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Acute Cholecystitis
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 dislodgement results in so-called biliary colic, while
persisting impaction of the stone produces gallbladder distension and inflammation, namely, AC. The latter is initially chemical, but gradually, as gut bacteria
invade the inflamed organ, infection supervenes. The combination of distension,
ischemia, and infection may result in a gallbladder empyema, necrosis, perforation, pericholecystic abscess, or bile peritonitis. Doubtless you must have heard
or read numerous times about the classical symptoms and signs of AC. Let us
therefore concentrate on problem areas.
20.1
How to Differentiate Between Biliary Colic and AC
Time is the best discriminator between biliary colic and AC as the pain and
epigastric/right upper quadrant (RUQ) symptoms of biliary colic are self-limited,
disappearing within a few hours. Conversely, 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
(slight) elevation of bilirubin or liver enzymes may back it up. But, note that a
lack of some or all features of inflammation or 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
(US) or a radionuclide HIDA (hepatic iminodiacetic acid) scan, which are readily
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_20.1, © Springer-Verlag Berlin Heidelberg 2010
187
188 Moshe Schein · Ahmad Assalia
available. Which of the two you should ask for first depends on its availability and
the expertise in your hospital. We prefer ultrasound as, in addition to documenting the gallstones, it may provide incidental information concerning the liver, bile
ducts, pancreas, kidneys, and peritoneal fluid, possibly suggesting alternative
diagnoses. The ultrasonographic findings in AC include a distended, stone—or
sludge-containing gallbladder; thickened wall; mucosal separation; pericholecystic fluid collection; or intramural gas. Not all of these findings are necessary to
make a diagnosis. Positive radionuclide scan in AC means nonfilling of the gallbladder by the isotope. The specificity of the test is increased (i.e., fewer false
positives) if morphine is administered, causing spasm of the sphincter of Oddi
and reflux of isotope into the cystic duct. A false-positive result may occur in
patients with significant hyperbilirubinemia. There are other (chronic) causes of
nonfilling of the gallbladder (e.g., mucocele), but a negative scan with the isotope
entering the gallbladder excludes AC. Of course, not a few of these patients will
come your way after having undergone a computed tomographic (CT) examination in the emergency room. This can show the same features of AC as US.
Whatever test you use, remember the following: you cannot diagnose AC
when the gallbladder is nondistended.
Associated jaundice mild-to-moderate elevation of bilirubin and hepatic
enzymes is a relatively common feature of advanced AC, caused by reactive
inflammation of the hepatic pedicle and the surrounding liver parenchyma. Thus,
you need not attribute the jaundice to choledocholithiasis unless there are also
clinical and ultrasonographic features of ascending cholangitis or bile duct stones
(see below).
Associated hyperamylasemia similarly, mild elevation of the serum
amylase 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.
In my [MS] environment, where there are no waiting lists for any operation
and the operating room (OR) is always available, distinguishing between biliary
colic and AC is purely an academic exercise because both conditions suggest the
need for an early cholecystectomy, usually within 24 hrs.
Management
In the vast majority of patients, the treatment of AC could be summarized
in a few words: proceed to laparoscopic cholecystectomy (LC). We know, however, that you would like a little more detail.
20.1 Acute Cholecystitis 189
Nonoperative Management
The natural history of AC is such that in more than two-thirds of patients
treated nonoperatively 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 os (NPO, nothing by mouth; nasogastric
tube only if the patient is vomiting); analgesia (use a nonopioid if you believe in
the hypothetical importance of avoiding constriction 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
operation 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 “organized” is the
inflammatory response, the more fibrosis and scar tissue forms—and the more difficult and traumatic the LC and hence the need to convert it to an open procedure.
Surgical Management
Cholecystectomy is the optimal procedure; it eradicates the inflammation and
infection and prevents their recurrence. Based on your clinical impression, it will be
performed either as an “emergency” (rarely needed) or, usually, “early” procedure.
Emergency Cholecystectomy
An immediate, emergency procedure should be performed following resuscitation in patients with clinical evidence of diffuse peritonitis and systemic toxic-
i ty or pr es e nc e of ga s wi t hi n t h e g al l bl a dd e r w al l—features suggesting perforation,
necrosis, or empyema of the gallbladder. Most surgeons today would attempt a
trial LC in this situation, converting to “open” in the presence of technical difficulties. We would warn, however, against prolonged peritoneal insufflation in the
critically ill patient and would avoid prolonged attempts with laparoscopic dissection of the necrotic, perforated and difficult-to-grasp gallbladder. Emergency
cholecystectomy for complicated AC in the critically ill or compromised patient
190 Moshe Schein · Ahmad Assalia
Fig. 20.1.1. “I never convert…”
could be open as described below. Obviously, a brief open cholecystectomy is
easier on your patient than an open cholecystectomy following 2 hrs of futile laparoscopic excavation! (> Fig. 20.1.1).
