1. Case on Gallbladder

2. General data
89 year old , woman
Chief Complaint
Severe abdominal pain

3. History of Present Illness
3 days PTA nausea, vomiting, fever, and abdominal pain

4. Past Medical History diabetes mellitus hypertension
gastroesophageal reflux disease (GERD)
sick sinus syndrome with a pacemaker
Rx: metformin, indapamide, pantoprazole, and aspirin

5. Physical Examination
Lethargic but opens her eyes when called; sleepy but arousable and conversant
not oriented to time or place
T 36C , BP 100/67 mm Hg, PR 100 bpm,
RR 18 cpm; O2 saturation 96% on room air
Head and Neck --‐ unremarkable

6. Physical Examination
Heart --‐ paced rhythm with a 3/6 holosystolic murmur heard best at the right upper sternal
border
Lungs --‐ coarse rales at bilateral bases
Abdomen: distended and tender mostly at the right upper and lower quadrants
(+) guarding
(-) rebound tenderness

7. Salient Features 89 y/o DM nausea, vomiting, fever, and abdominal pain
Abdomen: distended and tender mostly at the right upper and lower quadrants
(+) guarding
(-) rebound tenderness

8. X-ray
Ist day:
gas within the gallbladder lumen, dissecting within the gallbladder wall to form a gaseous ring or in the pericholecystic tissues

9. X-ray
2nd day

10. CT Scan
Gas w/in wall of gallbladder horzontal…. Vertical, within lumen

11. Differential diagnosis

12. Diagnosis: Emphysematous Cholecystitis
Differential diagnosis:
Acute Cholecystitis
Chronic Cholecystitis

13. Acute Cholecystitis Pathogenesis: Secondary to gallstones in 90-95%
Obstruction of a cystic duct  gallbladder distention, inflammation and edema of the gallbladder wall
Initially an inflammatory process
There could be secondary bacterial contamination
Gallbladder wall becomes grossly thickened and reddish with subserosal hemmorhages

14. Acute Cholecystitis Mucosa is hyperemic and with patchy necrosis
Severe cases- inflammatory process could lead to ischemia and necrosis of the gallbladder wall
Acute gangrenous cholecystitis and an abscess or empyema
obstructed + secondary bacterial infection
Though more frequently, gallstone is dislodged and the inflammation resolves

15. Acute Cholecystitis Clinical Manifestations:
Biliary colic (but the pain does not subside)
Unremitting; may persist for several days
Febrile; may present with anorexia, nausea, vomiting; reluctant to move (as the inflammatory process affects the parietal peritoneum)
Focal tenderness; guarding
Usually present in the RUQ

16. Acute Cholecystitis
(+) Murphy’s sign (inspiratory arrest with deep palpation in the right subcostal area)
Mild to moderate leukocytosis (some may have normal WBC)
Severe jaundice – common bile duct stones or obstruction of the bile ducts
In older and those with diabetes mellitus, acute cholecystitis may have a subtle presentation  delay in diagnosis
(mortality is hogher in these patients)

17. Chronic Cholecystitis
Pain develops when a stone obstructs the cystic duct  increased tension in the gallbladder wall
Pathologic changes vary from apparently normal gallbladder with minor chronic inflammation in the mucosa to a shrunken, non-functioning gallbladder with gross transmural fibrosis and adhesions to nearby structures

18. Chronic Cholecystitis
Clinical manifestations:
Chief symptom is PAIN
Constant and increases in severity over the first half hour and typically lasts 1 – 5 hours
Located in the epigastrium or RUQ and frequently radiates to the right upper back or between the scapulae
Severe and comes abruptly (during the night or after a fatty meal)
Episodic (patients feel discrete attacks of pain, in between they feel well)

19. Chronic Cholecystitis
Clinical Manifestations:
Laboratory values (WBC, Liver function test) usually normal in patients with uncomplicated gallstones

20. Emphysematous Cholecystits
Is thought to begin with acute cholecystitis
Followed by ischemia or gangrene of the gall bladder wall and infection by gas-producing organisms
Bacteria most frequently cultured in this setting includes anaerobes (C. welchii, C. perfringens) and aerobes (such as E.coli)
Occurs more frequently in elderly and in patients with diabetes mellitus

