eMedicine Specialties > Radiology > Gastrointestinal

Cholecystitis, Acute: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Coauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; Tufail Ahmed Patankar, MBBS, FRCR, PhD, DMRD, DMRE, DNBE, Consulting Neuroradiologist and Interventional Neuroradiologist, Department of Neuroradiology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust; Lalam Radhesh Krishna, MBBS, MRCS, Specialist Registrar, Department of Radiology, North Manchester General Hospital; Hemalatha Chandramohan, MBBS, Staff Physician, Department of Geriatric Medicine, Stepping Hill Hospital, United Kingdom; David Sherlock, MBBS, FRCS, Consulting Staff, Department of Surgery, North Manchester General Hospital, Christie Hospital; Ravi Devidas Kadasne, MBBS, MD, Specialist in Radiology, Emirates International Hospital, UAE
Contributor Information and Disclosures

Updated: Feb 4, 2009

Intervention

Diagnostic aspiration of the GB

Acalculous cholecystitis poses a difficult diagnostic and therapeutic dilemma. It often occurs as a complication of serious illness in an already hospitalized patient, and the diagnosis is often overlooked. Percutaneous aspiration of GB bile has been suggested as a means of diagnosis in such patients. The technique involves the transhepatic passage of a 22-gauge needle under ultrasonographic guidance into the GB. Accurate needle-tip placement in the GB is ascertained with the gentle aspiration of bile. The bile is sent for Gram staining and culturing. A Gram stain showing 1 or more bacteria and 1 or more leukocytes and positive bile cultures suggest the diagnosis. A specificity of 87% has been reported for Gram stains and bile cultures, but the sensitivity is low.

On the whole, GB bile aspiration is of limited use in the diagnosis of AC. Two reasons have been given for the low sensitivity of GB bile aspiration: First, most patients suspected of having acalculous cholecystitis are already taking systemic antibiotics that may render their bile cultures negative. Second, in the early stages of AC, the GB wall may be inflamed, but no leukocytes or bacteria may be present in the bile.

GB aspiration has been used in the treatment of AC in noncritically ill patients who are at high surgical risk. Chopra et al evaluated GB aspiration and percutaneous cholecystostomy in 53 patients with AC who were at high surgical risk but were not critically ill.33 No significant differences were found in the primary clinical outcome measures between those patients who were treated with GB aspiration and those who underwent percutaneous cholecystostomy. The authors recommended that GB aspiration be considered the procedure of choice in high-risk patients with AC who are not critically ill. They suggested that percutaneous cholecystostomy be reserved as a salvage procedure in cases in which GB aspiration is technically or clinically unsuccessful.

Emergency percutaneous cholecystostomy

Percutaneous cholecystostomy is most often performed in AC patients who are poor surgical risks. Such patients are often hospitalized with major medical or surgical problems, and their existing illness may be complicated by acalculous cholecystitis.

Surgical cholecystostomy has been shown to be a valuable technique in achieving decompression of the inflamed GB until the patient's condition allows definitive surgery, but the technique is not without complications.

Percutaneous cholecystostomy allows decompression of the inflamed GB and provides a potential route for stone extraction. The GB is localized by sonography or fluoroscopy after oral administration of contrast material. CT-guided access may be of value if no sonographic window is found.

Debate continues regarding whether the extrahepatic approach or the transhepatic approach is to be preferred. The decision involves consideration of anatomy and whether stone extraction is planned. A transhepatic route is associated with less risk of bile leakage and catheter dislodgement. Use of the transhepatic route increases the likelihood of accessing the nonperitoneal bare area of the liver, whereas a subhepatic or transperitoneal approach provides a more favorable route when stone extraction is planned. The GB is punctured by use of a Seldinger technique with traction dilatation; a 12F or 14F catheter is placed over a stiff guidewire.

Alternatively, a trocar technique with a smaller catheter system may be used. This approach is preferred when stone extraction is not planned and when the objective is decompression of the GB at the patient's bedside. A locking pigtail catheter is preferred because it provides anchorage and prevents catheter dislodgement. The patient undergoes sedation with diazepam or midazolam, as well as local anesthesia.

After catheter placement, bile is withdrawn. The final catheter placement is confirmed by ultrasonography; if doubt exists, iodinated contrast material is gently injected via the catheter, and a radiograph is obtained. A forceful or high-volume injection of contrast material poses the risk of ascending cholangitis. After its placement, the catheter is left to drain freely. Flushing with sodium chloride solution may improve catheter patency.

Contraindications to percutaneous cholecystostomy include coagulopathy that cannot be corrected and massive ascites that cannot be drained.

