Xanthogranulomatous cholecystitis: Diagnostic dilemma and surgical solution in geriatric patients: A case report.

INTRODUCTION: Xanthogranulomatous Cholecystitis (XGC) is a rare inflammatory condition characterized by the presence of xanthogranulomas within the gallbladder wall, often mimicking gallbladder carcinoma (GBC). Diagnosis is challenging and may require biopsy. Once GBC is excluded, an open cholecystectomy is recommended, although laparoscopic cholecystectomy is increasingly being performed with great caution. This case report aims to evaluate clinical and radiological features, surgical outcomes, and treatment approaches for XGC. CASE PRESENTATION: A 70-year-old patient presented with right hypochondrial pain and a palpable gallbladder. A CT scan revealed a distended lithiasic gallbladder with a thickened irregular wall and hepatic nodules. A hepatic MRI suggested xanthogranulomatous cholecystitis. A CT-guided biopsy of the liver nodule showed no signs of malignancy. An open cholecystectomy with a trans-cystic drain was performed. Histological examination confirmed chronic xanthogranulomatous cholecystitis. The patient was discharged on postoperative day 10. A clinical and radiological follow-up at 6 months postoperatively showed no abnormalities. CLINICAL DISCUSSION: XGC presents diagnostic challenges due to its resemblance to GBC. Imaging aids in diagnosis, but biopsy may be necessary. Open cholecystectomy is the recommended surgical treatment due to excessive local inflammation and the risk of concomitant malignancy. CONCLUSION: Managing XGC demands a holistic approach that integrates all clinical insights and mandates close collaboration among a multidisciplinary team of surgeons, radiologists, and pathologists. Further research is needed to refine diagnostic and therapeutic strategies for this rare condition, especially in geriatric patients.

Metagenomic Analysis of Biliary Microbial Flora in Patients with Gallbladder Cancer or Gallstones-Associated Chronic Cholecystitis.

Biliary dysbiosis is associated with gallbladder cancer (GBC). We aimed to look for biliary bacteria specifically detected in GBC patients. We used 16S rRNA-based metagenomic analysis to elucidate biliary microbiota in 30 GBC and 30 gallstones-associated chronic cholecystitis patients. Relative abundance of five genera, Streptococcus, Enterococcus, Halomonas, Escherichia and Caulobacter was significantly associated with GBC. Of 15-species, 7 were detected significantly higher in GBC, Streptococcus anginosus, Streptococcus constellatus, Streptococcus intermedius, Actinomyces bowdenii, Actinomyces israelii, Actinomyces gerencseriae, and Escherichia fergusonii were biosafety level-2 infectious bacteria; other 8 species were biosafety level-1 bacteria. These bacterial species may be involved in pathogenesis of GBC.

Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series.

Introduction: Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult). Case series: The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy. Discussion: Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury. Conclusion: The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.

Chyle and Bile Leak Following Open Cholecystectomy: A Rare Complication.

Gallstone disease is extremely common and frequently and safely treated by cholecystectomy. Chyle leak is a rare but significant side effect of many abdominal surgeries with rarely reported post-cholecystectomy. In this case, we report a 78-year-old lady with multiple comorbidities and symptomatic gallstones who underwent open cholecystectomy complicated by bile and chyle leak, which was successfully managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting for bile leak and conservative management for the chyle leak, which included drainage, low-fat diet, and octreotide.

A Rare Case of Duplicated Gallbladder in the United Arab Emirates.

Gallbladder duplication is a rare congenital aberration that requires special attention due to its clinical, diagnostic, and surgical complexity. Its symptoms are usually consistent with cholecystitis and other gallbladder etiologies. This is a case report of a 39-year-old male patient with a known case of chronic cholecystitis and cholelithiasis. He presented with mild epigastric abdominal pain over two months; as a result, he opted for elective cholecystectomy. Subsequently, a type I septate duplicated gallbladder was incidentally diagnosed following a histopathology report. This literature is the first report of a case of septate gallbladder duplication presenting with cholecystitis in the United Arab Emirates.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons.

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

A case of Vagococcus fluvialis isolated from the bile of a patient with calculous cholecystitis.

