Acute A
in the
Cholecystitis
Elderly
Surgical Emergency
Douglas J. Morrow, MD; Jerome Thompson, MD; Samuel
E.
Wilson,
\s=b\ A retrospective review of 88 male patients older than 60 years of age with biliary tract disease showed a mortality of 6.8%. More than 40% of the patients (39 of 88) had acute cholecystitis. Medical therapy failed for almost all of the patients (38 of 39) with acute inflammatory disease and they then required an operation during their initial hospitalization. In this acute disease group, 21% had empyema of the gallbladder, 18% had gangrenous cholecystitis or free perforation of the gallbladder, and 15% had subphrenic or liver abscesses. Escherichia coli and Klebsiella were obtained from 78% of the bile cultures, and obligate anaerobes were present in 25% of them. A delay in diagnosis and operation occurred in 33% of the patients with acute disease. Factors responsible for this delay included a deceptively benign clinical presentation and the requirement for prolonged resuscitation. Since response to conservative measures is unlikely in the elderly patient with acute cholecystitis, optimal management consists of resuscitation and prompt operation for control of infection.
(Arch Surg 113:1149-1152, 1978) seriousness of cholecystitis in certain groups of is generally underestimated. Although the overall mortality of cholecystectomy in 28,000 patients surveyed by the Ohio Chapter of the American College of Surgeons was 1.8%, the/mortality in patients older than 65 years of age increases to 6.7%.' Furthermore, emergency operation for acute cholecystitis in this older age group has a reported mortality of 11% to 17%.-':i A recent survey of six hospitals in the western United States disclosed that biliary tract operations were associated with a 6.4% mortal¬ ity at one institution where the patient population was 91% male.4 By comparison, postcholecystectomy deaths oc-
Thepatients
-
Accepted for publication June 5, 1978. From the Surgical Service, Veterans Administration Wadsworth Hospital Center (Drs Morrow and Wilson); and the Department of Surgery, UCLA School of Medicine (Drs Morrow, Thompson, and Wilson), Los Angeles. Reprint requests to Surgical Service (691/112K), Veterans Administration Wadsworth Hospital Center, Los Angeles, CA 90073 (Dr Wilson).
MD
curred in less than 1% of the patients in each of the other five community hospitals surveyed.' Stimulated by these findings, we retrospectively reviewed our experience with biliary tract disease over a five-year period in male patients older than 60 years of age. Factors responsible for the poor outcome in management of acute cholecystitis and cholangitis in the aged will be identified and preventive measures
proposed.
MATERIALS AND METHODS From Jan 1,1971, through Dec 31,1975, 88 patients older than 60 years of age underwent surgery for biliary tract stone disease at the Wadsworth Veterans Administration Hospital Center, Los Angeles. These medical records were abstracted with regard to clinical presentation, delay in diagnosis, incidence of associated
disease, laboratory and roentgenographic evaluations, operative findings, bacteriology, and postoperative morbidity and mortality. The 88 patients were separated into two groups; the first group included 39 patients who were operated on in emergency situa¬ tions for acute disease, and the second group consisted of 49 patients who were operated on electively. The mean age was 70
years for the total population, 70.5 years for the emergency group, and 69.9 years for the elective group.
RESULTS
The symptoms and signs encountered in the 88 patients given in Table 1. All but one of the 39 patients with acute cholecystitis experienced some abdominal pain. More surprisingly, only 24 patients (62%) in the acutely ill group had a temperature elevation greater than 37.8 °C, and although 29 patients (74%) had abdominal tenderness, peritoneal signs were present in less than half. The frequent absence of overt right upper quadrant peritonitis resulted in delay in diagnosis of longer than 24 hours in 13 patients (33%) with acute cholecystitis. In seven patients, a characteristic clinical presentation of fever, mental disorientation, and jaundice without substantial abdominal findings was noted. are
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/16/2015
