European Journal of Radiology, 15 (1992) 0 1992 Elsevier Science Publishers
175-179
175
B.V. All rights reserved. 0720-048X/92/$05.00
EURRAD 00302
Acute cholecystitis: G. de Manzoni”,
ultrasonographic
staging and percutaneous
F. Furlan b, A. Guglielmi”, G. Brunellib, E. Laterzaa, Borzellino a, C. Cordiano a
cholecystostomy
F. Ricci”, M. Gennaa,
G.
aEmergency Surgery Department, bDepartment of Radiology I. Verona University Medical School, Borgo Trento Hospital, Verona, Italy (Received 20 October 1991; accepted after revision 20 March 1992)
Key words: Cholecystitis, ultrasound study: Ultrasound,
cholecystitis;
Radiology, interventional
Abstract
Experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in 29 high-risk and elderly patients is reported. The treatment group included 14 men and 15 women, 21 of whom were over 70 years of age. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy: 95.6%). The percutaneous cholecystostomy was successful in 27 of 29 cases and these patients had a sudden improvement in their clinical condition; failure of the procedure was due in one patient to dislodgement of the catheter and in another patient to the guide-wire slipping out of the gallbladder. Six patients complained of pain radiating to the right shoulder which disappeared within 30-60 minutes after the procedure. Twenty-three of the 27 patients subsequently underwent elective cholecystectomy. In 22 patients the ultrasonographic findings were compared with the histology; thus enabling us to establish an ultrasonographic staging of acute cholecystitis related to the seriousness of the disease. Percutaneous cholecystostomy is the treatment of choice in high-risk patients, in the elderly, as well as in young patients with impending perforation.
Introduction Acute cholecystitis is the third major cause of emergency admission to a surgical ward and its incidence increases with increasing age [ 11. In patients wih this disease there is a 1:3 ratio of those aged < 70 years to those aged > 70 years [2]. In recent years the treatment of acute lithiasic and alithiasic cholecystitis in high-risk patients has changed with the introduction of percutaneous cholecystostomy (PC) [ 3-81. There is also a high risk of complications in elderly patients with acute cholecystitis, especially in the first few hours after admission; therefore we have performed PC in these cases as well as in young patients with expected risk of perforation. Correspondence
rona, Italy.
to: Dr. G. de Manzoni,
Via A. Emo 14, 37138 Ve-
This report presents the experience obtained in the treatment of acute cholecystitis with PC and it suggests a new ultrasonographic staging that could help in the choice of acute cholecystitis treatment. Patients Between January 1989 and January 1991, 29 patients with acute cholecystitis (27 calculous and 2 acalculous) were treated with PC. The treatment group included 14 men and 15 women; of these, 8 were aged < 70 years, 6 were aged 70-75 years, and 15 were aged >75 years. Of the 8 patients ~70 years, one had hepatic cirrhosis, one suffered a cardiological condition, one had a recent cerebrovascular accident and in the remaining five patients ultrasonography revealed a critically damaged gallbladder wall with pericholecystic fluid collection, suggesting an impending perforation.
