Danielle Fritze
Justin B. Dimick
Presentation
A 70-year-old woman with multiple chronic medical conditions presents to the emergency room with 36 hours of right upper-quadrant (RUQ) pain and subjective fever. She describes numerous prior episodes of postprandial RUQ abdominal pain that resolves after several hours. While her pain is occasionally accompanied by nausea and vomiting, she denies jaundice, alcoholic stools, or dark urine. On exam, she is febrile to 38.5°C with otherwise normal vital signs. Her abdomen is soft with a well-healed vertical midline incision. She has marked tenderness to palpation in the right subcostal region and a positive Murphy’s sign.
Differential Diagnosis
While this patient’s symptoms of fever, RUQ pain, and vomiting represent the classic manifestations of acute cholecystitis, the clinical presentation is not always straightforward. Frequently, acute cholecystitis must be distinguished from other complications of cholelithiasis. Biliary colic results from temporary impaction of a gallstone in the gallbladder neck. It is characterized by postprandial abdominal pain, nausea, and vomiting that resolve over several hours. Signs of systemic inflammation, such as fever and elevated white blood cell count, are usually absent. Gallstones in the common bile duct (CBD), that is, choledocholithiasis, may cause RUQ pain with spontaneous passage of a stone or could progress to ascending cholangitis or biliary pancreatitis. Acalculous biliary disease is also a diagnostic consideration. Sphincter of Oddi dysfunction or biliary dyskinesia with low gallbladder ejection fraction often mimics the symptoms of biliary colic. Acute acalculous cholecystitis may be the end result of gallbladder hypoperfusion but usually is limited to critically ill patients. Nonbiliary abdominal pain due to gastroenteritis, acute hepatitis, ulcer disease, or bowel obstruction must also be excluded.
Workup
The diagnosis of acute cholecystitis is strongly suggested by this patient’s history and is supported by characteristic findings on her physical exam. Constant, burning, RUQ pain is the most common presenting symptom in patients with cholecystitis. The pain occurs following ingestion of a high-fat meal and may awaken the patient from sleep. Many patients have known gallstones and nearly half report prior episodes of biliary colic. Approximately 5% to 10% of patients with biliary colic will go on to develop acute cholecystitis or another complication of gallstones each year. Physical exam reveals fever and right subcostal or epigastric tenderness, possibly with localized guarding. Occasionally, a tender mass is palpable just inferior to the right costal margin. Inspiratory arrest with deep palpation in the RUQ, known as Murphy’s sign, is a classic finding in acute cholecystitis.
Further evaluation of RUQ pain includes laboratory tests and imaging. This patient had an elevated white blood count of 13,000, bilirubin of 1 mg/dL, and normal liver and pancreatic enzymes. Leukocytosis with a predominance of neutrophils is common and helps to distinguish acute cholecystitis from biliary colic. Serum transaminases, bilirubin, and pancreatic enzymes are within the normal range or mildly elevated. Elevated liver enzymes or bilirubin should raise suspicion for choledocholithiasis but may also result from extrinsic compression of the common hepatic duct by a stone impacted in the neck of the gallbladder (Mirizzi syndrome). Elevated amylase and lipase indicate pancreatitis, potentially related to choledocholithiasis.
While acute cholecystitis may be diagnosed by several imaging modalities, abdominal ultrasound (US) is considered first line in the evaluation of RUQ pain. This patient’s US was consistent with acute cholecystitis, demonstrating gallstones with gallbladder wall thickening, pericholecystic fluid, and a normal caliber CBD (Figure 1). Some patients experience a sonographic Murphy’s sign, that is, pain caused by the US probe pressing directly on an inflamed gallbladder. Although CBD stones are not consistently identified by US, dilation of the CBD (>8 mm) suggests biliary obstruction. However, bile duct dilation on US is a specific but not very sensitive indicator of obstruction. Often, patients with elevated bilirubin or alkaline phosphatase levels will have normal size bile ducts on US.
FIGURE 1 • US with classic findings of cholecystitis: cholelithiasis, thickened gallbladder wall and pericholecystic fluid.