The WBC count was increased (greater than 10,000 cells/cu mm) in 24 of the 39 acutely ill patients (65%). In addition, the total bilirubin and alkaline phosphatase levels were elevated in 21 of these patients (59%) and the SCOT or SGPT level was increased in 23 patients (62%). The 39 patients treated as emergencies had a total of 57 associated diseases. Evidence of coronary artery disease, manifested by either a previous myocardial infarction or angina pectoris, was noted in 15 patients (38%) and ten patients (26%) had severe pulmonary disease. Hyperten¬ sion was present in six patients (15%) and diabetes mellitus in five patients (13%). Eleven of the 88 patients (13%) had radiopaque gall¬ stones on plain x-ray films of the abdomen. Of the 15 patients with acute disease who were undergoing intrave¬ nous (IV) cholangiography, the common bile duct alone visualized in four, and a gallbladder with stones was opacified in two. Neither the gallbladder nor the bile ducts visualized in nine patients. Intravenous cholangiograms were taken in 20 patients (41%) prior to elective cholecystectomy and were abnormal in 19. In ten patients, the common bile duct alone visualized. There was nonvisualization of the gallbladder and bile ducts in five patients, and opacification of a gallbladder that contained stones was noted in four patients. At operation, 17 patients (44%>) in the acute disease group had simple acute cholecystitis (Table 2). However, eight patients (21%) had acute purulent cholecystitis, seven patients (18%) had acute gangrenous cholecystitis or free perforation of the gallbladder, and six patients (15%) had subphrenic or liver abscesses. Common bile duct stones were present in six of the 39 emergency patients (15%). In the elective group, 41 of 49 patients (85%) had chronic cholecystitis, and common bile duct stones were found in 18% of these patients. Seven patients scheduled electively unexpectedly had acute inflammatory findings. The operative procedures are given in Table 3. Two patients with acute disease had previously undergone cholecystectomy. The remaining 37 patients had cholecystectomy, with 19 patients requiring an additional proce¬ dure. Cholecystostomy was not used for any patient oper¬ ated on as an emergency but was performed once in the elective group. Bile specimens were obtained for culture in 41 patients and 27 specimens were positive (Table 4). Bactobilia occurred in 79% of the emergency patients and in 38% of the elective group. Twelve patients had more than one organism present on bile culture. Obligate anaerobes and facultative anaerobes coexisted in five patients whereas only one patient had obligate anaerobic flora alone. Escherichia coli and Klebsiella were the most common isolates, occurring in 21 patients. Bacteroides and clostridia were the most common anaerobic pathogens (five patients). In the acute disease group, 16 patients had preoperative blood cultures and seven of these were positive. Both morbidity and mortality were high in the emergen¬ cy group. Four deaths occurred during the hospitalization period for a mortality of 10%, and 17 of the 39 acute disease group patients (44%) had postoperative complications
Table 1.—Physical 60 Years of Age
Findings in 88 Patients Older Than Undergoing Biliary Tract Surgery
of 37.8 °C Abdominal tenderness Peritonitis Jaundice Mass
Temperature
Disorientation
Hypotension
V
tx2
t¿
=
= =
No. (%) of Patients
No. (%) of Patients
Undergoing Emergency Operation (N = 39) 24 (62) 29(74) 16(41) 11 (28) 7(18) 5(13) 2(5)
Undergoing Elective
Operation (N = 49) 10(20)* 25(51)t
7(14» 9(18) 2(4)
13.8; P < .01. 5.04; P < .05. 1.35; NS.
Table 2—Pathology in 88 Male Patients Older Than 60 Years of Age Undergoing Biliary Tract Surgery No. (%) of Patients
Chronic cholecystitis, cholelithiasis Acute cholecystitis Acute purulent cholecystitis,
Empyema cholecystitis Gangrenous cholecystitis Perforated
Common bile duct stones Concomitant intra-abdominal abscess
or
No.
(%) of Patients
Undergoing Emergency Operation (N = 39) 7(18) 17(44)
Undergoing
8(21) 4(10) 3(8) 6(15)
2(4)
Elective
Operation (N = 49) 41 (84) 4(8)
1(2) 7(14)*
liver
6(15)
0.06, NS.
Table 3—Operations Perfomed in 88 Male Patients Older Than 60 Years of Age Undergoing Biliary Tract Procedures No. (%) of Patients
No. (%) of Patients
Undergoing Emergency Operation (N 39) 20(51)
Undergoing
14(36)
12(25)
5(13)
3(6) 1 (2)
=
Cholecystectomy Cholecystectomy and choledochotomy Cholecystectomy and transduodenal
sphincferoplasty_
Cholecystostomy
Elective
Operation (N = 49) 33 (67)
(Table 5). Wound infection, the most common postopera¬ tive complication of both emergency and elective proce¬ dures occurred in 20% of the patients. Two patients in the emergency group had retained common bile duct stones. Medical complications were particularly prevalent in the emergency group, with renal failure occurring in four patients and hepatic failure in two patients. The mortality of the elective group was 2% (one death)
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/16/2015
Table 4.—
in 27 Patients With Positive Bile Duct Cultures
Bacteriology
No.
Bacteriology Aerobes and Facultative Anaerobes Escherichia coll Klebslella Enterobacter Enterococci
(%)
of Patients
15(56) 6(22) 2(7) 2(7) 3(11) 3(11) 1 (4) 1(4) 1(4) 1 (4)
Streptococcus Staphylococcus Pseudomonas Salmonella Proteus Cltrobacter Anaerobes Bacteroides Anaerobic cocci Clostridia
3(11) 2(7) 2(7)
Table 5—Complications After Biliary Tract Procedures in 88 Male Patients Older Than 60 Years of Age No.
