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A 53-year-old man presented with a 2-week history of progressive skin rash, numbness, arthralgia and myalgia, as well as a 9-month history of cough and wheezing. He was diagnosed with new-onset asthma and underwent inhaled steroid therapy; however, this treatment was ineffective for cough and

A 78 year-old female status post subarachnoid haemorrhage developed abdominal pain and obstructive jaundice. CT scan showed acute cholecystitis and dilation of the intrahepatic ducts. Endoscopic retrograde cholangiography revealed hepatic duct stenosis due to compression by an enlarged gallbladder. No stones were seen in the common hepatic duct and the cystic duct was patent. An endoscopic retrograde biliary drain was placed to relieve the obstructive jaundice due to acute acalculous cholecystitis. Percutaneous transhepatic drainage was performed to treat the acute acalculous cholecystitis. Hepatic duct stenosis was improved on endoscopic retrograde cholangiography performed 19 days after percutaneous transhepatic drainage. It may be reasonable to treat ‘Mirizzi-like syndrome’ non-operatively.

We herein report a case of spontaneous isolated dissection of the celiac artery. A Japanese man in his 50s visited an emergency unit, complaining of sudden epigastralgia. Contrast-enhanced computed tomography indicated dissection of the celiac artery with patent false and true lumina, extending to the splenic and common hepatic arteries. On day 3 of hospitalization, the dissection progressed to the proper and right hepatic arteries. Progression of the dissection to the right hepatic artery provoked acalculous ischemic cholecystitis, and cholecystectomy followed. The resected gallbladder revealed extensive aseptic necrosis with little inflammatory reaction, and the gallbladder neck was spared from ischemia.

Background: Acute acalculous cholecystitis (AAC) is characterized by acute necrotizing inflammation with no calculi and is diagnosed based on imaging, intraoperative, and pathological examinations. Key Message: Although AAC has been studied clinically for a long time, it remains difficult to diagnose and treat. The pathogenesis of AAC is still not fully understood, and it is often regarded as a relatively independent clinical disease that is different from acute calculous cholecystitis (ACC). Pathological studies suggest that AAC is the manifestation of a critical systemic disease, while ACC is a local disease of the gallbladder. Summary: Concerning the pathogenesis, diagnosis, and treatment of AAC, we reviewed the research progress of AAC, which will enhance the understanding of the early diagnosis and treatment of AAC.

We herein report the case of 21-year-old female diagnosed with adult-onset Still's disease (AOSD) three years earlier who presented with fever and right upper abdominal pain. She was diagnosed with acute acalculous cholecystitis (AAC) based on hepatic dysfunction, elevated C-reactive protein, and gallbladder wall thickening on abdominal ultrasound. Based on the presence of pancytopenia, hyperferritinemia, and hemophagocytosis by a bone marrow examination, she was diagnosed with macrophage activation syndrome (MAS)/hemophagocytic lymphohistiocytosis (HLH) which was refractory to glucocorticoid pulse therapy. The combination of intravenous cyclosporine A with glucocorticoids was able to successfully control the disease activity of AOSD-related AAC and MAS/HLH.

Zusammenfassung. Es gibt verschiedene Ursachen für die relativ häufig auftretenden sonografischen Veränderungen von Gallenblasenwand und Umgebung. Ihre Interpretation ist nicht selten eine grosse Herausforderung für die behandelnde Ärztin/den behandelnden Arzt und wird hier kurz diskutiert. Bei unserer Patientin sind diese Veränderungen auf eine Hepatitis A zurückzuführen, wobei Letztere für multiple extrahepatische Manifestationen verantwortlich zeichnet. In Kenntnis dieser Ätiologie sollte auf eine Gallenblasenentfernung verzichtet werden, um unnötige Komplikationen zu vermeiden.

Background: Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder without gallstones in the setting of critical illness. It represents 2%–15% of acute cholecystitis (AC) cases....

It may be necessary a consideration about the best approach to the acute concomitant problems that critical COVID-19 patients can develop. They require a rapid diagnosis and an early treatment by a multidisciplinary team. As a result, we would like to describe two clinical cases a patient with diagnosis of COVID-19 pneumonia with good respiratory evolution that, after extubation suffered an acalculous cholecystitis and a patient with COVID-19 pneumonia that suffered an overinfection with necrotising pneumonia that presented with haemoptysis and was finally treated with arterial embolisation by the interventional radiologist’s team.

