Emergency General Surgery

The Vicious Rolling Stones – Part 1

River stones remain, while water flows away.

Romanian proverb

During Med School, the teaching of General Surgery is quite straight-forward. To each disease corresponds a specific treatment: acute appendicitis needs appendectomy, colorectal cancer requires resection, etc… Unfortunately, in the real world, this is far from the truth.

Real patients are not explicative case scenarios…

Let’s take one of the most common examples: acute cholecystitis.

In books, the usual patient with acute cholecystitis is an overweight middle-aged woman who presents in the Emergency Department complaining about the onset of abdominal pain in the right upper quadrant and fever. This patient has leukocytosis and elevated C-reactive protein (CRP) at lab exams, and features of acute cholecystitis on abdominal ultrasound (US).

This description may not be wrong, but it is like a picture out of focus. You know the subject in the picture is a human being wearing a blue T-shirt, but you don’t know if it is a man or a woman, if he/she is wearing glasses, if he/she is young or old… You have just an idea of what the picture is representing.

In this post, we are going to explain the shades of gray of the management of patients with acute cholecystitis.

The process of managing patients with acute cholecystitis is composed of 4 steps:

  1. Making the diagnosis;
  2. Assessing the severity of the disease;
  3. Assessing the patient’s general performance status (e.g. Charlson Comorbidity Index (CCI) and/or American Society of Anesthesiologists (ASA) Score);
  4. Treating the disease according to the severity and the patient’s general status.

It should be said that this 4-step process represents the correct pathway for the management of all stages of this disease.

Introduction to Acute Cholecystitis

Acute cholecystitis is an acute inflammation of the gallbladder. The pathogenesis generally involves two events:

  • Bowel bacteria rising from the duodenum to the gallbladder through the bile ducts;
  • Cystic duct obstruction, leading to bile stasis, which activates inflammatory mediators and allows bacteria to grow.

This is explained by the fact that 85-95% of acute cholecystitis involves patients with gallstones. In fact, 3.8-12% of patients with cholelithiasis develop acute cholecystitis during their lifetime.

On the contrary, 3.7-14% of acute cholecystitis arises in patients without stones. In these cases, the possible pathogenesis is a hypovolemic status, secondary to trauma or major surgery (e.g. cardiac surgery), which reduces/stops the vascularization of the gallbladder. For this reason, acalculous cholecystitis is generally more severe than the others and evolves more often into gangrenous or necrotic cholecystitis.

The major concerns about acute cholecystitis are the high number of patients affected by this disease, the relatively high mortality rate (≈1%), and the possible serious complications secondary to the surgical intervention (e.g. main bile duct injury…).

Diagnosis & Severity Grading

The diagnosis of acute cholecystitis is made taking into account clinical features, lab exams, and imaging.

The parameters to consider are the following:

  1. Local signs of inflammation
    1. Murphy’s sign
    2. Right upper quadrant pain, mass, and/or tenderness
  2. Systemic signs of inflammation
    1. Fever
    2. Elevated CRP
    3. Leukocytosis
  3. Imaging findings
    1. Imaging findings characteristics of acute cholecystitis

Suspicion of acute cholecystitis is posed if there is one item in A and one in B, whereas diagnosis is made if the suspect is confirmed by imaging.

Which is the recommended imaging technique to use in case of suspected acute cholecystitis?

  • Abdominal US: this is the first-line imaging method. It is cost-effective, is not invasive, and can be made at the bedside;
  • Magnetic resonance imaging (MRI) or magnetic resonance cholangiopancreatography (MRCP): useful if the abdominal US was not diagnostic;
  • Contrast-enhanced abdominal computed tomography (CT) scan: useful in case of gangrenous or emphysematous cholecystitis. However, since it is usually difficult to obtain an MRI in an emergency setting, the CT scan can be used as the second-line imaging method.

The severity assessment of acute cholecystitis is mandatory to determine which is the best treatment option.

