Br. J. Surg. Vol. 62 (1975) 697-700
Acute cholecystitis P . A. M . R A I N E A N D A . A. G U N N * SUMMARY
One hundred and fifty-six successive patients have been admitted with the clinical diagnosis of acute cholecystitis and have been treated by operation on the next operating list. The diagnosis was correct in 154 and a diagnostic pathway has been determined. The clinical features, investigations, bacteriology and pathology are discussed. There is an increased need for choledochotomy in acute cholecystitis and this bile is more commonly infected than in the elective patient. It is suggested that those with infection can be identified prior to operation and should be treated with antibiotics on admission. The morbidity of operation on patients with uninfected bile is no greater than in those receiving elective surgery, and operative treatment is recommended for both groups of patients,
THE management of acute cholecystitis remains controversial. The proponents of conservative treatment record the difficulty in confirming the diagnosis, with an error rate of between 5 and 24 per cent (Essenhigh, 1966; Van der Linden and Sunzel, 1970). Emergency surgery is said to carry a h ][her risk, wit spread of infection and increased technical difficulty, particularly in detecting stones in the common bile duct (Wenkert et al., 1969; Jersky, 1970). Surgical treatment is advocated to abolish symptoms by removing the source of infection, to avoid further attacks and to allow the patient to return to normal life at an early date (Sokhi and Longland, 1973). This form of treatment reduces the time spent in hospital and expedites return to work with decreased insurance claims (Payne, 1969). A consecutive series of patients has received operative treatment on the next operating list, and the clinical, operative, bacteriological and pathological data were recorded in a prospective manner. Patients Between 1965 and 1973, 156 patients were admitted to one surgical unit with the clinical diagnosis of acute cholecystitis. Attempts were made to confirm the diagnosis and to correct any abnormalities in the general health of the patient before the operation. During the same period 421 patients were admitted from the waiting list for elective biliary surgery and formed a basis for comparison. Clinical details (Table Z) The emergency group of patients showed an increase in the ratio of male to female patients and the mean age was greater despite the shorter duration of symptoms. The increased frequency of a history of
jaundice and abnormal liver function tests indicated that the pathological process was more advanced. The diagnosis was correct with two exceptions. Both of these patients had pain, jaundice and a leucocytosis; the first had a duodenal perforation with marked oedema of the lesser omentum, and the second was proved to have haemorrhage into an infected hepatic metastasis. Abdominal X-rays showed stones in 25, a calcified gallbladder in 4, a soft tissue swelling in 4 and gas in the biliary tract in 9 patients. N o abnormality diagnostic of biliary tract disease was seen in the remaining 131, although a number of films showed other signs indicative of pathology in the right hypochondrium. Table I: CLtNICAL FEATURES OF THE EMERGENCY AND ELECTIVE GROUPS Emergency Sex ratio (female : male)
Mean age (yr) Duration of symptoms (%) 5 yr History of jaundice (%) Abnormal liver function (%) Positive straiaht X-rav CQ
3: 1 55.2
52.0 19.0 36.4 49.3 21.3
13.7 40.8 23.5 20.0 16.0
Oral cholecystography is only of value in patients who are neither vomiting nor have become jaundiced; 87 patients had this investigation and in 70 contrast was not concentrated in the gallbladder. When there is no vomiting, pyloric stenosis, diarrhoea, malabsorption and impaired liver function, absence of opacification was interpreted as evidence of obstruction of the cystic duct. Intravenous cholangiography is limited to patients with normal liver function and by difficulties of interpretation when the ducts are poorly opacified. Twenty-four patients had this examination; 15 showed a normal duct system without filling of the gallbladder, 6 had stones in the common duct and 3 had a dilated duct. Liver function tests were abnormal in 75 patients which suggested an element of obstruction in the common bile duct and placed a limit on the use of diagnostic X-rays. The biIirubin was raised in 64 cases, the alkaline phosphatase in 41, SGPT in 19 and prothrombin ratio in 24 patients. Operative treatment (Table ZZ) All the operations were performed within 5 days of admission and the duration of symptoms before ~~
* Bangour General Hospital, West Lothian. 697
P. A. M. Raine and A. A. Gunn admission varied from less than 24 hours to 9 days. Thirty-one per cent of the patients required choledochotomy compared with 12 per cent in the elective series. Operative cholangiography has proved to be effective in the emergency situation (Table ZZI), although 13 patients did not have this investigation: 7 because they were admitted early in the series before the technique was routine, 3 for technical reasons and Table 11: OPERATIVE TREATMENT OF THE EMERGENCY AND ELECTIVE GROUPS Treatment Emergency Cholecystectomy 105 Cholecystectomy and choledochotomy 48 Choledochotomy 1 Additional procedures 6 Sphincterotomy Choledochoduodenostomy 1 Gastric operations 2
Elective 343 57 18 9 16 30
Table 111: RESULTS OF OPERATIVE CHOLANGIOGRAPHY IN THE EMERGENCY GROUP Result: Satisfactory cholangiogram No. of cases: 139 Stones in the common bile duct 38 Unsatisfactory cholangiogram 2 Cholangiogram not attempted 13 Table IV: INCIDENCE OF PYREXIA AND LEUCOCYTOSIS IN THE EMERGENCY GROUP IN PATIENTS WITH ACUTE CHOLECYSTITIS COMPARED WITH THOSE WITH CHRONIC CHOLECYSTITIS Acute Chronic cholecystitis cholecystitis 32.2 15.8 Pyrexia over 37 "C 50.8 42.1 Leucocytosis over 10 000 Pyrexia and leucocytosis 20.3 15.8 No uvrexia o r leucocvtosis 37.3 57.9 Results given as percentages.