Introduction Novel Coronavirus disease 2019 or COVID-19 has rapidly spread throughout the world and has become an unprecedented pandemic. It has a vast spectrum of clinical presentations and can affect various organs. Rarely, it has been reported to cause acalculous cholecystitis in a non ICU setting patient. Case presentation Here we report a rare association of COVID 19 with acalculous cholecystitis in a 40 years old healthy woman. She developed fever, malaise, generalized body weakness, and right hypochondrial pain after fourteen days of COVID 19 infection, raising the possibility of Post COVID dysregulated immune response resulting in acalculous cholecystitis. She was managed conservatively with broad spectrum antibiotics. Discussion Acalculous cholecystitis primarily occurs due to the gall bladder's hypomotility and most commonly seen in critically ill patients such as severe burns, mechanically ventilated patients, and prolonged parenteral nutrition. The management depends upon treating the underlying pathology and, in some severe cases, may need surgical intervention as well. Up to our knowledge, COVID 19, causing acalculous cholecystitis, is a rare association described only in a few critically ill patients but not in young, healthy patients. It can be attributed to the body's dysregulated immunological response against the virus resulting in systemic inflammation. Conclusion Currently, there is are no clear guidelines for managing acute cholecystitis in COVID-19 patients. It depends on the patient's clinical state and disease severity. We aim to highlight the importance of early diagnosis and management in such clinical scenarios to avoid fatal complications., Highlights • Association between post COVID 19 and acute acalculus cholecystitis. • The possible mechanisms causing acute acalculus cholecystitis in COVID 19 and post COVID 19. • Post COVID 19 Immune dysregulation phenomena in acute acalculus cholecystitis. • Prompt identification and management of acalculus cholecystits in COVID 19.

Author(s): Langenohl, Robert; Young, Scott; Couperus, Kyle | Abstract: Background: Acute cholecystitis is the acute inflammation of the gallbladder. In adults it is most frequently caused by a gallstone(s) obstructing outflow from the cystic duct, leading to gallbladder distention and edema with eventual development of biliary stasis and bacterial overgrowth, often requiring operative management. However, in children acalculous cholecystitis is more common and is often the result of an infectious process.Case Report: Here we present a case of acute acalculous cholecystitis caused by infection with Epstein-Barr virus in an otherwise healthy three-year-old male.Conclusion: Acalculous cholecystitis is an uncommon but potentially significant complication of Epstein-Barr virus infection in the pediatric population. Emergency providers should consider this diagnosis in any child being evaluated for EBV with the complaint of abdominal pain.

The patient was a 67-year-old man with advanced hepatocellular carcinoma (HCC) due to chronic hepatitis B. Due to refractoriness to radiofrequency ablation and transcatheter arterial chemoembolization, lenvatinib, a new oral mutikinase inhibitor, was started with a daily dose of 12 mg. However, on day 6 the patient developed acute-onset, right upper quadrant pain associated with fever; laboratory tests revealed leukocytosis and liver dysfunction. CT scan showed the swollen gallbladder with wall thickening with no evidence of gallstones, and the diagnosis of acute acalculous cholecystitis was made. After the resolution of cholecystitis by antibiotics and endoscopic nasogallbladder drainage placement, lenvatinib was resumed at a reduced daily dose of 4 mg. However, acute acalculous cholecystitis recurred, supporting lenvatinib as a cause of acute acalculous cholecystitis. Using the Naranjo adverse drug reaction probability scale, a score of 6 was derived, which indicates that this adverse event was probably caused by lenvatinib. In summary, we present a patient with advanced HCC who underwent repeated episodes of acute acalculous cholecystitis as a rare adverse event associated with lenvatinib.

Gallbladder volvulus is a rare cause of acalculous cholecystitis which clinically presents as acute abdomen and can rapidly evolve in a severe life-threatening sepsis. Awareness is crucial for differential diagnosis leading to the early and effective treatment. We present the case of an elderly woman who underwent laparoscopic cholecystectomy after pre-operative ultrasound diagnosis of gallbladder volvulus.

The recent increase in measles cases will result in a higher incidence of associated complications. Hepatobiliary complications are among rare complications of measles. Here, we present a case of measles complicated by acute acalculous cholecystitis (AAC), which we believe to be only the second case reported in the literature. A 17-year-old woman presented with a maculopapular rash, high fever, sore throat, runny nose, nausea, and generalized body aches. Measles was diagnosed by anti-measles immunoglobulin M (IgM) positivity and a 4-fold increase in immunoglobulin G (IgG) 2 weeks later. On day 5, Murphy's sign was positive and antibiotic therapy was initiated. Two days later, laparoscopic cholecystectomy was performed due to persistent fever and abdominal pain. The pathology result was consistent with nonspecific cholecystitis. As this case highlights, it should be kept in mind that AAC, which is a rare complication of the multisystem involvement caused by measles, can occur during recovery from the infection.

