title: Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis?
abstract: Gangrenous cholecystitis is difficult to diagnose clinically and carries risk of morbidity and mortality if not treated urgently. Complex scoring systems exist to predict the condition. C reactive protein may be a single independent predictor as suggested in this small study.
  
  
  BACKGROUND
  Gangrenous cholecystitis (GC) is a serious sequel of acute cholecystitis occurring in 2-30% patients and has a mortality of 0.2-0.5%. Urgent surgical intervention is important to reduce morbidity and mortality therefore it is important to identify patients with GC from non-severe cholecystitis. The aim of this study is to determine biochemical and radiological markers, which is associated with the development GC and the value of C-reactive protein (CRP) at different cut-offs in predicting GC.
  
  
  METHODS
  This is an observational cohort study of all consecutive patients who presented with biliary symptoms to the emergency department in a large NHS Hospital in the UK, from January to December 2012. They had cholecystectomies performed either during index admission or electively at later date by a team of 4 upper gastrointestinal surgeons. The gangrenous nature of the gallbladder was determined by operative findings and/or histopathology results. Parameters including age, gender, albumin, jaundice, gallbladder wall thickness on ultrasound scan, highest preoperative white blood count (WBC) and CRP value, were examined for their predictive value.
  
  
  RESULTS
  141 patients presented with acute biliary problems. 22 underwent emergency cholecystectomy and 119 were discharged and called back for elective surgery. Of these, 16 were gangrenous (11%). Patients with GC were significantly older (p = 0.016), had significantly higher CRP (p < 0.001) and WBC (p = 0.001), significantly lower albumin levels (p < 0.001) and higher percentage with thick walled gallbladder (p < 0.001). We found that a CRP value of more than 200 mg/dL has a 50% positive predictive value and 100% negative predictive value in predicting gangrenous cholecystitis with 100% sensitivity and 87.9% specificity.
  
  
  CONCLUSIONS
  In this study CRP on its own has been shown to have high predictive value in predicting GC, but larger studies are needed to validate this finding. Monitoring trend of CRP in patients with acute cholecystitis may help early diagnosis and decision for early surgical intervention.
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom.
authors.forename: K W J
authors.initials: KW
authors.lastname: Mok
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom.
authors.forename: R
authors.initials: R
authors.lastname: Reddy
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom.
authors.forename: F
authors.initials: F
authors.lastname: Wood
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Turner
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom.
authors.forename: J B
authors.initials: JB
authors.lastname: Ward
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom.
authors.forename: K G
authors.initials: KG
authors.lastname: Pursnani
authors.affiliation: Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom. Electronic address: ravidate@hotmail.com.
authors.forename: R S
authors.initials: RS
authors.lastname: Date
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis*; D002763:Cholecystectomy; D041881:Cholecystitis, Acute / Q000097:blood* / Q000473:pathology / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D005734:Gangrene; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies
chemical_list: D015415:Biomarkers; D002097:C-Reactive Protein
keywords: C-reactive protein; Emergency cholecystectomy; Gangrenous gallbladder; Severe cholecystitis