While characteristic US findings are sufficient to diagnose acute cholecystitis in a patient with a concordant history and exam, other imaging modalities may be helpful in cases of diagnostic uncertainty. hepatobiliary iminodiacetic acid (HIDA) scan is considered the gold standard for diagnosis of acute cholecystitis in this setting, with sensitivity and specificity >95%. It is particularly useful in distinguishing cholecystitis from biliary colic and other nonbiliary processes but may have false-positive results in the setting of chronic cholecystitis. Nonvisualization of the gallbladder at 60 minutes is diagnostic for cholecystitis (Figure 2). Gallbladder contraction may be stimulated by morphine or cholecystokinin to further increase HIDA’s accuracy in diagnosing cholecystitis. Measurement of the gallbladder ejection fraction by HIDA also allows for identification of biliary dyskinesia.
FIGURE 2 • HIDA scan consistent with acute cholecystitis. At 45 minutes after injection of contrast, there is opacification of he intra- and extrahepatic biliary tree and duodenum. The gallbladder is not visualized.
In patients for whom there is a suspicion of choledocholithiasis, visualization of the biliary tree with Magnetic resonance cholangiopancreatography (MRCP) may help with the diagnosis (Figure 3). Therapeutic sphincterotomy and stone extraction may be accomplished by ERCP in those patients with signs or symptoms of persistent biliary obstruction. While CT scan should not routinely be used to evaluate suspected cholecystitis given its low sensitivity and specificity, abdominal CT may suggest the diagnosis by revealing cholelithiasis, an enhancing and thickened gallbladder wall, pericholecystic fluid, and surrounding inflammatory fat stranding (Figure 4).
FIGURE 3 • MRCP demonstrating a thickened gallbladder wall and gallstones within the cystic duct, but no biliary dilation or choledocholithiasis. The filling defects within the gallbladder likely represent small polyps. Reformatted images delineate the patient’s biliary anatomy.
FIGURE 4 • CT scan consistent with acute cholecystitis demonstrating a dilated, thick-walled gallbladder with surrounding inflammatory stranding. A large gallstone is lodged in the gallbladder neck.
Diagnosis and Treatment
The initial management of acute cholecystitis includes NPO status with systemic broad-spectrum antibiotics and resuscitation as dictated by the patient’s condition. Ideally, cholecystectomy is performed upon diagnosis, within 48 hours of the onset of symptoms. Surgery is performed during the same hospitalization if possible, despite how long the patient has had symptoms. Although some advocate delaying operation if the patient has had symptoms >72 hours, we do not follow this practice. Despite the myth that cholecystectomy is easier after a “cooling off” period, evidence indicates that interval cholecystectomy, performed more than 6 weeks after recovery from acute cholecystitis, does not result in fewer operative complications and is associated with a longer length of hospital stay. During this time, the acute process progresses to chronic fibrotic scarring, which can make dissection even more difficult. Thus, we believe early urgent cholecystectomy is the treatment of choice if at all feasible.
Cholecystectomy may be accomplished via either a laparoscopic or an open approach. Laparoscopic cholecystectomy is associated with decreased length of hospital stay, less patient discomfort, and shorter recovery time. Patients with a hostile abdomen, known aberrant anatomy, significant inflammation, or who are unlikely to tolerate pneumoperitoneum are best served with open cholecystectomy.
In patients whose comorbidities or clinical condition pose a prohibitive operative risk, drainage of the gallbladder may be accomplished via percutaneous or laparoscopic cholecystostomy. Decompensated cardiac failure, unstable angina, and severe or poorly controlled chronic lung disease are among the conditions that may render surgery unnecessarily high risk. Critically ill patients who develop acute cholecystitis in the setting of multiorgan failure or septic shock are particularly well served with cholecystostomy tube. A cholecystostomy tube may remain in place indefinitely, especially for patients with a limited life expectancy, or serve as a bridge to cholecystectomy when and if the patient’s condition improves. Any trial of tube removal must be preceded by contrast injection to confirm a patent cystic duct. Up to 50% of patients will develop recurrent cholecystitis following tube removal; thus, most patients benefit from cholecystectomy if they are a fit operative candidate. Performing cholecystectomy after a tube placement poses a unique technical challenge given the chronic nature of the inflammation and fibrosis around the triangle of Calot. In this setting, the risk of conversion to an open procedure, or the necessity to perform a partial cholecystectomy, is quite high and should be considered prior to taking the patient to the operating room.
Although this particular patient has multiple comorbidities, these do not constitute a prohibitive operative risk, so the choice is made to proceed with cholecystectomy. An attempt at laparoscopy is planned with anticipated conversion to an open operation should adhesions from her prior colectomy inhibit reasonable progress or obscure relevant anatomy. In order to avoid disrupting the mesh from her ventral hernia repair, alternate port placement will be used.
