Comparison of laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in aged acute calculous cholecystitis: a cohort study.

BACKGROUND: In elderly patients with calculous acute cholecystitis, the risk of emergency surgery is high, and percutaneous cholecystostomy tube drainage (PC) combined with delayed laparoscopic cholecystectomy (DLC) may be a good choice. We retrospectively compared laparoscopic cholecystectomy (LC) to DLC after PC to determine which is the better treatment strategy. METHOD: We performed a retrospective cohort analysis of 752 patients with acute calculous cholecystitis. Patients with the following conditions were included: (1) age > 65 years old; (2) patients with a grade 2 or 3 severity of cholecystitis according to the 2013 Tokyo Guidelines (TG13); (3) the surgeons who performed the LC were professors or associate professors and (4) the DLC was performed in our hospital after PC. Patients who missed their 30-day follow-up; were diagnosed with bile duct stones, cholangitis or gallstone pancreatitis or were pregnant were excluded from the study. A total of 51 of 314 patients who underwent LC and 73 of 438 patients who underwent PC + DLC were assessed. PC + DLC and LC patients were matched by cholecystitis severity grade according to the TG13, and the National Surgical Quality Improvement Program (NSQIP) calculator was used to predict mortality (n = 21/group). Preoperative characteristics and postoperative outcomes were analysed. RESULTS: Compared to the matched LC group, the DLC group had less intraoperative bleeding (42.2 vs 75.3 mL, p = 0.014), shorter hospital stays (4.9 vs 7.4 days, p = 0.010) and lower rates of type A bile duct injury (4.8% vs 14.3%, p = 0.035) and type D (0 vs 9.5%, p = 0.002) according to Strasberg classification, residual stones (4.8 vs 14.3%, p = 0.035) and gastrointestinal organ injury (0 vs 3.6%, p < 0.001). Patients in the DLC group had lower incidences of ICU admission and death and a significantly lower incidence of repeat surgery. CONCLUSION: In elderly patients treated for acute calculous cholecystitis, the 30-day mortality and complication rates were lower for PC + DLC than for LC. However, the total hospitalisation time was significantly prolonged and the costs were significantly higher for PC + DLC.

Parasitic Infection of the Gallbladder: Cystoisospora belli Infection as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis.

Herein we describe two cases of Cystoisospora belli infection of the gallbladder in patients with chronic abdominal pain and review the published literature to date. C. belli is an intracellular protozoan parasite that typically infects the small bowel of immunocompromised hosts. Little is known of the significance of C. belli infection of the gallbladder at this point as only four cases have been reported as yet, only one of which occurred in an immunocompetent patient. It is often treatable with antibiotics, and the patient's immune status, including HIV testing, should be investigated. Neither of the patients at our institution was found to be immunocompromised, and HIV-1/2 antibody testing was non-reactive in both.

Acute acalculous cholecystitis in malaria: a review of seven cases from an adult cohort.

PURPOSE AND METHODS: Acute acalculous cholecystitis (AAC) is an uncommon condition related to serious clinical conditions, such as surgery, trauma, burn injuries and sepsis. The diagnosis of AAC remains challenging to make, since it generally occurs as a secondary event in acutely ill patients with another disease. Imaging evaluation is crucial, and well-known criteria are accepted for the diagnosis. To our knowledge, only case reports of AAC related to 12 malaria adult patients have been published. In this series, seven cases of AAC from a cohort of 42 adult patients with severe imported falciparum malaria [according to the World Health Organization (WHO) criteria] are presented. The aim is to report the cases and look for malaria conditions that may affect the incidence of this unusual malaria complication. RESULTS: Ultrasonography revealed gallbladder with wall thickening in all patients, plus other(s) major criteria. Each patient presented five to nine WHO severe malaria criteria: all had hyperparasitaemia and hyperbilirubinaemia. All patients developed renal failure, six pulmonary oedema/acute respiratory distress syndrome (ARDS) (five were mechanically ventilated) and five shock. Treatment was non-operative in five patients, cutaneous cholecystostomy was done in two and the outcome was favourable in all. CONCLUSIONS: Patients with AAC have significantly more commonly five or more criteria of severe malaria: renal insufficiency, pulmonary oedema/ARDS, parasitaemia higher than 30 %, nosocomial infection and a prolonged intensive care unit (ICU) stay. Increased awareness for this unusual and potentially severe complication of malaria is needed.

