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We present a 20 years old male with no known comorbid in emergency complaining of pain localized to the right upper quadrant for two days, followed by fever (101F) with 15-16 episodes of vomiting, which were non-bilious and containing food particles. The patient was vitally stable on examination and had a mild jaundiced look; the abdomen was soft and tender over the right hypochondrium. Ultrasound of the abdomen showed a hypoechoic liver and thick-walled acalculous gall bladder along with pericholecystic fluid, suggesting acute cholecystitis. On further evaluation, the diagnosis of gangrenous cholecystitis was made, and an emergency exploratory laparotomy along with a cholecystectomy was performed.

We present a 20 years old male with no known comorbid in emergency complaining of pain localized to the right upper quadrant for two days, followed by fever (101F) with 15-16 episodes of vomiting, which were non-bilious and containing food particles. The patient was vitally stable on examination and had a mild jaundiced look; the abdomen was soft and tender over the right hypochondrium. Ultrasound of the abdomen showed a hypoechoic liver and thick-walled acalculous gall bladder along with pericholecystic fluid, suggesting acute cholecystitis. On further evaluation, the diagnosis of gangrenous cholecystitis was made, and an emergency exploratory laparotomy along with a cholecystectomy was performed. [ABSTRACT FROM AUTHOR]

Emphysematous cholecystitis is a potentially life-threatening variant of acute cholecystitis, characterized by the presence of gas in the gallbladder wall/lumen due to the proliferation of gas-producing bacteria. Symptoms include upper right quadrant pain, fever, nausea, and vomiting. Laboratory tests may show nonspecific indications of systemic infection, and radiological assessment, especially CT scanning, is crucial for diagnosis. This case underscores the significance of early diagnosis and intervention in managing emphysematous cholecystitis to prevent serious complications and reduce the higher mortality rate compared to acute cholecystitis.

Introduction: Gangrenous cholecystitis (GC) is a serious complication associated with cholecystitis and usually presents with greater mortality than uncomplicated cholecystitis. It may be associated with cholelithiasis or can be due to acalculous cholecystitis. Acalculous cholecystitis is usually associated with elderly age and or associated with comorbidities such as diabetes mellitus (DM), coronary artery disease, and chronic debilitated bedridden patients. Since these patients are elderly, have other symptomatology of chronic illnesses, and usually suffer from peripheral neuropathy, the diagnosis can be missed in initial stages. We present here a case series of five patients with GC who presented in whom the diagnosis was missed initially and subsequent surgical intervention resulted in rapid recovery. Material and Methods: The aim of this study was to emphasize on the importance of keeping index of suspicion and early surgical intervention in such cases to prevent morbidity and mortality. Patients studied in this case series were initially admitted to the medical ward and surgical consult was sought later. Delay in seeking surgical consult ranged from 1 to 4 days. All of them underwent cross-sectional imaging in form of contrast-enhanced computed tomography abdomen and subsequent open cholecystectomy based on imaging findings of perforated gallbladder, intraoperatively these patients were found to have perforated gallbladder secondary to GC. Results: Out of the five patients studied, 3 (60%) were female and 2 (40%) were male, with a mean age of 64.5 (55–73) years. DM constitute most frequently accompanying medical issues (80%). Surgical site infection was seen as the most common postoperative complication. Longer delay time before diagnosis was determined as independent risk factor affecting morbidity and mortality.

Mucinous ovarian cancer occurs sporadically, with a frequency of approximately 3–5% among all subtypes of ovarian cancer. Extreme leukocytosis >40,000 and 50,000 has been described in most solid tumors and is associated with a poor prognosis, although there is a lack of literal data of its occurrence after cytoreductive surgery and HIPEC in the treatment of advanced mucinous ovarian cancer. There is higher risk of the occurrence of cholecystitis in oncology patients compared to the general population, although there is no formal evidence for this, and the association with ovarian cancer is accompanied by a relative risk of 1.38. Hypercalcemia-hyperleukocytosis is a syndrome associated with head and neck cancers, although, to our knowledge, it has not been described in mucinous ovarian cancer, especially after cytoreductive surgery and HIPEC.

Perforation of the gallbladder wall leads to a local perivesical abscess or progression to biliary peritonitis. The study aimed to analyse clinical, laboratory, and imaging indicators that have the strongest relationship with the presence of gangrenous cholecystitis and perforation of the wall and to design a predictive scoring system that highlights the risk of developing gangrenous cholecystitis with perforation. We performed a retrospective analysis of a total of 331 patients operated for five years (2016-2020) at the Department of Surgical Diseases" of Medical University - Pleven, with histologically verified chronic cholecystitis (120 patients; 36.4%), acute cholecystitis (100 patients; 30.1%), and destructive cholecystitis (111 patients; 33.5%). The statistical analysis identified nine main factors with the most substantial statistical significance in patients with gangrene and perforation of the gallbladder wall: age >65, male gender, diabetes mellitus, cardiovascular pathology, tachycardia>90 bpm, WBC>14.109, the thickness of gallbladder wall > 4 mm with pericholecystic fluid, ASAT and ALAT > 40 UI, CRP>150 ng/l. The total possible score was 11 points. The positive predictive value of the scale was 96% and identified the cases with micro-perforation and perivesical abbesses among the group with the highest total score. [ABSTRACT FROM AUTHOR]

