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Common cause of acute disease risk factors is the cystic duct obstruction, about 80% of patients caused by gallstones, when the cystic duct obstruction, bile concentration, high concentration of bile salts can damage the gallbladder mucosa, causing inflammation change. There are some patients is invasion of pathogenic bacteria, most retrograde and invasion by bile duct, gall bladder, mainly pathogenic bacteria Escherichia coli, Bacillus and Pseudomonas aeruginosa and other gas. If combined with anaerobic gas infection, will cause acute emphysematous. A small part is due to acute trauma caused by chemical stimulation. When severe trauma and major surgery, the decline in contractile function of gallbladder, bile stasis, bile salt concentration, stimulate the gallbladder mucosa disease, infection, may have pancreatic juice back into the gallbladder caused by acute acalculous. Symptoms of the disease symptoms of acute cholecystitis are right upper quadrant pain, nausea, vomiting and fever. Acute cholecystitis may cause right upper quadrant pain, pain and the beginning is very similar to biliary colic, acute cholecystitis, but due to its duration of abdominal pain is often longer, for breathing and changes in position often makes the pain increased, so more like the right side of the supine patient to relieve abdominal pain. Some patients have nausea and vomiting, but vomiting is generally not severe. Most patients also accompanied by fever, body temperature is usually between 38.0 â„ƒ ~ 38.5 â„ƒ, high fever and chills are rare. A small number of patients have mild yellow whites of the eyes and skin. Treatment of diseases of minor symptoms of acute cholecystitis can be considered the first non-surgical therapy with a control inflammation, pending further identification of the disease after elective surgery. Of heavy acute suppurative or gangrenous cholecystitis or gallbladder perforation, surgical treatment should be timely, but must be prepared to preoperative preparation, including the correction of water-electrolyte and acid-base balance disorders, and the application of antibiotics. Non-surgical therapy for most (about 80 ~ 85%) of early acute cholecystitis patients effectively. This method includes spasm and pain, the application of antibiotics to correct water-electrolyte and acid-base balance disorders, and systemic support therapy. During the non-surgical therapy must be closely observed changes in condition, such as signs and symptoms have developed, surgical treatment should be promptly replaced. Especially the elderly and diabetes, conditions change rapidly, should pay attention. According to statistics, about 1 / 4 of patients with acute cholecystitis will be developed into gangrene or perforation of the gallbladder. For patients with acute acalculous cholecystitis due to rapid progression of the disease, generally do not use non-surgical therapy, preoperative preparation should be at the ready in time after the surgery. The fo
Acute acalculous cholecystitis in the elderly Clinical characteristics and surgical treatment
2000, Hepatobiliary and Pancreatic Surgery Volume 12, Issue 1 clinical study
Of: Zhang Jianxin Wang Xuqing Qu Jianguo Cheng Guozuo
Unit: Zhenjiang, Jiangsu Province 212001, China Medical College Hospital, General Surgery
Key words: Cholecystitis; surgical treatment
Abstract: Objective: To investigate elderly patients with acute acalculous cholecystitis (Acute acalculous cholecystitis, AAC) Clinical features and the best timing of surgery. Methods: A case-control through the establishment of strict compared 52 elderly patients with AAC and acute cholecystitis (Acute calculous cholecystitis, ACC) of the coexisting disease, gallbladder pathology and postoperative outcome; and timing of surgery in the elderly of different AAC gallbladder disease and postoperative results were compared. Results: Compared with the old ACC, AAC-based cardiovascular disease in patients with coexisting diseases increased significantly (P <0.001); gallbladder suppuration, gangrene and perforation rate was significantly higher (P value <0.01, "0.001," 0.05); postoperative complication rate was significantly increased (P <0.001). No significant difference in mortality (P> 0.05). More than 48 hours of surgery, the incidence of gallbladder gangrene and perforation rate of AAC and postoperative complication rate and mortality within 48 hours of surgery compared with significantly higher (P values were <0.001, "0.001," 0.05). Conclusion: Older AAC comorbidities and more heavy gallbladder disease, high incidence of postoperative complications; should be within 48 hours of symptom onset in the surgery.