Though a rare event, gallbladder perforation (GBP) can occur in children and adolescents in the absence of pre-existing cholelithiasis. Moreover, type 1 perforation is seldom found in this cohort. Vague clinical presentation and inconclusive routine investigations can often result in delayed diagnosis. Computed tomography (CT) and intraoperative diagnosis should be utilized to timely diagnose and prevent fatal outcomes. Here, we present a rare case of type 1 GBP in an otherwise healthy 15-year-old boy with no known underlying etiology. Our purpose is to emphasize that although rare, a high clinical suspicion of GBP should be kept in mind even when dealing with acute abdomen in a pediatric population for preventing associated mortality.

Scrub typhus is a neglected tropical disease predominantly occurring in Asia. The causative agent is a bacterium transmitted by the larval stage of mites found in rural vegetation in endemic regions. Cases of scrub typhus frequently present as acute undifferentiated febrile illness, and without early diagnosis and treatment, the disease can develop fatal complications. We retrospectively reviewed de-identified data from a 23-year-old woman who presented to an emergency department with complaints of worsening abdominal pain. On presentation, she appeared jaundiced and toxic-looking. Other positive findings on abdominal examination were a positive Murphey’s sign, abdominal guarding and hepatosplenomegaly. Magnetic resonance cholangiopancreatography demonstrated acalculous cholecystitis. Additional findings included eschar on the medial aspect of the left thigh with inguinal regional lymphadenopathy. Further, positive results were obtained for immunoglobulins M and G, confirming scrub typhus. Workups for other infectious causes of acute acalculous cholecystitis detected human herpesvirus 4 (Epstein-Barr virus). Whether that represented acute infection or re-activation of the Epstein-Barr virus could not be determined. As other reports have described acute acalculous cholecystitis in adult scrub typhus patients, we recommend doxycycline to treat acute acalculous cholecystitis in endemic regions while awaiting serological confirmation.

Aim Nowadays, in vast majority of emergency patients with gastrointestinal obstruction laparoscopy is not the treatment of choice. In our department laparoscopy is routinely used in emergency admitted patients, also those with abovementioned condition, sometimes yielding unexpected and thrilling results. The aim of this work is to present a laparoscopic internal hernia repair with simultaneous “Phrygian-cap-type” gallbladder excision, performed on a patient with small intestine obstruction and chronic acalculous cholecystitis. Material and Methods A 57-year-old patient was admitted to our department as an emergency, with a one week history of symptomatic cholecystitis accompanied by gastrointestinal obstruction. CT revealed atypical suprahepatic displacement of the small intestine. An attempt of conservative treatment failed after the re-initiation of oral nutrition. The patient was qualified for laparoscopy. Results An anatomical variant of the liver ligaments was visualized with two defects in the anteriorly displaced coronary ligament and shortening of the falciform ligament. Those defects formed the hernia ring entrapping a small intestine of a total length of about 1.5 m. The falciform ligament was dissected. To avoid re-entrapment of the intestine, most of the coronary ligament was severed. Consecutively the inflamed gallbladder was removed. The unusual anatomical variation of its structure, the so-called “Phrygian cap”, was an additional difficulty. The postoperative course was uneventful. Conclusions The presented material demonstrates the possibility of immediate treatment of intestinal obstruction, even in a complicated cases, with laparoscopic manner, without the need of conversion to the open method.

Epstein-Barr virus (EBV) infection with associated acute acalculous cholecystitis (AAC) has been reported in 18 pediatric patients. Our case is that of a seven-year-old girl with acute EBV infection and associated AAC.

Patient: Female, 17-year-old Final Diagnosis: Epstein-Barr virus infection Symptoms: Jaundice • malaise • right upper quadrant abdominal pain Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology • Infectious Diseases Objective: Rare coexistence of disease or pathology Background: Infectious mononucleosis secondary to Epstein-Barr Virus is a common infection in young adults. Infection usually involves a self-limiting course of fevers, sore throat, malaise, and myalgias. Transaminitis is a relatively common complication; clinical jaundice, however, is rare. This case report highlights an uncommon complication of Epstein-Barr Virus infection in which hepatocellular injury led to clinical jaundice as well as radiologic evidence of gallbladder pathology mimicking acute calculous cholecystitis. Case Report: A 17-year-old girl with no prior medical history presented to our Emergency Department 1 week after being diagnosed with infectious mononucleosis. She was hemodynamically stable and her physical exam was notable for scleral icterus with right upper quadrant tenderness and positive Murphy’s sign. Multiple imaging modalities performed showed gallbladder wall thickening without common bile duct dilatation. A hepatobiliary iminodiacetic acid (HIDA) scan showed evidence of hepatocyte dysfunction with normal gallbladder filling. The imaging results obtained in conjunction with her laboratory testing and active infectious mononucleosis infection confirmed the patient’s presentation was a result of her Epstein-Barr virus infection and did not require surgical intervention for cholecystectomy. Conclusions: This case report highlights a rare complication of Epstein-Barr Virus infection and demonstrates the utility of interpreting hepatic function testing in conjunction with relevant imaging modalities in cases of clinical jaundice. By doing so, we were able to conclude the patient’s gallbladder pathology was related to acute acalculous cholecystitis (AAC) and did not warrant surgical intervention. The patient was given supportive care measures and made a full recovery.