21. Emphysematous Cholecystits
Clinical manifestation are essentially indistinguishable from those of non-gaseous cholecystitis
Diagnosis - made on plain abdominal film
by finding gas within the gallbladder lumen, dissecting within the gallbladder wall to form a gaseous ring or in the pericholecystic tissues
Morbidity and mortality rates are considerable therefore prompt surgical intervention couples with appropriate antibiotics is mandatory

22. Emphysematous Cholecystits
Morbidity and mortality rates are considerable therefore prompt surgical intervention couples with appropriate antibiotics is manadatory

24. Diagnostic Procedures

25. Plain Abdominal X-Ray Low cost Readily available
Pathognomonic findings in: calcified gallstones
Used in:
Limey bile, porcelain GB
Emphysematous cholecystitis
Gallstone ileus
Film shows the gallbladder with multiple stones. The wall of fundus is delineated by intramural gas. Extramural gas also appears to be present in the soft tissues over the superior aspect of the gallbladder.
The film shows an enlarged gallbladder with multiple stones. The wall of the gallbladder is outlined by intramural gas.

26. Ultrasonography Procedure of choice for detection of stones
sensitivity and specificity of 95%
Thickening of the gallbladder wall
Focal tenderness over the gallbladder when compressed by the sonographic probe (sonographic Murphy's sign)
Murphy's sign, an inspiratory arrest with deep palpation in the right subcostal area, is
characteristic of acute cholecystitis.
Curvilinear gaseous artifacts in the gallbladder, the "ring-down effect" or "comet tail," are diagnostic of emphysematous cholecystitis, but the frequency with which these are observed is not clear.
As the gas leaks out from the wall of the gallbladder into the bile, a picture described as "effervescent bile" can be observed.
ACOUSTIC SHADOWING

27. Biliary radionuclide scanning (HIDA scan)
Indications:
Acute cholecystitis
- Lack of filling of the gallbladder after 4 hours indicates an obstructed cystic
duct and, in the clinical setting of acute cholecystitis
- Evidence of cystic duct obstruction on biliary scintigraphy is highly diagnostic for acute cholecystitis.
Normal HIDA scan excludes acute cholecystitis
Accurate identification of cystic duct obstruction, Simultaneous assessment of bile ducts
The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis, which appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and duodenum. Evidence of cystic duct obstruction on biliary scintigraphy is highly diagnostic for acute cholecystitis. The sensitivity and specificity for the diagnosis are about 95% each.

28. CT scan thickening of the gallbladder wall pericholecystic fluid
presence of gallstones
gas within the wall of the gallbladder and within the lumen of the gallbladder
frequently performed on patients with acute abdominal pain

29. MRCP
Offers a single non-invasive test for the diagnosis of biliary tract and pancreatic
disease
Sensitivity is 95%
Specificity is 89%
MRI with magnetic resonance cholangiopancreatography (MRCP)

30. Management

31. Medical Management For complicated acute cholecystitis:
Cefoxitin 2 grams IV every 8 hours
Ertapenem 1 gram IV every 24 hours
Beta-lactam/Beta-lactamase inhibitors:
Ampicillin-sulbactam grams IV every 6 hours (add Gentamicin 240 mg IV once a day if with risk for enterococcal infection
For patients with allergy to beta-lactam antibiotics:
Fluoroquinolone 400 mg IV every 12 hours plus
Metronidazole 500 mg IV every 6 hours
Fluid replacement and correction of electrolyte deficits
Initiated in preparation for surgery and are not intended to reverse the basic disease process.