Metabolomic study of serum from rabbits with acute acalculous cholecystitis.

OBJECTIVES: (1)H-NMR is a powerful approach of metabolomics. This study aimed to apply it to detect the serum metabolites in rabbits with acute acalculous cholecystitis (AAC), and to analyze their potential roles in AAC. METHODS: Fourteen rabbits were randomly divided into two groups, the AAC group and the CON group. In the AAC rabbit model, Escherichia coli solution was injected into the gallbladder, while same volume of saline, instead of E. coli solution, was injected into the gallbladder of the CON rabbit. General morphological, light microscopic and transmission electron microscopic observations were used to evaluate the model. Metabolic profiles of serum from rabbits with AAC were investigated through (1)H-NMR spectroscopy coupled with multivariate statistical analysis, such as principal components analysis and orthogonal partial least-squares discriminant analysis. RESULTS: The pathohistology of gallbladders showed a significant difference between the two groups, proving the successful induction of inflammation in the gallbladders of the AAC group. The serum concentration of lipids (LDL and VLDL) increased during AAC, while the concentrations of phospholipids, lactic acid, 3-hydroxybutyric acid, lysine, citric acid, asparagine, histidine, glucose and some other small molecular metabolites decreased. CONCLUSION: The profiling of serum metabolites in rabbits with acute acalculous cholecystitis changed significantly. These changes referred to the metabolic disturbance of carbohydrate, amino acids and lipids, inhibition of immunological functions and inflammation reaction.

Diagnostic accuracy of computed tomography imaging of surgically treated acute acalculous cholecystitis in critically ill patients.

BACKGROUND: Acute acalculous cholecystitis (AAC) is a potentially fatal condition mainly affecting critically ill patients. Current experience from computed tomography (CT) findings in AAC is contradictory. METHODS: CT images of 127 mixed medical-surgical intensive care unit patients were retrospectively reviewed for the following findings: bile density, thickness and enhancement of the gallbladder (GB) wall, subserosal edema, greatest perpendicular diameters of the GB, width of extrahepatic bile ducts, gas within the GB, ascites, peritoneal fat edema, and diffuse tissue edema. Forty-three of these patients underwent open cholecystectomy, and 8 patients revealed a normal GB, 26 an edematous GB, and 9 a necrotic AAC. RESULTS: Abnormal CT findings were present in 96% of all the intensive care unit patients. Higher bile density in the GB body and subserosal edema was associated with an edematous GB (specificity, 93.6%; sensitivity, 23.1%). The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB (specificity, 99.2%, 94.9%, and 92.4%, respectively; and sensitivity, 11.1%, 37.5%, and 22.2%, respectively). CONCLUSIONS: The frequency of nonspecific abnormal findings in the GB of critically ill patients limits the diagnostic value of CT scanning in detecting AAC. However, in the case of totally normal GB findings in CT, the probability of necrotic AAC is low.

Acalculous cholecystitis and tamponade: an unusual combination?

Although pericardial effusion is a well-known feature of Churg-Strauss syndrome, cardiac tamponade has rarely been encountered. The present report describes a case of Churg-Strauss syndrome that presented as an acute cholecystitis and was complicated by tamponade. Histopathological exam of both pericardium and gall bladder was conclusive for Churg-Strauss syndrome.

[A case of spontaneous hemorrhagic cholecystitis without gallstone].

