from the JAMA Network this is JAMA clinical reviews interviews and ideas about Innovations in Medicine Science and clinical practice I'm Dr KristIn Walter associate editor at JAMA and a pulmonary critical care physician I'm joined today by Dr Anthony Charles who is chief of the division of trauma critical care and acute care surgery director of the ECMO program and director of global surgery at the University of North Carolina in Chapel Hill North Carolina Dr Charles is also an associate editor at JAMA we will be discussing the article of the Dr Charles co-wrote with Dr Jared R Gallagher entitled acute cholecystitis a review which was published in the March 8 2022 issue of Jama thank you for joining us Dr Charles thank you very much and I'm happy to be here to start off approximately how many people in the U.S are diagnosed with acute cholecystitis each year approximately 200 000 people are diagnosed with acute cystitis in the United States and the most important risk factor for acute cholecystitis is the presence of gallstones can you discuss how many people in the U.S are estimated to have gallstones and what percentage will go on to develop acute cholecystitis over their lifetime close to 25 million people currently have gallstones in the United States but only approximately 20 percent of those patients will actually become symptomatic of any sort of gallbladder issues within those approximately five percent will end up having acute cholecystitis so it sounds like there are a lot of people walking around with gallstones uh what are some important risk factors for gallstones first of all patients with hemolytic anemias particularly sickle cell disease and thalassemia have an increased risk of having gallstones obesity is a known risk factor but interestingly also a rapid weight loss if you lose approximately 25 percent of your week within a year you'll have a higher chance of having gallstones there are some medications that have been known to be associated with the formation of gallstones and those are things like Oxford tide or hypoglycemic medications particularly the newer Newark glucagon are like peptide analogues are like exanatide and lower anglutite so this will be the main risk factors for causal information and what about difference in Sex and also pregnancy so gallstones are more likely in women than in men but as you age by the time you're over 65 this differences go away and of course pregnancy is a known risk factor for gallstones the exact ideology of why pregnancy causes gallstones is not very clear but in the prenatal period and also in the postpartum period there's a high chance of having all students or or biliary sludge which is this combination of mucos and cholesterol crystals within the gallbladder and in terms of pathophysiology your article discusses how after a gallstone obstructs the cystic duct acute cholecystitis progresses in three distinct phases can you describe those phases for us certainly there's the acute phase in which you have initials of gallbladder wall congestion and edema and this typically lasts two to four days from the onset of symptoms this stem can then progress into what is a what I'll call a hemorrhagic phase in which you have blood within the wall of the gallbladder and that can potentially lead to necrosis of the wall of the gallbladder in some patients this may perforate uh let's get the area of necrosis and ischemia and then the third phase of course is after you are roughly around about three to five days after the onset of symptoms you may end up going through what I call a chronic or a purulent face and this is characterized by leukocyte infiltration passed within the gallbladder and gross infection within the gallbladder wall typically these patients will have the the omentum stuck to the gallbladder and they are less sick at this point in time and this the third faces occurs on day six and later and how would you define acute complicated cholecystitis acute complicated cholecystitis is essentially a patient that has acute cholecystitis that has resulted in either gangrene as the gallbladder wall is dead has a gallbladder wall perforation a resulting in biliary peritonitis or has essentially a cholecysto duodenal fistula that is the gallbladder has now attached itself to the duodenum and stones have gone across and then they have what we call a gallstone Alias that is the stone is now of causing a small ball of structure this will be the as of the complicated cholecystitis in which the managements are slightly more challenging and now I'd like to shift to a calculus acute cholecystitis how common is this condition and what are some risk factors for a calculus corollary cystitis so a calculator Society is typically a cause between five and ten percent of the population the risk factors are essentially patients in the critical care setting critically ill patients they're in the ICU for other non-biliary related reasons either following major trauma major Burns being on a total parenteral Nutrition is a risk factor for a calculus cholecystitis this will be the main risk factors but other things such as you know I haven't had cardiopulmonary bypass will be a reason to have a calculus cholecystitis and just to clarify that represents about five percent of all acute cholecystatus cases correct and what is thought to be the pathogenesis of acute cholecystitis without a gallstone because certainly with gallstone it makes sense there's a blockage of the duct but what is the pathogenesis of this disease certainly what typically