Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis?

UNLABELLED: Gangrenous cholecystitis is difficult to diagnose clinically and carries risk of morbidity and mortality if not treated urgently. Complex scoring systems exist to predict the condition. C reactive protein may be a single independent predictor as suggested in this small study. BACKGROUND: Gangrenous cholecystitis (GC) is a serious sequel of acute cholecystitis occurring in 2-30% patients and has a mortality of 0.2-0.5%. Urgent surgical intervention is important to reduce morbidity and mortality therefore it is important to identify patients with GC from non-severe cholecystitis. The aim of this study is to determine biochemical and radiological markers, which is associated with the development GC and the value of C-reactive protein (CRP) at different cut-offs in predicting GC. METHODS: This is an observational cohort study of all consecutive patients who presented with biliary symptoms to the emergency department in a large NHS Hospital in the UK, from January to December 2012. They had cholecystectomies performed either during index admission or electively at later date by a team of 4 upper gastrointestinal surgeons. The gangrenous nature of the gallbladder was determined by operative findings and/or histopathology results. Parameters including age, gender, albumin, jaundice, gallbladder wall thickness on ultrasound scan, highest preoperative white blood count (WBC) and CRP value, were examined for their predictive value. RESULTS: 141 patients presented with acute biliary problems. 22 underwent emergency cholecystectomy and 119 were discharged and called back for elective surgery. Of these, 16 were gangrenous (11%). Patients with GC were significantly older (p = 0.016), had significantly higher CRP (p < 0.001) and WBC (p = 0.001), significantly lower albumin levels (p < 0.001) and higher percentage with thick walled gallbladder (p < 0.001). We found that a CRP value of more than 200 mg/dL has a 50% positive predictive value and 100% negative predictive value in predicting gangrenous cholecystitis with 100% sensitivity and 87.9% specificity. CONCLUSIONS: In this study CRP on its own has been shown to have high predictive value in predicting GC, but larger studies are needed to validate this finding. Monitoring trend of CRP in patients with acute cholecystitis may help early diagnosis and decision for early surgical intervention.

Peritonitis from an abdominal wall biloma: a unique reason to avoid prophylactic surgical drainage.

Prophylactic drainage of the peritoneal space after major surgery is widely practised despite evidence against its efficacy. We describe the case of a 56-year-old woman who underwent a converted cholecystectomy and whose correctly sited abdominal drain resulted in the formation of a biloma between the external and internal oblique musculature. Subsequent leakage from the biloma into the abdominal cavity presented as peritonitis days after surgery, necessitating an emergency laparotomy. This case represents the first reported description of an abdominal wall biloma as a complication of post-cholecystectomy abdominal drainage. The evidence surrounding prophylactic drainage is discussed.

Angelchik prosthesis with oesophageal adenocarcinoma: our surgical approach.

The Angelchik prosthesis is an incomplete doughnut-shaped device composed of silicone elastomer used in the treatment of gastro-oesophageal reflux disease (GORD). It is used to encircle the lower oesophagus at the gastro-oesophageal junction (GOJ). The ease of the operation led to the insertion of over 25,000 such prostheses world-wide. However, a variety of major complications including intractable dysphagia, prosthesis migration and gastric erosion required a quarter of these devices to be removed. Development of adenocarcinoma in patients with Angelchik prosthesis is a rare occurrence. This article describes two patients who developed adenocarcinoma above their prosthesis and whose cardio-oesophagectomy was technically challenging due to the formation of a dense inflammatory capsule around the prosthesis. Our surgical approach to curative oesophageal resection with the Angelchik prosthesis in situ is also discussed.

Effect of cyclic hormonal changes during normal menstrual cycle on esophageal motility.