Mucinous ovarian cancer occurs sporadically, with a frequency of approximately 3–5% among all subtypes of ovarian cancer. Extreme leukocytosis >40,000 and 50,000 has been described in most solid tumors and is associated with a poor prognosis, although there is a lack of literal data of its occurrence after cytoreductive surgery and HIPEC in the treatment of advanced mucinous ovarian cancer. There is higher risk of the occurrence of cholecystitis in oncology patients compared to the general population, although there is no formal evidence for this, and the association with ovarian cancer is accompanied by a relative risk of 1.38. Hypercalcemia-hyperleukocytosis is a syndrome associated with head and neck cancers, although, to our knowledge, it has not been described in mucinous ovarian cancer, especially after cytoreductive surgery and HIPEC. [ABSTRACT FROM AUTHOR]

Background: The utility of the SAND balloon catheter in laparoscopic cholecystectomy for acute cholecystitis (AC) remains unclear. Methods: A retrospective cohort study of patients who underwent emergency cholecystectomy at Shinshu University was performed to evaluate the efficacy of the SAND balloon catheter in cases of AC (SAND balloon utilization: Group S, n = 44; non‐utilization: Group non‐S, n = 47). Results: The duration of surgery was significantly shorter in Group S than in Group non‐S (p =.031). Despite comparable incidences of blood transfusions in the two groups, intraoperative blood loss was significantly less in Group S than in Group non‐S (p =.013). The incidence of postoperative intraperitoneal infection tended to be higher in Group non‐S (p =.076). Within Group non‐S, bile spillage during operation was found in 16 (34.0%) patients. The multivariate analysis revealed that gangrenous AC was the strongest independent risk factor for bile spillage during operation (odds ratio [OR]: 19.1; 95% confidence interval [CI]: 2.84–78.4; p =.002), followed by surgeons with ≤10 years of experience (OR: 11.3; 95% CI: 1.81–70.6; p <.010). Conclusions: Implementation of the SAND balloon catheter in patients with AC is a safe and efficacious surgical option. This catheter is recommended in cases of gangrenous cholecystitis and for surgeons with limited experience. [ABSTRACT FROM AUTHOR]

Epigastric pain is a common complaint in patients who present to the emergency department (ED); abdominal pain is the most common chief complaint in older adult patients who request treatment by a provider (A. B. Friedman et al., 2022). These patients may experience atypical presentations, which can result in delayed or missed diagnosis altogether, increasing morbidity, and mortality. This is the case of an older adult man who presented with chest and epigastric pain. The clinical presentation, atypical signs, and symptoms of gangrenous gallbladder are presented herein along with the differential diagnoses and diagnostics for this patient. The care for and the "what not to miss" in the management of this patent are also examined in this article. It is imperative that ED providers diagnose gangrenous gallbladder early on, especially in the older adult population, who may present with covert signs and symptoms to prevent complications and avoid poor outcomes including death in this age group. [ABSTRACT FROM AUTHOR]

Abstract Background Cholecystoduodenal fistula is an infrequent complication of gallbladder diseases. In the majority of cases, the fistula is formed by direct communication between the gallbladder and duodenum due to gallstone impaction in the gallbladder neck. We herein report a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis. Case presentation An 80-year-old woman suspected of having emphysematous cholecystitis by a previous doctor was referred to our hospital for urgent surgery. The initial diagnosis based on additional examinations was gangrenous cholecystitis penetrating the hepatoduodenal ligament. Since she did not complain of signs of peritonitis and was taking an anticoagulant medicine, we avoided surgery and selected percutaneous gallbladder drainage (PTGBD) instead. Contrast imaging of the PTGBD tube and upper endoscopy identified the indirect cholecystoduodenal fistula via the hepatoduodenal ligament. Despite repeated attempts at endoscopic fistula closure using clips, the fistula did not close successfully. We therefore performed laparoscopic cholecystectomy and fistula closure. The postoperative clinical course was uneventful, and she left the hospital on postoperative day 15. The resected gallbladder contained small black stones, and a histological examination revealed gangrenous cholecystitis with no malignant signatures. Conclusion We encountered a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis that was successfully treated by laparoscopic cholecystectomy and fistula closure. It is important to recognize the possible formation of indirect cholecystoduodenal fistula in cases of gangrenous cholecystitis penetrating the hepatoduodenal ligament.

