title: Synchronous pyogenic liver abscess and acute cholecystitis: how to recognize it and what to do (emergency cholecystostomy followed by delayed laparoscopic cholecystectomy).
abstract: BACKGROUND
  The treatment of synchronous pyogenic liver abscess (PLA) and acute cholecystitis (AC) may be challenging. Moreover, because of the similarity of symptoms and the suboptimal accuracy of ultrasound (US), PLA(s) may be undetected, unless a computer tomography (CT) scan is performed. The aims of this study were (1) to evaluate the results of emergency cholecystostomy (CS) and late laparoscopic cholecystectomy (LC) in such a population and (2) to identify the criteria for selecting patients with AC and a high risk of having synchronous PLA(s) for referral for a CT scan.
  
  
  METHODS
  A retrospective analysis of the outcome of 12 patients with AC and PLA(s) treated by emergency CS followed by delayed LC from January 1996 through May 2010 at a tertiary-care university hospital was performed. Clinical, laboratory, and radiological data of patients with synchronous AC and PLA(s) are compared with those of 66 patients with "simple" AC.
  
  
  RESULTS
  The association of age >55 years, temperature >38°C, WBC count >12,000/ml, and ASAT >50 UI/l and/or ALAT >75 UI/l allows for the selection of patients at high risk of PLA to undergo a CT scan (sensitivity: 100%; specificity: 86%). All treated patients had a sudden improvement within 24 h following CS. PLA was treated in 10/12 patients (83%). Hospital stay lasted 21.5 ± 3.5 days. Ten patients underwent elective LC 12 ± 4 weeks after CS with no conversion and 30% perioperative morbidity. Operating time was 91 min. Hospital stay was 1.7 days [7 patients (70%) underwent surgery as an outpatient].
  
  
  CONCLUSIONS
  A simple algorithm is presented for the selection of patients with AC to undergo a CT scan to identify synchronous PLA. Emergency CS followed by delayed LC is a viable, first-line treatment option for synchronous PLA and AC.
authors.affiliation: Service de Chirurgie Digestive, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Université Paris XI, 157, Rue de la Porte de Trivaux, 92141, Clamart, France. renatocosti@hotmail.com
authors.forename: Renato
authors.initials: R
authors.lastname: Costi
authors.forename: Alban
authors.initials: A
authors.lastname: Le Bian
authors.forename: François
authors.initials: F
authors.lastname: Cauchy
authors.forename: Papa Saloum
authors.initials: PS
authors.lastname: Diop
authors.forename: Alessio
authors.initials: A
authors.lastname: Carloni
authors.forename: Laurence
authors.initials: L
authors.lastname: Catherine
authors.forename: Claude
authors.initials: C
authors.lastname: Smadja
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D041881:Cholecystitis, Acute / Q000175:diagnosis* / Q000601:surgery; D002767:Cholecystostomy / Q000379:methods*; D004630:Emergencies; D004638:Emergency Treatment; D005260:Female; D006801:Humans; D007902:Length of Stay; D046290:Liver Abscess, Pyogenic / Q000175:diagnosis* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D057832:Watchful Waiting