While primarily a respiratory disease, COVID-19 can affect several organ systems and has been recently linked to cases of acalculous cholecystitis. We present a previously healthy elderly patient who presented to the emergency department with sepsis and was found to have COVID-19 after initially testing negative on PCR, along with suspected concomitant acalculous gangrenous cholecystitis. The patient passed away before any surgical intervention could be made. This case aims to discuss the potential relationship between acalculous cholecystitis and COVID-19.

Acute acalculous cholecystitis is a gallbladder wall inflammation without gallstones. It was not reported before as a manifestation of systemic juvenile idiopathic arthritis. Here, we describe a 13-month-old boy presented with prolonged intermittent fever, skin rash, arthritis, serositis, and hepatomegaly. After workup, he was diagnosed with systemic juvenile idiopathic arthritis and acute acalculous cholecystitis based on an ultrasound abdomen showing thick gallbladder wall with free fluid. After treatment with three days of intravenous pulse methylprednisolone, he improved dramatically, and repeated ultrasounds showed normal gallbladder. This suggests that Acute acalculous cholecystitis can be a part of systemic juvenile idiopathic arthritis and hypothesised that surgical intervention can be avoided with the use of corticosteroids.

Gall bladder perforation as a sequel of typhoid-induced acalculous cholecystitis is a rare clinical encounter, reported sparsely in literature. Here, we discuss a case wherein successful laparoscopic management of typhoid-induced gall bladder perforation was performed. A 24-year-old female presented with a history of 5 days of fever and acute pain in the abdomen for 2 days. Computed tomography scan suggested gall bladder perforation which was confirmed on diagnostic laparoscopy. Laparoscopic cholecystectomy with peritoneal lavage was performed. The patient did well postoperatively and was discharged on post-operative day 4 after drain removal. One should be aware about the possibility of gall bladder perforation as a sequel of acalculous cholecystitis in typhoid fever. Minimal access surgery techniques can be applied for confirming the diagnosis as well as the definitive treatment.

The most commonly accepted pathophysiologic mechanism for the appearance of the “hot rim” sign is inflammatory changes from the gallbladder spreading to and affecting the surrounding liver. The “hot rim” sign has clinical relevance, because it is associated with a high incidence of perforated or gangrenous cholecystitis. The presence of these above-mentioned conditions increases the likelihood of complications and warrants urgent surgical evaluation. We present present the findings of on hepatobiliary scintigraphy and adjunct single-photon emission computed tomography/computed tomography-fused imaging in a case of acalculous cholecystitis, which has been confirmed on histopathology (marked degree of acute gangrenous cholecystitis).

A 69-year-old Japanese woman was transferred to our hospital due to pancytopenia with a fever. She had Murphy's sign, and computed tomography showed pleural effusion and a swollen gallbladder without gallstones. We diagnosed her with systemic lupus erythematosus (SLE)-associated acute acalculous cholecystitis (AAC). Partly because her clinical and laboratory findings were not serious enough to warrant immediate surgical intervention, and partly because her poor general condition made her ineligible for surgery, surgical therapy was not selected. Corticosteroid therapy was performed with azathioprine, and the swelling in her gallbladder improved. As a conservative therapy for SLE-associated AAC, corticosteroid therapy combined with azathioprine might be beneficial.

An 81-year-old man with a history of hypertension and hyperlipidemia presented with epigastric pain for 3 days, which was associated with skin yellowing and vomiting. There were neither fever, diarrhoea, tea-coloured urine nor the consumption of traditional Chinese medicine or raw seafood. Examination showed jaundice and right upper quadrant tenderness. Chest X-ray and ECG were unremarkable. Urine dipstick test was 1+ for bilirubin. Figure 1 A bedside ultrasound performed in the emergency department illustrating the heterogeneous mass at the body of the gallbladder. Figure 2 In view of the persistence …

Gallbladder inflammation is most often determined by the presence of gallstones. Acalculous cholecystitisusually occurs in patients with multiple comorbidities or with an immunosuppressed status, and therefore itsevolution is faster and more severe compared to acute calculous cholecystitis. The presence of a fish bone intothe peritoneal cavity, through a gastrointestinal fistula is not very rare, but acute cholecystitis caused by a fishbone is unexpected. Here, we present the case of a 75-year old woman who had eaten fish two months beforeand presented at the Emergency Room with perforated acalculous cholecystitis and a right subphrenic abscess.The laparoscopic approach permitted the evacuation of the subphrenic abscess, bipolar cholecystectomy andremoval of a fish bone from nearby the cystic duct. Postoperative evolution was uneventful, with hospitaldischarge after five days. The patient was in good clinical condition at two months follow-up.