BACKGROUND: Chronic cholecystitis, characterized by persistent inflammation of the gallbladder, predominantly stems from the prolonged presence of gallstones. Calculous cholecystitis has demonstrated a consistent escalation in its incidence over time.Gallbladder stones have been recognized as a predisposing factor for the development of biliary tract infections.Concomitantly, there have been substantial shifts in the distribution and resistance profiles of pathogenic microorganisms responsible for biliary tract infections. The timely acquisition of bile samples for pathogen analysis is of paramount importance, given its critical role in guiding judicious clinical pharmacotherapy and enhancing patient prognosis. CASE PRESENTATION: We present a case involving a 66-year-old female patient who had previously undergone subtotal gastrectomy due to diffuse large B-cell lymphoma. The patient was admitted to our institution with complaints of abdominal pain. Subsequent diagnostic evaluation revealed concurrent choledocholithiasis and cholecystolithiasis. The patient underwent surgical cholecystectomy as the therapeutic approach. Histopathological examination of the excised gallbladder disclosed characteristic features indicative of chronic cholecystitis. Subsequent laboratory analysis of the patient's bile specimen yielded Gram-positive cocci, subsequently identified through biochemical assays, mass spectrometry, and 16 S rRNA analysis as Vagococcus fluvialis. Further in vitro antimicrobial susceptibility testing using disk diffusion and microfluidic dilution showed that this strain exhibited inhibition zone diameters ranging from 12.0 to 32.0 mm in response to 26 antibiotics, including ampicillin, cefazolin, cefuroxime, cefotaxime, ceftriaxone, cefepime, ampicillin/sulbactam, piperacillin, ciprofloxacin, cefoperazone/sulbactam, imipenem, meropenem, piperacillin/tazobarb, penicillin, erythromycin, chloramphenicol, vancomycin, methotrexate/sulfamethoxazole, teicoplanin, linezolid, tigecycline, cefoxitin, ceftazidime, levofloxacin, minocycline and tobramycin. However, the inhibition zone diameters were 6.0 mm for amikacin, oxacillin, clindamycin, and tetracycline. The patient received ceftazidime anti-infective therapy both preoperatively and within 24 h postoperatively and was discharged successfully one week after surgery. CONCLUSION: In this study, we present the inaugural isolation and identification of Vagococcus fluvialis from bile specimens of patients afflicted with calculous cholecystitis. This novel finding lays a substantial experimental groundwork for guiding clinically rational antimicrobial therapy and advancing the exploration of relevant pathogenic mechanisms pertaining to Vagococcus fluvialis infections.

Massive Hemothorax Caused by Removal of Percutaneous Transhepatic Abscess Drainage Tube for Bile Leak After Subtotal Cholecystectomy: A Case Report.

A 59-year-old man with a past medical history of gallstones was diagnosed with acute cholecystitis and received antibiotic treatment. He was discharged after ten days of hospitalization and was due to undergo laparoscopic cholecystectomy. Three months later, however, he had to be readmitted due to a recurrence of acute cholecystitis. Subsequently, laparoscopic reconstituting subtotal cholecystectomy was performed because Inflammation of the gallbladder was severe. At the first postoperative outpatient visit, the patient reported obstructive jaundice, and computed tomography (CT) scan revealed fluid collection in the hepatic bed and a missed common bile duct stone. Percutaneous transhepatic abscess drainage (PTAD) was performed on admission, and endoscopic stone removal was attempted the following day but was challenging due to a periampullary diverticulum. During laparotomy for stone extraction, the patient experienced prolonged shock and CT showed bleeding from the liver and massive right hemothorax. After open chest drainage and hemostasis, transcatheter arterial embolization (TAE) was performed. Such a case has never been reported before, and the PTAD tube should be handled cautiously.

Use of Percutaneous Cholecystostomy for the Management of Complicated Cholecystitis Causing Gastric Outlet Obstruction in an Elderly Patient.

The management of complicated cholecystitis in an elderly patient can present a complex clinical decision for surgeons. There is literature supporting the use of immediate laparoscopic cholecystectomy for cases of uncomplicated cholecystitis in elderly patients and complicated cholecystitis in the general population. There are, however, no clear guidelines for treating the unique presentation of an elderly patient with complicated cholecystitis. This is likely due to the many clinical risk factors that must be considered when caring for these complex patients often with many medical comorbidities. In this report, we present the case of an 81-year-old male with complicated chronic cholecystitis leading to the exceedingly rare complication of gastric outlet obstruction. The patient was successfully treated with percutaneous cholecystostomy tube placement and interval subtotal laparoscopic cholecystectomy.