Table V: POSTOPERATIVE COMPLICATIONS IN THE EMERGENCY AND ELECTIVE GROUPS Comulication Emergencv Elective Pulmonary atelectasis 40 56 Pulmonary embolus 1.9 1.2 Deep vein thrombosis 0.7 1.6 Wound haematoma 1.3 2.6 Wound infection 5.9 5.0 Disruption 1.3 2.1 Biliary fistula 1.3 0.9 Biliary peritonitis 2.6 0.2 Subphrenic abscess 1.9 1.4 Waltman Walter's syndrome 1.3 0.2 Bacteriogenic shock 2.6 0.2 Oliguria 1.3 0.7 Death 0.2 2.5 Results given as percentages.
1 patient was iodine sensitive. In 2 patients the stones were felt and the duct opened without prior cholangiography. It proved difficult to record in detail the technical problems encountered, but the degree of difficulty was indicated and was found to increase progressively after 7 days from the onset of symptoms. Pathological and bacteriological findings The pathologist reported acute cholecystitis in 9.3 per cent, acute and chronic cholecystitis in 67.4 per cent and chronic cholecystitis in 23.3 per cent. Although this appears paradoxical, patients presenting with acute right hypochondria1 pain may have obstruction in the biliary tract with or without inflammation. In these three groups of patients there was no difference in sex, age or duration of symptoms, but half of the patients with chronic cholecystitis had a history of jaundice compared with less than a third of the other patients. The proportion of patients undergoing oral cholecystography was similar in each group but half of those with chronic disease had a functioning gallbladder compared with 1 in 10 of the remainder. Thirty-five per cent oftheimmediatesurgery patients had positive culture results of the bile, gallbladder or stones compared with 19 per cent in the elective series. Positive culture was more frequent in the patients with acute or acute with chronic pathological changes. An attempt was made to correlate the pathological findings with the presence of a pyrexia or leucocytosis but this proved of little value (Table W ) . Postoperative complications (Table V ) Postoperative complications were recorded prospectively and, in particular, an X-ray was taken of the chest on the third postoperative day. Fifty-eight per cent of the patients in the emergency and elective groups had at least one complication, but when the 'postoperative chest' was excluded the incidence was 19.5 per cent in the emergency group and 16 per cent in the elective group. However, the finding of a positive culture of the bile increased the incidence to over 30 per cent in both groups of patients. The complications that were more frequent in the emergency patients were thoseassociated with infection and leakage of bile. The mortality was 2.5 per cent in this series compared with 0.2 per cent in the elective operations in the same period. The 4 deaths were in patients aged over 60 years with symptoms for more than 6 days. Each patient had infected bile but the
Table VI: DETAILS OF THE PATIENTS WHO DIED IN THE EMERGENCY GROUP Duration of Sex Age symptoms (d) Pathology Operation Post-mortem findings 61 F 9 Acute cholecystitis Cholecystectomy Coronary atheroma, pyelonephritis, pulmonary congestion F 68 6 Perforated empyema Cholecystectomy, choledochotomy Pulmonary emboli M 70 8 Acute cholecystitis, biliary Cholecystectomy, choledochotomy Massive cerebral infarction peritonitis F 60 6 Acute cholecystitis Cholecystectomy, choledochotomy Fatty infiltration of the heart
post-mortem failed t o confirm this as the cause of death (Table VI).