176
Methods All the patients were examined with ultrasound within 4 hours of admission. The ultrasonographic findings used to determine the diagnosis of acute cholecystitis were: 1 cholelithiasis; 2 positive sonographic Murphy sign; 3 thickening of the gallbladder wall by 4 mm or more; 4 gallbladder transverse distention to 5 cm or more; 5 echo-reduced layer in the gallbladder wall; 6 pericholecystic fluid collection; 7 intraluminal echogenic mass [ 9-121 (Fig. la,b,c). The latter three findings were judged to be suggestive of complications (e.g., impending perforation, empyema). The PC was performed within 1-12 hours (average 4 hours) in all patients with a confirmed diagnosis of acute cholecystitis. Following surgery all gallbladders underwent histological examination to establish the accuracy of ultrasonography and to verify a possible correlation between ultrasonographic findings and pathological ones. Before beginning the procedure, patients received 10 mg diazepam and 2 ml Fentanyl i.v. for local anesthesia. Under real time ultrasound guidance an 18 gauge needle is inserted in the gallbladder at its attachment to the liver through the upper third of the gallbladder bed using an intercostal transhepatic approach (Fig. 2a). We found this approach safer than the subcostal route used in our first cases; it secures passage through the liver thus reducing the possibility of catheter dislodge-
a
ment. When the needle tip is seen in the gallbladder lumen, a J-shaped guide-wire is inserted. The needle is retracted and further procedures are monitored by fluoroscopy. Then a standard drainage catheter (7-8 french) is placed into the gallbladder over the guidewire. After complete aspiration of the bile, the correct position of catheter is confirmed by injection of contrast material (Fig.2b,c). All tubes are placed to gravity drainage. Results The PC was successful in 27/29 cases (93.1%). All these patients had a sudden improvement in their clinical condition and the white blood cell count was normal within 24-48 hours. One failure was due to the guide-wire slipping out of the gallbladder; the patient refused a second attempt and was operated immediately. In the second case, dislodgement of the catheter less than 12 hours after the cholecystostomy, together with failure of the drainage replacement, also necessitated surgery. None of them had bile peritonitis. In 23/27 patients, whose conditions were improved by PC, elective cholecystectomy was performed 4-12 days after the drainage (average, 7 days). In 2 cases of alithiasic acute cholecystitis the catheter was removed after 15 and 20 days, respectively and the patients did not have to undergo surgery; in another 2 patients of advanced age (84 and 87 years) with unfavorable car-
b
Fig. 1. a; Acute cholecystitis stage I. The ultrasound scan shows thickening (5 mm) of the gallbladder wall (between arrows). A large stone (S) casing shadowing is seen. G: gallbladder. b; Acute cholecystitis stage II. Ultrasound scan shows the hypoechoic layer in the thickened gallbladder wall (between arrows). Multiple stones (S) are seen within the gallbladder. G: gallbladder. c; Acute cholecystitis stage III. Liquid band (c) surrounding the gallbladder corresponds to pericholecystic fluid collection. Thickening (11 mm) of the gallbladder wall is seen (between arrows). G: gallbladder.
a
b
Fig. 2. a; Ultrasound scan of cholecystostomy performed with the Seldinger technique demonstrates initial needle puncture (arrow). b; Transcholecystic cholangiogram after catheter insertion shows large stones within the gallbladder. c; Transcholecystic cholangiogram after catheter insertion showing gallbladder and common bile duct. Suspected of acute cholecystitis (clinical examination)
I
4
Ultrasonography I Acute Chblecystitis
Stage III
Stage I and II
< 70 years old
\
I
High-risk patients Patients > 70 years old
*
Percutaneous Cholecystostomy
Medical treatment + ultrasonographic follow-up
I
I
Elective Cholecystectomy
Elective Chdecystectomy
I
Conservative treatment (*)
* - Acute acalculous cholecystitis - High operative risk patients
Fig. 3. Ultrasonographic
flowsheet in patients with acute cholecystitis.
diopulmonary conditions, we chose not to operate and the drainages were removed after 16 and 20 days respectively. The time to perform the procedures varied from lo30 minutes. A minor complication was pain radiating to the right shoulder (6 cases) which disappeared within 30-60
minutes from the end of procedure. No bile peritonitis or hemorrhage or vagal reactions occurred. In one patient the common bile duct was filled with contrast medium (via the gallbladder catheter) which enabled demonstration of the presence of stones. This patient subsequently underwent ERCP with removal of stones before cholecystectomy.
178 TABLE
1
Correlation between ultrasonographic Ultasonographic
findings
Pericholecystic fluid collection Wall thickening 28 mm Wall thickening 4-8 mm Echo-reduced layer in the wall Intraluminal echogenic mass
findings and pathologic examinations in 22 patients with acute cholecystitis Histology of the gallbladder wall Inflammatory changes involving the entire wall (15 cases)
Inflammatory changes involving mucosa only (7 cases)
14 14 1 15 4
0 0 7 7 0
Pathological examination of the specimen confirmed the ultrasonographic diagnosis of acute cholecystitis in 22/23 cases (accuracy 95.6%). In two cases there was severe mucosal dysplasia. In 15 /22 cases analyzed by pathology the gallbladder wall was completely damaged with lymphogranulocyte infiltration and necro-hemorrhagic areas involving the serosa and perivisceral tissues; in the other 7 cases inflammatory and necrotic and hemorrhagic changes involved only the mucosal layer. Correlating the ultrasonographic findings with the pathological changes of the gallbladder wall (Table l), it was noticed that pericholecystic fluid (seen in 14/22 cases) and thickening of the wall 3 8 mm (seen in 14/ 22 cases) were present only in those cases that showed inflammatory changes involving the entire gallbladder wall. Thickening of the wall < 8 mm was found in 8/22 cases (2 cases 7 mm and 6 cases 66 mm): in 7 cases it was correlated with inflammatory changes involving only the mucosal layer and in one case (7 mm thickening) the gallbladder was badly damaged. Intraluminal echogenic mass was present in 4/22 cases: in all these cases the entire gallbladder wall was damaged. The echo-reduced layer in the gallbladder wall, representing edema [ 131, was not indicative of an advanced stage of cholecystitis as it was present in all 22 cases.