Clinical Efficacy of Laparoscopic Cholecystectomy via Cystic Plate Approach for Gallstone Patients with Chronic Cholecystitis.

Introduction: Chronic cholecystitis has evolved into one of the digestive system diseases that negatively affect the quality of life of patients. This study was conducted to explore the clinical efficacy of laparoscopic cholecystectomy via cystic plate approach for the treatment of gallstones with chronic cholecystitis. Materials and Methods: Totally 184 gallstone patients with chronic cholecystitis who underwent laparoscopic cholecystectomy in The First People's Hospital of Wuhu from January 2021 to October 2022 were randomly divided into a control group (n = 92) and an observation group (n = 92). In the observation group and control group, the gallbladder was removed using the cystic plate approach and traditional approach, respectively. Surgical indicators and complications of patients were compared. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) were measured by enzyme-linked immunosorbent assay. The quality of life of patients was assessed using the SF-36 scale. Results: The recovery time of gastrointestinal function, intraoperative blood loss, and postoperative drainage volume in the observation group were significantly lower than those in the control group (P < .05). At 24 hours after surgery, the serum levels of IL-6, TNF-α, and CRP in the observation group were much lower than those in the control group (P < .05). Three months after surgery, the observation group showed a much higher quality of life score than the control group (P < .05). Conclusion: Laparoscopic cholecystectomy via cystic plate approach can effectively treat chronic gallstones with chronic cholecystitis. It shortened the recovery time of gastrointestinal function, reduced postoperative inflammation, and improved the quality of life.

Utility of near infrared fluorescent cholangiography in detecting biliary structures during challenging minimally invasive cholecystectomy.

BACKGROUND: Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invasive cholecystectomy through technical standardization by means of a precise anatomical landmark identification (Critical View of Safety) and advanced technology for biliary visualization. Among these systems, the adoption of magnified stereoscopic 3-dimensional view provided by robotic platforms and near infrared fluorescent cholangiography (NIRF-C) is the most promising. METHODS: In this prospective cohort study, we evaluated all consecutive minimally invasive cholecystectomies (laparoscopic and robotic) performed with NIRF-C between May 2022 and January 2023 at General Surgery Unit, Department of Health Sciences, University of Milan, San Paolo Hospital (Milan, Italy). Inclusions criteria were as follows: (1) acute cholecystitis (emergency group), (2) history of chronic cholecystitis or complicated cholelithiasis (deferred urgent group), (3) difficult cases (patients affected by cirrhosis, with scleroatrophic gallbladder or BMI > 35 kg/m2). For each group, the detection rate and visualization order of the main biliary structures were reported (cystic duct, CD; common hepatic duct, CHD; common bile duct, CBD; and CD-CHD junction). RESULTS: A total of 101 consecutive patients were enrolled, including 83 laparoscopic and 18 robotic cholecystectomies. All patients were stratified into three subgroups: (a) emergency group (n = 33, 32.7%), (b) deferred urgent group (n = 46, 45.5%), (c) difficult group (n = 22, 21.8%). Visualization of at least one biliary structure was possible in 94.1% of cases (95/101). Interestingly, all four main structures were detected in 43.6% of cases (44/101). The CD was the structure identified most frequently, being recognized in 91/101 patients (90.1%), followed by CBD (83.2%), CHD (62.4%), and CD-CHD junction (52.5%). In the subset of patients that underwent emergency surgery for AC, the CD-CHD confluence was identified in only 45.5% of cases. However, early and precise identification of CBD (75.8%) and CD (87.9%) allowed safe isolation, clipping, and transection of the cystic duct. In the deferred urgent group, the CBD and the CD were easily identified as first structure in a high percentage of cases (65.2% and 41.3% respectively), whereas the CD-CHD junction was the third structure to be identified in 67.4% of cases, the highest value among the three subgroups. In the difficult group, NIRF-C did not prove to be a useful tool for biliary visualization. The rates of failure of visualization were elevated: CBD (27.3%), CD (18.2%), CHD (54.5%), and CD-CHD (68.2%). CONCLUSIONS: NIRF-C is a powerful real-time diagnostic tool to detect CBD and CD during minimally invasive cholecystectomy, especially when inflammation due to acute or chronic cholecystitis subverted the anatomy of the hepatoduodenal ligament.

Fascioliasis associated with chronic cholecystitis in a woman from Sistan and Baluchestan province, a non-endemic region in Southeastern Iran.