Pregnancy has an inhibitory effect on motility of the gastrointestinal tract most likely related to increased levels of circulating female sex hormones. Similar fluctuations of hormones occur during the normal menstrual cycle, but to a much lesser degree. We studied the effect of these sequential hormonal changes on esophageal motility and acid exposure by performing an ambulatory esophageal motility/pH study (AEM/pH) during the follicular (days 2-4) and luteal phases [days 4-8 after the luteinizing hormone (LH) surge] of the menstrual cycle. Ten normal menstruating women aged 21-39 years, (mean age 31) were studied with a Konigsberg catheter positioned such that the pH probe was 5 cm above and pressure transducers 7 and 15 cm above the LES. Ovulation was predicted by LH detection kit, and serum progesterone levels were obtained in the luteal phase. Each study was performed for 16 hr and included meal, upright, and supine periods. Peristaltic contractions increased during the meal periods and decreased during supine periods. Simultaneous and isolated contractions increased during supine periods and decreased with meals. Number and amplitude of distal esophageal contractions did not differ significantly between follicular and luteal phase during meal, upright and supine periods. Median percentage of time of distal esophageal pH<4 and median acid clearance were similar between the two phases. In conclusion, esophageal motility and acid exposure, as measured by AEM/pH, are not affected by the hormonal changes that occur during the menstrual cycle.

Different effects of an oral anticholinergic drug on gastroesophageal reflux in upright and supine position in normal, ambulant subjects: a pilot study.

OBJECTIVE: There is controversy in the literature on the effects of anticholinergic drugs on gastroesophageal reflux. Our aim was to study more extensively the effects of an oral anticholinergic drug on esophageal motility and gastroesophageal reflux in normal ambulant subjects under different circumstances: upright, supine, fed, and fasted state. METHODS: Fifteen healthy subjects (seven men, eight women), mean age 34 yr (range, 22-61 yr) underwent randomized placebo-controlled 16-h evening and overnight ambulatory esophageal motility/pH study. After a 3-day loading dose of either oral dicyclomine (Dic) 20 mg four times daily or placebo (Pla), an ambulatory esophageal motility/pH study was performed while taking medication or placebo. Each study was analyzed for meal, first and second h postprandial, upright and supine periods, and first 2 h supine after bedtime snack. RESULTS: The mean number of reflux episodes decreased with dicyclomine during the first h postprandial (Dic, 1.9 vs Pla, 2.5; p < 0.05). During the first 2 h supine, mean number of reflux episodes increased with dicyclomine (Dic, 1.4 vs Pla, 0.8; p < 0.09), as did mean percent time pH < 4 (Dic, 2.6 vs Pla, 0.5; p < 0.04), with an increase in clearance time (Dic, 0.9 vs Pla, 0.3; p < 0.05; in min). Mean peristaltic amplitude decreased with dicyclomine during the 2nd h postprandial (Dic, 48.8 vs Pla, 56.3; p < 0.04). CONCLUSIONS: Oral dicyclomine caused a decrease in early postprandial upright reflux episodes, but also significantly increased the percent time pH < 4 during the first two h supine. Therefore, its effects are dependent on body position and fasted or fed state. Our results justify additional studies with oral anticholinergic agents in patients with gastroesophageal reflux disease.

Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become firmly established as a procedure of choice for gallstone disease. The procedure usually necessitates general anaesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. There is a paucity of data in the literature on the procedure being performed under regional (epidural) anaesthesia, especially in patients with coexisting pulmonary disease and pregnancy, who are deemed high risk for general anaesthesia. We report our preliminary experience with LC using epidural anaesthesia in patients with chronic obstructive pulmonary disease (COPD). METHODS: We performed LC in six patients (one man and five women), with a median age of 56 years (range, 38-74), under epidural anaesthesia over an 8-month period. All patients were ASA grade III/IV and the mean FEB1/FVC was 0.52 (range, 0.4-0.68), due to chronic asthma (two cases) and COPD (four cases). They were admitted a day prior to surgery for pulmonary function tests, nebulisers, and chest physiotherapy. An epidural catheter was introduced at T10/11 intervertebral space, and a bolus of 0.5% Bupivacaine was administered. Depending on the patient's pain threshold and the segmental level of analgesia achieved, incremental doses of 2 ml of 0.5% Bupivacaine along with boluses of intravenous 100 mcg Alfentanil was given to each patient. The patients were breathing spontaneously. No nasogastric tube was inserted, and a low-pressure (10 mmHg) pneumoperitoneum was created. LC was performed according to the standard technique. RESULTS: All the patients tolerated the procedure well and made an uneventful postoperative recovery. Median operating time was 50 min; average length of hospital stay was 2.5 days (range, 2-4). The epidural catheter was removed the morning after the operation. Only one patient required postoperative opioid analgesia. Two patients complained of persistent shoulder tip pain during surgery and required intraoperative analgesia (Alfentanil). There was no change in the patient's cardiorespiratory status, including PO2 and pCO2, and no complications occurred either intra- or postoperatively. CONCLUSIONS: LC can be performed safely under epidural anaesthesia in patients with severe COPD. Intraoperative shoulder tip or abdominal pain does not seem to be a major deterrent and can be effectively controlled with small doses of opioid analgesia.

