Clinical features and outcomes of patients with severe acute pancreatitis complicated with gangrenous cholecystitis

BACKGROUND: The effects of gangrenous cholecystitis (GC) and consequent surgical interventions on the clinical outcomes and prognosis of patients with severe acute pancreatitis are not clear. The present study was to characterize the clinical outcomes of patients with severe acute pancreatitis complicated with GC. METHODS: We retrospectively analyzed 253 consecutive patients hospitalized for acute pancreatitis in intensive care unit. Among them, 68 were diagnosed as having severe acute pancreatitis; 10 out of the 68 patients had GC. We compared these 10 patients with GC and 58 patients without GC. The indices analyzed included sepsis/septic shock, pancreatic encephalopathy, acute respiratory distress syndrome, acute renal failure, multiple organ dysfunction syndrome, and death. RESULTS: Specific CT images of GC in patients with severe acute pancreatitis included enlarged and high-tensioned gallbladder, wall thickening, lumenal emphysema, discontinuous and/or irregular enhancement of mucosa, and pericholecystic effusion. The rates of severe sepsis/septic shock (70.0% vs 24.1%, P【0.01), pancreatic encephalopathy (50.0% vs 17.2%, P【0.05), acute respiratory distress syndrome (90.0% vs 41.4%, P【0.01), multiple organ dysfunction syndrome (70.0% vs 24.1%, P【0.01), acute renal failure (40.0% vs 27.6%, P【0.05), and death (40.0% vs 13.8%, P【0.05) were significantly higher in patients with GC than in those without GC.CONCLUSION: CT scans can help to identify early GC in patients with severe acute pancreatitis; early diagnosis and intervention for patients with GC can reduce morbidity and mortality.

Laparoscopic cholecystectomy for gangrenous cholecystitis in around nineties: Two case reports

BACKGROUND Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course.We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis,who safely underwent laparoscopic cholecystectomy(LC)and both demonstrated a good outcome.CASE SUMMARY Case 1:An 89-year-old female.She underwent abdominal contrast-enhanced computed tomography(CECT)due to abdominal pain and diarrhea.Her gallbladder wall indicated the absence of contrast enhancement,thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC.Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated,she was able to be discharged without any serious complications.Case 2:A 91-year-old female.She made an emergency visit with a chief complaint of abdominal pain.Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall.She was diagnosed with gangrenous cholecystitis and underwent LC.Her gallbladder had swelling and diffuse necrosis.Although her preoperative blood culture was positive,she showed a good outcome following surgery.CONCLUSION Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery,if an early diagnosis can be made and appropriate treatment can be carried out,then even very elderly individuals may be discharged without major complications.

Gangrenous Cholecystitis with Atypical Presentation in an Elderly Diabetic Woman

In elderly patients, numerous factors subsidize the diagnostic challenge and high incidence of complications in this specific population, taking gangrenous cholecystitis as a critical example. The aim of this work is to report an unusual case of gangrenous choleystitis in an elderly diabetic women and its atypical clinical presentation. A 79-year-old female patient came to our observation;her medical history showed nausea and vomiting of about 2 hours which rapidly ended with symptomatic therapy, without recurrence, and a 3-week history of intermittent fever associated with productive cough. No abdominal discomfort was declared. Physical examination of the abdomen was negative. Laboratory analysis revealed leukocytosis with the remaining criteria within the normal range. After 2 days, she started with a mildabdominal pain in the epigastric region that rapidly progressed to the right upper quadrant, right flank and right iliac fossa, without nausea, vomiting or fever. Abdominal computer tomography findings revealed thickness of the gall-bladder and important densification of the vascular bed. Acute cholecystitis was diagnosed. The patient was then submitted to a laparoscopic cholecystectomy under general anaesthesia with findings suggestive of gangrenous acute cholecystitis confirmed by histologic examination of the specimen. Delays in diagnosing acute cholecystitis in specific populations, such as elderly diabetics, result in a higher prevalence of morbidity and mortality due to potentially serious complications as gangrenous cholecystitis. Consequently, the diagnosis should be measured and investigated promptly in order to prevent poor outcomes.

Necrotizing Fasciitis Secondary to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A Rare Case Report Presentation

Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.

Therapeutic experience of an 89-year-old high-risk patient with incarcerated cholecystolithiasis:A case report and literature review

BACKGROUND The global pandemic of coronavirus disease 2019 pneumonia poses a particular challenge to the emergency surgical treatment of elderly patients with high-risk acute abdominal diseases.Elderly patients are a high-risk group for surgical treatment.If the incarceration of gallstones cannot be relieved,emergency surgery is unavoidable.CASE SUMMARY We report an 89-year-old male patient with acute gangrenous cholecystitis and septic shock induced by incarcerated cholecystolithiasis.He had several coexisting,high-risk underlying diseases,had a history of radical gastrectomy for gastric cancer,and was taking aspirin before the operation.Nevertheless,he underwent emergency laparoscopic cholecystectomy,with maintenance of postoperative heart and lung function,successfully recovered,and was discharged on day 8 after the operation.CONCLUSION Emergency surgery for elderly patients with acute abdominal disease is safe and feasible during the coronavirus disease 2019 pandemic,the key is to abide strictly by the hospital's epidemic prevention regulations,fully implement the epidemic prevention procedure for emergency surgery,fully prepare before the operation,accurately perform the operation,and carefully manage the patient postoperatively.