Acute Cholecystitis Moshe Schein

Moshe Schein

“In dropsy of the gallbladder… and in gallstones we should not wait ‘til the patient’s strength is exhausted, or ‘til the blood becomes poisoned with bile, producing hemorrhage; we should make an early abdominal incision, ascertain the true nature of the disease, and then carry out the surgical treatment that necessities of the case demand.” (James Marion Sims, 1813–1883)

Acute cholecystitis (AC) is either calculous or,less commonly,acalculous.Since the clinical picture of these two entities differs they are discussed separately.

Calculous Acute Cholecystitis

Acute cholecystitis is initiated by a gallstone,which obstructs the gallbladder’s outlet. Its spontaneous dislodgment results in so-called biliary colic while persisting impaction of the stone produces gallbladder distention and inflammation, namely AC. The latter is initially chemical but gradually, as gut bacteria invade the inflamed organ, infection supervenes. The combination of distention, ischemia, and infection may result in a gallbladder empyema, necrosis, perforation, peri-cholecystic abscess or bile-peritonitis.You must have heard or read numerous times about the classical symptoms and signs of AC. Let us concentrate therefore only on problem areas.

How to Differentiate Between Biliary Colic and AC

Time is the best discriminator as the pain and right upper quadrant (RUQ) symptoms of biliary colic are self-limiting, disappearing within a few hours. Con- versely, in AC, the symptoms and signs persist. Furthermore,AC is accompanied by local (e.g., local peritonitis or tender mass) and systemic (e.g., fever, leukocytosis) evidence of inflammation, while biliary colic is not.

The clinical picture, which you know so well (we do not need to mention Murphy’s sign again), is very suggestive. Laboratory findings of leukocytosis and elevation of bilirubin and/or liver enzymes may back it up. But note that a lack of some or all features of inflammation/infection does not rule out AC – as is true also for acute appendicitis.

Luckily, you can (and should) confirm your diagnosis of AC with ultrasound

or a radionuclide HIDA (hepatic iminodiacetic acid) scan,which are readily available.

Which of the two you should ask for first depends on its availability, and the exper- tise in your hospital. We prefer ultrasound as it may also provide incidental infor- mation concerning the liver, bile ducts, pancreas, kidneys and peritoneal fluid, pos- sibly suggesting alternative diagnoses. The ultrasonographic findings in AC include a distended, stone or sludge-containing gallbladder, thickened wall, mucosal sepa- ration, peri-cholecystic fluid collection or intramural air. Not all of these findings are necessary to make a diagnosis. Positive radionuclide scan in AC means non- filling of the gallbladder by the isotope. The specificity of the test is increased (e.g., fewer false-positives) if morphine is administered, causing spasm of the sphincter of Oddi and reflux of isotope into the cystic duct. There are other (chronic) causes of non-filling of the gallbladder (e.g., mucocele) but a negative scan with the isoto- pe entering the gallbladder excludes AC.

Associated Jaundice  Mild to moderate elevation of bilirubin and hepatic enzymes is a relatively common feature of AC, caused by reactive inflammation of the hepatic pedicle and the surrounding liver parenchyma.Thus,you need not attri- bute the jaundice to choledocholithiasis, unless there are also clinical and ultra- sonographic features of ascending cholangitis and/or bile duct stones (

Chap. 20).

Associated Hyperamylasemia  Similarly, mild elevation of the serum amy- lase does not mean that the patient is suffering from biliary pancreatitis.Commonly, hyperamylasemia is produced by AC with no signs of acute pancreatitis detected at operation.

Management

Non-operative Management

The natural history of AC is such that in more than two-thirds of patients treat- ed non-operatively the increased intra-gallbladder pressure will be relieved by dislodgment of the obstructing stone and resolution of the process. Conservative therapy, which should be started in all AC patients after the diagnosis is established, includes: nil per mouth (nasogastric tube only if the patient is vomiting), analgesia (use a non-opioid if you believe in the hypothetical importance of avoiding constric- tion of the sphincter of Oddi), and antibiotics (active against enteric Gram-negative bacteria).

In the “old days”patients were discharged home after responding to a few days

of conservative treatment to return for a delayed, “interval”, cholecystectomy a few

weeks later. This approach has been discontinued because of unpredictable failure

to respond and recurrences of AC prior to the planned operation. Today, we reserve

delayed cholecystectomy for patients who are medically unfit to undergo an opera- tion in the acute stage, provided they respond to conservative management. There is abundant evidence showing that the earlier the operation – the easier it is. The acute inflammatory edema provides tissue planes,which facilitate cholecystectomy.

Conversely, the more one delays the operation – the more fibrosis and scar tissue forms – and the more traumatic the operation.