Complication rates are low; complications include procedure-related death (<0.5%), vagal reactions, catheter dislodgement, catheter misplacement, bile leakage, delayed GB rupture, and hemorrhage.

Definitive percutaneous cholecystostomy

Initially, percutaneous cholecystostomy was used as a stopgap procedure to help patients recover from a serious underlying illness. However, in some cases, the procedure has been performed as definitive treatment for patients who are poor candidates for surgery. Both patients with calculous AC and patients with acalculous AC have been treated by percutaneous cholecystostomy.

Percutaneous cholecystostomy in GB perforation

Percutaneous cholecystostomy has been used as a temporizing procedure in patients with GB perforation. In some patients, no further treatment has been required after the procedure.

Medicolegal Pitfalls

  • Accurate and prompt diagnosis is essential to prevent gangrenous cholecystitis, to prevent perforation and its associated increased morbidity and mortality, and to initiate prompt medical treatment before surgical intervention.
  • A high index of clinical suspicion should be maintained for those patients who are prone to develop acalculous AC, because early diagnosis allows the appropriate therapy to be instituted, optimizing the outcome.
  • A negative aspirate from the GB does not exclude the diagnosis of AC.
  • Acute emphysematous cholecystitis predominantly affects elderly diabetic men. It is associated with high mortality and morbidity; therefore, prompt diagnosis and emergent surgical intervention are crucial. Plain abdominal radiographs, ultrasonography, and CT form the cornerstone of diagnosis. In one case, however, a nondiabetic woman developed sepsis in association with acute emphysematous cholecystitis. She experienced rapid deterioration within 24 hours. She was initially misdiagnosed as having peptic ulcer disease on the basis of normal findings on abdominal radiographs, ultrasonography, and CT scans.34

Special Concerns

  • Acalculous cholecystitis occurs more often in males, usually in those older than 65 years, and in children. The reported mortality of 5-10% is principally confined to patients older than 60 years.
  • Some elderly patients and children with acute acalculous cholecystitis (AAC) present in the outpatient setting. If their conditions are diagnosed and treated early, they have a good prognosis.
  • The morbidity and mortality associated with emphysematous cholecystitis are distinctly higher; 30-50% of such patients are diabetic.
  • Some elderly patients have few signs of AC at the time of their initial presentation.
  • Primary sarcoma of the gallbladder is a rare gallbladder malignancy that mainly occurs in middle-aged women. Patients generally present with acute cholecystitis; the prognosis is very poor.35
 


More on Cholecystitis, Acute

Overview: Cholecystitis, Acute
Imaging: Cholecystitis, Acute
Follow-up: Cholecystitis, Acute
Multimedia: Cholecystitis, Acute
References
Further Reading
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Keywords

acute cholecystitis, acute acalculous cholecystitis, acalculous cholecystitis, AC, AAC, necrotizing cholecystitis, emphysematous cholecystitis

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP is a member of the following medical societies: American Institute of Ultrasound in Medicine, Radiological Society of North America, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Tufail Ahmed Patankar, MBBS, FRCR, PhD, DMRD, DMRE, DNBE, Consulting Neuroradiologist and Interventional Neuroradiologist, Department of Neuroradiology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust
Tufail Ahmed Patankar, MBBS, FRCR, PhD, DMRD, DMRE, DNBE is a member of the following medical societies: British Society of Neuroradiologists and Royal College of Radiologists
Disclosure: Nothing to disclose.

Lalam Radhesh Krishna, MBBS, MRCS, Specialist Registrar, Department of Radiology, North Manchester General Hospital
Disclosure: Nothing to disclose.

Hemalatha Chandramohan, MBBS, Staff Physician, Department of Geriatric Medicine, Stepping Hill Hospital, United Kingdom
Disclosure: Nothing to disclose.

David Sherlock, MBBS, FRCS, Consulting Staff, Department of Surgery, North Manchester General Hospital, Christie Hospital
Disclosure: Nothing to disclose.

Ravi Devidas Kadasne, MBBS, MD, Specialist in Radiology, Emirates International Hospital, UAE
Disclosure: Nothing to disclose.

Medical Editor

John L Haddad, MD, Clinical Associate Professor, Department of Radiology, Weill Medical College of Cornell University; Director of Body MRI, Department of Radiology, Methodist Hospital in Houston
John L Haddad, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Arnold C Friedman, MD, FACR, Associate Chairman, Department of Radiology, University of Florida Health Science Center; Chief, Department of Radiology, Shands-Jacksonville Hospital
Arnold C Friedman, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

 
 
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