Globus sensation is associated with hypertensive upper esophageal sphincter but not with gastroesophageal reflux.

Globus sensation (globus) is best described as a constant feeling of a lump or fullness in the throat. Although the etiology of globus remains unclear, it has been attributed to a hypertensive upper esophageal sphincter (UES) resting pressure and to gastroesophageal reflux (GER). The aim of this study was, therefore, to determine if significant associations existed among globus, UES resting pressure, and GER. We reviewed the records of all patients who had stationary esophageal manometry over a 21/2-year interval with specific attention to symptoms of globus, UES pressures, and ambulatory pH studies. Patients with hypotensive UES (<30 mm Hg) were excluded. Chi square (chi2) test was used to determine significant associations. Six hundred fifty patients had normal UES resting pressures and 101 patients had hypertensive UES (>118 mm Hg). Seventeen of the 650 (3%) (16 women/1 man; mean age: 48, range 32-81 years) with normal UES described globus. Conversely, 28 of the 101 (28%) (15 women/13 men; mean age: 43, range 23-61 years) patients with hypertensive UES described globus. There was a significant association between hypertonicity of the UES and globus (chi2=93.42, P < 0.0001). In patients with normal UES, globus occurred predominantly in females (chi2=6.33, P < 0.01). Twenty-three (16 women/7 men; mean age: 43, range 23-60 years) of the 45 patients with globus had prior ambulatory pH studies. Six of 23 (26%) had GER. Compared to an age-, sex-, and UES-pressure-matched group of 23 patients (16 women/7 men; mean age: 44, range 22-75 years) without globus, nine (39%) had GER, thus showing no significant association of globus with GER (P=0.35). There also was no significant association of GER with normal UES or with hypertensive UES in these patients. In conclusion, there is a significant association between hypertensive UES and globus. The data suggest two possible etiologies: female patients with normal UES pressure potentially having increased afferent sensation and a group with equal sex distribution but abnormally elevated UES resting pressure. This study does not support GER as an etiology of globus.

Experimental study of acid burden and acute oesophagitis.

BACKGROUND: The relationship of the pH of oesophageal refluxate and its pepsin content to injury of oesophageal mucosa remains unclear. A study was made of the earliest morphological alterations in the oesophageal mucosa secondary to varying concentrations of hydrochloric acid with or without pepsin. METHODS: Adult cats had varying concentrations of acid with and without 1 per cent porcine pepsin infused into the oesophagus through a paediatric feeding tube placed 5 cm above the oesophagogastric junction at a rate of 1 ml/min for 30 min. At autopsy 24 h later, the oesophagus was removed intact and scored by an expanded modification of a previously published histopathological scoring system. This included estimates of the intensity and distribution of four morphological features: basal cell hyperplasia (BCH), intraepithelial leucocytes (IELs), subepithelial leucocytes and ulcers. Each of these four categories was scored from 0 to 4, with a maximum injury score of 16. RESULTS: Mean(s.e.m.) scores were as follows: pH 1, 15.0(1.0); pH 1 with pepsin, 13.3(1.4); pH 2, 15.3(0.7); pH 2 with pepsin, 11.7(1.1); pH 3, 1.8(1.6); pH 3 with pepsin, 3.7(1.9); pH 4 with or without pepsin, 0.6(0.2). Differences between pH 3 and 4 versus pH 1 and 2 were significant (P < 0.05). CONCLUSION: Injury to the oesophagus is more dependent on the pH of refluxate than on the presence of pepsin. Peptic injury appears to occur at a critical threshold of acid burden (pH < 3) as opposed to a graded level of injury based on a pH scale.