Surgical Management

Cholecystectomy is the optimal procedure; it eradicates the inflammation/

infection and prevents its recurrence. Based on your clinical impression it will be performed either as an “emergency” (rarely needed) or, usually,“early”.

Emergency Cholecystectomy

An immediate, emergency procedure should be performed following resusci- tation in patients with clinical evidence of diffuse peritonitis and systemic toxicity, or presence of gas within the gallbladder wall – features suggesting perforation, necrosis or empyema of the gallbladder. Most surgeons today would attempt a trial laparoscopic cholecystectomy (LC) in this situation, converting to “open” in the presence of technical difficulties.We would warn,however,against prolonged perito- neal insufflation in the critically ill patient and would avoid prolonged attempts with laparoscopic dissection of the necrotic, perforated and difficult-to-grasp gall- bladder. Emergency cholecystectomy for complicated AC in the critically ill or compromised patient could be “open” as described below. Obviously, a brief open cholecystectomy is easier on your patient than an open cholecystectomy following 2 hours of futile laparoscopic attempts! (

Fig. 19.1).

Early Cholecystectomy

Patients in whom emergency cholecystectomy is not clinically indicated should undergo an early cholecystectomy. But what is “early”? For some it means that you do not need to rush to the operating room in the middle of the night but operate during day-hours,under favorable “elective”conditions.For others it means to operate on the “first elective list”. Depending on the surgeon’s schedule and the availability of the OR, patients are often left “to cool down” for days awaiting their

“semi-elective” cholecystectomy, which is often performed at the end of the elective

lists. Occasionally, a waiting period as short as 48 hours results in deterioration

of the patient, but as we have observed already the majority of AC will settle down without an early operation.

Clinical appraisal of the severity of AC is notoriously unreliable; patients with gallbladder empyema or necrosis may be initially clinically silent only to deteriorate suddenly while those with impressive RUQ signs may harbor just a simple AC.

A mandatory operation within 24 hours will prevent any problems arising from a delay in operation. Furthermore, we wish to point out again that the operative dissection (laparoscopic or open) is easier and less bloody during the early phase of inflammation, with tissue planes becoming progressively more difficult as the process progresses. Thus, our definition of early cholecystectomy is an operation within 24 hours of admission.

Note: there is a subgroup of patients who will benefit from a delayed approach, in order to prepare them better for surgery. For example, decompensated cardiac failure should be treated and coagulation disturbances corrected. Do not brandish your knife at unprepared patients.

The High-risk Patient who Needs an Emergency Procedure

With today’s advanced anesthetic techniques and ICU support it is rare to encounter a patient who cannot be subjected to an emergency procedure under general anesthesia. But what are we to do with the occasional extremely sick patient who is “not even fit for a hair cut under local” as they used to say? The best option

Fig. 19.1. “I never convert…”

is a tube cholecystostomy under local anesthesia. This can be done by you in the operating room, or – even better and less traumatic – by the radiologist, inserting the tube into the gallbladder percutaneously, and transhepatic, under CT guidance.

Failure of the patient to improve within 24–48 hours, particularly after the percuta- neous procedure, should suggest the presence of undrained pus or necrotic gall- bladder wall, and the need to operate.

Acute Cholecystitis in Cirrhotic Patients

An emergency cholecystectomy in cirrhotic patients with portal hypertension not uncommonly culminates in a bloody disaster due to an intra- or post-operative hemorrhage from the congested gallbladder’s hepatic bed or large venous collaterals at the duodenohepatic ligament. Although conventional laparoscopic cholecystec- tomy has been judged safe in “Child’s A”portal hypertension patients (see

Chap.16), we believe that the secret here is to stay away from trouble, by avoiding dissection near engorged and rigid hepatic parenchyma and the excessively vascular triangle of Callot. Subtotal or partial cholecystectomy is the procedure of choice in this situation (see below).

Technical Points

Cholecystectomy

As mentioned,“emergency” procedures may be “open” unless you like to play around with the laparoscope in desperately ill patients. In early cholecystectomy you may start laparoscopically, accepting a need to convert to “open” in up to one third of the patients. It is important not to be carried away, persisting with laparo- scopic dissection in the face of hostile anatomy. A practical rule of thumb is to convert to laparotomy if after 45–60 minutes of laparoscopy you feel like you are

“going nowhere”. In many patients a decision to convert can be made much earlier than this even, and you should not be afraid to abandon the laparoscopic approach at any stage if the circumstances are obviously unfavorable. Inappropriate per- sistence with the laparoscopic approach may well end in disaster with a bile duct injury. For an excellent list of rules of thumb to prevent this calamity look at the article by Lawrence W. Way

.

1

Way LW, Stewart L, Gantert W, Liu K, Lee CM Whang K, Hunter JG (2003) Causes and pre-

vention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and

cognitive psychology perspective. Ann Surg 237:460–469.