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 OR in the middle of the night but operate in
the daylight 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 “semielective” cholecystectomy, which is often performed at the end of the
elective lists. Occasionally, a waiting period as short as 48 hrs results in deterioration of the patient, but as observed already, the majority of patients with 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 hrs will prevent any problems arising from a delay in operation. Furthermore, it should be pointed 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, the definition here of early cholecystec-
tomy is an operation within 24 hrs of admission.
20.1 Acute Cholecystitis 191
Note: there is a subgroup of patients who will benefit from a delayed
approach 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 intensive care unit (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 haircut under local,” as they used to say? The best
option is a tube cholecystostomy under local anesthesia. This can be done by you in
the OR 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 hrs, particularly after the percutaneous procedure,
should suggest the presence of undrained pus or necrotic gallbladder wall and the
need to operate. Saying this, we have to admit that this last statement may be unnecessary because we have never experienced a patient whose AC—however severe it is—
cannot be alleviated with tube cholecystostomy and antibiotics.
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 postoperative hemorrhage from the congested gallbladder’s hepatic bed or large
venous collaterals at the duodenohepatic ligament. Although elective conventional LC has been judged safe in “Child A” portal hypertension patients (>Chap.
17), we believe that the secret here is to stay away from trouble. This means avoid-
ing dissection near engorged and rigid hepatic parenchyma and staying away
from the excessively vascular triangle of Calot in the emergency situation, particularly in patients with advanced cirrhosis. 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—like most of us—may start laparoscopically, accepting a need to convert to
192 Moshe Schein · Ahmad Assalia
open—depending on your laparoscopic skills, patience, and courage—in up to
one-third of the patients. It is important, however, not to be carried away, persisting with laparoscopic dissection in the face of hostile anatomy. A practical rule
of thumb is to convert to laparotomy if after 45–60 min of laparoscopy you feel
like you are “going nowhere.” In many patients, a decision to convert can be
made even much earlier than this, and you should not be afraid to abandon the
laparoscopic approach at any stage if the circumstances are obviously unfavorable. Inappropriate persistence with the laparoscopic approach may well end in
disaster with a bile duct injury. Having reviewed many litigated cases of post-LC
disasters, there is no doubt in our mind that timely decision to convert could
have prevented most such catastrophes. For an excellent list of rules of thumb to
prevent this calamity, look at the article by Way et al. (2003) and pay attention to
the commentary by co-editor AA in this chapter.
You may need some advice on the open procedure, which is becoming rare
in elective practice and is increasingly being reserved for the “difficult” cases—
the routine, “maxi,” full-size gallbladder abdominal incision belongs to history.
In the acute situation, start with a “midi” (5–10 cm) transverse RUQ incision,
extending “piecemeal” as necessary. When converting from LC, simply extend
the epigastric trocar site laterally—very rarely will you need a larger incision
than one that connects the epigastric trocar site to the lateral one in the RUQ. Be
aware that the results with open cholecystectomy through a midi- (<8 cm) or
“mini-” (<5 cm) incisions are as good as those with LC.
The wise man’s rule is to go fundus first (dome down) and stay near the
gallbladder. After needle decompression (connect a wide-bore needle to the suc-
tion) of the distended gallbladder, hold the fundus up and away from the liver
with an instrument and dissect down toward the cystic duct and artery, which
are the last attachments to be secured and divided. By observing this rule, it is
virtually impossible to damage anything significant such as the bile duct. When
you are done, fold the omentum into the empty gallbladder bed; it helps in hemostasis, avoids formation of collections, and prevents the duodenum or colon from
adhering to the liver, which will make your life much easier should you need in
the future to reoperate, say to explore the common bile duct (CBD) for retained
stones. Should you leave a drain? Sometimes and selectively (see >Chap. 42).
Subtotal (Partial) Cholecystectomy
Asher Hirshberg MD, summarized subtotal cholecystectomy aptly: “It is
better to remove 95% of the gallbladder [i.e., subtotal cholecystectomy] than
101% [i.e., together with a piece of the bile duct].”
20.1 Acute Cholecystitis 193
And yes, yes, yes—any weathered surgeon will tell you that this is the procedure to use to avoid misery in problematic situations such as those involving
scarring—the “impossible” triangle of Calot—portal hypertension, or coagulopathy. Partial or subtotal cholecystectomy was popularized in the United States
by Max Thorek (1880–1960); 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 remains 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, after all stones have been evacuated, 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’s pouch tissue and suturebuttress 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 CBD obstruction, you will rarely 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 “painted” with diathermy (some say until you smell fried
liver), and the omentum is brought into the area. In this operation, the structures
in 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.
An extremely rare (so rare it deserves being published as an isolated case
report) complication of subtotal cholecystectomy is the late enlargement of the
gallbladder remnant—if left too large—presenting as symptomatic cholelithiasis, with US reporting “stones within the gallbladder.” Differential diagnosis
would include late enlargement of the cystic duct remnant and a duplication of
the gallbladder (one of which was missed during the initial operation). This complication has been also described following conventional LC, in which the surgeon divided and occluded Hartmann’s pouch instead of the cystic duct. Whatever
the specific cause, the treatment is a “re-cholecystectomy” (preferably open) with
a preoperative magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) providing a road map for
the biliary anatomy. When doing a subtotal cholecystectomy, always make a
detailed operative report, including the indications, and explain to the patient
what was done and why, by this pre-emptively suppressing any future lawsuit.