The morbidity and mortality of cholecystectomy can increase to 10% in high surgical risk patients. The technique for percutaneous cholecystolithotomy consists of 3 steps: (1) percutaneous cholecystostomy, (2) tract dilation and cholecystolithotomy, and (3) tract evaluation and catheter removal. Cholecystoscopy is critical in guiding the lithotripsy probe for fragmentation of large stones and is useful for locating small stone fragments not seen in cholangiography. Cholecystoscopy is also useful for assessing ambiguous lesions and in distinguishing between stone vs debris or mass. Technical success rate of percutaneous cholecystolithotomy using cholecystoscopy ranges from 93% to 100%. Procedure related complication rate has been reported as 4%-15%. The most common complication is bile leak during the procedure or after catheter removal. Although recurrence rate of gallstones has been reported up to 40%, the symptom recurrence rate is much lower. Therefore, percutaneous cholecystolithotomy using cholecystoscopy can be an alternative to cholecystectomy in high surgical risk patients with symptomatic gallstones.

Background Percutaneous cholecystostomy (PC) with interval cholecystectomy is an effective treatment modality in high-risk patients with acute cholecystitis. However, some patients still fail to undergo interval cholecystectomy after PC, with the reasons rarely reported. Hence, this study aimed to explore the factors that prevent a patient from undergoing interval cholecystectomy. Methods Data from patients with acute cholecystitis who had undergone PC from January 1, 2017 to December 31, 2019 in our hospital were retrospectively collected. The follow-up endpoint was the patient undergoing cholecystectomy. Patients who failed to undergo cholecystectomy were followed up every three months until death. Univariate and multivariate analyses were performed to analyze the factors influencing failure to undergo interval cholecystectomy. A nomogram was used to predict the numerical probability of non-interval cholecystectomy. Results Overall, 205 participants were identified, and 67 (32.7%) did not undergo cholecystectomy during the follow-up period. Multivariate analysis revealed that having a Tokyo Guidelines 2018 (TG18) grade III status (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.27–11.49; p = 0.017), acalculous cholecystitis (OR: 4.55; 95% CI: 1.59–12.50; p = 0.005), an albumin level p = 0.037), and a history of malignancy (OR: 4.65; 95% CI: 1.62–13.37; p = 0.004) were independent risk factors for a patient’s failure to undergo interval cholecystectomy. Among them, the presence of a history of malignancy exhibited the highest influence in the nomogram for predicting non-interval cholecystectomy. Conclusions Having a TG18 grade III status, acalculous cholecystitis, severe hypoproteinemia, and a history of malignancy influence the failure to undergo cholecystectomy after PC in patients with acute cholecystitis.

Although the Coronavirus Disease 2019 (COVID-19) infection mainly affects the lung, its gastrointestinal (GI) involvements are also well-known, especially hepatic involvement presenting as mild to moderate transaminitis. However, COVID-19 infection presenting with gall bladder involvement with acalculous cholecystitis is extremely rare in the medical literature. So far, only two cases have been reported, and herein, we are reporting the third case of a patient who developed COVID-19 presenting as an acute acalculous cholecystitis.

Haemorrhagic cholecystitis is a seldom seen cause of right upper quadrant pain that can result in gallbladder rupture, massive intraperitoneal haemorrhage and death if untreated. Haemorrhagic cholecystitis is usually seen in the presence of cholelithiasis, malignancy, trauma and coagulopathies. Here, we present the unusual case of an elderly man presenting with acalculous haemorrhagic cholecystitis, who was successfully treated with laparoscopic cholecystectomy. We review the radiological and laparoscopic findings of haemorrhagic acalculous cholecystitis. This case highlights the importance of prudent use of radiological imaging to differentiate haemorrhagic cholecystitis from alternate pathology and early surgical intervention to avoid massive intraperitoneal haemorrhage and the high mortality with which it is associated.