happens is that you have bile stasis so imagine if you will a patients in the ICU has not been fed orally the bile on the gallbladder essentially just sits there you don't get the normal squeeze to eject bile from the gallbladder the gallbladder distends and with this distension you're essentially compress the blood vessels to the wall of the gallbladder and some people actually believe that you actually have some Associated endothelial injury secondary to the inflammation caused by the bile stasis that you started off with and that's what we think causes it it is very hard to say but that's a presumptive uh hypothesis regarding how a calculus cholecystitis occur more importantly these patients have other reasons to have endothelial injury they're usually in the ICU for sepsis or for trauma or for burn and this can result in a hypoperfusion State and that clearly would reduce the blood supply to the one of the gallbladder and hence you may end up having a calculus quality status of the inflammation of the wall of the gallbladder interesting in terms of the diagnosis of acute cholecystitis ultrasonography is considered the initial Imaging modality of choice can you describe the diagnostic accuracy of the ultrasound for acute echolicystitis and what's the typical findings are on ultrasound so certainly so the ultrasound is actually preferred as the first modality because it is non-invasive and it is relatively low cost and easily accessible and most nearly all hospitals will have it and there's no ionizing radiation associated with this this sensitivity for diagnosis or calculus Society is about each one percent and the specific disease is about 80 in acute cholecystitis the signs of acute cholecystitis on ultrasound include pericolicistic fluid which is essentially freed around the gallbladder the gallbladder will be distended you'll see edema of the gallbladder wall and gallstones or sludge may be seen and that those are the typical signs of acute cholecystitis on ultrasonography and what are some other Imaging modalities that may be used for diagnosis of acute cholecystitis and when should they be used certainly if a patient has signs or symptoms of vacuole societies and ultrasounds does not give you the typical findings the alternative uh include a CT scan of the abdomen and pelvis looking at the right of accordance a CT scan may be used uh the gallstone detection of the CT scan is dependent on the type of gallstones that are present if they're cholesterol Stones they may not essentially light up and also on CT scan depending on the thickness of the slices on the CT scan you may actually miss stones on the gallbladder however CT scan may also show your thickened gallbladder wall pericolocystic fluid fat stranding around the gallbladder the hepatobiliary cintigraphy is actually regarded as the gold standard also known as a Hider scan and essentially this is a test in which our radio Tracer technician label radio Tracer is injected into the patient and the patients should have been fastened for four to six hours and effectively if the patient has got a patent cystic duct the gallbladder will light up on the scan which means the patient does not have acute cholecystitis if the patient has acute cholecystitis the gallbladder will not be visualized and this is a very very sensitive and specific test for acute cholecystitis the sensitivity is about 96 and the specificity is about 90 percent all the tests that potentially can help you is a MRI and magnetic resonance imaging or an MRCP MRI of gallbladder will show gallstones make sure gallbladder won't thickening gallbladder oil distension fluid around the liver and pericolas cystic fluid and any single one of the signs a suggestion of acute cystitis the MRI has a sensitivity of 88 and a specificity or 89 percent the importance of the MRCP lies in the fact that if there are other concomitant issues in the biliary system such as cholidocolithiasis that is Stones within the common bile duct you may see this and this may help assist in planning the therapeutic approach but all in all ultrasound is the first test that you should get and I particular scentography is the gold standard in terms of treatment cholecystectomy is a recommended treatment for calculus acute cholecystitis and the laparoscopic approach is the standard of care in the U.S can you discuss the benefits of doing an early cholecystectomy within one to three days of onset of symptoms versus later certainly in the past there was a belief that if a patient shows up with a cused choli societies perhaps one should wait to let the inflammation cool down but there's been several studies and randomized clinical trials that have shown that undergoing laparoscopic cholecystectomy within 24 hours of admission is beneficial one the patient spends less time in the hospital your complication rates are lower recoveries quicker than the Infectious process is limited this was come when we compare early versus delayed and delayed is typically defined as having your cholecystectomy approximately three days after admission there's a significant advantage to having your gallbladder removed early and what percentage of cholecystectomies that start with a laparoscopic approach end up being converted to an open cholecystectomy approximately two to fifteen percent of patients undergoing laparoscopic cholecystectomy will be converted to an open cholecystectomy and are there certain risk factors that make it more likely that a cholecystectomy will need to be converted from a laparoscopic to an open