Hemorrhagic acalculous cholecystitis is an extremely rare but potentially fatal disease if detection is delayed. Its risk factors include critical illness, diabetes, malignant disease, uremia, and bleeding diathesis. This is the first case report in which hemorrhagic acalculous cholecystitis not accompanied by any risk factor. We herein present a case of hemorrhagic acalculous cholecystitis in a previously healthy patient who suffered from acute abdomen.

[Cationic Blue O staining for the cytological detection of Helicobacter pylori].

This investigation was undertaken to study whether cationic blue O staining might be used to improve the cytological diagnosis of H. pylori infection at gastric and extragastric sites. One hundred and sixty-four patients with chronic inflammatory diseases of the stomach and gallbladder were examined with cytological and molecular studies. Impression smears from the gastric mucosa and bile portions A, B, and C were studied. The stain proposed by the authors ensures a high efficiency in detecting H. pylori in different biological materials (gastric biopsy specimens, bile) with the determination of the degree of contamination makes it possible to evaluate the morphological changes in the gastric mucosa and bile epithelium. The detection results of smear H. pylori correlated with those of DNA in this microorganism, by using the polymerase chain reaction. The proposed cytological study may be recommended for both the primary diagnosis of H. pylori infection in patients with diseases of the stomach, duodenum, and gallbladder and the monitoring eradication therapy and its deserves extensive use by cytological laboratories.

Delayed necrotizing acalculous cholecystitis after multiple trauma.

This is a case report of a necrotizing acalculous cholecystitis 7 weeks after multiple orthopedic trauma successfully treated by operative intervention.

Acalculous and clostridial cholecystitis in a pig.

A 21-month-old domestic Hanford pig (Sus scrofa domestica) in a 1-year study for experimental myocardial infarction was euthanized at the end of the study. One week earlier, the animal had symptoms and elevated clinical chemistry results suggestive of hepatobiliary disease, which resolved after medical therapy. At necropsy, the gallbladder was markedly enlarged, discolored, and had a thickened wall. Within the gallbladder, there was abundant friable green-brown material. A culture of the gallbladder luminal material yielded Clostridium perfringens type A. Histopathology of the gallbladder demonstrated multifocal areas of necrosis of varying depths, admixed with an inflammatory infiltrate that was also observed on the serosa and within the associated adipose tissue. Luminal material was composed of cellular debris and bile sludge admixed with numerous bacterial rods. Smooth-muscle hypertrophy of numerous small arterioles with narrowed lumina was observed in the gallbladder. A diagnosis of acalculous cholecystitis presumably because of ischemia of the gallbladder with secondary clostridial infection was made. To the authors' knowledge, this is the first reported case of acalculous cholecystitis with evidence of vascular compromise in a pig, as well as cholecystitis secondarily attributed to Clostridium perfringens type A.

Recent advances in management of acalculous cholecystitis.

Acalculous cholecystitis is a life-threatening gallbladder infection that typically affects the critically ill. A late diagnosis can have devastating outcomes because of the high risk of gallbladder perforation if untreated. The diagnosis is not straightforward as Murphy's sign is difficult to illicit in the critically ill and many imaging findings are either insensitive or non-specific. This article reviews the current imaging literature to improve the interpretation of findings. Management involves a percutaneous cholecystostomy, surgical cholecystectomy, or more recently an endoscopically placed metal stent through the gastrointestinal tract into the gallbladder. This article reviews the current literature assessing the outcomes of each treatment option and suggests a protocol in determining the modality of choice on the basis of patient population. Specifically, endoscopic ultrasound-guided gallbladder drainage is a novel drainage approach for patients who are poor candidates for surgery and obviates the need for a percutaneous drain and all its complications. It has promising results but has caveats in its uses.

Tight junction proteins in gallbladder epithelium: different expression in acute acalculous and calculous cholecystitis.

