2General data89 year old , womanChief ComplaintSevere abdominal pain
3History of Present Illness 3 days PTA nausea, vomiting, fever, and abdominal pain
4Past Medical History diabetes mellitus hypertension gastroesophageal reflux disease (GERD)sick sinus syndrome with a pacemakerRx: metformin, indapamide, pantoprazole, and aspirin
5Physical ExaminationLethargic but opens her eyes when called; sleepy but arousable and conversantnot oriented to time or placeT 36C , BP 100/67 mm Hg, PR 100 bpm,RR 18 cpm; O2 saturation 96% on room airHead and Neck --‐ unremarkable
6Physical ExaminationHeart --‐ paced rhythm with a 3/6 holosystolic murmur heard best at the right upper sternalborderLungs --‐ coarse rales at bilateral basesAbdomen: distended and tender mostly at the right upper and lower quadrants(+) guarding(-) rebound tenderness
7Salient 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
8X-rayIst day:gas within the gallbladder lumen, dissecting within the gallbladder wall to form a gaseous ring or in the pericholecystic tissues
13Acute Cholecystitis Pathogenesis: Secondary to gallstones in 90-95% Obstruction of a cystic duct gallbladder distention, inflammation and edema of the gallbladder wallInitially an inflammatory processThere could be secondary bacterial contaminationGallbladder wall becomes grossly thickened and reddish with subserosal hemmorhages
14Acute Cholecystitis Mucosa is hyperemic and with patchy necrosis Severe cases- inflammatory process could lead to ischemia and necrosis of the gallbladder wallAcute gangrenous cholecystitis and an abscess or empyemaobstructed + secondary bacterial infectionThough more frequently, gallstone is dislodged and the inflammation resolves
15Acute Cholecystitis Clinical Manifestations: Biliary colic (but the pain does not subside)Unremitting; may persist for several daysFebrile; may present with anorexia, nausea, vomiting; reluctant to move (as the inflammatory process affects the parietal peritoneum)Focal tenderness; guardingUsually present in the RUQ
16Acute 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 ductsIn older and those with diabetes mellitus, acute cholecystitis may have a subtle presentation delay in diagnosis(mortality is hogher in these patients)
17Chronic Cholecystitis Pain develops when a stone obstructs the cystic duct increased tension in the gallbladder wallPathologic 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
18Chronic Cholecystitis Clinical manifestations:Chief symptom is PAINConstant and increases in severity over the first half hour and typically lasts 1 – 5 hoursLocated in the epigastrium or RUQ and frequently radiates to the right upper back or between the scapulaeSevere and comes abruptly (during the night or after a fatty meal)Episodic (patients feel discrete attacks of pain, in between they feel well)
19Chronic Cholecystitis Clinical Manifestations:Laboratory values (WBC, Liver function test) usually normal in patients with uncomplicated gallstones
20Emphysematous Cholecystits Is thought to begin with acute cholecystitisFollowed by ischemia or gangrene of the gall bladder wall and infection by gas-producing organismsBacteria 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
21Emphysematous Cholecystits Clinical manifestation are essentially indistinguishable from those of non-gaseous cholecystitisDiagnosis - made on plain abdominal filmby finding gas within the gallbladder lumen, dissecting within the gallbladder wall to form a gaseous ring or in the pericholecystic tissuesMorbidity and mortality rates are considerable therefore prompt surgical intervention couples with appropriate antibiotics is mandatory
22Emphysematous Cholecystits Morbidity and mortality rates are considerable therefore prompt surgical intervention couples with appropriate antibiotics is manadatory
25Plain Abdominal X-Ray Low cost Readily available Pathognomonic findings in: calcified gallstonesUsed in:Limey bile, porcelain GBEmphysematous cholecystitisGallstone ileusFilm 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.
26Ultrasonography Procedure of choice for detection of stones sensitivity and specificity of 95%Thickening of the gallbladder wallFocal 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, ischaracteristic 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
27Biliary radionuclide scanning (HIDA scan) Indications:Acute cholecystitis- Lack of filling of the gallbladder after 4 hours indicates an obstructed cysticduct 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 cholecystitisAccurate identification of cystic duct obstruction, Simultaneous assessment of bile ductsThe 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.
28CT scan thickening of the gallbladder wall pericholecystic fluid presence of gallstonesgas within the wall of the gallbladder and within the lumen of the gallbladderfrequently performed on patients with acute abdominal pain
29MRCPOffers a single non-invasive test for the diagnosis of biliary tract and pancreaticdiseaseSensitivity is 95%Specificity is 89%MRI with magnetic resonance cholangiopancreatography (MRCP)
31Medical Management For complicated acute cholecystitis: Cefoxitin 2 grams IV every 8 hoursErtapenem 1 gram IV every 24 hoursBeta-lactam/Beta-lactamase inhibitors:Ampicillin-sulbactam grams IV every 6 hours (add Gentamicin 240 mg IV once a day if with risk for enterococcal infectionFor patients with allergy to beta-lactam antibiotics:Fluoroquinolone 400 mg IV every 12 hours plusMetronidazole 500 mg IV every 6 hoursFluid replacement and correction of electrolyte deficitsInitiated in preparation for surgery and are not intended to reverse the basic disease process.
32Surgical ManagementRecommended surgical approaches for acute cholecystitis and gangrenous cholecystitis:Open cholecystectomyLaparoscopic cholecystectomyAs soon after diagnosis as possible, within 72 hours of admissionlower complication rates and morbidity ratesspend less time in the hospitallowers the costs and avoids recurrent attacks and emergency operations
33Dietshould not be administered anything by mouth until a decision has been made regarding surgeryupon discharge, dietary recommendations reflect the presence of active comorbid diseasesthe episode of emphysematous cholecystitis itself should not impose any dietary requirements
34Activityearly postoperative activity is dictated by surgical considerationsupon discharge after the operation, the patients should experience no limitation of activity
36Epidemiology and Prognostic Determinants of Patients with Bacteremic Cholecystitis or Cholangitis American Journal of Gastroenterology (2007) 102:563–569Chien-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.
37Clinical QuestionWhat are the prognostic determinants of a patient with emphysematous cholecystitis?
38Search P- 89 year old females with emphysematous cholecystitis I- SurgeryO- Overall survivalM- Cohort
39Epidemiology 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.
40Is 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.
41Was 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 infection2 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
42Was follow up sufficiently long and complete? Yes. The study only included 30-day mortality and it lasted from June 2001 to May 2002.
43Were 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.
44Was 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.
45Overall, is the study valid? Since all of the validity questions were fulfilled, the study is considered to be valid.
46Are 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.
47Can 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.