gency cholecystectomy [ 14,18,19] whereas mortality in emergency cholecystectomy is 19-20% compared to a maximum of 5 % in routine cholecystectomy [ 20-231. Elderly patients need urgent treatment because complications occur more frequently due to bad perfusion of the gallbladder and early bacterial growth. A major complication of acute cholecystitis is gallbladder perforation, which often has a misleading course and a reported 25 y0 mortality rate [ 11,241. An early diagnosis and evaluation of the disease stage is necessary to help to decide the timing of surgical intervention. Ultrasonography has become very important in the diagnosis of acute cholecystitis and its accuracy is reported to be between 81-96% [3,10,12,25]. In our experience ultrasonographic accuracy was 95.6 % . Ultrasonography allows the evaluation of the risk of complications in the course of the disease, which is clinically very difficult because symptoms of complicated acute cholecystitis are similar to those of uncomplicated cases [ 241. Correlating ultrasonographic findings with pathological changes of the gallbladder wall, enabled ultrasonographic staging of acute cholecystitis (Table 2). This ultrasonographic staging, together with the age and the clinical condition, assists decision making in the treatment of patients with this disease.
Discussion
TABLE 2
Acute cholecystitis is a very frequent disease and it mainly affects elderly people. However, timing of surgical intervention remains a matter of debate, i.e., whether to operate within 24 hours (emergency surgery), within 48-72 hours (early surgery) or after resolution of acute problems with conservative treatment (delayed surgery) [ 14-171. In patients aged over 70 years morbidity in routine cholecystectomy is 22% and increases to 44% in emer-
Ultrasonographic staging of acute cholecystitis related to the histologic changes of the gallbladder Stage I
Stage II Stage III
Thickening of the gallbladder wall 2 4 mm and < 8 mm, cholelithiasis and positive sonographic murphy sign Stage I + hypoechoic band in the gallbladder wall; thickening of the gallbladder wall < 8 mm Thickening of the gallbladder wal > 8 mm and/or pericholecystic fluid collection and/or intraluminal echogenic mass
179
In the last years percutaneous cholecystostomy has become a safe and effective procedure in the treatment of critically ill patients with lithiasic or alithiasic cholecystitis [ 3-7,26,27]. For these patients emergency cholecystectomy carries the risk of high morbidity and mortality. Considering that percutaneous cholecystostomy was relatively easy to perform, with few complications and a dramatic clinical improvement after catheter insertion, we used this treatment in elderly patients to avoid emergency cholecystectomy with its high mortality rate. Moreover, in our opinion, ultrasonographic findings of impending perforation of the gallbladder (stage III of acute cholecystitis) represent an absolute indication for percutaneous cholecystostomy, also in otherwise healthy patients under 70 years of age. Based on this study, we suggest the following indications for the treatment of acute cholecystitis (Fig 3).
References De Dombal FT. Diagnosis of acute abdominal pain. 1980, Edinburgh, Churchill Livingstone, 70-85. Glenn F. Surgical management of acute cholecystistis in patients 65 years of age and older. Ann Surg 1981; 193: 56-59. Baumel H, Chazelet C, Fabre JM, Deixonne B, Mouroux J, Bloncourt J. Cholecistites aigues alithiasiques post-agressives: place de la cholecystostomie percutanee. Chirurgie 1987; 113: 140-147. McGahan GP, Lindfors KK. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology 1989; 173: 481-485. VanSonnenberg E., D’Agostino HB, Casola G, Vamey RR, Ainge GD. Interventional radiology in the gallbladder: diagnosis, drainage, dissolution, and management of stones. Radiology 1990; 174: l-6. Vogelzang RL, Nemcek AA. Percutaneous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988; 168: 29-34. Werbel GB, Nahrwold DR, Joehl RJ, Vogelzang RL, Rege RV. Percutaneous cholecystostomy in the diagnosis and treatment of acute cholecystitis in the high-risk patient. Arch Surg 1989; 124: 782-786. Teplick SK, Brandon JK, Wolferth CC, Amron G, Gambescia R, Zitomer N. Percutaneous interventional gallbladder procedures: personal experience and literature review. Gastrointest Radio1 1990; 15: 133-136.