Abstract Background Gangrenous cholecystitis has a high risk of perforation and sepsis; therefore, cholecystectomy in the early stage of the disease is recommended. However, during the novel coronavirus disease 2019 (COVID-19) pandemic, the management of emergent surgeries changed to avoid contagion exposure among medical workers and poor postoperative outcomes. Case presentation A 56-year-old man presented to our hospital with abdominal pain. Computed tomography revealed intraluminal membranes, an irregular or absent wall, and an abscess of the gallbladder, indicating acute gangrenous cholecystitis. Early laparoscopic cholecystectomy seemed to be indicated; however, a COVID-19 antigen test was positive despite no obvious pneumonia on chest computed tomography and no symptoms. After discussion among the multidisciplinary team, antibiotic therapy was started and percutaneous transhepatic gallbladder drainage (PTGBD) was planned for the following day because the patient’s vital signs were stable and his abdominal pain was localized. Fortunately, the antibiotic therapy was very effective, and PTGBD was not needed. The cholecystitis improved and the patient was discharged from the hospital on day 10. One month later, laparoscopic delayed cholecystectomy was performed after confirming a negative COVID-19 polymerase chain reaction test result. The postoperative course was uneventful, and the patient was discharged on postoperative day 2 in satisfactory condition. Conclusion We have reported a case of acute gangrenous cholecystitis in a patient with asymptomatic COVID-19 disease. This report can help to determine treatment strategies for patients with gangrenous cholecystitis during future pandemics.

A 72-year-old female without abdominal symptoms visited our hospital for routine follow-up while undergoing pancreatic cancer treatment (using TS-1). Her vital signs were normal, and her abdomen was soft and non-tender. Blood test revealed elevated C-reactive protein levels with normal white blood cell count. Computed tomography was performed for follow-up of pancreatic cancer. Contrast-enhanced computed tomography showed partial discontinuity and irregular thickness of the gallbladder wall; however, a definitive diagnosis was not obtained due to unclear imaging. Contrast-enhanced transabdominal ultrasonography revealed intraluminal membranes in the gallbladder and a perfusion defect at the bottom, indicating gangrenous cholecystitis. Surgical resection was performed, and pathological examination showed severe necrosis of the gallbladder wall, consistent with the findings of contrast-enhanced transabdominal ultrasonography.

Objective: Acute cholecystitis (AC) is an acute inflammatory disease of the gallbladder. Although there are algorithms used today in the diagnosis of AC, there is still a need for inexpensive and fast diagnostic parameters. The systemic immune-inflammation index (SIII) is a novel prognostic indicator of systemic inflammation. In our study, the prognostic value of SIII in the differential diagnosis of AC was investigated. Materials and Methods: Our study was designed as a retrospective single-center study. The study was conducted with 150 patients who were admitted to the emergency department with abdominal pain and diagnosed with AC and a control group of 150 patients not diagnosed with AC. Results: In our results, the white blood cell, neutrophil, and C-reactive protein mean values were found to be statistically significantly higher in the study group than in the control group. Once the cutoff value was established at 743.92 (×109/dL), the SII was found to have a sensitivity of 70% and a specificity of 59.2% in the diagnosis of AC. This assessment was also performed for neutrophil-to-lymphocyte ratio, and with a cutoff value of 2.91, it had a sensitivity of 62% and a specificity of 61.3%. There was no significant relationship between the Gangrenous cholecystitis (GC) and non-GC groups in terms of the diagnostic value of SIII. Conclusion: The present study found that the SIII is an index that can be used in the diagnosis of AC but be unsuccessful in distinguishing between GC and non-GC types. [ABSTRACT FROM AUTHOR]

Abstract Background Dermatomyositis is a rare idiopathic inflammatory disease with diverse presentations that can have varying degrees of cutaneous and systemic involvement. This phenotypic heterogeneity makes DM a therapeutic challenge. Some therapeutic drugs, such as hormones and immunosuppressants, have poor therapeutic effects. In recent years, tofacitinib has been reported to be effective in the treatment of dermatomyositis. Case presentation We report a case of anti-MDA5 antibody-positive dermatomyositis that was relieved after treatment with tofacitinib, during which gallbladder gangrene and suppurative cholecystitis occurred. After cholecystectomy, we continued to use tofacitinib and achieved a good therapeutic effect. Conclusions Tofacitinib is effective in the treatment of anti-MDA5 antibody-positive dermatomyositis, but the risk of infection is increased. It can still be used after infection control. Close follow-up should be performed during the use of tofacitinib.

A 50-year-old male presented to the emergency department of a hospital with an acute myocardial infarction who underwent cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO). The patient developed persistent jaundice during the course of the disease, which was later found to be gangrenous cholecystitis. We believe this case report will alert clinicians to the possibility of this complication and encourage early detection and intervention to improve the prognosis. Traditionally, the gallbladder has received secondary attention in patients receiving ECMO support, as vital organs tend to be prioritized. However, this case report illustrates the importance of preserving gallbladder function in patients receiving ECMO support.