Proximal and distal esophageal contractions have similar manometric features.

The human esophagus is composed of striated muscle proximally and of smooth muscle distally with a transition zone between the two. Striated muscle contracts much faster than smooth muscle. The change in pressure over time (dP/dt) of the contraction amplitude should therefore be higher in proximal than in distal esophagus, reflecting the presence of striated muscle proximally. There were 34 normal esophageal manometries of patients analyzed for swallow amplitude and dP/dt in the pharynx and esophagus. An additional 11 healthy controls were similarly studied. Amplitudes in pharynx and proximal and distal esophagus were not different. The mid-esophagus had a pressure trough (P < 0.001). The dP/dt in the pharynx was much higher than that in the esophagus (P < 0.001). The dP/dt of proximal and distal esophagus were of the same order of magnitude. The manometric behavior of the striated muscle portion of the proximal esophagus differs from that seen in the pharynx and shows similar characteristics to distal esophageal smooth muscle.

Comparison of lower oesophageal sphincter pressure measurement using circumferential vs unidirectional transducers.

UNLABELLED: Average values from unidirectional (UND) transducers have traditionally been used in standard manometric evaluation of lower oesophageal sphincter pressures (LOSPs). A single circumferential (CMF) transducer has recently become popular. Our aim was to compare LOSP measurements made using the two techniques. Ten healthy volunteers were intubated with a Konigsberg manometry catheter containing five solid-state transducers (four unidirectional at 90 degrees angles radially and 2.5-cm intervals and one circumferential, 3 cm distal). LOSP was measured using the station pull-through technique in the supine and upright positions with Synectics Polygram software for computerized analysis. Mean UND pressures were plotted against CMF pressures and a linear regression and correlation analysis was performed. A similar analysis was done for LOS length. A significant difference (P < 0.01) was found between mean (+/- SE) supine and upright LOSPs for both mean UND (20.21 +/- 1.36 vs 15.56 +/- 1.28 mmHg) and CMF (20.41 +/- 1.96 vs 16.17 +/- 1.61 mmHg); however no difference was shown between supine and upright lengths. There was a high degree of correlation between LOSP (r = 0.83) and a weaker correlation (r = 0.65) between LOS lengths when measured by CMF and UND transducers. CONCLUSION: UND and CMF transducers provide identical measurements when evaluating the LOS.

Evaluation of the antireflux mechanism following laparoscopic fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastro-oesophageal reflux disease (GORD), but the underlying motility mechanisms that explain the success of this operation remain unclear. METHODS: Twenty patients with a history of GORD underwent stationary oesophageal manometry and prolonged ambulatory pH monitoring, both before and 3 months after fundoplication. RESULTS: Eighteen patients were completely cured of reflux symptoms and stopped all antireflux medication after operation. After fundoplication there was a significant increase (P < 0.01) in median resting lower oesophageal sphincter (LOS) pressure and length. Median residual LOS pressure during swallow-induced LOS relaxation also increased significantly after operation (P < 0.01). The number of reflux episodes decreased from a median of 48 to 3 after fundoplication (P < 0.01). The time at pH less than 4 decreased from 5.7 to 0 per cent in the supine position (P < 0.01), and from 9.8 to 0.2 per cent while upright (P < 0.001). CONCLUSION: Early subjective results at 3 months following laparoscopic antireflux surgery show improved symptoms. One of the mechanisms underlying the antireflux action of fundoplication is an increase in median residual LOS pressure at the gastro-oesophageal junction. This may be a purely mechanical effect of the fundic wrap extrinsic to the LOS.

An objective assessment of laparoscopic antireflux surgery.

