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The Treatment and Revised Classification of Gallbladder Perforation in Acute Cholecystitis: the Importance of Intrahepatic and Abdominal Abscess Formation
Lygia Stewart*1, Gary Jarvis2, J. Mcleod Griffiss2
1UCSF / SF V AMC, San Francisco, CA; 2Infectious Disease, UCSF / SF VAMC, San Francisco, CA
Background: Intrahepatic and abdominal abscess is a rarely reported complication of acute cholecystitis. Prior perforated cholecystitis classification systems have not included hepatic abscess as an entity. We reviewed our series and report risk factors, and treatment outcomes of perforated cholecystitis with a focus on a the presentation of cases with an associated abscess.
Methods: 618 patients with gallstones were studied; there were 536 men, 82 women; average age 62 (range 17-104). Among these patients, 241 had acute cholecystitis. Gallstones, bile, and blood (as applicable) were cultured, Stone type recorded. Illness severity was classified as: none (no inflammatory manifestations), SIRS (fever, leukocytosis, tachycardia), severe (abscess, cholangitis, empyema), or MODS (bacteremia, hypotension, organ failure). We looked for factors associated with gallbladder perforation and abscess. Multivariate analysis was performed to determine associated factors and optimal treatment approach.
Results: Of 241 acute cholecystitis cases, 58 had associated perforation (20 intrahepatic abscess, 15 abdominal/peritoneal abscess, 20 free perforation, 3 cholecystoenteric fistula). Biliary bacteria were present in 58% of uncomplicated acute cholecystitis and 91% of perforated cases (P< 0.0001); predominant organisms were: E. coli, Klebsiella, Staph, and Enterococcus. On multivariate analysis, gallbladder perforation was associated with biliary bacteria (P=0.002). Diabetes was present in 41% of cases with perforation, but only 20% of uncomplicated cases (P = 0.002). MODS manifestations were present in 41% of cases with perforation, but only 16% of uncomplicated cases, (P<0.0001). 47% of perforation/abscess cases were initially treated with cholecystostomy (C-tube), while C-tube was used in 17% of non-perforated cases. Peri-operative hospital stay was shorter for perforation cases initially treated with C-tube (hosp >1 week, 29% vs 86%, C-tube vs none, P=0.006); similar to uncomplicated peri-operative stays (29% hosp >1 week, P=NS).
Conclusions: This is the largest series of abscess associated with acute cholecystitis in the literature; and most detailed study of gallbladder perforation. We propose a new classification of gallbladder perforation that includes distinct entities of peritoneal abscess, intrahepatic abscess, free perforation, and cholecystoenteric fistula. Optimal treatment of intrahepatic abscess / perforated cholecystitis is C-tube followed by interval laparoscopic cholecystectomy.
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