There is no need to educate you further on the topic of laparoscopic chole- cystectomy. However you may need some advice on the open procedure, which is becoming rare in elective practice, and is increasingly being reserved for the “dif- ficult” cases.

The routine, “maxi”, full-size gallbladder abdominal incision belongs to his- tory.In the acute situation start with a “midi”– 5 to 10 cm – transverse RUQ incision, extending “piecemeal” as necessary. When converting from LC simply extend the epigastric trocar site laterally.

The wise-man’s rule is: “go fundus first (dome down) and stay near the gall- bladder”. After needle-decompression (connect a wide-bore needle to the suction) of the distended gallbladder, hold the fundus up and away from the liver with an instrument and dissect down towards the cystic duct and artery, which are the last attachments to be secured and divided. By observing this rule it is virtually impos- sible to damage anything significant such as the bile duct.

Subtotal (Partial) Cholecystectomy

Asher Hirshberg, MD, summarized it aptly: “It is better to remove 95% of the gallbladder (i.e., subtotal cholecystectomy) than 101% (i.e., to together with a piece of the bile duct).

And yes, yes, yes – any weathered surgeon will tell you that this is the proce- dure to use, in order to avoid misery, in problematic situations such as fibrotic triangle of Calot,portal hypertension,or coagulopathy.Partial or subtotal cholecyst- ectomy has been popularized in the United States by Max Thorek (1880–1960) and thus some call it the Thorek procedure. Thorek, by the way, was a keen aphorist and also said: “…how old is our newest knowledge, how painfully and proudly we struggle to discoveries, which, instead of being new truth, are only rediscoveries of lost knowledge”.

The gallbladder is resected starting at the fundus; the posterior wall (or what

has remained of it when a necrotizing attack has occurred) is left attached to the

hepatic bed and its rim is diathermized or oversewn for hemostasis with a running

suture. At the level of Hartmann’s pouch, the cystic duct opening is identified from

within. The accurate placement of a purse-string suture around this opening, as

described by others, is not satisfactory, because the suture tends to tear out of the

inflamed and friable tissues. A better option is to leave a 1-cm rim of Hartmann

pouch tissue and suture-buttress it over the opening of the cystic duct. When no

healthy gallbladder wall remains to close the cystic duct, it is absolutely safe just

to leave a suction drain and bail out. In the absence of distal common bile duct

obstruction you won’t see even a drop of bile in the drain because in such cases the

cystic duct is obstructed due the inflammatory process. The exposed and often

necrotic mucosa of the posterior gallbladder wall is fried with diathermy (some say until you smell fried liver…) and the omentum is brought into the area. In this operation, the structures in the Calot’s triangle are not dissected out and bleeding from the hepatic bed is avoided; it is a fast and safe procedure having the advantages of both cholecystectomy and cholecystostomy.

Cholecystostomy

In our hands,subtotal cholecystectomy has almost replaced “open”tube chole- cystostomy for the “difficult” gallbladder. This latter procedure is indicated in the very rare patient who must be done under local anesthesia and then only when per- cutaneous cholecystostomy is not available or is not successful.

After the infiltration of local anesthesia place a “mini” incision over the point of maximum tenderness or the palpable gallbladder mass.You can mark the position of the fundus on the skin at the pre-operative ultrasound as it is rather unpleasant for both you and the patient to enter the abdomen, under local anesthesia, and find that the gallbladder is far away.Visualization of gallbladder wall necrosis at this stage mandates a subtotal cholecystectomy; otherwise open the fundus and remove all stones from the gallbladder and Hartmann’s pouch. For improved inspection of the gallbladder lumen,and complete extraction of stones and sludge,a sterile(!) procto- scope may be useful. Thereafter, insert into the fundus a tube of your choice (we prefer a large Foley), securing it in place with a purse-string suture. Fix the fundus to the abdominal wall, as you would do with a gastrostomy. A tube cholangiogram performed a week after the operation will tell you whether the cystic duct and bile ducts are patent; if so the tube can be safely removed. Whether an interval cholecystectomy is subsequently indicated is controversial. Cystic duct obstruction on the other hand (according to the prevailing dogma) mandated interval cholecyst- ectomy.

Choledocholithiasis Associated with Acute Cholecystitis

About a tenth of patients who suffer from AC also have stones in the bile

ducts. Remember, however, that AC may produce jaundice and liver enzyme dis-

turbances in the absence of any ductal pathology. AC is very rarely associated

with active complications of choledocholithiasis. In other words, AC combined

with acute pancreatitis, ascending cholangitis, or jaundice is unusual. The

emphasis, therefore, should be on the treatment of AC, which represents the

life-threatening condition; ductal stones, if present, are of secondary impor-

tance.