(%) of Patients
Undergoing Emergency Operation (N = 39) 1(21) 4(10) 4(10) 2(5)
Wound infection Pneumonia Renal failure Biliary fistula Retained
common
(%) of Patients
Undergoing Elective
Operation (N = 49) 10(20) 4(8) 2(4) 2(4)
duct
stone
Hepatic failure Intra-abdominal abscess Myocardial infarction
and 11 of 49
No.
2(5) 2(5) 1(3) 1 (3)
1
(2) 1(2) 1 (2) 1(2)
patients (22%) experienced postoperative
One patient had a retained common bile duct stone and in two patients prolonged drainage from biliary fistulae developed.
complications.
COMMENT
Calculous disease of the gallbladder is the most common indication for intra-abdominal surgery in the elderly. Between the ages of 60 and 70, 27% of white females and 12% of white males have gallstones, with the incidence continuing to increase with age. Since life expectancy at age 70 is approximately ten years, the enormity of this problem for' the surgeon is readily apparent. For example, Ibach et al, in a review of 151 patients older than 60 years of age who had biliary tract surgery, found that 23% of these patients had common bile duct stones, an incidence approximately twice that for all patients with gallbladder disease. Postoperative complications, mostly related to wound infection, occurred in 18% of his elderly patients but less widely appreciated was the mortality of 16.7% in patients undergoing emergency cholecystectomy. Even in a series of carefully selected patients undergoing elective cholecystectomy, the complication rate rose considerably with age, and the only death occurred in the older than 60 group." Although this increased morbidity and mortality of cholecystitis in elderly patients is often alluded to, the '
factors responsible have not been identified. concerned by the difficulty in establishing early diagnosis of acute biliary tract disease in our patients. More than 24 hours elapsed before diagnosis was ascertained in 33% of the acutely ill group. Of those patients operated on in emergency situations, almost all had some degree of abdominal pain; however, results of physical findings on abdominal examination were frequently not in keeping with the advanced degree of sepsis. More than a third of these acutely ill patients were afebrile and a quarter of them had no abdominal tender¬
specific We
were
Furthermore, some patients were disoriented, making clarification of the clinical picture difficult. The results of the laboratory evaluation are not consistently ness.
since the WBC count and the total bilirubin and alkaline phosphatase determinations may be within normal limits. The oral cholecystogram has limited diagnostic useful¬ ness in patients with an acute illness. Although the IV cholangiogram was abnormal in all patients who had the roentgenogram, nonvisualization of the biliary tree, our most common report, is too imprecise and nonspecific a finding. Abdominal ultrasonography, infrequently used during the time period covered by this study, is now proving to be an excellent noninvasive diagnostic test. Recently, Prian et al,7 using gray scale ultrasonography in 100 patients with suspected biliary tract disease, diagnosed cholelithiasis with 97% specificity and 88% sensitivity.7 At present, we routinely obtain abdominal ultrasonography as the initial test for early diagnosis of patients suspected of having acute inflammatory disease of the biliary tract. If this study is equivocal and the patient is not jaundiced, we proceed to IV cholangiography. In the acutely ill group, substantial time intervals elapsed from admission to operation, with only one fourth of the patients being operated on within 24 hours of admission. The four reasons for these delays merit discus¬ sion. First, the diagnosis of acute biliary tract disease in the older patient may be obscure because of the deceptively benign presentation. Second, many of the patients in the emergency group were critically ill, often necessitating prolonged resuscitation. Third, there was a high incidence of associated disease, especially cardiopulmonary disease, hypertension, and diabetes; in addition time was consumed for evaluation and treatment of these concurrent medical problems. Finally, because of the absence of peritonitis when the patient is initially seen, the advanced age of this patient group, and the incidence of associated disease, there was a desire to delay surgical intervention with the hope that the patient would respond to medical therapy and permit elective operation under more favorable condi¬ tions. Unfortunately, only one of 39 patients admitted with acute disease was able to be discharged without opera¬ tion. Considering the frequent lack of clinical findings in the emergency group, the severity of the cholecystitis encoun¬ tered was remarkable. Approximately 40% of our acutely ill patients had empyema of the gallbladder, gangrenous cholecystitis, or free perforation, and 15% had concomitant
helpful,
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/16/2015
subphrenic
or
nature will
liver abscesses. Advanced
sepsis of this
