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Trends in Acute Cholecystitis With and Without Choledocholithiasis
Roman Grinberg*, John Afthinos, Karen E. Gibbs
Staten Island University Hospital, Bayside, NY
Introduction: Acute cholecystitis with concomitant choledocholithiasis is an uncommon presentation of biliary tract disease. Traditional sources have placed the incidence at under 12%. We sought to evaluate the incidence of this disease entity in the setting of a large national database and to identify trends in management.
Methods: The NIS database was queried from 2005 to 2010 for all patients presenting with acute cholecystitis (AC) and acute cholecystitis with choledocholithiasis (AC/CH). Age, gender, comorbid conditions were quantified. Rates of cholecystectomy, intraoperative cholangiogram and ERCP were evaluated. Post-procedural complications were also quantified. Multivariate logistic regression analyses were performed to evaluate for risk factors for independent risk factors predicting presentation of AC with choledocholithiasis.
Results: We identified 321,802 patients diagnosed with AC and AC/CH, of which 73,648 (23%) had AC/CH. Female patients comprised 61% of the total population. Mortality was 0.73% in the AC group and 0.74% in the AC/CH group (p=NS). In the AC group 7% of patients underwent ERCP, while in the AC/CH group 63% underwent ERCP (p < 0.001). Laparoscopic cholecystectomy was undertaken in 72% of all patients with AC; it was performed for 70% of the patients with AC/CH (p=NS). Within the AC group, 25% had an intraoperative cholangiogram as compared to 45.5% in AC/CH group (p<0.05). CBD exploration occurred in 0.7% of the AC patients and 9.5% of AC/CH patients (p < 0.01). Length of stay for the AC group was 4.27 + 4.8 days, compared to 5.6 + 4.8 days for the AC/CH group. Female gender (OR 1.2, p < 0.001) and severe liver disease (OR 1.3, p < 0.001) are independent risk factors for presentation of AC/CH.
Conclusion: The incidence of acute cholecystitis with concomitant choledocholithiasis was 23%. The increased length of stay for these patients is most likely related to additional consultations/procedures (i.e. ERCP). Female gender and severe liver disease are independent predictors of AC/CH. Our data suggests that, in the appropriate clinical setting, surgeons should have a higher degree of suspicion for concomitant choledocholithiasis in patients presenting with acute cholecystitis.
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