BACKGROUND: Complicated gastroesophageal reflux disease (GERD) requires long-term medical therapy, which in some instances is incompletely effective or poorly tolerated. Additionally, there is concern about the consequences of prolonged acid suppression therapy. Surgical correction of GERD has been a therapeutic option for decades. With the advent of video-assisted laparoscopic surgery, antireflux surgery has had a resurgence in popularity. PATIENTS AND METHODS: Between October 1992 and June 1995, 20 patients who underwent laparoscopic antireflux surgery were completely studied preoperatively and 3 months postoperatively with 24-hour pH monitoring and esophageal manometry. Follow-up averaged 18 months. The indication for surgery was medically refractory disease in 75%, intolerance to medication in 10%, and concern regarding the consequences of long-term medical therapy in 15%. Two thirds of these patients had complicated GERD. RESULTS: Operative time averaged 4 hours. There was no conversion to an open procedure. There was no mortality. Two patients had recurrent reflux, for a failure rate of 10%. Overall, postoperative reflux episodes and percent of time pH was less than 4 dropped significantly. Lower esophageal sphincter function showed a statistically significant increase in mean postoperative resting pressure and residual sphincter pressure during swallowing. There was no change in motility postoperatively. CONCLUSIONS: Laparoscopic antireflux surgery is a safe, effective, therapeutic alternative in the management of gastroesophageal reflux disease.

Effective gastric acid suppression after oral administration of enteric-coated omeprazole granules.

Omeprazole is inactivated by exposure to gastric acid and is formulated as a gelatin capsule containing enteric-coated granules that release the drug in alkaline medium. In clinical situations where patients are unable to take the capsule orally, the optimum means of administration is uncertain. Eleven normal volunteers were given omeprazole 20 mg every day for one week before breakfast in random order as either a 20-mg capsule with water or free enteric-coated granules with either 8 oz of orange juice, 8 oz of water with 2 Alka-Seltzer antacid tablets (aspirin free), or 1 teaspoon of apple sauce. On day 7 of each regimen, an 8-hr intragastric pH study was performed following omeprazole 20 mg and standard breakfast. The median percentage of time of gastric acid pH > 4 after an omeprazole capsule was 68.5 (25-100); after granules with orange juice 59 (43-100); after granules in Alka-Seltzer solution 63 (31-100), and after granules in apple sauce 65 (30-99), with no significant differences (ANOVA). The time for the gastric pH to reach <4' after having been above was also similar for all four regimens (ANOVA). Omeprazole granules administered orally in a variety of ways achieve gastric acid suppression as effectively as the intact capsule.

Effect of transjugular intrahepatic portosystemic shunt on secondary hypersplenism.

BACKGROUND: Portal hypertension is frequently associated with secondary hypersplenism, two common clinical manifestations of which are leukopenia and thrombocytopenia. Surgical portosystemic shunts alleviate portal hypertension but their effect on hypersplenism remains unpredictable. Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure for portal decompression. From current reports it is not clear if TIPS improves hypersplenism in patients with portal hypertension. We present a retrospective review of our experience with TIPS to determine the effect on hypersplenism. PATIENTS AND METHODS: Sixty-five patients who had a TIPS procedure between December 1991 and June 1994 were evaluated retrospectively. The records were specifically reviewed for platelet and white blood cell counts performed before the procedure, within a week after the procedure, and then again within the subsequent 3 weeks. Hypersplenism was defined as thrombocytopenia (platelet count of <100,000/mm3), leukopenia (white blood cell count of <5,000/mm3), or both. RESULTS: Thrombocytopenia alone was present in 33 patients and leukopenia alone in 4 patients before TIPS was performed. Both leukopenia and thrombocytopenia were present in 12 individuals. At least one of these indices of hypersplenism was present in 49 patients. Leukocyte count improved in 11 of 16 patients (69%) whereas platelet count improved in 34 of 45 patients (75%) within a week of the procedure. In the subsequent 3 weeks, leukopenia was relieved in 5 of 10 patients (50%) and thrombocytopenia in 21 of 28 patients (75%), respectively. Of the 12 patients who had both leukopenia and thrombocytopenia before TIPS, the indices improved in 4 patients (33%) within a week of the procedure. Thrombocytopenia was more consistently corrected as opposed to leukopenia, albeit in the short term. CONCLUSION: The TIPS procedure is a promising, minimally invasive method of portal decompression that is effective in the treatment of complications of portal hypertension including secondary hypersplenism.