9 Cooperberg PL, Gibney RG. Imaging of the gallbladder 1987. Radiology 1987; 163: 605-613. 10 Martinez A, Bona X, Velasco M, Martin J. Diagnostic accuracy of ultrasound in acute cholecystitis. Gastrointest Radio1 1986; 11: 334-338. 11 Miyazaki K, Uchiyama A, Nakayama F. Use of ultrasonographic risk score in the timing of operative intervention for acute cholecystitis. Arch Surg 1988; 123: 487-489. 12 Rails PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD, Ngo C, Radin DR, Halls JM. Real-time sonography in suspected acute cholecystitis. Radiology 1985; 155: 767-771. 13 Lim JH, Ko YT, Kim SY. Ultrasound changes of the gallbladder wall in cholecystitis: a sonographic-pathological correlation. Clin Radio1 1987; 38: 389-393. 14 Morrow DJ, Thompson J, Wilson SE. Acute cholecystitis in the elderly. A surgical emergency. Arch Surg 1978; 113: 1149-l 152. 15 Noorby S, Herlin P, Holmin T, Sjodahl R, Tagesson C. Early or delayed cholecystectomy in acute cholecystitis? A clinical trial. Br J Surg 1983; 70: 163-165. 16 Navarra S, Melita P, Calbo L. Colecistiti acute. Trattamento immediato o differito? Min Chir 1983; 38: 1391-1396. 17 Roggero F, Bertolotti MG. Colecistiti acute: il nostro orientamento terapeutico. Min Chir 1983; 38: 1095-1102. 18 Huber DF, Martin EW, Cooperman M. Cholecystectomy in elderly patients. Am J Surg 1983; 146: 719-721. 19 Lygidakis GN: Operative risk factors of cholecystectomycholedochotomy in the elderly. Surg Gyn Obstet 1983; 157: 1519. 20 Addison NV, Finan PJ. Urgent and early cholecystectomy for acute gallbladder disease. Br J Surg 1988; 75: 141-143. 21 Arianoff AA, Arianoff VA. Analisis comparative, por grupos de edades, de las colecistitis. Rev Esp Enf Ap Digest 1986; 69: 344-350. 22 Howghton PWJ, Jenkinson LR, Donaldson LA. Cholecystectomy in the elderly: a prospective study. Br J Surg 1985; 72: 220-222. 23 Sullivan DM, Hood TR, Griffen WO. Biliary tract surgery in the elderly. Am J Surg 1982; 143: 218-220. 24 Forsberg L, Andersson R, Hederstrom E, Tranberg G. Ultrasonography and gallbladder perforation in acute cholecystitis. Acta Radio1 1988; 29: 203-205. 25 Soiva M, Haveri M, Taavitsainen M, Suramo I. The value of routine sonography in clinically suspected acute cholecystitis. Stand J Gastroenterol 1986; 21: 70-74. 26 Klimberg S, Hawkins I, Vogel SB. Percutaneous cholecystostomy for acute cholecystitis in high-risk patients. Am J Surg 1987; 153: 125-129. 21 Larssen TB, Gothlin JH, Jensen D, Amesjo B, Soreide 0. UItrasonically and fluoroscopically guided therapeutic percutaneous catheter drainage of the gallbladder. Gastrointest Radio1 1988; 13: 37-40.