Key words: R574 Document code: A
Article ID :1007-1954 (2000) 01-01-0032-03
Clinical features and surgical treatment of acute acaculous cholecystitis in the aged
ZHANG Jian-xin, WANG Xu-qing, QU Jian-guo, et al.
Department of surgery, the affiliated hospital, Zhengjian Medical College, Zhengjiang, 212001
Abstract: Objective: To evaluate the clinical features and optimal timing of ope ration for acute acalculous cholecystitis in the aged.Methods: A case-co ntrol study of 52 patients with AAC and acute calculous cholecystitis (ACC) was u ndertaken.Their coexisting diseases , gallbladder pathology, postoperative morbi dity and mortality were compared.The gallbladder pathology, postoperative mor bidity and mortality of patients with AAC operated in different timing of surger y were compared.Results: Incomparison to ACC, the AAC had highe r incidence of coexisting diseases (P <0.001), suppuration (P <0.01), gangrene (P <0.001) and perforation (P <0.05) as well as signif icantly higher morbidity (P <0.001) .95% of cases with AAC who und erwent operation more than 48 hours after the onset of symptoms sufferedg gangernt and perforation, conversely only 18% of cases operated within 48 hours h ad gang erne and perfortion (P <0.001). The morbidity and mortality of pat ients with AAC operated within 48 hours were 15.15 % and 3.03%, respectively, in c ontrast to 68.42% and 31.58% in patients operated more than 48 hours (P <0.001 and P <0.05). Conclusions: In comparison to ACC, t he AAC in the elderly has a higher incidence of coexisting diseases, gangrene and perforation as well as higher morbidity.Operation within 48 hours is necessary for AAC in the elderly patients.
Key Words cholecystitis; acalcul ous surgery; operative â–²
Acute acalculous cholecystitis (Acuteacalculouscholecystitis, AAC) is a very dangerous clinical acute abdomen, generally occurs in surgery, trauma, shock and other stress conditions. However, the elderly with serious underlying diseases were common place, and there is increasing trend . Non-stress conditions to investigate the clinical characteristics of the elderly and the best AAC timing of surgery, we summarize the data of 52 elderly patients with AAC, and with the same period in elderly patients with acute cholecystitis (Acute calculous cholec ystitis, ACC) were compared, are reported below.
1 Materials and methods
1.1 The choice of cases were 52 patients in our hospital between 1980-1998 were treated 60 patients over the age of AAC. The diagnosis of all cases were
Confirmed by surgery and pathology, not including any surgery, trauma and other stress conditions for the AAC clinical cases.
1.2 from the same case with the group over the age of 60 ACC cases, surgical treatment, according to the patient's gender, age, time from onset to surgery and surgical approach selected group of patients with ACC match 52 cases of basic as the control group. Basic situation of the two groups were shown in Table 1.
Table 1 AAC ACC group of patients with the basic situation of project AAC (n = 52) ACC (n = 52) age (years) 66.865.5 sex ratio (M / F) 39/1939/19 time from onset to surgery (cases) <48 1919 3333 â‰¥ 48 hour surgical procedure (patients) cholecystectomy gallbladder fistula 21, 5051
1.3 Statistical analysis by Ï‡2 test.
AAC and ACC groups aged 2.1 comorbidities situation AAC group, 40 patients (76.92%), suffering from coexisting diseases, the ACC group, only 16 cases (30.77%) had comorbidities (Ï‡2 = 22.29, P <0.001). AAC group and cardiovascular disease-related comorbidities in 34 patients (65.38%), with the ACC group, 12 patients (23.08%) was significantly increased compared with (Ï‡2 = 18.87, P <0.001). Two sets of specific comorbidities in Table 2.