X-ray of abdomen 1
Diagnosis Thcrc was n o formal scheme for the diagnosis of acute cholecystitis and two errors were made. However, a diagnostic pathway can be determined from the
information obtained and appears t o be helpful in confirming the clinical suspicion of acute biliary tract disorder if not of histological acute cholecystitis
Infection Various studies have suggested that infection is
important in the mortality and morbidity of biliary operations (Haw and Gunn, 1973; Keighly and Graham, 1973). Infection in the bile was more common in the emergency series, as was the need for chokdochotomy. and these facts may explain the higher mortality. However, where infection was not proved the morbidity and mortality were the same in both groups. Certain criteria have bccn shown t o be associated with an increased incidence of positive bile culture (Haw and Gunn, 1973), and if the diagnosis can be made the patient should receive appropriate antibiotic therapy prior to having the source of the infection removed. An analogy can be drawn with the treatment of acute appcndicitis. In the other patients where infection is considered unlikely there is no evidence of increased morbidity
IV Cholangiogram 3 (+ 15)
Straight X-rays reveal the presence of biliary disease in 25 per cent but d o no1 exclude other causes of pain such as acute pancreatitis. In the remainder jaundice suggests biliary tract disease and the liver function tests identify its obstructive nature. The presence of abnormal liver function tests limits the use of oral and intravenous cholangiography. and in such patients percutaneous transhepatic cholangiography is potentially dangerous. Retrograde cholangiography could have a place where the cause of the jaundice is in doubt, but in the majority laparotomy is essential and operative cholangiography permits accurate evaluation. If the straight X-rays are negative and the patient is not jaundiced, chokcystography by the oral route is possible unless the patient is vomiting. when intravenous cholangiography is preferred. The oral cholecystogram may fail t o reveal any filling of the gallbladder. and an intravenous cholangiogram would be ncccssary if there was reasonable doubt of the diagnosis. In this series 15 patients without jaundice and with a negative straight X-ray had n o further investigation and the decision t o operate for acute cholccystitis was made on clinical grounds alone. A further 23 patients with a non-functioning gallbladder were treated by opcration without an intravenous cholangiogram as suggested above. Clinical judgement varies and it is suggested that the diagnostic pathway should be followed to provide further evidence of acute cholecystitis.
Fig. 1. The diagnostic pathway in the prcsent series.
following operation, which is straightforward. If competent surgeons are available it is suggested that thesc patients should be treated by operation. but, if so decided, they could be treated conservatively with close observation.
C o n r l ~ I . A diagnosis of chokcystitis can be reached in nearly every patient admitted as an emergency with 'acute cholccystitis', although in 25 per cent the pathology is chronic cholecystitis with no evidence of acute inflammation. 2. The operative mortality in patients with 'acute' cholccystitis is higher than in elective operations, but the former is a different group of patients with a higher incidencc of infection and of stones in the common duct. 3. I t is argued that the best treatment for a patient with 'acute' cholecystitis with a calculated risk of infection is to prescribe medical treatment including antibiotics and t o operate within a few days. The exception would be in patients with symptoms of acute cholecystitis for more than I week when it is known that the technical difficulties increase. 4. Patients with 'acute' cholccystitis without a calculattd risk of infection can be safely treated by operation. 5. In conclusion it is necessary to emphasize that surgery o n a tense inflamed gallbladder requires technica1 competence and experience. Ref(1966) Management of acute cholc. 1032-1038. cystitis. Br. J. S u r ~53, HAW c. s. and GUNN A. A. (1973) The significance of infection in biliary disease. J . R. Coll. SwR. ESSENHIGH D. M.
Edinb. 18, 209-212. (1970) The management of acute cholecystitis. S. Ajr. J. Sirrg. 8, 41-45.
P. A. M. Raine and A. A. G u n and GRAHAM N. G. (1973) Infective cholecystitis. J.R. Coll. Surg. Edinb. 18, 213-220. PAYNE R . A. (1969) Evaluation of the management of acute cholecystitis. Br. J . Surg. 56, 200-203. SOKHI G. s. and LONGLAND c. 3. (1973) Early and delayed operation in acute gall-stone disease. Br. J . Surg. 60, 937-939. KEIGHLEY M. R . B.
(1970) Early versus delayed operation for acute cholecystitis. Am. J . Surg. 120, 7-13. WENKERT A. and HALLGREN T. (1969) Evaluation of conservative treatment of acute cholecystitis. Acta Chir. Scmd. 135, 701-706 VAN DER LINDEN w . AND SUNZEL H.
IN accordance with the underlying pathologic principles, surgical treatment may be directed toward removing or destroying the bleeding varix, reducing so far as possible the amount of blood entering the portal circulation or increasing the collateral channels to such an extent that the portal hypertension and stasis will be relieved. While the first is not altogether a surgical impossibility, it would be a decidedly dangerous procedure. Cauterization of the varices through the esophagoscope is the only method by which it has been attempted, and so far this has met with little success. Another method of attack would be to ligate the coronary vein or group of veins between the cardia and the trunk of the portal vein but the feasibility of this procedure is open to question. The second possibility, that of reducing the amount of blood entering the portal circulation, involves removal of the spleen, which contributes about 20 per cent of the total portal stream. This has already given good results in selected cases. Considering that the whole tendency of portal cirrhosis is to divert the stream of portal blood away from the liver, leaving the arterial blood to provide for the parenchymal requirements, the most logical and effective method of dealing radically with the embarimed portal circulation would doubtless be to perform a simple Eck fistula. By this means the portal hypertension would be relieved, stasis immediately abolished, and the development of varices arrested. The ideal procedure would be side-to-side anastomosis of the portal vein and inferior vena cava without ligating any trunks. This would not interfere with any other blood already reaching the liver. Although Eck fistulas have been tried at various times, the resultant uniform failure seems to be entirely due to difficulties in the operation itself. Provided a satisfactory technic can be evolved, such as that employed by Mann and his associates in their experimental work with Eck fistula on dogs, there is no reason why in suitable cases it should not be successful.
ARCHIBALD H. McINDOE (1928) Vascular lesions of portal cirrhosis. Arch. Pathol. Lab. Med. 5, 23-42.