There are three severity grades according to the last guidelines (Tokyo 2018): mild (grade I), moderate (grade II), and severe (grade III).

Grade I (Mild) Acute Cholecystitis
It does not meet any of the criteria of Grade II and Grade III acute cholecystitis. Alternatively, it can be defined as a disease in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder.
Grade II (Moderate) Acute Cholecystitis
It needs at least one of the following conditions without signs of organ dysfunction:
– Leukocytosis (>18,000/mm3);
– Palpable tender mass in the right upper abdominal quadrant;
– Duration of complains >72 h;
– Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis).
Grade III (Severe) Acute Cholecystitis
It is associated with dysfunction of any one of the following organs/systems:
– Cardiovascular: hypotension requiring treatment with dopamine (≥5 μg/kg/min), or any dose of norepinephrine;
– Neurological: decreased level of consciousness;
– Respiratory: PaO2/FiO2 ratio <300;
– Renal: oliguria, creatinine >2 mg/dL;
– Hepatic: PT-INR >1.5;
– Hematological: platelet count <100,000/mm3.
Initial Management

Patients referring to the Emergency Department with acute cholecystitis may need supportive care and antibiotics.

Supportive care depends on the severity of the patient’s conditions. It may consist of just painkillers, or a septic shock workup along with a complete resuscitation process (fluids, oxygen, vasopressors, etc…).

Antibiotics are required by all patients with acute cholecystitis, regardless of the severity grading. However, the antibiotic regimen differs according to the severity.

In the following table are resumed the main antibiotic regimens recommended:

Therapy RegimenGrade IGrade IIGrade III
Penicillin-basedAmpicillin/sulbactamPiperacillin/tazobactamPiperacillin/tazobactam
Cephalosporin-basedCefazolin ± metronidazoleCeftriaxone ± metronidazoleCefepime ± metronidazole
Carbapenem-basedErtapenemErtapenemImipenem/cilastatin, meropenem, ertapenem
Monobactam-basedAztreonam ± metronidazole
Fluoroquinolone-basedCiprofloxacin, levofloxacin ± metronidazoleCiprofloxacin, levofloxacin ± metronidazole
Vancomycin is recommended in Grade III if Enterococcus spp. is isolated in bile/blood cultures.
Linezolid or daptomycin is recommended if vancomycin-resistant Enterococcus (VRE) is known to be colonizing the patient.
Ampicillin/sulbactam is not recommended if there is >20% resistance rate.
Fluoroquinolones use is recommended in case of susceptibility of cultured isolates or in patients with β-lactam allergies.
Metronidazole is warranted if a biliary-enteric anastomosis is present and the antibiotic regimen does not cover sufficiently anaerobic bacteria.

Healthcare-associated cholecystitis should be treated with the same antibiotic regimen as community-acquired grade III acute cholecystitis regardless of the severity grading.

Another matter of great discussion is the optimal duration of antimicrobial therapy for patients with acute cholecystitis. In patients with grade I or II acute cholecystitis, the general rule is to stop antibiotics right after surgery. On the contrary, in patients with grade III acute cholecystitis antibiotics should be continued for 4-7 days after the source of infection has been controlled.

Different management if the patient has pericholecystic abscesses or perforated gallbladder. In these cases, antimicrobial therapy should be continued until the patient is afebrile, without leukocytosis, and without abdominal findings.

It is enough for now…

Next time we are going to explore the different treatment options according to the severity grading, the patients’ performance status, etc…

Be cool…

References
  1. Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:41-54.
  2. Gomi H, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:3-16.
  3. Mayumi T, et al. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:96-100.
How to Cite This Post

Bellio G, Marrano E. The Vicious Rolling Stones – Part 1. Surgical Pizza. Published on December 21, 2020. Accessed on May 5, 2021. Available at [https://surgicalpizza.org/emergency-surgery/the-vicious-rolling-stones-part-1].

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