There is a paucity of information of tight junction (TJ) proteins in gallbladder epithelium, and disturbances in the structure of these proteins may play a role in the pathogenesis of acute acalculous cholecystitis (AAC) and acute calculous cholecystitis (ACC). Using immunohistochemistry, we investigated the expression of TJ proteins claudin-1, -2, -3, and -4, occludin, zonula occludens (ZO-1), and E-cadherin in 9 normal gallbladders, 30 gallbladders with AAC, and 21 gallbladders with ACC. The number of positive epithelial and endothelial cells and the intensity of the immunoreaction were determined. Membrane-bound and cytoplasmic immunoreactivities were separately assessed. We found that TJ proteins were uniformly expressed in normal gallbladder epithelium, with the exception of claudin-2, which was present in less than half of the cells. In AAC, expression of cytoplasmic occludin and claudin-1 were decreased, as compared with normal gallbladder. In ACC, expression of claudin-2 was increased, and expression of claudin-1, -3, and -4, occludin, and ZO-1 were decreased, as compared with normal gallbladder or AAC. We conclude that there are significant differences in expression of TJ proteins in AAC and ACC, supporting the idea that AAC represents a manifestation of systemic inflammatory disease, whereas ACC is a local inflammatory and often infectious disease.

Cellular turnover and expression of hypoxic-inducible factor in acute acalculous and calculous cholecystitis.

INTRODUCTION: Epithelial corrective and destructive mechanisms have not been studied in inflammatory gallbladder disease. METHODS: Epithelial apoptosis, cell proliferation and expression of hypoxia-inducible factor (HIF)-1alpha were compared in gallbladders from patients with acute acalculous cholecystitis (AAC; n = 30) and acute calculous cholecystitis (ACC; n = 21), and from patients undergoing surgery for other reasons (normal gallbladders; n = 9), which were removed during open cholecystectomy. The immunohistochemical stains included antibodies to Ki-67 (proliferation), M30 (apoptosis) and HIF-1alpha. Proliferation and apoptosis were expressed as percentages of positive cells. HIF-1alpha expression was expressed as absent, weak, or strong. RESULTS: Apoptosis (median [25th to 75th percentile]) was significantly increased in AAC (1.31% [0.75% to 1.8%], P < 0.001) and ACC (1.10% [0.63% to 1.64%], P = 0.001), compared with control samples (0.20% [0.07% to 0.45%]. The proliferation rate was significantly increased in AAC (8.0% [4.0% to 17.0%], P < 0.001) and ACC (14% [7.5% to 26.5%], P = 0.001) compared with control samples (1.0% [1.0% to 3.0%]). Strong HIF-1alpha staining was observed in 57% of AAC, in 100% of ACC and in 44% of control specimens (P < 0.001). Intense HIF-1alpha expression was associated with increased cell proliferation (P = 0.002). CONCLUSION: Cell proliferation and apoptosis were increased in AAC and ACC, as compared with normal gallbladders. Expression of HIF-1alpha was lower in AAC than in ACC.

Celiac territory ischemic syndrome in a patient on chronic hemodialysis.

Mesenteric ischemia among chronic dialysis patients is usually of the nonocclusive type. Chronic occlusive mesenteric ischemia has been reported rarely in the dialysis population. The subset of"celiac-territory ischemic syndrome" has not been described in dialysis. The current report involves a 66-year-old female on chronic dialysis for 11 years. She experienced abdominal pain following sessions of hemodialysis, that later became more pronounced after eating. Abdominal angiography showed heavily calcified aorta, celiac trunk and superior mesenteric artery (SMA), with a 50% narrowing of the celiac and superior mesenteric arteries. During the following 9 months the symptoms worsened and weight loss set in. She was admitted with an episode of upper abdominal pain. Acalculous cholecystitis was found, along with multiple gastric and duodenal erosions including the second part, with an antral ulcer and multiple duodenal bulb ulcers. Repeated abdominal angiography showed progression of the stenotic lesions with significant narrowing of both the celiac trunk and the SMA. A stent was placed in the SMA. Following the procedure, the patient noted marked symptomatic improvement. On follow-up gastroduodenoscopy, all ischemic ulcers had healed completely. Serum albumin rose from a nadir of 31 to 40 g/l, and an extremely elevated c-reactive protein of 205,000 microg/l returned to normal (8,000 microg/l). The diagnosis of chronic occlusive mesenteric ischemia should be suspected among dialysis patients with post-prandial pain and weight loss in the face of calcified vessels. Predominant celiac territory ischemic syndrome presents as gastric and duodenal erosions and ulcers with or without acalculous cholecystitis.