Table 2 AAC and AAC set of circumstances comorbidities comorbidities AAC group (n = 52) AAC group (n = 52) P = number of cases the value of the number of%% cases of hypertension 2955.771019.2314.81 <0.01 coronary 1834.62815.385.13 <0.05 diabetes 917.3147 .691.41> 0.05 cerebrovascular disease 47.6923.850.18> 0.05 peripheral vascular disease 35.7711.920.26> 0.05 obstructive pulmonary disease 47.69611.540.11> 0.05 cirrhosis 47.6959.620.12> 0.05
AAC and ACC groups aged 2.2 gallbladder pathology and postoperative complications and death can be seen from Table 3, ACC group to edema of gallbladder disease-based (76.92%, P <0.001), while the AAC group Zeyi purulent gallbladder (38.46 %), gangrene (30.77%), perforation (15.38%) more common, compared with the ACC group was significantly higher (P value was <0.01, "0.001," 0.05). The incidence of postoperative complications in the AAC group was 34.62%, significantly higher than the AAC group (P <0.001), while the mortality rate was 13.46% in the AAC group, although higher than the ACC group, but there was no significant difference test ( P> 0.05). Postoperative complications as shock, ARDS, heart and kidney failure, gastrointestinal bleeding, and incision and abdominal infection. The cause of death, mostly caused by the complications of MOF.
Table 3 AAC and ACC groups gallbladder disease and complications and death compared groups of gallbladder edema gallbladder perforation gallbladder septic complications of gallbladder gangrene number of death cases the number of cases% cases% Number% Number% number of cases% cases the number of cases? C ( n = 52) 815.382038.461630.77815.381834.62713.46ACC (n = 52) 4076.92815.3835.7711.9247.6911.92Ï‡2 value 36.627.6010.884.3811.303.39P value <0.001 <0.01 <0.01 <0.050.001> 0.05
2.3 The timing of the elderly AAC gallbladder pathology of different surgical and postoperative complications, mortality can be seen from Table 4, the incidence within 48 hours of surgery, gallbladder disease is more common in septic (P <0.001); and more than 48 hours from onset to surgery hours, gallbladder disease mainly as gangrene and perforation (P = <0.001, "0.05). Within 48 hours of onset of surgical complication rate and mortality than 48 hours after surgery were significantly lower (P = <0.001, "0.05).
Table 4 AAC groups of different timing of surgery and postoperative complications of gallbladder disease and death situation is more time for total cases of gallbladder surgery gallbladder edema gallbladder gangrene septic complications of gallbladder perforation cases deaths cases the number% number% number% number of cases cases the number of cases% cases% Number% â‰¤ 48 33824.241957.58412.1226.06515.1513.03> 48 hours 1900.0015.261263.16631.591368.40631.58Ï‡2 value
3 Discussion 3.1 The clinical features of elderly AAC
3.1.1 AAC-related comorbidities and more elderly people. AAC often occurs in trauma, major surgery, shock, severe infection and stress conditions such as multiple blood transfusions, but Savoca et al  found that in the absence of the acute severe in older patients often occurs AAC, in particular in the original artery atherosclerosis and other cardiovascular diseases, the elderly are more likely, and there is increasing trend. The results of this set of data also confirmed this phenomenon. AAC in the 52 elderly patients, 76.92% of patients with coexisting diseases, of which hypertension, coronary heart disease, diabetes, cerebrovascular and peripheral vascular disease, the majority. Especially hypertension and coronary heart disease significantly increased ACC AAC patients compared (P value <0.001 and "0.05.) The present study showed that the AAC gallbladder ischemia is a major factor in the pathogenesis, Warren  By contrast AAC patients found that the cystic artery, gallbladder, blocking small blood vessels is an important cause of ischemia caused by the gallbladder, the gallbladder may be due to different levels of ischemic causing gallbladder dysfunction, edema, gallbladder wall thickening, mucosal necrosis, as well as gallbladder infarction. Obstruction caused by gall bladder causes the small blood vessels in addition shock, severe trauma and infection, multiple transfusions, the atherosclerosis, diabetes and other infrastructure also contribute to gallbladder disease small vessel occlusion is one of the important reasons. Gallbladder mucosal ischemia can make it hazardous substances on the susceptibility of bile increased bile bacteria while easy to damage tissue in growth and reproduction, resulting in secondary infection, leading to AAC worse.
3.1.2 AAC of gallbladder disease re-aged, more complications. Many scholars [1,3,4] observed that, in elderly patients with AAC, gallbladder gangrene, perforation rate and complication rate and mortality was significantly higher than those of elderly patients with ACC. This information through the establishment of more stringent control group comparison, the older group of cystic lesions of ACC to edema mainly in the older group Zeyi AAC purulent gallbladder, gangrene and perforation more common, compared with the ACC group, the suppuration, gangrene and perforation were significantly higher (P values were <0.01, "0.001," 0.05). An important cause of this situation because the cystic artery as a terminal blood vessels, once the obstacles blocking the blood supply caused by the gallbladder. Because the elderly re-AAC gallbladder disease, the coexistence of multiple underlying diseases, the incidence of postoperative complications was significantly higher than elderly patients with ACC (P <0.001) postoperative mortality in this group is far more AAC AAC increased, but no significant statistical test differences.