BACKGROUND: Fascioliasis, caused by Fasciola hepatica, is a neglected zoonotic food-borne trematodiasis. The Caspian littoral in northern Iran is endemic for the disease, and human fascioliasis is well-known in that region. In the present study, we report the diagnosis, identification, and clinical management of a human case of fascioliasis associated with common bile duct (CBD) obstruction from a non-endemic remote area in southeastern Iran. CASE PRESENTATION: A 42-year-old female was admitted to Afzalipour Medical Center hepatobiliary surgery ward in Kerman with abdominal pain for the past three months. Dilated biliary tract and an ill-defined mass in CBD were reported in abdominal ultrasonography and magnetic resonance cholangiopancreatography, respectively. During distal CBD operation, nine leaf-like motile flatworms were isolated. A morphological study confirmed all the isolates as Fasciola, and further molecular investigations, identified the flukes as F. hepatica using both pepck multiplex PCR and cox1 sequencing. CONCLUSION: Molecular and morphological findings of the study indicated the presence of human fascioliasis in the southeastern province of Sistan and Baluchestan in Iran. Fascioliasis is among the etiologies of chronic cholecystitis, and physicians should consider chronic cholecystitis associated with fascioliasis in the differential diagnosis. In the present report, endoscopic ultrasound was usefully applied for the accurate diagnosis of biliary fasciolosis.

Extranodal Marginal Zone Mucosa-Associated Lymphoid Tissue Lymphoma of the Gallbladder: A Case Report and Literature Review.

We describe the case of a patient with extranodal marginal zone mucosa-associated lymphoid tissue (MALT) lymphoma of the gallbladder discovered incidentally after elective cholecystectomy. A 76-year-old female with a history of non-Hodgkin's lymphoma of the right breast and rectal cancer stage Tis requiring trans-anal excision presented with chronic intermittent abdominal pain. Computed tomography (CT) scan showed multiple calcified gallstones impacted in the gallbladder, with no evidence of enlarging lymphadenopathy indicating an elective cholecystectomy. The intra- and post-operative courses were unremarkable, but pathology review revealed immunohistochemistry positive for CD20 and BCL-2 with a Ki67 proliferation index of 5%, which was diagnostic of extranodal marginal zone MALT lymphoma of the gallbladder. The patient was followed up by a medical oncologist, and after extensive discussion, the decision was made to continue observation with close monitoring without systemic chemotherapy given the asymptomatic presentation. We also examined the pertinent literature to MALT lymphoma of the gallbladder and discussed theories suggested for its pathophysiology.

Clinical effect of laparoscopic cholecystectomy in the treatment of chronic cholecystitis with gallstones.

Chronic cholecystitis is a common disease that causes inflammation in the gallbladder and is usually associated with gallstones. Laparoscopic cholecystectomy has been widely used as a minimally invasive surgical technique to treat this condition. However, the clinical effect of laparoscopic cholecystectomy in the treatment of chronic cholecystitis with gallstones needs further investigation. This study aimed to investigate the clinical effect of laparoscopic cholecystectomy in treating chronic cholecystitis with gallstones. 90 patients with chronic cholecystitis and gallstones were randomly divided into control and research groups. The control group underwent traditional open cholecystectomy, while the research group received laparoscopic cholecystectomy. Perioperative indexes, oxidative stress indexes, serum inflammatory factors, liver function indexes and the incidence of complications were observed and compared. Results showed that laparoscopic cholecystectomy significantly reduced the operation time, blood loss, anal exhaust time, abdominal pain duration, and hospital stay compared to traditional open cholecystectomy (P < 0.05). Moreover, laparoscopic cholecystectomy significantly reduced the levels of oxidative stress indexes (GSH-Px), inflammatory factors (IL-6, TNF-α, and CRP), and liver function indexes (TBIL, AST, and ALT) compared to traditional open cholecystectomy. Moreover, the complication rate of the research group was significantly lower than that of the control group (P < 0.05). In conclusion, laparoscopic cholecystectomy for chronic cholecystitis with gallstones is a safe and effective procedure that reduces the perioperative stress response and promotes the rapid recovery of the postoperative body. The findings of this study provide a basis for the clinical promotion of laparoscopic cholecystectomy as the preferred surgical treatment for chronic cholecystitis with gallstones.

