It is agreed that the disease goes through a definite chain of obstruction, chemical injury, inflammation and bacterial invasion. The commonest isolated bacteria are: E Coli 60%, Klebsiella, streptococcus and others². A total of 95% of acute cholecystitis are associated with stones and 15% of gallbladders with stones develop acute cholecystitis. Other predisposing factors include old age, diabetes mellitus, typhoid fever, renal impairment, arteritis, polyarteritis nodosa³ and malignant hypertension. Five cases have been reported following Trucut liver biopsy and a few following gallbladder torsion⁴. Other associated problems include ductal stones in 20%, chronic pancreatitis in 7% and Cancer of the gall bladder in 1%.

Bacteriology

Csenders⁵ showed that when the common bile duct or gall bladder is aspirated the prevalence of positive bacterial cultures is 0% in normal people, 22% - 46% in patients with gall stones or acute cholecystitis and 58.2% in common bile duct stones without cholangitis or previous cholecystectomy. Similar bacteria were isolated from the gall bladder and common bile duct. Gender or number of stones did not influence the number of positive cultures but advancing age increased the positive cultures.

Acalculous acute cholecystitis accounts for about 5%. The bile is lithogenic or sometimes the stone has already been passed. Acalculous acute cholecystitis is usually associated with major surgery, burns, fasting, general. anaesthesia, analgesics, dehydration, ileus, multiple transfusions, sepsis, ductal stenosis, choledochal cyst, diabetes mellitus, and old age. Sometimes stool may show some stones.

Complete recovery following acute inflammation occurs in 75% recover completely and only 25% are met with complications which may even be fatal. Gangrene occurs about the third day in about 15%. Empyema occurs in 5% and it is more common in elderly male with diabetes mellitus. Perforation occurs in about 5%. The perforation may be into the local organs, it may form a peri-cholecystitis abscess or a patient may develop generalized peritonitis.

The usual symptoms of pain 30-90 min after a meal, fever, nausea and vomiting may not be present in a number of patients ^(6). A palpable mass appears after 24 hour in a third of patients, toxicity, guarding, and jaundice indicate complications. Murphy's sign is not useful in elderly patients^7,8 as illustrated below:

• Predictive 0.58
• Sensitivity 0.48
• Specificity 0.71

The treatment is immediate cholecystectomy. On admission to hospital, a nasogastric tube (3mm) for gastric decompression is passed and intravenous fluids and antibiotics, (cefuroxime or mezlocillin) prescribed. Immediate cholecystectomy carries a mortality of 5-10 percent^10. However there is a small percentage of patients who have other medical diseases which require to be stabilised first. Among these if life is threatened (impending gangrene or rupture) they are offered cholecystostomy and later when they have stabilised cholecystectomy is done. If life is not threatened the medical condition is stabilised and later cholecystectomy is done.

1. Open cholecystectomy. Moss¹ performed 158 OC in 4 years and was able to discharge all of them the following day. However 3 patients developed complications and required readmission.
2. Laparascopic cholecystectomy. Altaca ⁹ did 12 OC and 23 LC and had 13% complications in OC as opposed to 15% in LC. Petterson¹⁰ attempted 13 laparoscopic cholecystectomy but completed it in 9 and the other 4 (31%) required conversion to open cholecystectomy. Laparoscopic cholecystectomy increases the operating time and cosmesis but highly reduces the hospital stay. The difference in complications is not statistically significant.

Conditions to be considered in the differential diagnosis are shown in Table 1. However LC is contraindicated where there is an older scar or if one is suspecting adhesions. In terms of relative costs, percutaneous cholecystostomy costs US$ 1620, open cholecystectomy US$ 3155, while laparoscopic cholecystectomy costs US$ 5,000. However LC is contraindicated where there is an older scar or if one is suspecting adhesions. In terms of relative costs, percutaneous cholecystostomy costs US$ 1620, open cholecystectomy US$ 3155, while laparoscopic cholecystectomy costs US$ 5,000.