3.2 The timing of the elderly surgical AAC
In view of the clinical and the elderly AAC cause, pathological characteristics, non-surgical treatment is often not effective, surgery is the only measure to control the progression of the disease. But the operation time is very important. Johnson , Yang Wenqi  and a summary of the past  have found that more than 48 hours duration of surgery, gallbladder gangrene and perforation were significantly increased, the number of postoperative complications and death also increased significantly. The data showed that more than 48 hours duration of surgery, the incidence of gallbladder gangrene and perforation rate was 95%, and 48 hours of surgery, 18% of the gangrene and perforation rate was significantly higher than (P <0.001). Similarly, the different timing of surgery on the prognosis of elderly AAC also affected. This group within 48 hours of the onset of complications of surgery and mortality rate of more than 48 hours of onset of surgery was significantly lower (P <0.001, P <0.05). Thus, for early surgical treatment is effective in reducing postoperative complications AAC elderly, the key to reducing mortality.
3.3 Diagnosis and treatment of the elderly points AAC
After the outbreak of the disease was, therefore improve the efficacy of early diagnosis is an important prerequisite. Clinical diagnosis of AAC first need to have a high degree of vigilance, to fully understand the clinical features of AAC. The author has pointed out , after surgery or trauma, and associated with cardiovascular disease, diabetes and other medical diseases of the elderly, and the past no bile duct disease, when the right upper abdominal pain and unexplained fever, should consider this disease possible. In addition to detailed history and medical examination, B-ultrasound is a simple and effective diagnostic method. AAC is mainly B-ultrasonography gallbladder wall thickening, but also includes enlargement of the gallbladder, gallbladder hydrops and gallbladder cavity surrounding sediments.
Coexisting disorders, because elderly people, low compensatory ability of the vital organs, so once a clear diagnosis, preoperative preparation should be actively strengthened. Including the correction of low blood pressure and physiological disorders, and other measures to maintain vital organ function, but the preoperative preparation should strive for 48 hours after the onset of complete, no reason for delay in surgery time. Surgical excision is the preferred approach to the gallbladder, gallbladder fistula only in patients can not tolerate cholecystectomy, or removal of the gallbladder when other reasons can not be used as a rescue. A recent report by B ultrasound-guided percutaneous gallbladder puncture nephrostomy  and endoscopic gallbladder duodenal fistula  treatment of AAC, its advantage is less invasive, without laparotomy, but can not detect intra-abdominal conditions have delayed the risk of disease, so not yet widely used. Surgery should be routine oxygen and ECG monitoring, as far as possible to maintain blood pressure within normal limits. After operation of health care for cholecystectomy, but also deal with the complications of the original co-exist for effective disease monitoring, and should strengthen support and anti-infection treatment. â–
Author: Zhang Xin (1957 -), male, Jiangsu Taizhou, the Deputy Chief Physician, Associate Professor, Master, biliary and pancreatic surgery is mainly engaged in basic and clinical research.
 Savoca PE, Longo WE, Zucker KA, et al.The increasing prevalence of a calculous cholecystitis in outpatients [J]. Ann Surg ,1990,211:433-437.
 Warren BL.Small vessel occlusion in aucte acalculous cholecystitis [J]. Surgery ,1992,111:163-168.
 Fox MS, Wilk PJ, Weissmann HS, et al.Acute acalculous cholecystitis [J]. Sury Gynecol Obstet ,1984,159:13-16.
 Yang Wenqi, Peng Cheng, Xu Oman. Elderly patients with acute acalculous cholecystitis operation time [J]. Journal of General Surgery ,1998,13:155-157.
 Johnson LB.The importance of early diagnosis of acut acalculous ch olecystitis [J]. Surg Gynecol Obstet, 1987,164:197-203.