175-179
175
B.V. All rights reserved. 0720-048X/92/$05.00
EURRAD 00302
Acute cholecystitis: G. de Manzoni”,
ultrasonographic
staging and percutaneous
F. Furlan b, A. Guglielmi”, G. Brunellib, E. Laterzaa, Borzellino a, C. Cordiano a
cholecystostomy
F. Ricci”, M. Gennaa,
G.
aEmergency Surgery Department, bDepartment of Radiology I. Verona University Medical School, Borgo Trento Hospital, Verona, Italy (Received 20 October 1991; accepted after revision 20 March 1992)
Key words: Cholecystitis, ultrasound study: Ultrasound,
cholecystitis;
Radiology, interventional
Abstract
Experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in 29 high-risk and elderly patients is reported. The treatment group included 14 men and 15 women, 21 of whom were over 70 years of age. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy: 95.6%). The percutaneous cholecystostomy was successful in 27 of 29 cases and these patients had a sudden improvement in their clinical condition; failure of the procedure was due in one patient to dislodgement of the catheter and in another patient to the guide-wire slipping out of the gallbladder. Six patients complained of pain radiating to the right shoulder which disappeared within 30-60 minutes after the procedure. Twenty-three of the 27 patients subsequently underwent elective cholecystectomy. In 22 patients the ultrasonographic findings were compared with the histology; thus enabling us to establish an ultrasonographic staging of acute cholecystitis related to the seriousness of the disease. Percutaneous cholecystostomy is the treatment of choice in high-risk patients, in the elderly, as well as in young patients with impending perforation.
Introduction Acute cholecystitis is the third major cause of emergency admission to a surgical ward and its incidence increases with increasing age [ 11. In patients wih this disease there is a 1:3 ratio of those aged < 70 years to those aged > 70 years [2]. In recent years the treatment of acute lithiasic and alithiasic cholecystitis in high-risk patients has changed with the introduction of percutaneous cholecystostomy (PC) [ 3-81. There is also a high risk of complications in elderly patients with acute cholecystitis, especially in the first few hours after admission; therefore we have performed PC in these cases as well as in young patients with expected risk of perforation. Correspondence
rona, Italy.
to: Dr. G. de Manzoni,
Via A. Emo 14, 37138 Ve-
This report presents the experience obtained in the treatment of acute cholecystitis with PC and it suggests a new ultrasonographic staging that could help in the choice of acute cholecystitis treatment. Patients Between January 1989 and January 1991, 29 patients with acute cholecystitis (27 calculous and 2 acalculous) were treated with PC. The treatment group included 14 men and 15 women; of these, 8 were aged < 70 years, 6 were aged 70-75 years, and 15 were aged >75 years. Of the 8 patients ~70 years, one had hepatic cirrhosis, one suffered a cardiological condition, one had a recent cerebrovascular accident and in the remaining five patients ultrasonography revealed a critically damaged gallbladder wall with pericholecystic fluid collection, suggesting an impending perforation.
176
Methods All the patients were examined with ultrasound within 4 hours of admission. The ultrasonographic findings used to determine the diagnosis of acute cholecystitis were: 1 cholelithiasis; 2 positive sonographic Murphy sign; 3 thickening of the gallbladder wall by 4 mm or more; 4 gallbladder transverse distention to 5 cm or more; 5 echo-reduced layer in the gallbladder wall; 6 pericholecystic fluid collection; 7 intraluminal echogenic mass [ 9-121 (Fig. la,b,c). The latter three findings were judged to be suggestive of complications (e.g., impending perforation, empyema). The PC was performed within 1-12 hours (average 4 hours) in all patients with a confirmed diagnosis of acute cholecystitis. Following surgery all gallbladders underwent histological examination to establish the accuracy of ultrasonography and to verify a possible correlation between ultrasonographic findings and pathological ones. Before beginning the procedure, patients received 10 mg diazepam and 2 ml Fentanyl i.v. for local anesthesia. Under real time ultrasound guidance an 18 gauge needle is inserted in the gallbladder at its attachment to the liver through the upper third of the gallbladder bed using an intercostal transhepatic approach (Fig. 2a). We found this approach safer than the subcostal route used in our first cases; it secures passage through the liver thus reducing the possibility of catheter dislodge-
a
ment. When the needle tip is seen in the gallbladder lumen, a J-shaped guide-wire is inserted. The needle is retracted and further procedures are monitored by fluoroscopy. Then a standard drainage catheter (7-8 french) is placed into the gallbladder over the guidewire. After complete aspiration of the bile, the correct position of catheter is confirmed by injection of contrast material (Fig.2b,c). All tubes are placed to gravity drainage. Results The PC was successful in 27/29 cases (93.1%). All these patients had a sudden improvement in their clinical condition and the white blood cell count was normal within 24-48 hours. One failure was due to the guide-wire slipping out of the gallbladder; the patient refused a second attempt and was operated immediately. In the second case, dislodgement of the catheter less than 12 hours after the cholecystostomy, together with failure of the drainage replacement, also necessitated surgery. None of them had bile peritonitis. In 23/27 patients, whose conditions were improved by PC, elective cholecystectomy was performed 4-12 days after the drainage (average, 7 days). In 2 cases of alithiasic acute cholecystitis the catheter was removed after 15 and 20 days, respectively and the patients did not have to undergo surgery; in another 2 patients of advanced age (84 and 87 years) with unfavorable car-
b
Fig. 1. a; Acute cholecystitis stage I. The ultrasound scan shows thickening (5 mm) of the gallbladder wall (between arrows). A large stone (S) casing shadowing is seen. G: gallbladder. b; Acute cholecystitis stage II. Ultrasound scan shows the hypoechoic layer in the thickened gallbladder wall (between arrows). Multiple stones (S) are seen within the gallbladder. G: gallbladder. c; Acute cholecystitis stage III. Liquid band (c) surrounding the gallbladder corresponds to pericholecystic fluid collection. Thickening (11 mm) of the gallbladder wall is seen (between arrows). G: gallbladder.