Rationale: Acute retroviral syndrome is the symptomatic presentation of acute human immunodeficiency virus (HIV) infection, which often manifests as a self-limited infectious mononucleosis-like syndrome and occurs 2 to 6 weeks after exposure to HIV. Atypical manifestations including hepatitis, meningitis, or hemophagocytic lymphohistiocytosis have been reported. However, manifestations of acute acalculous cholecystitis during acute HIV infection are rarely reported. Patient concerns: A 30-year-old man with nausea and loose stools, followed by fever and abdominal pain at the right upper quadrant for 10 days. Diagnosis: Acute retroviral syndrome, complicated with acute acalculous cholecystitis. Interventions: Percutaneous transhepatic gallbladder drainage was performed and treatment with co-formulated bictegravir/emtricitabine/tenofovir alafenamide was initiated upon HIV diagnosis. Outcomes: The patient's symptoms improved after the drainage. The levels of liver enzyme including aspartate transaminase alanine aminotransferase decreased to a level within normal limits 1 month after initiation of antiretroviral therapy. Conclusion: Acalculous cholecystitis in combination with acute hepatitis could be manifestations of acute HIV infection. For individuals at risk of acquiring HIV infection who present with manifestations of acute acalculous cholecystitis, HIV testing should be considered.

Surgeons routinely provide palliative care, but often the technical procedure needed for the palliative intervention is beyond our training and comfort zone. This case is an example of surgical palliative care that utilizes image-guided techniques to provide optimal care. A frail elderly patient with multiple comorbidities who had been hospitalized for other diseases was diagnosed with acute acalculous cholecystitis. General surgery and gastroenterology were initially consulted, and the patient was referred to interventional radiology for a percutaneous cholecystostomy. The procedure was technically successful, and the patient’s clinical status improved. A few days later, a follow-up cholecystogram showed a decompressed gallbladder, patent cystic duct, a common bile duct free of stones, and dilute contrast in the duodenum. After 2 weeks, the fistula tract was interrogated and found to be intact. The cholecystostomy tube was removed without incident. This case is presented as a call to action for surgeons to learn the skills required to place percutaneous cholecystostomies themselves and to add it to their surgical armamentarium.

Background Acute calculous cholecystitis (AC) is one of the most frequent surgical emergencies in our field. Laparoscopic cholecystectomy is considered the treatment of choice, although not sufficiently widespread. Objective To analyze the application of the Tokyo Guidelines in the management of AC and to determine the influence of the degree of severity on management and prognosis. Method Prospective, observational study of patients with a primary diagnosis of AC between 2010 and 2015.. Exclusion criteria: AC recurrence; AC as a secondary diagnosis; acalculous cholecystitis; concurrent biliary pathology. Severity was classified according Tokyo 2013 Guidelines. Results 998 patients were included: 338 (33.9%) mild AC, 567 (56.8%) moderate AC, and 93 (9.3%) severe AC. A total of 582 (58.3%) patients were operated on. Postoperative complications Dindo-Clavien grade ≥ II 12.6%: mild AC 3.6%; moderate AC 12.2%; severe AC 49.0% (p < 0.001). Overall mortality 2%: mild AC 0%; moderate AC 0.5%; severe AC 18.0% (p < 0.001). Conclusion Urgent laparoscopic cholecystectomy remains the treatment of choice for mild and moderate AC. In patients with severe AC, the risks and benefits of surgery should be assessed, given the high degree of complications and associated mortality.

Cholesterol embolization syndrome (CES) is an atherosclerotic complication affecting different systems with various clinical manifestations, usually triggered iatrogenically by interventional and surgical procedures or thrombolytic therapy, although spontaneous cases have been reported. The hepatobiliary system can also be affected when the showered cholesterol crystals obliterate small vessels within this system causing both ischaemic and inflammatory responses. We describe a case of a male patient who initially developed multiple lacunar cerebral infarcts 10 days post-thrombolytic therapy and percutaneous coronary intervention (PCI) due to acute myocardial infarction. Several weeks later he developed acalculous cholecystitis complicated by liver abscess and kidney injury. The consequences and latency of manifestations within different organs and the temporal relationship with well-known trigger factors raised the suspicion of CES. LEARNING POINTS Cholesterol embolization syndrome (CES) is an atherosclerotic complication that usually develops after a vascular procedure/surgery or thrombolytic therapy or, rarely, spontaneously, and results in nonspecific cutaneous, renal, central nervous system and, less often, gastrointestinal manifestations that may mimic other systemic diseases. The delayed appearance of multi-organ manifestations from the precipitating factors may lead to difficulties in diagnosing CES. Complicated acalculous cholecystitis can be one of the infrequent hepatobiliary manifestations of CES.

