vitro fertilization and embryo transfer pregnacy who developed acute cholecystitis. Previously there were two unsuccessful cycles, one complicated with ovarian hyperstimulation syndrome. Due to clinical deterioration during intravenous antibiotic therapy laparoscopic cheolecystecomy was performed and acute cholecystitis found. The postoperative course was uneventful. During the first 24 h tocolysis with intravenous fenoterol in addition to peroral atenolol 2 × 50 mg was administered. Postoperative course was uneventuful with further normal pregnancy. Elective cesarean section was made in term pregnancy (39 weeks) with singleton with Apgar 10/10. Current guidelines do not recommend prophylactic tocolysis in pregnant population with acute abdomen but there is no mention of the IVF-ET subpopulation of patients. Also, there are no guidelines for thromboprophylaxis in such patients with
increased risk of thromboembolic accidents. To our knowledge this is the first case report of a laparoscopic
cholecystectomy during IVF-ET gestation.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Background Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. Method This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. Results For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful lapa-roscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. Conclusion The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

Question: A 52-year-old woman without any significant medical history presented to the emergency department with a 2-day history of poor appetite, chills, and abdominal pain. The patient was alert at the emergency room. The initial temperature was 98.6°F (37°C), pulse 132 beats/min, respiratory rate 18 breaths/min, and blood pressure 97/57 mm Hg. The patient exhibited scleral icterus and yellowish skin color. Physical examination revealed a distended abdomen with muscle guarding and right upper quadrant tenderness.

Leptospirosis typically presents with fever and thrombocytopenia, with or without jaundice. Acute necrotising pancreatitis and acalculous cholecystitis are rare presentations of this spirochetal infection. Here is the case of necrotising pancreatitis and acalculous cholecystitis associated with leptospirosis in an elderly patient. Leptospirosis was diagnosed by serological tests and abdominal CT imaging. The patient was successfully treated medically with intravenous antibiotics (imipenem and ceftriaxone) and proper hydration.