only respond operation. are infrequently reported in patients with biliary sepsis. Keighley et al," using anaerobic bactériologie technique, isolated strict anaerobes in 13% of the patients undergoing biliary operations. This increased incidence of anaerobic bacteria, also noted in our patients, suggests that patients with acute cholecystitis be initially treated not only with an aminoglycoside but also with an antibiotic effective against bacteroides and clostridia." The operation performed was adapted to the pathologi¬ cal findings. In the total group of patients, cholecystostomy was performed only once. The patient with acute cholecystitis who has been carefully resuscitated preoperatively is best treated with cholecystectomy rather than cholecystostomy. Salleh and Balasegaram"' in their review of 218 cases of acute cholecystitis all treated by urgent surgery within 12 hours of admission did not perform cholecystostomy on any patient. MacDonald" in his review of 65 patients with acute cholecystitis performed cholecys¬ tostomy only twice when gallbladder removal would have been both technically difficult and hazardous. Another review of acute cholecystitis documented a 27% mortality in patients who underwent cholecystostomy and a 2% mortality in those who underwent cholecystectomy.'Admittedly, cholecystostomy was usually reserved for the critically ill patient or the patient whose condition deterio¬ rated during surgery. However, of six patients who had cholecystostomy and died of ascending cholangitis, none to
Anaerobes
had undergone common bile duct decompression." Certain¬ ly, if a cholecystostomy is to be performed, one must ensure that there is no coexisting suppurative cholangitis. The traditional approach to acute cholecystitis has been initial conservative management followed by elective cholecystectomy. Recent reports, however, offer support for the policy of early cholecystectomy for acute cholecys¬ titis. McArthur et al," in a comparison of these two methods using a randomized controlled trial, found that patients whose conditions were treated by early cholecys¬ tectomy were hospitalized for shorter periods without increased postoperative morbidity and mortality. The medical failure rate was 20%. In a controlled clinical trial in Sweden, Linden and Souzel1' compared early operations with delayed operations for acute cholecystitis in 140 patients. They concluded that early operation in suspected cholecystitis avoided the hazard of missing other acute surgical conditions such as perforated duodenal ulcer and appendicitis. In addition, recurrence of cholecystitis during a waiting period was obviated and the septic course and hospital stay of the patient was shortened. For our group of acutely ill elderly patients, the medical failure rate was almost 100%. We recommend that acute biliary tract disease in elderly patients be treated as a true surgical emergency. Ample time is allowed to resuscitate the patient and to secure the diagnosis but subsequent to this the patient should have prompt surgical interven¬ tion.
References 1. Arnold DJ: 28,621 Cholecystectomies in Ohio: Results of a survey in Ohio hospitals by the gallbladder survey committee, Ohio Chapter American College of Surgeons. Am J Surg 119:714-719, 1970. 2. Glenn F, Hays DM: The age factor in the mortality rate of patients undergoing surgery of the biliary tract. Surg Gynecol Obstet 100:11-18, 1955. 3. Ibach JR Jr, Hume HA, Erb WH: Cholecystectomy in the aged. Surg Gynecol Obstet 126:523-528, 1968. 4. Wilson SE, Longmire WP Jr: Does method of surgeon payment influence surgical care? J Surg Res 24:437-468, 1978. 5. Ratner JT, Rosenberg GM: Management of gallstones in the aged. J Am Geriatr Soc 23:258-264, 1975. 6. Wright HK, Holden WD, Clark JH: Age as a factor in the mortality rate for biliary tract operations. J Am Geriatr Soc 11:422-425, 1963. 7. Prian GW, Norton LW, Eule J Jr, et al: Clinical indications and accuracy of gray scale ultrasonography in the patient with suspected biliary tract disease. Am J Surg 134:705-711, 1977.
Keighley MRB, Drysdale RB, Quoraishi AH, et al: Antibiotic treatment biliary sepsis. Surg Clin North Am 55:1379-1390, 1975. 9. Stone HH, Kolb LD, Geheber CE, et al: Use of aminoglycosides in surgical infections. Ann Surg 183:660-666, 1976. 10. Salleh HBM, Balasegaram M: Treatment of acute cholecystitis by routine urgent operation. Br J Surg 61:705-708, 1974. 11. MacDonald JA: Early cholecystectomy for acute cholecystitis. Can 8.
of
Med Assoc J 3:796-799, 1974. 12. Gagic N, Frey CF, Gaines R: Acute cholecystitis. Surg Gynecol Obstet 140:868-874, 1975. 13. Gagic N, Frey CF: The results of cholecystostomy for the treatment of acute cholecystitis. Surg Gynecol Obstet 140:255-257, 1975. 14. McArthur P, Cuschieri A, Sells RA, et al: Controlled clinical trial comparing early with interval cholecystectomy for acute cholecystitis. Br J
Surg 62:850-852,
1975. 15. Van der Linden W, Souzel H: Early versus delayed operation for acute cholecystitis: A controlled clinical trial. Am J Surg 120:7-13, 1970.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Michigan User on 06/16/2015