Our management of patients with diagnosed AC and suspected choledo- cholithiasis would be tailored to the severity of the AC, the ultrasound appearances of the bile ducts, and the condition of the patient.Add to the decision tree your local facilities. As you know, there are many ways to skin this particular cat:

 Acute cholecystitis, mildly elevated bilirubin and enzymes, bile ducts not dilated on ultrasound: we would start with LC combined with intra-operative cholangiography. Should the latter be positive we would proceed with an open common bile duct exploration or – if the stones are small – leave them to be dealt with by ERCP (endoscopic retrograde cholangiopancreatography) after the opera- tion. Of course, if you are skilled at laparoscopic trans-cystic common bile duct exploration, have at it!

 If the bile ducts are dilated on ultrasound, there are liver function distur- bances, and the AC is clinically not “severe” we would treat it conservatively and evaluate the duct with MRCP (magnetic resonance cholangiopancreatography) or ERCP. Any ductal stones would be dealt by endoscopic sphincterotomy prior to LC.

 In the critically ill patient with or without gallbladder empyema or perforation we would even “waive” the cholangiogram, leaving the symptomatic ductal stones to endoscopic retrieval after the life-saving cholecystectomy or cholecystostomy.

Acalculous Cholecystitis

This is a manifestation of the disturbed microcirculation in critically ill patients.Although of multifactorial etiology (e.g. prolonged fasting, administration of total parenteral nutrition etc.) the common pathogenic pathway is probably gall- bladder ischemia, mucosal injury and secondary bacterial invasion. Acalculous cholecystitis is a life-threatening condition developing during a serious illness, e.g., following major surgery or after severe injury. Stones may occasionally be present in the acutely inflamed gallbladders in these circumstances but are probably etiologically irrelevant.

Clinical diagnosis is extremely difficult in the postoperative, critically ill or traumatized patient as abdominal complaints are masked. Fever, jaundice, leuko- cytosis and disturbed liver function tests are commonly present but are entirely nonspecific.Early diagnosis requires a high index of suspicion on your part: suspect and exclude cholecystitis as the cause of an otherwise unexplained “septic state” or SIRS (systemic inflammatory response syndrome).

Ultrasonography performed at the bedside is the diagnostic modality of

choice.Gallbladder wall thickness (>3.0–3.5 mm),intramural gas,the “halo”sign and

pericholecystic fluid, are very suggestive. Similar findings on CT examination would

confirm the diagnosis. False-positive and negative studies have been reported with

both imaging modalities. Hepatobiliary radio-isotope scanning is associated with

a high incidence of false-positive studies. However, filling of the gallbladder with the radio-isotope (morphine assisted, if necessary) excludes cholecystitis. A highly suggestive clinical scenario and diagnostic uncertainty together are an indication for abdominal exploration.

Management should be promptly instituted as acalculous cholecystitis progresses rapidly to necrosis and perforation. Select the best treatment modality based on the condition of your patient and the expertise available in your hospital.

In patients stable enough to undergo general anesthesia cholecystectomy is indi- cated.When coagulopathy,portal hypertension or severe inflammatory obliteration of the triangle of Calot are present, subtotal cholecystectomy appears to be safer.

Laparoscopic cholecystectomy may be performed in well-selected and stable patients. Note: Insufflation pressure during laparoscopy should be kept under 10 mmHg in order not to upset the flimsy cardio-respiratory balance and hemo- dynamics in such patients.

“Open” tube cholecystostomy under local anesthesia may be indicated in the moribund patient when expertise for percutaneous, transhepatic cholecystostomy is not locally available. The latter is the procedure of choice in the severely ill patient when diagnostic certainty is strong.

Remember: Many of these patients will have a totally necrotic or perforated gallbladder. In these, cholecystostomy may not suffice. Percutaneous cholecystos- tomy is a blind procedure; when rapid resolution of “sepsis” does not follow suspect residual pus or necrosis, or an alternative intra-abdominal or systemic diagnosis.

Antibiotics in Acute Cholecystitis

Although routinely administered the role of antibiotics is only adjunctive to the operative treatment as outlined above. In its early phase AC represents a sterile inflammation, while later on in most instances it represents a “resectable infection”, i.e. infection contained within the gallbladder that is to be removed (

Chap. 12).

Therefore, cases with simple AC need only peri-operative antibiotic “coverage”, which is discontinued postoperatively. In gangrene or contained empyema of the gallbladder we recommend a day or two of post-cholecystectomy antibiotic administration. In cases of perforation with a per-cholecystic abscess or bile peri- tonitis we suggest that you administer the maximal postoperative course of 5 days

(

Chap. 42).

When the gallbladder is “difficult” – go fundus first and stay near the wall.