A case report of dengue virus infection and acalculous cholecystitis in a pregnant returning traveler.

Dengue viral infections present a significant risk during pregnancy to both mother and fetus. A young woman at 13 weeks' gestation presented with fever and abdominal pain following a diarrheal illness after returning from Puerto Rico. Over the course of 5 days, she developed nausea, petechiae, severe thrombocytopenia, and acalculous cholecystitis. After a serologic diagnosis of acute infection with dengue virus, she was provided supportive care. An uncomplicated pregnancy led to delivery of a healthy infant at 40 weeks gestation. Travel during pregnancy to dengue-endemic areas poses a risk to both mother and fetus. Pregnancies complicated by dengue infection require close monitoring for potential maternal and fetal complications.

Pancreatitis and cholecystitis in primary acute symptomatic Epstein-Barr virus infection - Systematic review of the literature.

Acute pancreatitis and acalculous cholecystitis have been occasionally reported in primary acute symptomatic Epstein-Barr virus infection. We completed a review of the literature and retained 48 scientific reports published between 1966 and 2016 for the final analysis. Acute pancreatitis was recognized in 14 and acalculous cholecystitis in 37 patients with primary acute symptomatic Epstein-Barr virus infection. In all patients, the features of acute pancreatitis or acalculous cholecystitis concurrently developed with those of primary acute symptomatic Epstein-Barr virus infection. Acute pancreatitis and acalculous cholecystitis resolved following a hospital stay of 25days or less. Acalculous cholecystitis was associated with Gilbert-Meulengracht syndrome in two cases. In conclusion, this thorough analysis indicates that acute pancreatitis and acalculous cholecystitis are unusual but plausible complications of primary acute symptomatic Epstein-Barr virus infection. Pancreatitis and cholecystitis deserve consideration in cases with severe abdominal pain. These complications are usually rather mild and resolve spontaneously without sequelae.

Conservative management of intrahepatic perforation of the gallbladder secondary to acalculous cholecystitis.

Gallbladder (GB) perforation is a rare complication of acute acalculous cholecystitis. This complication mostly manifests as acute free perforation into the peritoneal cavity, subacute pericholecystic abscess, or chronic perforation with cholecystoenteric fistula. Perforation of the GB into the liver is extremely rare, and was reported only in adults, of whom all were treated surgically. The authors present an intrahepatic GB perforation secondary to acute acalculous cholecystitis, and its successful conservative management in a 13-year-old boy.

[The role of stomach epithelial cells being immunopositive for NO synthase in the formation of chronic cholecystitis]. / Znachenie épiteliotsitov zheludka, immunopozitivnykh k NO-sintaze, v formirovanii khronicheskogo kholetsistita.

The article provides information on 145 patients with chronic acalculous cholecystitis and 62 patients with chronic calculous cholecystitis subjected to a study of the quantitative characteristic of gastric antral epithelial cells immunopositive for NO synthase. The increased number of NO synthase immunopositive gastric epithelial cells at chronic cholecystitis was discovered. Most of them were discovered at the calculous process. The study discovered the relation between the gallbladder inflammatory activity, bile lithogenicity and the number of NO synthase immunopositive gastric epithelial cells. The clinical, biochemical and morphologic analyses showed that the application of Hepabene for treating patients with chronic acalculous cholecystitis produces a clinical and biochemical remission in a shorter term. Bile lithogenicity decreases; the quantitative characteristic of NO synthase immunopositive gastric epithelial cells normalizes. The study results make it possible to recommend Hepabene as a highly efficient drug for treating patients with chronic acalculous cholecystitis.