a
b
Fig. 2. a; Ultrasound scan of cholecystostomy performed with the Seldinger technique demonstrates initial needle puncture (arrow). b; Transcholecystic cholangiogram after catheter insertion shows large stones within the gallbladder. c; Transcholecystic cholangiogram after catheter insertion showing gallbladder and common bile duct. Suspected of acute cholecystitis (clinical examination)
I
4
Ultrasonography I Acute Chblecystitis
Stage III
Stage I and II
< 70 years old
\
I
High-risk patients Patients > 70 years old
*
Percutaneous Cholecystostomy
Medical treatment + ultrasonographic follow-up
I
I
Elective Cholecystectomy
Elective Chdecystectomy
I
Conservative treatment (*)
* - Acute acalculous cholecystitis - High operative risk patients
Fig. 3. Ultrasonographic
flowsheet in patients with acute cholecystitis.
diopulmonary conditions, we chose not to operate and the drainages were removed after 16 and 20 days respectively. The time to perform the procedures varied from lo30 minutes. A minor complication was pain radiating to the right shoulder (6 cases) which disappeared within 30-60
minutes from the end of procedure. No bile peritonitis or hemorrhage or vagal reactions occurred. In one patient the common bile duct was filled with contrast medium (via the gallbladder catheter) which enabled demonstration of the presence of stones. This patient subsequently underwent ERCP with removal of stones before cholecystectomy.
178 TABLE
1
Correlation between ultrasonographic Ultasonographic
findings
Pericholecystic fluid collection Wall thickening 28 mm Wall thickening 4-8 mm Echo-reduced layer in the wall Intraluminal echogenic mass
findings and pathologic examinations in 22 patients with acute cholecystitis Histology of the gallbladder wall Inflammatory changes involving the entire wall (15 cases)
Inflammatory changes involving mucosa only (7 cases)
14 14 1 15 4
0 0 7 7 0
Pathological examination of the specimen confirmed the ultrasonographic diagnosis of acute cholecystitis in 22/23 cases (accuracy 95.6%). In two cases there was severe mucosal dysplasia. In 15 /22 cases analyzed by pathology the gallbladder wall was completely damaged with lymphogranulocyte infiltration and necro-hemorrhagic areas involving the serosa and perivisceral tissues; in the other 7 cases inflammatory and necrotic and hemorrhagic changes involved only the mucosal layer. Correlating the ultrasonographic findings with the pathological changes of the gallbladder wall (Table l), it was noticed that pericholecystic fluid (seen in 14/22 cases) and thickening of the wall 3 8 mm (seen in 14/ 22 cases) were present only in those cases that showed inflammatory changes involving the entire gallbladder wall. Thickening of the wall < 8 mm was found in 8/22 cases (2 cases 7 mm and 6 cases 66 mm): in 7 cases it was correlated with inflammatory changes involving only the mucosal layer and in one case (7 mm thickening) the gallbladder was badly damaged. Intraluminal echogenic mass was present in 4/22 cases: in all these cases the entire gallbladder wall was damaged. The echo-reduced layer in the gallbladder wall, representing edema [ 131, was not indicative of an advanced stage of cholecystitis as it was present in all 22 cases.