Background Percutaneous cholecystostomy is performed by interventional radiologists for patients with calculous/acalculous cholecystitis who are poor candidates for cholecystectomy. Two anatomical approaches are widely utilized: transperitoneal and transhepatic. Purpose To compare the clinical outcomes of transperitoneal and transhepatic approaches to cholecystostomy catheter placement. Material and Methods From December 2007 to August 2015, 165 consecutive patients (97 men, 68 women) underwent either transperitoneal (n = 89) or transhepatic (n = 76) cholecystostomy at a single center. Indications were calculous cholecystitis (n = 21), acalculous cholecystitis (n = 35), hydrops (n = 1), gangrenous cholecystitis (n = 1), and other cholecystitis (n = 107). The most common high-risk co-morbidities were sepsis (n = 53) and cardiac (n = 11). Outcomes were compared using univariate and multivariable analysis. Results Post-procedure outcomes included tube dislodgement (transperitoneal [n = 6] and transhepatic [n = 3], P = 0.44), bile leak (transperitoneal [n = 5], transhepatic [n = 1], P = 0.14), gallbladder hemorrhage (transperitoneal [n = 2]; transhepatic [n = 3], P = 0.52), duodenal fistula (transperitoneal [n = 0], transhepatic [n = 1], P = 0.27), repeat cholecystostomy (transperitoneal [n = 1], transhepatic [n = 3], P = 0.27), and repeat cholecystitis requiring separate admission (transperitoneal [n = 6], transhepatic [n = 10], P = 0.15). All complications were Common Terminology Criteria for Adverse Events grade Conclusion There were no significant differences in short-term complications after transperitoneal and transhepatic approaches to percutaneous cholecystostomy catheter placement.

Epstein-Barr virus (EBV) is a member of the herpes virus family and is characterized by fever, lymphadenopathy, and sore throat. In this report, we present a 20-year-old woman with a four-day history of fever, chills, nausea, vomiting, jaundice and abdominal pain, and a diagnosis of acalculous cholecystitis, acute hepatitis with hemolytic anemia due to infectious mononucleosis. After the confirmation of acute acalculous cholecystitis along with hemolytic anemia, prednisolone was initiated for the patient. Supportive measures resolved the symptoms of acalculous cholecystitis.

Cholelithiasis is extremely common in the United States, affecting approximately 10 to 15% of the population. The vast majority of patients remain asymptomatic. Elective cholecystectomy for symptomatic cholelithiasis is a well-established procedure with excellent outcomes. The diagnosis in critically ill patients may not be straightforward. Inflammation and infection of the gallbladder can lead to significant morbidity and mortality. Whether the gallbladder is the primary etiology of hemodynamic compromise (as in emphysematous or gangrenous cholecystitis) or is the victim of secondary insult (as in ischemia-related acalculous cholecystitis), the intensivist must consider cholecystitis in the differential of clinical deterioration. This review contains 6 figures, 5 tables, and 59 references. Key words: acalculous, biliary disease, cholangitis, cholecystitis, emphysematous cholecystitis

Intravascular large B-cell lymphoma (IVLBCL) frequently involves the hepatobiliary system, but its clinical course and pathophysiology are still not fully known. We herein describe a case of IVLBCL mimicking acute hepatobiliary infection. An 85-year-old woman was admitted because of fever and epigastric pain, and she was diagnosed to have acute acalculous cholecystitis based on gallbladder wall thickening with fluid collection. The gallbladder swelling regressed within several days, and areas of intrahepatic hypoperfusion appeared. Inflammation continued despite treatment with antibiotics, and she died within 21 days. An autopsy examination revealed IVLBCL. IVLBCL can present as acute cholecystitis with an improvement in the imaging findings and the presence of a subsequent liver mass.

OBJECTIVES Chronic acalculous cholecystitis (CAC) increasingly is being diagnosed as a cause of recurring biliary symptoms in children, but its clinical diagnosis remains challenging. The primary objective was to evaluate the utility of hepatocholescintigraphy in pediatric patients with suspected CAC. A secondary objective was to describe their clinical follow-up after diagnosis. METHODS Medical records of patients (aged 9-20 years) who underwent hepatocholescintigraphy from February 2008 to January 2012 were reviewed. Patients with gallstones, and with ≤1 year of clinical follow-up, and studies without gallbladder (GB) stimulation were excluded. GB ejection fraction (GBEF) of

Diffuse thickening, a layered appearance of the gallbladder wall and the accumulation of surrounding fluid are considered as sensitive and relatively specific imaging findings of gallbladder inflammation. In the absence of gallstones, the diagnosis of acalculous cholecystitis can be further supported by the presence of fever, epigastric pain, right upper abdominal quadrant (RUQ) tenderness on inspiration and elevated markers of inflammation. In this report, we describe a 35-year-old schoolteacher who presented with all of the above clinical, laboratory and imaging findings that were eventually attributed to gallbladder oedema and liver congestion (abdominal imaging and RUQ tenderness) caused by an atrial myxoma interfering, with the atrioventricular circulation of the right heart and causing constitutional manifestations (fever and elevated markers of inflammation).

