|Year : 2022 | Volume
| Issue : 1 | Page : 36-39
Gangrenous Cholecystitis: A case report
Adedire Timilehin Adenuga
Department of Surgery, Cedarcrest Hospitals, Abuja, Nigeria
|Date of Submission||04-Jan-2021|
|Date of Decision||27-Apr-2022|
|Date of Acceptance||09-Aug-2021|
|Date of Web Publication||21-Jul-2022|
Adedire Timilehin Adenuga
Department of Surgery, Cedarcrest Hospitals, Abuja
Source of Support: None, Conflict of Interest: None
Gangrenous cholecystitis (GC) depicts gallbladder (GB) wall necrosis which occurs following prolonged acute cholecystitis that ultimately causes impairment in blood supply. GC is more common in the elderly and in patients with comorbidities. These patients may present with vague symptoms which may be confused with other conditions. Blood work may show elevated white cell count, and computed tomography may show lack of enhancement of the GB wall, air within the lumen or wall, and pericholecystic abscess. These patients would require proper resuscitation and an emergent cholecystectomy. This is the case report of a 75-year-old diabetic woman who presented acutely with a history of right upper abdominal pain and imaging finding of GC. She had an emergency subtotal cholecystectomy performed with good outcome.
Keywords: Complicated cholecystitis, gangrenous cholecystitis, open cholecystectomy, subtotal cholecystectomy
|How to cite this article:|
Adenuga AT. Gangrenous Cholecystitis: A case report. Niger J Gastroenterol Hepatol 2022;14:36-9
| Introduction|| |
Gangrenous cholecystitis (GC) is a severe form of acute cholecystitis associated with a high incidence of morbidity, mortality, and poor postoperative outcome. GC is seen in 10%–40% of patients with acute cholecystitis.,, The initial impaction of calculus at the infundibulum or cystic duct may be followed by secondary bacterial infection by Enterobacteriaceae. GC reflects the duration of the inflammatory and ischemic process where the obstruction of the cystic duct leads to prolonged increase in intraluminal pressure to the point where this pressure exceeds the arterial inflow causing ischemia.
Some factors associated with GC include advanced age, delayed presentation/surgery, cardiovascular diseases, diabetes mellitus, leukocytosis, elevated C-reactive protein (CRP) level, patients on total parenteral nutrition, trauma, obesity, impacted calculus at the infundibulum, and sepsis.,,
The morbidity rate following GC may be as high as 25% and mortality up to 40%., GC could progress into gallbladder (GB) perforation which is said to occur in up to 10% of cases. GB perforation may then lead to abscess formation, cholecystoenteric fistula, or generalized peritonitis with an even higher rate of morbidity and mortality., This is a case report showing the presentation and management of a patient with GC.
| Case report|| |
A 75-year-old woman presented with right upper abdominal pain of 10-day duration. The pain was said to be dull aching with moderate intensity. She had no jaundice or fever. There was a positive history of anorexia, and she had three episodes of nonbilious vomiting. She also noticed fast breathing, although there was no chest pain or cough. She had a past medical history of diabetes and hypertension with poor control. She was on metformin and glimepiride for diabetes and amlodipine for hypertension. She was admitted and initially managed for acute cholecystitis but was noticed to have worsening symptoms.
On examination, she was anicteric, afebrile, and dehydrated.
Respiratory rate was 28 cycles per minute. There was reduced air entry in the right lower lung zone. SpO2 was 88%–90% on room air.
She had right upper quadrant tenderness with a palpably enlarged tense GB. There were no demonstrable ascites. An urgent plain chest radiograph showed features of a right hydrothorax [Figure 1]. A diagnosis of complicated cholecystitis with reactive right pleural effusion was made. Liver function test result showed elevated alkaline phosphatase (ALP) – 229 (ref = 53–128), normal bilirubin level, and other liver enzymes. Full blood count showed elevated white cell count of 13.6 with neutrophilia 87.8%. Her initial fasting blood sugar level was 175 mg/dl.
Abdominal computed tomography (CT) done showed a markedly enlarged GB with gall stones and extensive pericholecystic fluid with lack of contrast enhancement of the GB wall [Figure 2]. She also had rising CRP level from 68 to 216 mg/l. She was comanaged with the medical team who commenced her on glucose:potassium: insulin (G:K:I) infusion for control of blood sugar. This was continued intraoperatively. She had a urethral catheter passed, and urine output measurement was done hourly.
The patient had right closed thoracostomy tube drainage (CTTD) and open reconstituting subtotal cholecystectomy under general anesthesia. Intraoperative finding revealed grossly dilated GB with necrosis extending up to the infundibulum with a frozen Calot’s triangle [Figure 3]. The GB was filled with numerous gallstones [Figure 4]. Postoperative period was uneventful. She had broad-spectrum intravenous antibiotics (co-amoxiclav and metronidazole) for the first 4 days and was converted to orals to complete 7 days. Blood glucose control was initially by G: K: I and was converted to oral metformin and glibenclamide after she commenced full oral intake.
Total fluid drained from the CTTD was about 1200 ml and the chest tube was removed on day 6 when the drain became inactive. She did well and was discharged on the 11th postoperative day. Histology was GC.
| Discussion|| |
GC is defined as GB necrosis due to progressive inflammation and infection which causes arterial supply impairment leading to wall ischemia.