Cholecystoappendiceal Fistula From Appendiceal Adenocarcinoma Requiring a Right Hemicolectomy With Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

Bilioenteric fistulae are rare and difficult to manage complications of chronic cholecystitis. While cholecystoduodenal and cholecystocolic fistulae are more common, a cholecystoappendiceal fistula is an extremely rare finding. We report the presentation and operative management of a 59-year-old male with cholecystoappendiceal fistula and associated abscess in the gallbladder fossa. The patient was appropriately resuscitated, the abscess drained by interventional radiology, and after a complete workup, underwent a laparoscopic appendectomy and cholecystectomy. Pathology revealed moderately differentiated appendiceal adenocarcinoma requiring a right hemicolectomy with cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). He has recovered well postoperatively with no complications. This case highlights the importance of having a very high index of suspicion for underlying malignancy when managing a fistula of any kind. To the best of our understanding, this is only the second reported case of a cholecystoappendiceal fistula.

Robotic Single-Site Cholecystectomy: A Single-Center Retrospective Study.

Objective Our goal is to describe and report the outcomes of patients undergoing robotic single-site cholecystectomy at a single institution. Background Cholecystectomy is a common procedure performed to remove the gallbladder. Robotic single-site cholecystectomy (RSSC) is rapidly emerging as a safe and feasible alternative to conventional 4-port laparoscopic techniques. Patients who undergo RSSC procedures may also have a decreased need for postoperative analgesics and a lower postoperative pain score. Methods From September 2020 to August 2023, there were 33 cases of RSSC performed by a single surgeon at a single institution. We recorded demographic data including sex, age, and BMI as well as postoperative outcome data including wound dehiscence, postoperative infection, biliary leakage, wound herniation, blood loss, and conversion to open procedure. Results The patient group included 24 females (72.7%) and nine males (27.3%) with a median age of 32 (Range: 9-70) and a median BMI of 24.2 kg/m2 (Range: 18.1-30.7). The majority of these patients were receiving cholecystectomies for benign conditions such as symptomatic cholelithiasis (n = 18, 54.5%), biliary dyskinesia (n = 13, 39.4%), acute cholecystitis (n = 1, 0.03%), and biliary colic (n = 1, 0.03%). The average estimated blood loss was 5.91 mL. Thirty-two patients (96.9%) were discharged home the same day of surgery. One patient was admitted overnight for observation due to severe biliary dyskinesia diagnosed preoperatively. The patient had no complications and was discharged the following day. One patient presented with acute abdominal wall cellulitis and omphalitis with no underlying abscess four weeks after the operation. They were treated with therapeutic antibiotics. No patients underwent conversion to an open procedure. There were no incidences of postoperative wound dehiscence or biliary leakages. One patient was admitted overnight for observation of biliary dyskinesia and another experienced abdominal wall cellulitis four weeks post-operation. Conclusions Although conventional multi-incision laparoscopic cholecystectomy remains the gold standard treatment for benign gallbladder disease, our study demonstrates the practicality and safety of Robotic Single-Site Cholecystectomy procedures.

Comparison of the Effects of Acute Appendicitis and Chronic Cholecystitis on Intestinal Mucosal Function During Surgery.

OBJECTIVE: The objective of this study is to explore the effect of acute appendicitis and chronic cholecystitis on inflammatory factors and intestinal mucosal function during operation. METHODS: This was a prospective cohort study. Forty-four patients including those who underwent elective cholecystectomy (Group A, n = 22) or emergency appendectomy (Group B, n = 22) were recruited. Before anesthesia and after surgery, arterial blood was collected for the measurement of plasma indices associated with inflammation or intestinal permeability. RESULTS:  Both the tumor necrosis factor-alpha (TNF-α) and C-reactive protein (CRP) levels were higher in Group B than in Group A (P < 0.05). The preoperative IL-10 level was higher in Group A than in Group B (P = 0.036), while after surgery, the opposite relationship was observed (P = 0.020). There were no intergroup or intragroup differences for D-Lac. The postoperative lipopolysaccharide (LPS) and human syndecan-1 (Sdc-1) levels were lower than the corresponding preoperative value (P < 0.05) in the two groups. Both the preoperative Sdc-1 and fatty acid binding protein (FABP2) levels in Group A were higher than the corresponding levels in Group B (P < 0.05). CONCLUSIONS: The study suggested that chronic cholecystitis had more severe damage to intestinal mucosal function than acute appendicitis. It is necessary to strengthen the protection of intestinal mucosa during the perioperative period.

Cholecystopathia chronica calcarea (Porcelain gall bladder): A case report from Nepal.