32. Surgical Management
Recommended surgical approaches for acute cholecystitis and gangrenous cholecystitis:
Open cholecystectomy
Laparoscopic cholecystectomy
As soon after diagnosis as possible, within 72 hours of admission
lower complication rates and morbidity rates
spend less time in the hospital
lowers the costs and avoids recurrent attacks and emergency operations

33. Diet
should not be administered anything by mouth until a decision has been made regarding surgery
upon discharge, dietary recommendations reflect the presence of active comorbid diseases
the episode of emphysematous cholecystitis itself should not impose any dietary requirements

34. Activity
early postoperative activity is dictated by surgical considerations
upon discharge after the operation, the patients should experience no limitation of activity

35. Journal

36. Epidemiology and Prognostic Determinants of Patients with Bacteremic Cholecystitis or Cholangitis
American Journal of Gastroenterology (2007) 102:563–569
Chien-Chang Lee, M.D., M.Sc, I-Jing Chang, M.D., M.P.H., Yi-Chun Lai, M.D., Shey-Ying Chen, M.D., and Shyr-Chyr Chen, M.D., M.B.A.

37. Clinical Question
What are the prognostic determinants of a patient with emphysematous cholecystitis?

38. Search P- 89 year old females with emphysematous cholecystitis
I- Surgery
O- Overall survival
M- Cohort

39. Epidemiology and Prognostic Determinants of Patients with Bacteremic Cholecystitis or Cholangitis
The authors prospectively collected comprehensive clinical, laboratory, and outcome data from 937 consecutive patients with microbiologically documented BSI in the emergency department. BTI was the confirmed source of 145 of the 937 BSIs. They determined the independent prognostic factors by evaluating the correlation between 30-day mortality and various factors, for example, comorbidity, clinical severity, related hepatobiliary complication, and decompressive procedures.

40. Is the objective of the article on prognosis similar to your clinical dilemma?
Yes. The objective of the study was to determine the prognostic determinants of short term mortality in cases of acute cholecystitis. Our patient presents with emphysematous cholecystitis, and the journal includes emphysematous cholecystitis under the category complicated cholecystitis.

41. Was there a representative sample of patients without the outcome at the start of observation?
The authors included:
Patients admitted to National Taiwan University Hospital (from June 2001 to May 2002) who presented with bloodstream infection
2 sets of positive blood cultures obtained from separate sites, a gram negative pathogen on one blood culture, or a gram positive culture on one blood culture in a patient with an intravascular device and compatible clinical information.
The patients documented to have BSI were then filtered and limited to the 145 with BTI. Biliary tract infection was confirmed by hyperbilirubinemia or elevated alkaline phosphatase levels and evidence of biliary obstruction via CT.
Excluded: those less than 15 years old, those with coagulase negative Staphylococcus spp. and those with other common skin flora isolated in single blood cultures without compatible clinical information

42. Was follow up sufficiently long and complete?
Yes. The study only included 30-day mortality and it lasted from June 2001 to May 2002.

43. Were the criteria for determining the prognostic factor and outcome explicit and credible?
Yes. Prognostic factors included age, gender, comorbidities, charlson score (range of comorbidities), organ failure, laboratory results, causative agent, and decompressive modality (surgical, endoscopic, or percutaneous). Outcome was determined by 30-day mortality.

44. Was there adjustment for other prognostic factors?
Yes. The authors compared baseline data for 30 day surviving and non-surviving patients using the x2 and Fisher tests for categorical variables and the Mann-Whitney U test for continuous variables. A causal diagram was used to select the factors for inclusion in the multivariate model, and the Cox progressional hazard regression model was used to determine the independent prognostic factors associated with 30 day survival.

45. Overall, is the study valid?
Since all of the validity questions were fulfilled, the study is considered to be valid.

46. Are the study patients similar to my own?
Yes. Our patient is included in the age range covered by the study sample, she has emphysematous cholecystitis, she has diabetes mellitus and hypertension (2 comorbidities included in the study), she also has evidence of altered consciousness and possible evidence of BTI (also prognostic factors included in the study). Although gram testing and culture were not mentioned, our patient presents with some clinical signs that match those designated by the researchers, namely: heart rate higher than 90 beats per minute and temperature reading at or below 36° C.

47. Can I use the results to decide on the intervention or reassure my patient?
Acute renal failure, septic shock, multiple underlying diseases, malignant obstruction, and direct-type hyperbilirubinemia were all found to be independent risk factors for mortality. The patient presents with complicated cholecystitis and multiple underlying diseases (hypertension, DM, sick sinus syndrome, and GERD), all of which increase the chances of 30 day mortality. The patient, therefore, must undergo surgical intervention.