Laparoscopic subtotal cholecystectomy is addressed below.
194 Moshe Schein · Ahmad Assalia
Cholecystostomy
In our hands, subtotal cholecystectomy has almost replaced open tube
cholecystostomy for the difficult gallbladder. Cholecystostomy is indicated in
the very rare patient who must be done under local anesthesia and then only
when percutaneous cholecystostomy is not available or is not successful.
After infiltration of local anesthetic, 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 preoperative US 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 proctoscope may be useful. Thereafter, insert into the fundus a
tube of your choice (we prefer a large Foley), securing it in place with a pursestring suture. Fix the fundus to the abdominal wall, as you would do with a gastrostomy, and if possible place some omentum around. A tube cholangiogram
performed a week later will tell you whether the cystic duct is patent and if so
whether the bile duct is free of stones. The tube can be safely removed a few weeks
later if all is well. Whether an interval cholecystectomy is subsequently indicated
is controversial. Cystic duct obstruction, on the other hand (according to the
prevailing dogma), would mandate interval cholecystectomy.
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 disturbances 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 is the potentially lifethreatening condition; ductal stones, if present, are of secondary importance.
Our management of patients with diagnosed AC and suspected choledocholithiasis would be tailored to the severity of the AC, the US 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:
Severe AC, mildly elevated bilirubin and enzymes, bile ducts not dilated
on US. We would start with LC combined with intraoperative cholangiography.
Should the latter be positive, we would proceed with an open CBD exploration or—
if the stones are small—leave them to be dealt with by ERCP after the operation. Of
course, if you are skilled at laparoscopic transcystic CBD exploration, go for it.
20.1 Acute Cholecystitis 195
If the bile ducts are dilated on US, there are liver function disturbances, and
the AC is clinically not “severe,” we would treat it conservatively and evaluate the
duct with MRCP or ERCP. Any ductal stones would be dealt with by endoscopic
sphincterotomy prior to LC.
In the critically ill patient with or without gallbladder empyema or perfora-
tion, we would even “waive” the cholangiogram, leaving the symptomatic ductal
stones to endoscopic retrieval after the life-saving cholecystectomy or cholecystostomy.
A realistic perspective: CBD exploration should be very rarely necessary in
an environment providing modern imaging and ERCP service.
Acalculous Cholecystitis
Acalculous cholecystitis is a manifestation of the disturbed microcircula-
tion in critically ill patients. Although of multifactorial etiology (e.g., prolonged
fasting, administration of total parenteral nutrition, etc.), the common pathogenic pathway is probably gallbladder ischemia, mucosal injury, and secondary
bacterial invasion. Acalculous cholecystitis is a life-threatening condition developing during a serious illness, such as 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, leukocytosis, and disturbed liver function tests are commonly present but are
entirely nonspecific. Early diagnosis requires a high degree 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 exam-
ination would confirm the diagnosis. False-positive and -negative studies have
been reported with both imaging modalities. Hepatobiliary radioisotope scanning is associated with a high incidence of false-positive studies. However, filling
of the gallbladder with the radioisotope (morphine assisted, if necessary) excludes
cholecystitis. A highly suggestive clinical scenario and diagnostic uncertainty
together are an indication for active treatment.
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
indicated. When coagulopathy, portal hypertension, or severe inflammatory
196 Moshe Schein · Ahmad Assalia
obliteration of the triangle of Calot are present, subtotal cholecystectomy appears
to be safer. LC may be performed in well-selected and stable patients. Note: insufflation pressure during laparoscopy should be kept as low as possible so the
flimsy cardiorespiratory balance and hemodynamics in such patients are not
upset.
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: a few 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 in this chapter. In its early phase, AC represents a sterile inflammation, while later in most instances it represents a “resectable infection,” that is, infection contained within the gallbladder that is to be
removed (>Chap. 12). Therefore, cases with simple AC need only perioperative
antibiotic “coverage,” which is discontinued postoperatively. In gangrene or contained empyema of the gallbladder, we recommend a day or two of postcholecystectomy antibiotic administration. In cases of perforation with a peri-cholecystic
abscess or bile peritonitis, we suggest that you administer the maximal postoperative course of 5 days (>Chap. 47). Which drug? Any drug effective against E. coli
can be used. Antianaerobic drugs are not necessary, and monotherapy suffices.
When the gallbladder is difficult, go fundus first and stay near the wall.
Technical Tips for Laparoscopic Cholecystectomy
Mastering the procedure for LC is considered basic and a “must” in modern surgical practice. Usually, this is considered the first laparoscopic procedure (sometimes
together with laparoscopic appendectomy) every trainee should learn. Adhering to
simple guidelines prevents catastrophes. As in every laparoscopic procedure, correct
positioning of the patient and trocars is essential for successful performance.
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