approach those in the delayed cholecystectomy group are more likely to be converted to open being male being of older age having a high body mass index all higher risk factors for undergoing uh conversion from laparoscopic to open but for us in surgery one of the greatest risk factors is having a prior abdominal operation so if you have an upper midline abdominal incision given the adhesions that may occur in the midline and also in the right upper quadrants this increases your chances of undergoing a conversion from laparoscopic to open cholecystectomy and then lastly having a complicated acute cholecystitis increases your chances of conversion to open and then shifting to pregnant individuals is there anything different about their management for acute cholecystitis that you'd like to discuss non-gynecological surgery occurs in approximately one to two percent of pregnant patients and a lot of the abdominal surgeries are going to get things like acute appendicitis cystectomy in the first trimester of pregnancy you're going to treat the patients the same some people have always felt that you should try and avoid an abdominal operation if you can in pregnancy but when it comes to acute cholecystitis the current guidelines from the American College of obstetrics and gynecologists and the Society of the American gastrointestinal and endoscopic surgeons recommends laparoscopic cholecystectomy be performed after acute cholecystitis in any trimester of pregnancy in the presence of Accu cholecystitis and what about elderly patients with acute cholecystitis should they receive any different treatment than standard treatment elderly patients should undergo standard treatments I think the decision in the elderly is really cloudied by any Associated comorbidities that they may have most people who actually would suggest that you should go ahead and remove an elderly and women say Elder years old age over 65 some people may not think that is old and so we'll just call them older patients age over 65. there's a survival benefits to going ahead and removing their gallbladder as opposed to any other alternative therapeutic strategies and another important point that was brought up in your review was the use of antibiotics in acute cholecystitis can you discuss the recommended use of pre-operative and post-operative antibiotics uh certainly once the diagnosis of acute our polycystitis has made a prior to your laparoscopic cholecystectomy patients should be placed on on IV antibiotics and typically the commonest organisms are gram negatives uh E coli capsular and those patients were placed on combination antibiotics such as amoxicillin tasobactin and in the pre-surgery period or the purpose of period antibiotics should be given the operating room you can also give antibiotics before you start the case post-operatively there's no evidence that a prolonged antibiotics or any antibiotics after the gallbladder has been removed is beneficial and certain patients for the curly cystitis have a high perioperative risk either due to critical illness or because they have multiple medical comorbidities can you discuss the option of percutaneous cholecystostomy tube placement in patients with the calculus sclerosis or patients that are critically ill with Calculus cholecystitis given their critical illness and their significant operative risks percutiness tube has always been an option essentially that is putting the tube through the liver into the gallbladder to decompress the gallbladder and trying to drain any sort of pure lenses on the gallbladder has been thought to provide a survival advantage in reality patience being managed in the presence of calculus cholecystitis being managed with purple discolor testosterone tube do worse they have a higher mortality High infection have a higher reoperative rates eventually that patients who you just take to the operating room and do a laparoscopy called statutory or an open cholesterectomy so by and large with Calculus or in calculus status laparoscopy color cystectomy possible open cholesterectomy is the way to go there's a small subset of patients in which surgery is significantly prohibitive those patients May benefit from a percutaneous cholesterol switch tube placement but this should be the exception rather than the rule is there anything we haven't discussed about acute cholecystitis or its management that you'd like to mention to our Jama audience certainly there appears to be a significant disparities in patients presenting with acute cholecystitis in the United States underrepresented minority patients since present later and this could be uh due to access of the healthcare system and hence there are more likely to present with complicated cholecystitis but by and large I think early laparoscopic cholesterectomy should be the standard of care that was Dr Anthony Charles who is chief of the division of trauma critical care and acute care surgery director of the ECMO program and director of global surgery at the University of North Carolina in Chapel Hill North Carolina thank you for sharing your thoughts with us about this important topic thank you very much it was my pleasure I'm Walter thank you for listening this episode was produced by Daniel morrow at the Jana Network the audio team here also includes Jesse mccorders Shelly steffens Lisa Hardy Audrey foreman and Mary Lynn perkola Dr Robert golub is the JAMA executive Deputy Editor to follow this and other Gemma Network podcasts please visit us online at jananetworkaudio.com thanks for listening