Acute acalculous cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. AAC is estimated to represent at least 50% to 70% of all cases of acute cholecystitis during childhood. Although this pathology was originally described in critically ill or post-surgical patients, most pediatric cases have been observed during several infectious diseases. In addition to cases caused by bacterial and parasitic infections, most pediatric reports after 2000 described children developing AAC during viral illnesses (such as Epstein-Barr virus and hepatitis A virus infections). Moreover, some pediatric cases have been associated with several underlying chronic diseases and, in particular, with immune-mediated disorders. Here, we review the epidemiological aspects of pediatric AAC, and we discuss etiology, pathophysiology and clinical management, according to the cases reported in the medical literature.

Background: Acute cholecystitis- inflammation of the gall bladder- is most usually brought on by gall stones. Gall stones are one of the most typical problems of the gastrointestinal system, impacting regarding 10% of individuals in Western world. Aim of the study: In this review we discussed background of cholecystitis, symptoms and possible complications. As well we highlighted importance and use of ultrasound in diagnosis of cholecystitis and other diagnoses possibilities and their efficiency. Materials: Articles search was performed in MEDLINE, EMBASE, and CINAHL databases up to May 2018 to identify studies about evaluation ultrasound in diagnosis of cholecystitis and other diagnoses possibilities and their efficiency. Conclusion: CT is debatably the most effective technique for imaging of challenging gallbladder condition, especially for straight imaging of emphysematous cholecystitis, gallstone ileus, and verification of presumed gallbladder perforation. Cholescintigraphy may assist ultrasound and CT for differentiating acute from chronic cholecystitis and for the diagnosis of acalculous cholecystitis.

Background Staple line leak is one of the most challenging complications following laparoscopic sleeve gastrectomy, with a rate reaching near 1%. Its management often implicates a multidisciplinary approach and experienced bariatric and metabolic surgeons. The literature is abundant on various approaches to treat single staple line leak with variable results. But what to do in front of an intra-op incidental finding of double gastric fistulae? Methods In this article, we describe a new successful surgical treatment option of double Baltazar technique for a patient who was found to have two gastric fistulae post-sleeve gastrectomy. We aim to demonstrate that this approach is safe and effective and can help avoid major side effects of traditional treatment options for such complications. Results The patient presented 20 days following a laparoscopic sleeve gastrectomy in a severe septic condition and was found to have a gastric leak. During surgical repair, unlike the usual single proximal fistula findings, another opening was identified more distally. Decision was made to proceed with a double fistulo-jejunostomy. It was a feasible technique, with no intra-op complications. Post-operatively, the patient had a successful recover, with no residual leak. Conclusions Double Baltazar technique is a successful and feasible treatment option for patients presenting with two gastric fistulae following sleeve gastrectomy. This is the first case report describing this new technique, and its success should encourage more similar trials and avoid more aggressive surgical options such as total gastrectomy or gastric bypass.

ObjectiveTo evaluate acute acalculous cholecystitis (AAC) as a potential safety risk for patients treated with alemtuzumab.MethodsThe Food and Drug Administration Adverse Event Reporting System and the medical literature were searched for cases of AAC in conjunction with alemtuzumab for all clinical indications.ResultsEight spontaneously reported cases meeting the case definition of AAC in close temporal association with alemtuzumab use were identified. Based on established criteria within the Food and Drug Administration Division of Pharmacovigilance for causality assessment, 4 cases were assessed as probable while 4 were possible. All cases occurred in patients with relapsing-remitting multiple sclerosis. Seven of the 8 cases presented with AAC during or shortly after alemtuzumab treatment, thereby suggesting an acute cytokine release syndrome as a putative pathogenic mechanism. The cases identified in this review differ from the typical AAC cases described in the medical literature based on female preponderance, lack of concurrent critical illnesses, inconsistent presence of other risk factors, and resolution with conservative treatment in the majority of cases.ConclusionsAAC represents a new and potentially life-threatening adverse event associated with alemtuzumab use in relapsing-remitting multiple sclerosis. In cases seen to date, early and conservative treatment resulted in good clinical outcome, although the natural history of AAC in this population without critical illness is not well defined. Awareness of this safety risk by general and specialty neurologists is important for prompt recognition and optimal management.