Background: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. Methods: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. Results: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. Conclusions: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands. [ABSTRACT FROM AUTHOR]

Background: Cholecystoduodenal fistula is an infrequent complication of gallbladder diseases. In the majority of cases, the fistula is formed by direct communication between the gallbladder and duodenum due to gallstone impaction in the gallbladder neck. We herein report a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis. Case presentation: An 80-year-old woman suspected of having emphysematous cholecystitis by a previous doctor was referred to our hospital for urgent surgery. The initial diagnosis based on additional examinations was gangrenous cholecystitis penetrating the hepatoduodenal ligament. Since she did not complain of signs of peritonitis and was taking an anticoagulant medicine, we avoided surgery and selected percutaneous gallbladder drainage (PTGBD) instead. Contrast imaging of the PTGBD tube and upper endoscopy identified the indirect cholecystoduodenal fistula via the hepatoduodenal ligament. Despite repeated attempts at endoscopic fistula closure using clips, the fistula did not close successfully. We therefore performed laparoscopic cholecystectomy and fistula closure. The postoperative clinical course was uneventful, and she left the hospital on postoperative day 15. The resected gallbladder contained small black stones, and a histological examination revealed gangrenous cholecystitis with no malignant signatures. Conclusion: We encountered a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis that was successfully treated by laparoscopic cholecystectomy and fistula closure. It is important to recognize the possible formation of indirect cholecystoduodenal fistula in cases of gangrenous cholecystitis penetrating the hepatoduodenal ligament. [ABSTRACT FROM AUTHOR]

Pneumatosis intestinalis (PI) and portal venous gas (PVG) are pathological conditions suggesting serious underlying diseases such as intestinal ischemia, intestinal wall infarction, and necrotizing enterocolitis. Therefore, early detection, comprehensive management, and timely treatment of the underlying disease are important for improving outcomes. We experienced a case of a patient who developed gangrenous cholecystitis secondary to PI and PVG. In this case, it was suggested that gangrenous cholecystitis may have been induced by retrograde infection due to the proliferation of intestinal bacteria and increased intestinal pressure caused by the reduced intestinal peristalsis due to PI and PVG. Herein, we report the successful treatment of this case with a literature review., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Harada et al.)

Abstract Background Gallbladder volvulus is a rare pathology first reported by Wendel in 1898. Although the main pathological process associated with gallbladder volvulus is not known, there is clinical evidence suggesting that lack of gallbladder adhesions to the liver leads to an eventual twisting around the cystic bile duct (a process that seems to favor older female populations). Case presentation In this report, an 81-year-old Caucasian elderly female presented to the emergency department with acute/severe right upper quadrant pain, which was also accompanied by an elevated leukocyte count. Relevant imaging showed a distended gallbladder with gallbladder wall thickening and a dilated common bile duct. The patient was subsequently admitted to the hospital for acute cholecystitis and scheduled for surgery the next day. Upon laparoscopic surgery, the gallbladder was black and gangrenous with no visible adhesions to the liver. Further inspection demonstrated that the gallbladder had twisted clockwise around the cystic bile duct. Conclusions While many previous cases have been reported since Wendel, further case studies are nevertheless important to help guide proper clinic evaluation and pinpoint the potential for a gallbladder volvulus.

Purpose: Gangrenous cholecystitis (GC) is a severe type of acute cholecystitis that implies higher mortality and morbidity rates than uncomplicated cholecystitis. The characteristics of GC are various for each case. However, preoperative predictors of GC with extensive necrotic change have not been investigated well.Methods: A total of 239 patients who were pathologically diagnosed with GC underwent laparoscopic cholecystectomy at our hospital between January 2013 and December 2021. Of these, 135 patients were included in this study and were subdivided into the extensive necrosis group (patients with necrotic change extending to the neck of the gallbladder, n = 18) and the control group (patients with necrotic change limited to the fundus or body, not extending to the neck, n = 117) according to each operation video. Patient characteristics and perioperative factors predicting extensive necrotic change were investigated.Results: Pericholecystic fat stranding (83.3 vs. 53.8%, p = 0.018) and absence of wall enhancement on preoperative CT images (50.0 vs. 24.7%, p = 0.026) were significantly associated with extensive necrosis. Seven of 18 patients in the extensive necrosis group showed necrotic changes beyond the infundibulum. The absence of wall enhancement on preoperative CT images (71.4 vs. 28.8%, p = 0.018) was significantly associated with necrotic changes beyond the infundibulum.Conclusions: Pericholecystic fat stranding and absence of wall enhancement on preoperative enhanced CT are predictors of extensive necrotic change in patients with GC. In addition, the absence of wall enhancement also predicts the presence of necrotic changes beyond the infundibulum. [ABSTRACT FROM AUTHOR]