This procedure is left for those who have other medical conditions, which are a contraindication to cholecystectomy, e.g. congestive cardiac failure. The purpose is to decompress the gall bladder in order to prevent gangrene and perforation. A cholecystectomy should be done as soon as the patient has stabilized. Cholecystostomy may be -open cholecystostomy. It has a mortality of 5-12 percent ^{11, 12, 13}.

It may be transhepatic or transperitoneal. It has fewer complications than the open. Ultra sound guided Percutaneous Cholecystostomy (UGPC), Patterson¹⁰ did 43 and 90% improved within 48 hours. However the surgeon must be at hand for further treatment. Special cases: Indin¹⁴ reported 18 children with acute cholecystitis. They all had organic disorders of the gall bladder and cystic duct. Khuroo¹⁵ has described ascaris as a cause of acute cholecystitis in addition to other complications. Wittman¹⁶ has suggested that acute cholecystitis may occur in Acquired Immune Deficiency Syndrome (AIDS). Surgeons are advised to take extra care while handling these emergencies.

Mortality increases with age and poor health but all in all is 5-12 percent^10. The common causes of death are sepsis, pneumonia and cardiac complications.

Conclusion

Inspite of the development of new antibiotics, imaging and laparoscopy, the mortality of acute cholecystitis has remained 5-12% for the last two decades.

1. Moss G. Pricing the outcome standards for conventional open cholecystectomy Am-J.Surg 1996; 172: 383-5.
2. Asmis-Ds. Vibrio 01 isolated in the gall bladder of a patient presenting with acute cholecystitis Am. J. Gastroenterology 1996; 91: 2241-2.
3. Counihan TL. Acute Cholecystitis resulting from heamobilia after Trucut needle: a case report and brief review of literature. Am surg. 1996; 62 (9): 757-8.
4. Hillejan L. Torsion of the gall bladder – a rare cause of a cute cholecystitis Central bl-Chir 1996; 121 (4): 326-8
5. Csenders. A simultaneous bacteriological assessment of bile from gall bladder and common bile duct in control subjects and patients with gall stones and common bile duct stones. Arch. surgery 1996 April: 131(4): 389-94.
6. Grober P.J Presence of fever and leukocytosis in a cute cholecystitis. Annemerg Med 1996; 28(3): 273-7.
7. Adedeji O.A Murphy’s sign in acute cholecystitis and elderly people. J.R.Coll.Surg. Ed 1996 April 41(2): 88-9.
8. Fitz Gibbons R.J. Jr. Acute cholecystitis. Does the clinical diagnosis correlate with pathological diagnosis? Surg – Endosc. 1996; 10(12) 1180-4
9. Altarca G. Laparascopic Cholecystectomy for acute cholecystitis. Surg – Laparascopic. Endosc. 1996 Feb; 6(1): 26 -8.
10. Petterson E.J. An alternative approach to a cute cholecystitis percuteneous cholecystostomy and internal laparascopic cholecystectomy Surg-Endosc.1996; 10(2): 1185-3
11. Hultman CS. The efficacy of percuteneous cholecystostomy in critically ill patients. Am-Surg 1996; 62(4): 263-9.
12. Horny A. Percuteneous Cholecystostomy for acute cholecystitis in critically ill patients. Surgery 1997; 121(4): 398-401.
13. Van Overhagen H. Percuteneous cholecystostomy for patients with acutecholecystitis and an increased surgical risk. Scandinavian-Intervent-Radiol 1996; 19(2): 72-6
14. Indin I.B. Non-Calculus Cholecystitis in children Khirugia Mosh 1996; 4: 15-7.
15. Khuroo M.S. Askariasis Gastroenterol-Clin-North Am. 1996 Sept; 25(5): 553-77.
16. Wittman M.M. Aids emergency operations and infection control. Infect control-Hosp-epid. 1996; 17(8): 532-8

© 2006 East and Central African Journal of Surgery