Introduction and importance: Porcelain gall bladder is an uncommon end-stage modification of chronic cholecystitis, with an incidence ranging from 0.06 to 0.8% along with a plausibility of malignant transformation. Case presentation: We present a 55-year-old female presenting with complaints of epigastric and right hypochondriac region pain who underwent prophylactic laparoscopic cholecystectomy after making a provisional diagnosis of calcified gall bladder on a computed tomography workup. On histopathological examination, she was later diagnosed with a porcelain gallbladder devoid of features suggestive of malignant transformation. Clinical discussion: Porcelain gallbladder is a cholecystopathological condition in which the gallbladder wall gets calcified, either completely or partially. Though the exact pathomechanism of gallbladder calcification is unknown, it is believed to be due to chronic inflammation. Recent studies have shown that gallbladder calcification is associated with a lower risk of the development of gallbladder cancer. Imaging studies, followed by post-operative histopathological examinations, are used to diagnose the porcelain gallbladder. Though the management of asymptomatic patients is debatable, prophylactic cholecystectomy is the preferred treatment for symptomatic porcelain gallbladder patients. Conclusion: Individual porcelain GB patients should be addressed based on the presenting condition, whether surgically or via clinical monitoring and follow-up, taking into consideration the advantages and limitations of both treatment modalities.

A “window” in the duodenal bulb: an atypical presentation of chronic cholecystitis

A 74-year-old male presented with melena and fatigue, without fever or abdominal pain. Laboratory examination revealed anemia, leukocytosis, elevated C-reactive protein levels and conjugated hyperbilirubinemia with elevated liver enzymes. Upper endoscopy identified blood in the stomach and duodenum and a 6 mm hole in the anterosuperior surface of the duodenal bulb with spontaneous drainage of a bloody brownish content. The mucosa surrounding the hole was normal and there was a discrete mucosal flap that throbbed with air insufflation. Abdominal computed tomography identified a fistulous tract between the duodenal bulb and the gallbladder with a 2 mm caliber, suggesting a cholecystoduodenal fistula. Diagnosis is often difficult because symptoms are nonspecific and variable but gastrointestinal bleeding is a rare clinical presentation. (AU)

Prognostic clinical indexes for prediction of acute gangrenous cholecystitis and acute purulent cholecystitis.

BACKGROUND: Preoperative prediction of severe cholecystitis (SC), including acute gangrenous cholecystitis (AGC) and acute purulent cholecystitis (APC), as opposed to acute exacerbation of chronic cholecystitis (ACC), is of great significance, as SC is associated with high mortality rate. METHODS: In this study, we retrospectively investigated medical records of 114 cholecystitis patients, treated in Shanghai No. 6 People's Hospital from February 2009 to July 2020. Gallbladder wall thickness (GBWT), indexes of blood routine examination, including white blood cell (WBC), alkaline phosphatase (ALP), the percentage of neutrophil, alanine transaminase (ALT), aspartate aminotransferase (AST), fibrinogen (FIB), gamma-glutamyl transferase, prothrombin time and total bilirubin were evaluated. One-way analysis of variance (ANOVA) was used to evaluate significant differences between a certain kind of SC and ACC to select a prediction index for each kind of SC. Receiver operating characteristic (ROC) curve analysis was conducted to identify the prediction effectiveness of these indexes and their optimal cut-off values. RESULTS: Higher WBC and lower ALP were associated with AGC diagnosis (P < 0.05). Higher percentage of neutrophils was indicative of APC and AGC, while higher GBWT was significantly associated with APC diagnosis (P < 0.05) The optimal cut-off values for these indexes were established at 11.1*109/L (OR: 5.333, 95% CI 2.576-10.68, P < 0.0001, sensitivity: 72.73%, specificity: 66.67%), 79.75% (OR: 5.735, 95% CI 2.749-12.05, P < 0.0001, sensitivity: 77.92%, specificity: 61.9%) and 5.5 mm (OR: 22, 95% CI 4.757-83.42, P < 0.0001, sensitivity: 78.57%, specificity: 85.71%), respectively. CONCLUSION: We established a predictive model for the differentiations of APC and AGC from ACC using clinical indexes, such as GBWT, the percentage of neutrophil and WBC, and determined cut-off values for these indexes based on ROC curves. Index values exceeding these cut-off values will allow to diagnose patients as APC and AGC, as opposed to a diagnosis of ACC.