 Zhang JX, Yao Changhong .45 cases of acute acalculous cholecystitis clinical analysis [J]. Jiangsu Medicine, 1992,1 8:389.
 Vauthey JN.Lerut J, Martini M, et al.Indications and limitations of percu taneous cholecystostomy for acute cholecystitis [J]. Surg Gynecol Obstet, 1993,17 6:49.
 Brugge WR.Friedman LS.A new endoscopic procedure provides insight into an old disease: acute acalculous cholecystitis [J]. Gastroenterology, 1994,106:1 718-1720.
Received Date :1999 -07-21
The onset of acute cholecystitis the cystic duct obstruction due to stones, resulting in the gallbladder bile, secondary bacterial infection caused by acute inflammation. Acute acalculous cholecystitis, cystic duct often non-blocking. The cause of most patients is not clear. Often occurs in trauma, or biliary abdominal surgery unrelated to the number of [medical education network order release].
Source: Medical Education Network
Etiology and pathology
The onset of acute cholecystitis the cystic duct obstruction due to stones, resulting in the gallbladder bile, secondary bacterial infection caused by acute inflammation. If only produced in the gallbladder mucosa inflammation, congestion and edema, called acute simple cholecystitis. Such as inflammation spread to the whole layer of the gallbladder, the gallbladder is full of pus, purulent fibrinous serosal exudate also is known as acute suppurative cholecystitis. Due to extreme swelling of gallbladder empyema, gallbladder wall caused by ischemia and gangrene, is the acute gangrenous cholecystitis. Necrosis of the gallbladder wall perforation may occur, leading to biliary peritonitis law. Gallbladder perforation occurred in the gallbladder area impacted stones at the bottom or neck of gallbladder, or ampulla. To adjacent organs such as gallbladder perforation, such as the duodenum, colon and stomach, can cause biliary fistula. At this time of acute inflammation of the gallbladder through the fistula may be drainage, inflammation can quickly disappear, the symptoms have been alleviated. If the gallbladder into the common bile duct can cause pus of acute cholangitis, acute pancreatitis can be a few people. Most pathogenic E. coli, Klebsiella bacteria and fecal streptococci, anaerobes accounted for 10 to 15%, but sometimes up to 45%.
Acute acalculous cholecystitis, cystic duct often non-blocking. The cause of most patients is not clear. Often occurs in trauma, or biliary some abdominal surgery unrelated to, and sometimes may also occur in some non-hemolytic anemia in children, surgery and trauma is generally believed that dehydration, fasting, the application of narcotic analgesics, and severe neuroendocrine stress response caused by other factors, resulting in reduced gallbladder contraction function, bile and gallbladder mucosa decreased resistance, on the basis of secondary bacterial infection, then cause acute inflammation of the gallbladder. There are some cases that is the nutrient vessels of the gallbladder caused by acute thrombosis. Such acute acalculous cholecystitis with calculous cholecystitis pathological evolution of similar, but the disease developed rapidly, usually within 24 hours, which developed into gangrenous cholecystitis, and the performance of the entire gallbladder gangrene.
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About 85% of acute cholecystitis in patients with early onset of paroxysmal abdominal and right upper quadrant colic, and has the right subscapular pain radiating area. Often accompanied by nausea and vomiting. Fever is generally 38 ~ 39% â„ƒ, no chills. 10 to 15% of patients may have mild jaundice. Physical examination see right upper quadrant tenderness and muscle tension. Murphy (Murphy) and positive signs. In about 40% of the patients, the right upper abdominal swelling and tenderness can be touched and gallbladders. Often slightly elevated white blood cell count, generally in the 10,000 ~ 15,000 / mm3. Such as the lesion to gallbladder gangrene, perforation, and lead to biliary peritonitis, systemic symptoms of infection can be significantly increased, and chills high fever, rapid pulse and increased white blood cell count was significantly increased (generally more than 20,000 / mm3). At this point, local signs of right upper quadrant tenderness, and muscle tension in the scope and degree of increase. Generally less acute cholecystitis affect liver function, or only mildly impaired liver function problems, such as serum bilirubin and ALT values increased slightly and so on. Acalculous cholecystitis in the clinical presentation and cholecystitis are similar, but often not typical.