Background: Gangrenous cholecystitis has a high risk of perforation and sepsis; therefore, cholecystectomy in the early stage of the disease is recommended. However, during the novel coronavirus disease 2019 (COVID-19) pandemic, the management of emergent surgeries changed to avoid contagion exposure among medical workers and poor postoperative outcomes. Case presentation: A 56-year-old man presented to our hospital with abdominal pain. Computed tomography revealed intraluminal membranes, an irregular or absent wall, and an abscess of the gallbladder, indicating acute gangrenous cholecystitis. Early laparoscopic cholecystectomy seemed to be indicated; however, a COVID-19 antigen test was positive despite no obvious pneumonia on chest computed tomography and no symptoms. After discussion among the multidisciplinary team, antibiotic therapy was started and percutaneous transhepatic gallbladder drainage (PTGBD) was planned for the following day because the patient's vital signs were stable and his abdominal pain was localized. Fortunately, the antibiotic therapy was very effective, and PTGBD was not needed. The cholecystitis improved and the patient was discharged from the hospital on day 10. One month later, laparoscopic delayed cholecystectomy was performed after confirming a negative COVID-19 polymerase chain reaction test result. The postoperative course was uneventful, and the patient was discharged on postoperative day 2 in satisfactory condition. Conclusion: We have reported a case of acute gangrenous cholecystitis in a patient with asymptomatic COVID-19 disease. This report can help to determine treatment strategies for patients with gangrenous cholecystitis during future pandemics. [ABSTRACT FROM AUTHOR]

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Background: Dermatomyositis is a rare idiopathic inflammatory disease with diverse presentations that can have varying degrees of cutaneous and systemic involvement. This phenotypic heterogeneity makes DM a therapeutic challenge. Some therapeutic drugs, such as hormones and immunosuppressants, have poor therapeutic effects. In recent years, tofacitinib has been reported to be effective in the treatment of dermatomyositis. Case presentation: We report a case of anti-MDA5 antibody-positive dermatomyositis that was relieved after treatment with tofacitinib, during which gallbladder gangrene and suppurative cholecystitis occurred. After cholecystectomy, we continued to use tofacitinib and achieved a good therapeutic effect. Conclusions: Tofacitinib is effective in the treatment of anti-MDA5 antibody-positive dermatomyositis, but the risk of infection is increased. It can still be used after infection control. Close follow-up should be performed during the use of tofacitinib. [ABSTRACT FROM AUTHOR]

Purpose: To identify early sonographic features of gangrenous cholecystitis. Materials and methods: 101 patients with acute cholecystitis and a pre-operative sonogram were retrospectively reviewed by three radiologists in this IRB-approved and HIPAA-compliant study. Imaging data were correlated with histologic findings and compared using the Fisher's exact test or Student t test with p < 0.05 to determine statistical significance. Results: Forty-eight patients had gangrenous cholecystitis and 53 had non-gangrenous acute cholecystitis. Patients with gangrenous cholecystitis tended to be older (67 ± 17 vs 48 ± 18 years; p = 0.0001), male (ratio of male:female 2:1 vs 0.6:1; p = 0.005), tachycardic (60% vs 28%; p = 0.001), and diabetic (25% vs 8%; p = 0.001). Median time between pre-operative sonogram and surgery was 1 day. On imaging, patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat (p = 0.001), mucosal discontinuity (p = 0.010), and frank perforation (p = 0.004), while no statistically significant differences were seen in the presence of sloughed mucosa (p = 0.104), pericholecystic fluid (p = 0.523) or wall striations (p = 0.839). In patients with gangrenous cholecystitis and echogenic pericholecystic fat, a smaller subset had concurrent mucosal discontinuity (57%), and a smaller subset of those had concurrent frank perforation (58%). The positive likelihood ratios for gangrenous cholecystitis with echogenic fat and mucosal discontinuity were 4.6 (95% confidence interval 1.9–11.3) and 14.4 (2.0–106), respectively. Conclusion: Echogenic pericholecystic fat and mucosal discontinuity are early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation. [ABSTRACT FROM AUTHOR]