GC is rare and requires a high index of suspicion. It is a surgical emergency, and in the light of the high rate of morbidity, which includes bile duct injury (BDI) and mortality, it should be treated with the utmost urgency. The mortality rate of GC has been reported as being between 15% and 50%.,
The pathophysiology for the development of GC has been described as being due to GB distension leading to increased tension and pressure on the GB wall. GB ischemia occurs as a result of vascular compromise of the cystic artery. The resulting poor perfusion results in ischemia and necrosis of the wall of the GB.
Diabetes causes microvascular disease, with the atherosclerotic vessels being increasingly susceptible to the increased intraluminal pressure leading to early ischemia. Diabetes also creates a microenvironment that promotes the growth of bacteria and infection. The presence of diabetic neuropathy further impairs clinical manifestation and early diagnosis.
A CRP level >200 mg/l was found to have a 50% positive predictive value and 100% negative predictive value in predicting GC with 100% sensitivity and 87.9% specificity. An elevated ALP associated with leukocytosis in patients with diabetes has been found to be associated with the presence of GC. All four were present in the index patient.
Although ultrasound is an excellent tool in the evaluation of hepatobiliary conditions, the ability of ultrasound to distinguish between GC and non-GC is limited. GB thickening, pericholecystic fluid, and a positive sonologic Murphy’s sign are seen in both GC and in simple acute cholecystitis. Abdominal CT is highly specific (96.0%) for identifying patients with acute GC but is insensitive (29.3%). Air in the GB wall or lumen, irregular or absent GB wall, intraluminal membranes, pericholecystic abscess, and lack of GB wall enhancement are specific CT findings of acute cholecystitis complicated by gangrene. An abdominal CT was requested in this patient to allow the adequate evaluation of the GB mass to rule out a malignant process in an elderly female patient. In this patient, there was no enhancement of the GB wall on contrast and there was associated extensive pericholecystic fluid. No GB or hepatic masses were seen.
Early cholecystectomy for acute cholecystitis is still not commonly done in our setting. Many times, these patients present later than the 72-h window which is currently recommended and requires fluid resuscitation. Most cholecystectomies are done as interval procedures with open cholecystectomy (OC) are still predominant. Patients with fulminant acute cholecystitis may progress despite being on conservative management.
Definitive treatment of GC includes resuscitation with intravenous fluids, intravenous broad-spectrum antibiotics to cover Gram-negative aerobes and anaerobes, nil per os, and use of analgesics. When there is clinical suspicion of gangrene or perforation of the GB, open surgery is preferred. Furthermore, in the presence of preoperative finding of pneumoperitoneum, open surgery enables thorough assessment of the peritoneal cavity to rule out a bowel perforation.
Laparoscopic cholecystectomy is another option as it is associated with less wound complications, better cosmesis, shorter hospital stay, and early return to work. Laparoscopy is still scarce in Nigeria, with most tertiary centers performing about 3–5 lap choles per year. Furthermore, in the light of the COVID-19 pandemic, aerosol-generating procedures such as endoscopy and laparoscopy have been limited as a means to protect theater staff. When laparoscopic means is elected, there should be a low threshold for conversion to open in the presence of distorted anatomy or fragile tissues. An intraoperative cholangiogram may be needed to avoid BDI. OC has a role in management of patients with GC as an alternative in cases of difficult laparoscopic cholecystectomy, especially when the Calot’s triangle is not easily visualized and also in a low-resource setting. The index patient had laparotomy done with a subtotal cholecystectomy.
In the setting of severe inflammation as occurs in GC, secure ductal identification by the critical view of safety may be challenging. Indeed, the inflammation may be so severe as to make the common bile duct look so much like the cystic duct with a proportional increase in the chance of biliary injury. Performing a total cholecystectomy in the setting of a frozen or severely inflamed Calot’s triangle risks a higher incidence of BDI, and a subtotal cholecystectomy may be indicated. There are two types of subtotal cholecystectomy – the reconstituting and fenestrating types. The former is associated with a slightly increased risk of cholecystolithiasis while the latter may be associated with an increased incidence of postoperative bile leak. Any of them is a good option in a difficult hepatocystic triangle and significantly reduces the incidence of BDI.
Placement of drains following subtotal cholecystectomy is the sine qua non to monitor for postoperative bile leak from the stump of the GB or due to a BDI. Cholecystostomy decompresses a severely inflamed GB and acts as a bridge toward definitive treatment. If the patient is in poor clinical condition and unable to tolerate anesthesia, a temporary drainage of the GB through insertion of a cholecystostomy tube may be preferred and definitive cholecystectomy done at a later date.
| Conclusion|| |
GC is a severe complication of acute cholecystitis associated with high risk of morbidity and mortality. Patients may present with comorbidities and require proper initial resuscitation and imaging. Cholecystectomy is the definitive procedure with varying approaches. In the presence of a distorted Calot’s triangle, a subtotal cholecystectomy may be preferred.
We would like to show gratitude to the entire staff and management of Cedarcrest Hospitals, Abuja, for their excellent professionalism in the care of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]