Case on Gallbladder

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

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

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

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

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

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

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

X-ray 2nd day

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

Differential diagnosis

Diagnosis: Emphysematous Cholecystitis Differential diagnosis: Acute Cholecystitis Chronic Cholecystitis

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

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

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

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)

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

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)

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

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

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

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

Diagnostic Procedures

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.

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

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.

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

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)

Management

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 1.5-3 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.

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

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

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

Journal

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.

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

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

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.

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.

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

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

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.

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.

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

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.

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.