Acute cholecystitis mainly relies on clinical manifestations and diagnosis of B-ultrasound can be obtained. B ultrasonic examination can show the increase of gallbladder volume, gallbladder wall thickening, often more than the thickness of 3mm, 85 ~ 90% of patients can show stones in the shadow. When in doubt in the diagnosis can be made isotope 99mTc-IDA scanning and photo biliary, manipulation of the bile duct usually appears on the video, the gallbladder due to cystic duct obstruction without showing to determine the diagnosis of acute cholecystitis. This method is correct up to 95% or more. Acute acalculous cholecystitis the diagnosis more difficult. The key to diagnosis of trauma or abdominal surgery after the clinical manifestations of acute cholecystitis, we should think of the possibility of the disease, on the few gas production caused by the bacillus of acute emphysematous cholecystitis, the gallbladder area plain film camera can be cavity were found in the gallbladder wall and the presence of gas. [Medical Education Network finishing pm]
Treatment to prevent
Of the symptoms are acute simple cholecystitis, consider first the control of inflammation with non-surgical therapy, pending further identification of the disease after elective surgery. Of heavy acute suppurative or gangrenous cholecystitis or gallbladder perforation, surgical treatment should be timely, but must be prepared to preoperative preparation, including the correction of water-electrolyte and acid-base balance disorders, and the application of antibiotics. Non-surgical therapy for most (about 80 ~ 85%) are effective in patients with early acute cholecystitis. This method includes spasm and pain, the application of antibiotics to correct water-electrolyte and acid-base balance disorders, and systemic support therapy. During the non-surgical therapy must be closely observed changes in condition, such as signs and symptoms have developed, surgical treatment should be promptly replaced. Especially the elderly and diabetes, conditions change rapidly, should pay attention. According to statistics, about 1 / 4 of patients with acute cholecystitis will be developed into gangrene or perforation of the gallbladder. For patients with acute acalculous cholecystitis due to rapid progression of the disease, generally do not use non-surgical therapy, preoperative preparation should be at the ready in time after the surgery. On the issue of antibiotic in acute cholecystitis, the cystic duct is blocked, antibiotics can not be with the bile into the gall bladder, infection of the gallbladder can not play the role expected of control, cholecystitis and complications of the drawer or not, is not Application by the Department of antibiotic. However, the application of antibiotics in the blood concentration of certain medications can reduce cholecystitis caused by systemic infection, and can effectively reduce postoperative infectious complications. Of fever and white blood cell count higher, especially for some older people, or with diabetes and other long-term immunosuppression in patients with a high degree of susceptibility to infection, systemic application of antibiotics is still very necessary. Generally applied to broad-spectrum antibiotics such as gentamicin, chloramphenicol, neomycin or ampicillin and other pioneers, and often in combination.
Surgery: current options for the timing of surgery, there are still controversial, is generally believed that early surgery should be used. Early surgery does not mean emergency surgery, but patients hospitalized after a period of non-surgical therapy and preoperative preparation, and also application of B-and isotope examination further confirmed the diagnosis after the onset of the premise of not more than 72 hours of surgery under . Early surgery does not increase surgical mortality and complication rates. Effective non-surgical treatment of patients can be delayed operation (or late surgery), usually after 6 weeks.
There are two surgical methods, one for cholecystectomy in acute edema around the gallbladder, anatomy often not clear, the operation must be careful to avoid accidental injury of bile duct and adjacent to this important organization. Conditions, the application of intraoperative cholangiography to detect bile duct stones and bile duct abnormalities may be present. Another surgery to cholecystostomy, mainly used in some elderly patients, in general, poor, or with severe heart and lung disease, estimated cholecystectomy who can not tolerate, and sometimes around the anatomy of the gallbladder in the acute phase is unclear Erzhi surgery operational difficulties and who can first make the cholecystostomy. Gallbladder surgery colostomy can be carried out under local anesthesia, the aim is to use a simple method of drainage cholecystitis, in which patients through the dangerous period, wait until the situation stabilized, usually in the gallbladder stoma 3 months after surgery, cholecystectomy again to eradicate lesions. Of acute cholecystitis and cholangitis, in addition for cholecystectomy, they also need the same time as common bile duct exploration and T tube drainage.
With the old resistance group into the increased incidence of stone disease, senile cholecystitis have continued