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Abstract Inflammationof thegallbladderwithoutevidenceof calculi isknownasacuteacalculouscholecystitis(AAC).AACisfrequentlyassociatedwithapoorprognosisandahighmortalityrate.Thus, early diagnosis and prompt surgical intervention has been recommended to improve theoutcomeofAAC.Herein,IpresentacasereportofAACcomplicatinglaparoscopicappendicectomy.UnlikepreviousstudiesthathavereportedtheneedforurgentinterventioninpatientswithAAC,inthisstudy,ourpatientrespondedtoconservativemanagement.Therefore,themanagementofAACafterlaparoscopicappendicectomyshouldbeindividualised.

Keywords:acalculous cholecystitis, acute disease, appendicitis, gut, laparoscopic surgery, appendicitis, disease management

Introduction

Inflammation of the gallbladder withoutevidenceof calculi is knownas acute acalculouscholecystitis (AAC). Inflammation of thegallbladderwithoutevidenceof calculi isknownas acute acalculous cholecystitis (AAC); thisconditionoccurs in5%-15%ofall casesofacutecholecystitis(1).AACisfrequentlyassociatedwithgangrene,perforation,andempyema.Duetotheseassociatedcomplications,AACcanbeassociatedwithhighmorbidityandmortality(2–3).AAChasbeenreportedincriticallyillpatientsaftercardiacsurgery, abdominal vascular surgery, trauma,burns, prolonged fasting with or without totalparenteral nutrition, sepsis, or atheroscleroticvascular disease (2–3).Here I present a case ofAAC arising as a complication of laparoscopicappendicectomy.

Case Report

A 53-year-oldwomanwith previously goodhealthpresentedwithanacuteonsetofabdominalpain.Theacuteabdominalpaininitiallyoccurredat the umbilical area andmigrated to the rightlower quadrant after 12 hours. Examinationof the abdomen on presentation revealedtendernessoverMcBurney’spointwith rebound

and rigidity.Computerised tomography imagingof theabdomenandpelvis revealedan inflamedappendix in theright iliac fossawithadiameterof1.5cm.Theappendixhadafluffyborderwithsurrounding soft tissue strands.Wall thickeninginthecaecumwasalsopresent.Laboratorystudiesperformed on admission were unremarkableexcept for an elevated C-reactive protein (CRP)levelof14mg/L(normalrangelessthan10mg/L). The patient was started on intravenoustigecycline, and a laparoscopic appendicectomywasperformedwithin2hoursofadmission.Theprocedure was uncomplicated with no episodesof haemodynamic instability during the pre-,intra-, and post-operative periods. Microscopicexaminationoftheappendixrevealedfeaturesofacute appendicitis, with focalmucosal erosions,suppurative changes, and serositis. The patientresumedafluiddiet onDay 1 post-laparoscopicappendicectomy. As she tolerated the fluid dietwell,sheresumedasoftsolidfooddietonDay2post-laparoscopicappendicectomy. However, on Day 3 post-laparoscopicappendicectomy, the patient developed rightupperquadrantdiscomfort.Physicalexaminationof the abdomen revealed tenderness over therightupperquadrant,buttherewasnoevidenceof rebound or rigidity. Although she remainedafebrile,herCRPhad increased to56mg/L.Noother abnormalitywas detected in the complete

Case Report

Submitted: 30Jun2010Accepted: 2Aug2010

Acute Acalculous Cholecystitis after Laparoscopic Appendicectomy that Responded to Conservative Management

Chee-Kin Hui 1,2

1 Centre for Alimentary Diseases, Endoscopy Centre, Central Hospital, Lower Albert Road, Central, Hong Kong, China

2 Dr Vio and Partners Limited, 3/F Seaview Commercial Building 21 Connaught Road West Sheung Wan, Hong Kong, China

76Malaysian J Med Sci. Jan-Mar 2011; 18(1): 76-78

Case Report |Acuteacalculouscholecytitis

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blood work-up or in the amylase and liverbiochemistry. Computerised tomography imaging of theabdomenwasrepeated,andasmallamountoffluidwasseeninthegallbladderfossa.Thegallbladderwallwasalsothickenedwithprominentcontrastenhancement(Figure1).However,noradiopaquestone was seen in the gallbladder or bile ducts.Thecommonbileductand the intrahepatic treewere normal in size. No abnormal mass, focalfluid collection or abscesswas seen in the rightiliac fossa. There was also no abnormal freefluid in the lowerabdomenorpelvis.Therefore,based on her right upper quadrant discomfort,rightupperquadranttenderness,thepresenceoffluid in the gallbladder fossa, and the thickenedgallbladderwallwithcontrastenhancement,shewasdiagnosedwithAACarisingasacomplicationoflaparoscopicappendicectomy. Asthepatientwashaemodynamicallystable,she was managed conservatively. In additionto intravenous tigecycline, which had beencommencedonthedayofadmission,thepatientwas also started on intravenous meropenemand amikacin. On Day 6 post-laparoscopicappendicectomy, her symptoms started toimprove. Her CRP on Day 6 post-laparoscopicappendicectomy had decreased to 32mg/L. OnDay 7 post-laparoscopic appendicectomy, herCRP normalised to 9 mg/L. As she remainedasymptomatic with a normal CRP, the patientwas discharged on Day 14 post-laparoscopicappendicectomy. Her liver biochemistry andamylaselevelswerenormalthroughoutthecourseofherhospitalisation.

