Conservative treatment for acute cholecystitis: clinical and radiographic predictors of failure.
BACKGROUND
Current treatment options for acute calculous cholecystitis include either early cholecystectomy, or conservative treatment consisting of intravenous antibiotics and an interval cholecystectomy several weeks later. Percutaneous drainage is reserved for patients in whom conservative therapy failed or as a salvage procedure for high risk patients.


OBJECTIVE
To identify clinical and radiographic factors leading to failure of conservative treatment.


METHODS
We prospectively collected data on consecutive patients admitted with the diagnosis of acute cholecystitis. Parameters were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy. Logistic regression analysis was performed to identify predictors for failure of conservative treatment.


RESULTS
The study population comprised 103 patients with a median age of 60 who were treated for acute cholecystitis. Twenty-seven patients (26.2%) required PC. On univariate analysis, age above 70 years, diabetes, elevated white blood cell count, tachycardia (> 100 beats/min) at admission, and a distended gallbladder (> 5 cm transverse diameter) were found to be significantly more common in the PC group (P < 0.001). WBC was higher in the PC group throughout the initial 48 hours. On multivariate analysis, age above 70 (odds ratio 3.6), diabetes (OR 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder (OR 8.5) were predictors for cholecystostomy (P < 0.001). Age above 70 (OR 5.2) and WBC $15,000 (OR 13.7) were predictors for failure of conservative treatment after 24 and 48 hours (P < 0.001).


CONCLUSIONS
Age above 70, diabetes, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (> 15,000) suggests refractory disease and should play a central role in the clinical follow-up and decision-making process for elderly patients with acute cholecystitis.
Barak
Orly
O
Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
Elazary
Ram
R
Appelbaum
Liat
L
Rivkind
Avraham
A
Almogy
Gidon
G
D000208:Acute Disease; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002763:Cholecystectomy; D002764:Cholecystitis / Q000000981:diagnostic imaging* / Q000628:therapy*; D002765:Cholecystography; D048909:Diabetes Complications; D005260:Female; D006801:Humans; D007958:Leukocyte Count; D008297:Male; D008875:Middle Aged; D013610:Tachycardia / Q000150:complications; D017211:Treatment Failure