Purpose: To compare conventional and dual-energy CT (DECT) for the diagnosis of acute cholecystitis and gangrene. Methods: Fifty-seven consecutive adult patients with abdominal pain who underwent IV contrast-enhanced abdominal DECT on a dual-layer (dlDECT) or rapid-switching (rsDECT) scanner from September, 2018 to April, 2021 with cholecystectomy and pathology-confirmed cholecystitis were retrospectively reviewed, and compared with 57 consecutive adult patients without cholecystitis from the same interval scanned with DECT. Images were reviewed independently by two abdominal radiologists with 12 and 16 years of experience in two sessions 4 weeks apart, blinded to clinical data. Initially, only blended reconstructions (simulating conventional single-energy CT images) were reviewed (CT). Subsequently, CT and DECT reconstructions including low-keV virtual monoenergetic images and iodine maps were reviewed. Gallbladder fossa hyperemia, pericholecystic fluid, subjective presence of gangrene, heterogeneous wall enhancement, sloughed membranes, intramural air, abscess, overall impression of the presence of acute cholecystitis, and intramural iodine density were assessed. Results: Gallbladder fossa hyperemia was detected with increased sensitivity on DECT (R1, 61.4%; R2, 75.4%) vs. CT (R1, 22.8%; R2, 15.8%). DECT showed increased sensitivity for gangrene (R1, 24.6%; R2, 38.6%) vs. CT (R1, 5.3%; R2, 14%), heterogeneous wall enhancement (DECT: R1, 33.3%; R2, 63.2% vs. CT: R1, 7%; R2, 31.6%), and cholecystitis (DECT: R1, 86%; R2, 89.5% vs. CT: R1, 77.2%; R2, 70.2%). In addition, DECT was more sensitive for the detection of acute cholecystitis (R1, 86%; R2, 89.5%) vs. CT (R1, 77.2%; R2, 70.2%). Iodine density threshold of 1.2 mg/ml, 0.8 mg/mL, and 0.5 mg/mL showed specificity for gangrenous cholecystitis of 78.26%, 86.96%, and 95.65%, respectively, using the rsDECT platform. Conclusion: DECT showed improved sensitivity compared to conventional CT for detection of acute cholecystitis. Iodine density measurements may be helpful to diagnose gangrene. [ABSTRACT FROM AUTHOR]

Background: Gallbladder volvulus is a rare pathology first reported by Wendel in 1898. Although the main pathological process associated with gallbladder volvulus is not known, there is clinical evidence suggesting that lack of gallbladder adhesions to the liver leads to an eventual twisting around the cystic bile duct (a process that seems to favor older female populations).Case Presentation: In this report, an 81-year-old Caucasian elderly female presented to the emergency department with acute/severe right upper quadrant pain, which was also accompanied by an elevated leukocyte count. Relevant imaging showed a distended gallbladder with gallbladder wall thickening and a dilated common bile duct. The patient was subsequently admitted to the hospital for acute cholecystitis and scheduled for surgery the next day. Upon laparoscopic surgery, the gallbladder was black and gangrenous with no visible adhesions to the liver. Further inspection demonstrated that the gallbladder had twisted clockwise around the cystic bile duct.Conclusions: While many previous cases have been reported since Wendel, further case studies are nevertheless important to help guide proper clinic evaluation and pinpoint the potential for a gallbladder volvulus. [ABSTRACT FROM AUTHOR]

While primarily a respiratory disease, COVID-19 can affect several organ systems and has been recently linked to cases of acalculous cholecystitis. We present a previously healthy elderly patient who presented to the emergency department with sepsis and was found to have COVID-19 after initially testing negative on PCR, along with suspected concomitant acalculous gangrenous cholecystitis. The patient passed away before any surgical intervention could be made. This case aims to discuss the potential relationship between acalculous cholecystitis and COVID-19. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. Methods: All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien–Dindo classification. Results: We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2–5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien–Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. Conclusion: The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC. [ABSTRACT FROM AUTHOR]

Objective: Acute cholecystitis is a condition that most clinicians know how to examine and treat, however, evaluation of the radiological findings of gangrenous gallbladder disease and estimation of the urgency of the situation may not be familiar to the emergency physician. Case Report: A 79-year-old female patient was admitted to our Emergency Department with abdominal pain. Findings of cholecystitis were found in her examination and tests. No clear information could be obtained on computed tomography. Abdominal ultrasound was requested because a high probability of gallbladder pathology was considered in the diagnosis. Floating membranes (considered as a sign of gangrenous cholecystitis) were seen in the gallbladder and free fluid at the pelvic level were detected. Due to the comorbidities of our patient, percutaneous drainage catheter was initially planned by the General Surgeon, but due to the deterioration of her general condition, she was taken to emergency operation. Perforation was detected in the gallbladder neck during the operation. She was treated at the hospital for 30 days and was discharged with recovery. Results and Conclusion: Acute gangrenous cholecystitis is a rare cause of gallbladder diseases. It is difficult to diagnose for emergency physicians when clinical signs are unclear. In this article; we aimed to remind emergency physicians that the picture of cholecystitis can worsen rapidly, what should be considered in the examinations and complications. [ABSTRACT FROM AUTHOR]

Abstract Typhoid gangrenous cholecystitis is uncommon and can be managed by subtotal cholecystectomy with nonclosure of the cystic duct if that is required for patient safety.