Surgical Approach
Laparoscopic cholecystectomy is performed under general anesthesia with the patient in supine position (Table 1). Access to the abdomen is generally obtained inferior to the umbilicus via open Hassan or closed Veress needle technique. Pneumoperitoneum is established and a 30-degree laparoscope inserted. Two additional operating ports are inserted in the RUQ and one in the subxiphoid epigastrium. Reverse Trendelenburg and tilting the operating table to the patient’s left facilitate displacement of the small bowel and omentum out of the operative field. The fundus of the gallbladder is grasped and retracted cephalad over the edge of the liver via the lateral subcostal port. A thick-walled, tightly distended or hydropic gallbladder may be extremely difficult to grasp. Needle aspiration of gallbladder contents facilitates grasping the gallbladder for retraction. The remainder of the operation is conducted through the subxiphoid and medial right subcostal ports. Any adhesions to the gallbladder are taken down to reveal the triangle of Calot. The infundibulum is retracted laterally to open the triangle, separating the cystic duct from the common hepatic duct. The overlying peritoneum is incised and the triangle of Calot is cleared of soft tissue. Dissection continues until the cystic duct and artery are the only remaining structures in the triangle and can be seen directly entering the gallbladder. This constitutes the “critical view of safety” (Figure 5). Opening the peritoneal reflections over the gallbladder and elevating the distal gallbladder off of the liver with electrocautery may facilitate this portion of the operation. This technique is particularly helpful in the setting of acute cholecystitis with dense inflammation of the gallbladder and surrounding structures. Once the critical view of safety is achieved, the cystic duct and artery are doubly clipped and divided. The gallbladder is dissected off of the liver with electrocautery, placed into a specimen bag, and removed from the abdomen. After hemostasis is assured, pneumoperitoneum is released, all port sites are closed, and the patient is allowed to emerge from anesthesia.
TABLE 1. Key Technical Steps and Potential Pitfalls in Laparoscopic Cholecystectomy
FIGURE 5 • The critical view of safety. The triangle of Calot has been neatly cleared of all tissue except the cystic artery and cystic duct. These two remaining structures are seen directly entering the gallbladder and may be safely divided. (From Mulholland, M., Greenfield’s Surgery, 5th ed. Lippincott Williams & Wilkins, 2011)
Special Intraoperative Considerations
Approximately 10% of attempts at laparoscopic cholecystectomy for acute cholecystitis result in conversion to an open operation. The primary indication for conversion is an inability to clearly define the anatomy of the biliary tract. Failure to establish the critical view of safety mandates conversion. Other indications include significant inflammation, failure to make satisfactory progress, any suspicion of injury to ductal or vascular structures, and concern for gallbladder cancer (Table 2).
TABLE 2. Indications for Conversion to Open
Intraoperative cholangiography (IOC) may be used routinely in cholecystectomy or reserved for select circumstances (Table 3). Direct imaging of the biliary tree may demonstrate choledocholithiasis in patients suspected of having common duct stones due to biliary dilatation, elevated liver enzymes, or pancreatitis (Figure 6). Stones may be removed via CBD exploration or ERCP, either during the operation or postoperatively. Additionally, IOC may aid in delineating biliary anatomy or identification of biliary injury.
TABLE 3. Indications for Intraoperative Cholangiogram
FIGURE 6 • IOC with choledocholithiasis. This intraoperative cholangiogram revealed stones stacked within the CBD.
Patients with severe inflammation pose a particular challenge. Needle decompression of a tense gallbladder allows for more effective retraction. IOC may be necessary to define ductal anatomy. Occasionally, it is not possible to definitively attain the critical view of safety due to unclear anatomy or inflammation, which would render further dissection unsafe. Frequently in these circumstances, the operation may be safely completed with conversion to open. In select cases, however, the patient may be better served with a partial cholecystectomy. The gallbladder is elevated off of the liver bed starting proximally with the fundus. It is then transected at the level of the gallbladder neck or infundibulum without complete dissection of the triangle of Calot. Remaining stones can then be removed through the gallbladder lumen. The distal gallbladder can then be oversewn with absorbable suture. Drains should be left in place, given the risk of a bile leak from the oversewn gallbladder. If partial cholecystectomy is performed, care must be taken to remove almost all of the gallbladder and any remaining stones. Otherwise, the patient could develop recurrent cholecystitis. If this approach is also ill-advised due to severe inflammation and/or anatomical distortion, a cholecystostomy tube may be placed laparoscopically.
