Gangrenous cholecystitis: Deceiving ultrasounds, significant delay in surgical consult, and increased postoperative morbidity!
BACKGROUND
Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspected acute cholecystitis. We sought to characterize preoperative risk factors and post-operative complications.


METHODS
Pathology reports of all patients undergoing cholecystectomy for suspected acute cholecystitis from June 2010 to January 2014 and admitted through the emergency department were examined. Patients with GC were compared with those with acute/chronic cholecystitis (AC/CC). Data collected included demographics, preoperative signs and symptoms, radiologic studies, operative details, and clinical outcomes.


RESULTS
Thirty-eight cases of GC were identified and compared with 171 cases of AC/CC. Compared with AC/CC, GC patients were more likely to be older (57 years vs. 41 years, p < 0.001), of male sex (63% vs. 31%, p < 0.001), hypertensive (47% vs. 22%, p = 0.002), hyperlipidemic (29% vs. 14%, p = 0.026), and diabetic (24% vs. 8%, p = 0.006). GC patients were more likely to have a fever (29% vs. 12%, p = 0.007) and less likely to have nausea/vomiting (61% vs. 80%, p = 0.019) or an impacted gallstone on ultrasound (US) (8% vs. 26%, p = 0.017). Otherwise, there was no significant difference in clinical or US findings. Among GC patients, US findings were absent (8%, n = 3) or minimal (42%, n = 16). Median time from emergency department registration to US (3.3 hours vs. 2.8 hours, p = 0.28) was similar, but US to operation was longer (41.2 hours vs. 18.4 hours, p < 0.001), conversion to open cholecystectomy was more common (37% vs. 10%, p < 0.001), and hospital stay was longer (median, 4 days vs. 2 days, p < 0.0001). Delay in surgical consultation occurred in 16% of GC patients compared with 1% of AC patients (p < 0.001).


CONCLUSIONS
Demographic features may be predictive of GC. Absent or minimal US signs occur in 50%, and delay in surgical consultation is common. Postoperative morbidity is greater for patients with GC compared with those with AC/CC.


METHODS
Epidemiologic study, level III; therapeutic study, level IV.
From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (D.D.Y., C.C., P.F., D.R.K., E.N.K., M.D., H.K., G.V.), Department of Surgery, and Department of Medicine (Y.C.), Massachusetts General Hospital, Boston, Massachusetts.
Daniel Dante
DD
Yeh
Catrina
C
Cropano
Peter
P
Fagenholz
David R
DR
King
Yuchiao
Y
Chang
Eric N
EN
Klein
Marc
M
DeMoya
Haytham
H
Kaafarani
George
G
Velmahos
D000328:Adult; D002763:Cholecystectomy / Q000379:methods / Q000401:mortality; D002764:Cholecystitis / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D041881:Cholecystitis, Acute / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D057210:Delayed Diagnosis / Q000401:mortality*; D005260:Female; D005734:Gangrene / Q000401:mortality / Q000473:pathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality* / Q000503:physiopathology; D011300:Preoperative Care / Q000379:methods; D011379:Prognosis; D012017:Referral and Consultation; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler / Q000379:methods