Figure1:Computerisedtomographyimages showing (A) a normal gallbladder

on the day of admission for acuteappendicitis and (B) a small amountof fluid in the gallbladder fossa withthickened gallbladder walls withprominentcontrastenhancement.

A

B

Discussion AAC following surgerywasfirst reported in1844 (4). Since then,AAChas been reported tooccur following cardiovascular surgery, aorticreconstruction, non-biliary tract procedures,and breast reconstruction (5–8). To the bestofmyknowledge, this is thefirst report ofAACcomplicatinglaparoscopicappendicectomy. The pathogenesis of AAC is postulated tobe diverse and has been called “a paradigm ofcomplex inter-relationships” by Barie et al. (9).However, the common denominator for this setofdiseasestatesisvisceralhypotension(3).AsdenovoAAChasbeenreported inhealthypatientswithout any co-existing illness, I believe that inthiswoman, the AAC complicating laparoscopicappendicectomy was due to biliary stasis that

worsened as the result of a spasm of the cysticduct, as postulated by Becker et al. (10). Theadministrationofmorphineduringtheimmediatepost-operative period may have aggravated thespasmofthecysticductinthispatient(10). AAC is frequently associated with a poorprognosis and a highmortality rate (1,2). Thus,investigatorshaverecommendedearlydiagnosisandpromptsurgicalinterventiontoimprovetheoutcomeofAAC.However,thisrecommendationwas based on studies inwhich the subjects hadmultipleco-morbiditiesorsevereillness,ortheywereelderlypatients(1,2). The patient described in this case reportrecoveredwithconservativemanagementanddidnot require surgical intervention. Therefore, the

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management of AAC in post-operative patientsshould be individualised. The clinical conditionandpre-morbidconditionofthepatientmustbeconsidered in the formulation of the treatmentstrategy. Inconclusion,this isthefirstcasereportofAAC complicating laparoscopic appendicectomyin a patient with no existing co-morbidity. Themanagement of AAC in post-operative patientswithnoco-morbidityshouldbeindividualised.

Acknowledgements

Special thanks to Dr Alex SY Kwok of TheSurgical Department, Dr Vio and PartnersLimited,andDrWaiKuenNgofTheDepartmentof Pathology, Central Hospital, for theircontributions.

Correspondence

DrChee-KinHuiMD(HongKong)CentreforAlimentaryDiseasesEndoscopyCentre,CentralHospital1LowerAlbertRoad,CentralHongKong,ChinaTel:85228671577Fax:85228454730Email:bckhui@gmail.com

References

1. RyuJK,RyuKH,KimKH.Clinicalfeaturesofacuteacalculous cholecystitis. J Clin Gastroenterol.2003;36(2):166–169.

2. Sessions S, Scoma RS, Sheikh FA, McGeehin WH,SminkRDJr.Acuteacalculouscholecystitisfollowingopenheartsurgery.Am Surg.1993;59(2):74–77.

3. McChesney JA, Northup PG, Bickston SJ. Acuteacalculous cholecystitis associated with systemicsepsis and visceral arterial hypoperfusion: A caseseries and review of pathophysiology. Dig Dis Sci.2003;48(10):1960–1967.

4. Duncan J. Femoral hernia; gangrene of thegallbladder; extravasationofbile;peritonitis;death.North J Med.1844;2:151–153.

5. Huffman JL, Schenker S. Acute acalculouscholecystitis: A review.Clin Gastroenterol Hepatol. 2010;8(1):15–22.

6. Mastoraki A, Mastoraki S, Kriaras I, Douka E,Geroulanos S. Complications involving gallbladderand biliary tract in cardiovascular surgery.Hepatogastroenterology.2008;55(85):1233–1237.

7. BarretJP.Acuteacalculouscholecystitisafterbreastreconstruction.Acta Chir Plast.2003;45(2):61–63.

8. OwenCC,JainR.Acuteacalculouscholecystitis.Curr Treat Options Gastroenterol.2005;8(2):99–104.

9. BariePS,FischerE.Acuteacalculouscholecystitis.J Am Coll Surgeons.1995;180(2):232–244.

10. Becker C, Dubin T, Glenn F. Induction of acutecholecystitis by activationof factorXII.J Exp Med.1980;151(1):81–90.