gency cholecystectomy [ 14,18,19] whereas mortality in emergency cholecystectomy is 19-20% compared to a maximum of 5 % in routine cholecystectomy [ 20-231. Elderly patients need urgent treatment because complications occur more frequently due to bad perfusion of the gallbladder and early bacterial growth. A major complication of acute cholecystitis is gallbladder perforation, which often has a misleading course and a reported 25 y0 mortality rate [ 11,241. An early diagnosis and evaluation of the disease stage is necessary to help to decide the timing of surgical intervention. Ultrasonography has become very important in the diagnosis of acute cholecystitis and its accuracy is reported to be between 81-96% [3,10,12,25]. In our experience ultrasonographic accuracy was 95.6 % . Ultrasonography allows the evaluation of the risk of complications in the course of the disease, which is clinically very difficult because symptoms of complicated acute cholecystitis are similar to those of uncomplicated cases [ 241. Correlating ultrasonographic findings with pathological changes of the gallbladder wall, enabled ultrasonographic staging of acute cholecystitis (Table 2). This ultrasonographic staging, together with the age and the clinical condition, assists decision making in the treatment of patients with this disease.
Discussion
TABLE 2
Acute cholecystitis is a very frequent disease and it mainly affects elderly people. However, timing of surgical intervention remains a matter of debate, i.e., whether to operate within 24 hours (emergency surgery), within 48-72 hours (early surgery) or after resolution of acute problems with conservative treatment (delayed surgery) [ 14-171. In patients aged over 70 years morbidity in routine cholecystectomy is 22% and increases to 44% in emer-
Ultrasonographic staging of acute cholecystitis related to the histologic changes of the gallbladder Stage I
Stage II Stage III
Thickening of the gallbladder wall 2 4 mm and < 8 mm, cholelithiasis and positive sonographic murphy sign Stage I + hypoechoic band in the gallbladder wall; thickening of the gallbladder wall < 8 mm Thickening of the gallbladder wal > 8 mm and/or pericholecystic fluid collection and/or intraluminal echogenic mass
179
In the last years percutaneous cholecystostomy has become a safe and effective procedure in the treatment of critically ill patients with lithiasic or alithiasic cholecystitis [ 3-7,26,27]. For these patients emergency cholecystectomy carries the risk of high morbidity and mortality. Considering that percutaneous cholecystostomy was relatively easy to perform, with few complications and a dramatic clinical improvement after catheter insertion, we used this treatment in elderly patients to avoid emergency cholecystectomy with its high mortality rate. Moreover, in our opinion, ultrasonographic findings of impending perforation of the gallbladder (stage III of acute cholecystitis) represent an absolute indication for percutaneous cholecystostomy, also in otherwise healthy patients under 70 years of age. Based on this study, we suggest the following indications for the treatment of acute cholecystitis (Fig 3).
References De Dombal FT. Diagnosis of acute abdominal pain. 1980, Edinburgh, Churchill Livingstone, 70-85. Glenn F. Surgical management of acute cholecystistis in patients 65 years of age and older. Ann Surg 1981; 193: 56-59. Baumel H, Chazelet C, Fabre JM, Deixonne B, Mouroux J, Bloncourt J. Cholecistites aigues alithiasiques post-agressives: place de la cholecystostomie percutanee. Chirurgie 1987; 113: 140-147. McGahan GP, Lindfors KK. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology 1989; 173: 481-485. VanSonnenberg E., D’Agostino HB, Casola G, Vamey RR, Ainge GD. Interventional radiology in the gallbladder: diagnosis, drainage, dissolution, and management of stones. Radiology 1990; 174: l-6. Vogelzang RL, Nemcek AA. Percutaneous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988; 168: 29-34. Werbel GB, Nahrwold DR, Joehl RJ, Vogelzang RL, Rege RV. Percutaneous cholecystostomy in the diagnosis and treatment of acute cholecystitis in the high-risk patient. Arch Surg 1989; 124: 782-786. Teplick SK, Brandon JK, Wolferth CC, Amron G, Gambescia R, Zitomer N. Percutaneous interventional gallbladder procedures: personal experience and literature review. Gastrointest Radio1 1990; 15: 133-136.
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