Metachronous double-hit by transarterial chemoembolisation (TACE) with fotemustine inducing dysplasia-like atypia in the gallbladder and stomach - A diagnostic pitfall Gastroduodenal ulcer, histology, immunohistochemistry, Drug-induced injury, gangrenous cholecystitis Keywords: Drug-induced injury; gastroduodenal ulcer; gangrenous cholecystitis; histology; immunohistochemistry EN Drug-induced injury gastroduodenal ulcer gangrenous cholecystitis histology immunohistochemistry 128 130 3 06/22/22 20220701 NES 220701 Case summary A 41-year-old female was diagnosed with ocular malignant melanoma in May 2020. [Extracted from the article]

Background: Gangrenous cholecystitis (GC) is a particularly severe form of acute cholecystitis (AC) and is associated with an increased risk of postoperative morbidity and mortality. Recent reports show that surgeons are remarkably unsuccessful in diagnosing GC.Methods: We conducted a retrospective study involving 587 patients with AC. Logistic regression analysis was used to identify independent predictive factors of GC. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second population. We validated 2 previously published scoring models.Results: Six independent predictive factors of GC were identified: [3-]4 ASA score, temperature, duration of symptoms, WBC, male gender, and pericholecystic fluid. A predictive score of GC was established based on these independent predictive factors. Sensitivity was 81.4%; specificity was 70%. The AUC of this clinicoradiological score was 0.83. The AUC of our score was higher than that of the first published score (the AUC was 0.75 in the original report and 0.78 in the validation model using our dataset) and that of the second published score (the AUC was 0.77 in the original report and 0.72 in the validation model using our dataset).Conclusions: The AUC of our score exceeded 0.80, indicating that this score can help in diagnosing patients with GC, and thus in prioritizing these patients for surgery or choosing the adapted technique of drainage in critically ill patients. [ABSTRACT FROM AUTHOR]

To evaluate the association between the CT rim sign and gangrenous cholecystitis (GC) and increased surgical difficulty. Patients who had a contrast enhanced CT of the abdomen and pelvis, followed by non-elective cholecystectomy were analyzed. The scans were reviewed for the CT rim sign by radiologists blinded to the pathologic and clinical outcomes. Demographic and clinical characteristics were compared between patients with and without GC using t -tests or Wilcoxon ranked sum test for continuous variables, and Fishers' exact test for categorical variables, when appropriate. A logistic regression model was fitted with multiple risk factors. Odds ratios as well as 95% confidence intervals were then calculated for the risk factors. A secondary analysis predicting increased surgical difficulty, defined as an operative time of greater than 2 h or increased conversion rate to open surgery, was also examined. A total of 100 patients were included; 20 of which had GC. On imaging, patients with GC were more likely to have a CT rim sign (65% vs 32.5%, OR = 3.80, 95% CI: 1.24–12.7, p = 0.011). The presence of the CT rim sign did not reach a statistically significant association with an operative time >2 h or conversion to open case (56.52% vs 33.77%, OR = 2.55, p = 0.056). The CT rim sign can be utilized to raise the possibility of GC, however the presence of the CT rim sign does not demonstrate an association with increased surgical difficulty. • Acute cholecystitis is one of the most common etiologies of acute abdominal pain in the emergency department. • CT rim sign is a likely more common imaging finding, which can suggest the possibility of gangrenous cholecystitis. • However, our study did not demonstrate an association between the CT rim sign and operative difficulty. [ABSTRACT FROM AUTHOR]

Objective:Cholecystitis is a generally widespread problem in adult population. Multiple findingshave been found in gross and microscopic examination of gallbladder. Existence of stones is one of the known causative factors that lead to histopathological changes in gallbladder. It is also responsible for the development of gallbladder carcinoma. The purpose of this study was to find out the histopathology of gall bladder specimens following surgical intervention. Study design: Observational study Place and duration of study: This study was conducted at Surgery Department of Abbasi Shaheed Hospital and Pathology Department of Ziauddin Hospital, from January 2017 to February 2020. Material and Methods: This observational study included 2,320 patients with acute orchroniccholecystitis secondary to gallstones that were admitt ed through the outpatient Department. Non-probability convenient sampling technique was used. Writt en and informed consent was taken from all the participants. Data was analyzed using SPSS version 20. Descriptive analysis was performed. Results: A total of 2,320 gallbladder specimens that presented for histo-pathological examination during the study period were included into the study, with male to female ratio of 1:3. The highest prevalence was found in the age group of 31-50 years. The results of histopathological examination of these gallbladder specimens showed that chronic cholecystitis was found in 1353 (58.3%), acute cholecystitis in 469 (20.2%), Gangrenous cholelithiasis 33 (1.4%) and cholestrolosis in 333 (14.3%) patients. Dysplasia was found in 8 (0.34%) patients, and gall bladder carcinoma was detected in 16 (0.69%) patients. There were 2181(94%)cases of calcular-cholecystitis. On morphological analysis, the commonest gall stones were made up of cholesterol and the most common lesion was chronic cholecystitis by histopathology. Conclusion: This study concludes that the chronic calcular-cholecystitis was dominant in our population. It is assumed that routine histopathological examination following cholecystectomies essential for all gallbladder specimens even in the non-existence of macroscopic signs of carcinoma, which was the case in our patients. [ABSTRACT FROM AUTHOR]