Prior abdominal operations are not an absolute contraindication to an attempt at laparoscopic cholecystectomy, but may necessitate deviation from standard port placement. The initial access to the abdomen should be obtained in a location remote from prior operations where possible to minimize the risk of visceral injury. The left subcostal region is often an excellent location. In cases where this is not practical, an open approach to placement of the first port allows direct visualization of any adhesion to the abdominal wall. Alternate port placement may also be considered in patients with indwelling mesh from a prior herniorrhaphy. The camera port and the right subcostal ports may often be placed lateral and superior to the anticipated margins of the mesh. Placing a port directly through indwelling synthetic mesh is technically possible but carries a risk of contamination of the prosthetic and subsequent infection, and may compromise the integrity of the hernia repair. While laparoscopic cholecystectomy is technically possible in many patients with prior abdominal surgery, primary open cholecystectomy must also be considered. The ultimate choice of surgical approach must be tailored to the individual.
Postoperative Management
Most patients with acute cholecystitis are able to return home the day after laparoscopic cholecystectomy. Regular diet may be resumed immediately after surgery, and oral pain medications usually provide ample analgesia. Antibiotics are not indicated beyond the immediate perioperative period. Some patients experience diarrhea associated with altered bile salt storage after cholecystectomy, but this is typically mild and temporary.
Persistent abdominal pain, fever, or hyperbilirubinemia should prompt evaluation for retained CBD stone, biliary leak, or biliary injury. US should be the initial imaging study as it noninvasively demonstrates biliary dilation and fluid collections. Similar information may be derived from abdominal CT. Biliary dilation should be further evaluated with ERCP to identify a retained CBD stone or biliary injury causing obstruction. During the same procedure, interventions such as stent placement, stone extraction, or sphincterotomy may be accomplished (Figure 7). Postoperative fluid collections may represent hematoma, biloma, or abscess. Percutaneous CT- or US-guided drain placement allows for adequate drainage of the collection as well as identification of its source. Return of bilious fluid should prompt ERCP to pinpoint the leak. During ERCP, an endobiliary stent may then be placed to encourage bile flow through the biliary tree into the duodenum rather than into the peritoneum.
FIGURE 7 • ERCP with bile leak. Postoperative ERCP demonstrating a cystic duct stump leak. A wire is seen within the common hepatic duct, which traverses the CBD and terminates in the duodenum. A stent is placed across this wire to encourage bile flow into the duodenum rather than through the leak.
Case Conclusion
The patient underwent laparoscopic cholecystectomy for acute cholecystitis. Despite residual adhesions from the patient‘s right hemicolectomy, the critical view is achieved and the operation completed laparoscopically. The patient recovers without incident and is discharged on postoperative day 1. On postoperative day 4, she returns to the ER with fever, increasing abdominal pain, leukocytosis, and hyperbilirubinemia. She is admitted to the hospital and treated with antibiotics. US demonstrates a fluid collection in the gallbladder fossa. A percutaneous drain is placed with return of bilious fluid. ERCP identifies a cystic duct stump leak, and a biliary stent is inserted endoscopically (Figure 7). The patient‘s condition improves and she returns home 2 days later. The volume of drain output decreases over the course of several weeks, and the drain is subsequently removed. The patient suffers no further complications and no recurrence of her biliary symptoms.
TAKE HOME POINTS
· Acute cholecystitis presents with RUQ pain, fever, and leukocytosis.
· RUQ ultrasound is the first-line diagnostic test.
· Acute cholecystitis must be distinguished from other biliary pathology such as biliary colic, choledocholithiasis, cholangitis, or biliary pancreatitis.
· Urgent laparoscopic cholecystectomy is the treatment of choice for most patients, even those presenting after 72 hours.
· During laparoscopic cholecystectomy, no structures should be divided until the critical view of safety is established.
· Inability to achieve the critical view of safety mandates conversion to open operation.
· Intraoperative cholangiogram may be useful in defining the patient’s biliary anatomy and identifying choledocholithiasis or biliary injury.
· Persistent postoperative pain, fever, or hyperbilirubinemia are concerning for retained CBD stone or biliary leak.
SUGGESTED READINGS
Csikesz N, Ricciardi R, Tseng JF, et al. Current status of surgical management of acute cholecystitis in the United States. World J Surg. 2008;32(10):2230–2236.
Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev. 2006;(4):CD005440.
Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804–2811.