Background Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD. Methods A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct. Results The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment. Conclusion This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

Background: Acute cholecystitis (AC) is a severe complication after cardiovascular surgery (CS). The purpose of this study was to delineate the clinical picture of AC after CS to propose an optimal treatment strategy. Methods: We retrospectively reviewed the records of 88 patients who underwent cholecystectomy for grade II or III AC between 2008 and 2019 (AC after CS: Group CS, n = 37; AC without CS: Group non‐CS, n = 51). Results: The proportion of grade III AC in Group CS was significantly higher than that in Group non‐CS (73% vs 41%, P =.005). Furthermore, the incidences of acalculous (81% vs 39%) and gangrenous (86% vs 59%) AC were significantly higher in Group CS (P <.05 for both). In Group CS, 11 patients had had percutaneous drainage preceding surgery, for whom cholecystectomy within 3 days was eventually necessary because their general condition was exacerbated. The incidence of a positive culture from the gallbladder bile and blood samples of Group CS were significantly higher (P <.05 for both); multidrug‐resistant bacteria were detected at an especially high rate. However, the morbidity rate was comparable, and zero mortality was achieved in both groups. Conclusions: Timely surgical intervention without hesitation is recommended for AC after CS. [ABSTRACT FROM AUTHOR]

Introduction: Gangrenous cholecystitis is a serious complication of untreated gallbladder inflammation, necessitating immediate intervention. The primary resolution involves cholecystectomy, the surgical removal of the gallbladder.The Billroth II gastrectomy, named after Theodor Billroth, addresses gastric conditions by removing a portion of the stomach and reconnecting the remaining section to the small intestine.Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive procedure that diagnoses and treats bile duct and pancreatic duct disorders, using an endoscope to access the ducts, administer contrast dye, and perform interventions like stone removal and stent placement. It aids in managing conditions such as bile duct stones, strictures, pancreatic tumors, and pancreatitis., Case Report: A 25-year-old male with a history of gastric ulcer and Billroth II anastomosis presented with right hypochondrium pain, fever, and vomiting. Examination and imaging indicated gallbladder edema, abscess, and fluid collection. Laparotomy revealed severe adhesions around the gallbladder, which were released, and an abscess was drained. Postsurgery, a biliary fistula was suspected, leading to the proposal of an ERCP procedure. During ERCP, a plastic stent was inserted to aid bile drainage., Discussion: Therapeutic ERCP effectively treats biliary exudate, including in patients with Billroth II gastrectomy. Using a side-viewing duodenoscope simplifies accessing Vater's papilla. This successful procedure had no complications, such as pancreatitis or bleeding, and the patient remained stable., Conclusion: ERCP in patients with a prior Billroth II gastrectomy is a risky procedure with potential complications. However, it can be considered as an alternative to avoid additional surgery if performed by experienced specialists with the necessary equipment., Competing Interests: The authors declare no conflicts of interest to declare., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Cholelithiasis can present from a milder form of biliary colic to a more severe and complicated one like empyema gallbladder and a lesser-known variant of gangrenous gallbladder called marbleization of the gallbladder. The clinical signs and symptoms are similar to acute cholecystitis. Diabetes mellitus could have a role in the process of marbleization. Diagnosing marbleization of the gall bladder is not easy preoperatively. Computerized tomography is a better diagnostic modality when compared to laboratory investigations. Urgent cholecystectomy is the only option, and there is no role of conservative treatment. We report a case of a 36-year-old man with newly diagnosed Diabetes Mellitus diagnosed initially as acute cholecystitis and managed conservatively. He did not respond to treatment and hence underwent cholecystectomy and intraoperatively was found to have marbleization of the gall bladder. [ABSTRACT FROM AUTHOR]

A 32-year-old patient presented with icterus, elevation of liver enzymes, clinical and laboratory manifestations of cholestasis and intra-abdominal echographic findings of thickening of the vesicular wall. The clinical evolution was torpid, with abdominal distention, hiccups and acute renal failure accompanied by metabolic acidosis, requiring renal purifying treatment. In an attempt to guarantee deep venous access using a catheter, a hematoma of the neck occurred and a left pneumothorax was induced, requiring a minimum mean pleurostomy and connection to the Overholt equipment. Subsequently, the patient had a cardiorespiratory arrest with electrical activity, without a pulse, and died after failed resuscitation, at 14 days of hospital stay. At the necropsy, an acute gangrenous cholecystitis without stones was found, complicated by haemobilia and obstruction of the biliary tract by an intracoledocyte clot and development of ascending cholangitis, all of which led to the death of the patient due to hepatorenal syndrome. [ABSTRACT FROM AUTHOR]