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Presence of Fever and Leukocytosis in Acute Cholecystitis
GENERAL CLINICAL I N V E S T I G A T I O N / B R I E F REPORT
Presence of Fever and Leukocytosis in Acute Cholecystitis From the Divisionof Emergency Medicine, LongIslandJewish Medical Center, Albert Einstein Collegeof Medicine, brewHyde Park, New York~;and Winthrop University Hospital, Mineola, New York.~
Peter J Gruber, MD* Robert A Silverman, MD ~ Steven Gottesfeld, DO* Edith Flaster, MS*
Receivedfor publication November 13, 1995. Revision received May 10, 1996. Acceptedfor publication May 21, i996. Presented at the Societyfor Academic Emergency MedicineAnnual Meeting, Washington DC, May I994. Copyright © by the American College of Emergency Physicians.
See related editorial, p 347.
Study objective: To determine the frequency of fever and leukocytosis in patients presenting to the emergency department with acute cholecystitis {AC). Methods: We carried out a retrospective review of charts from 1990 to 1993 at a university-affiliated hospital. Our subjects were ED patients with hepato-iminodiacetic acid (HIDA) scans interpreted as showing AC and who had undergoneCholecystectomy during hospitalization. Final diagnosis was determined on the basis of the pathology report. Feverwas defined as an oral temperature of I00 ° F (37.7° C) or greater or a rectal temperature of 100.4° F (38.0° C)or greater. Leukocytosiswas defined as a WBC count of 11,000/mm3 or greater. Results: Of the 198 cases studied, the pathologic diagnosis of nongangrenousAC was made in 103 (52%), gangrenousAC was diagnosed in 51 (26%), and chronic cholecystitis was diagnosed in 44 (22%). In patients with nongangrenousAC, 71% were afeNile, 32% lacked leukocytosis, and 28% lackedfever and leukocytosis. In patients with gangrenousAC, 59% were afebrile, 27% lacked leukocytosis,and 16% lackedfever and leukocytosis.
Conclusion: We found that patients with AC diagnosed in the ED frequently lacked fever or leukocytosis. The clinician should not rely on the presence of these signs in making the diagnosis of acute cholecystitis. [Gruber PJ, Silverman RA, Gottesfeld S, Flaster E: Presenceof fever and leukocytosis in acute cholecystitis. Ann ErnergMed September 1996;28:273-277.]
SEPTEMBER 1996 2 8 : 3 ANNALS OF EMERGENCY MEDICINE
273
CHOLECYSTITIS
Gruberet al
INTRODUCTION
Acute cholecystitis (AC) is a common abdominal emergency that results from chemical or bacterial inflammation of the gallbladder. 1,2 Of the approximately 500,000 gallbladder operations performed yearly in the United States, 17% to 31% are for acute cholecystitis. 3'4 The clinical presentation of AC is characterized by abdominal pain, anorexia, nausea, and vomiting. Textbooks of surgery and emergency medicine note that AC patients typically have fever and leukocytosis. 1,2,5 In our experience, however, many patients found in the emergency department to have AC lack fever, increased WBC count, or both. For the clinician who initially evaluates such patients, knowledge of the frequency of these signs on hospital presentation may be of assistance in the diagnosis. Our objective, therefore, was to determine the frequency of fever and leukocytosis in patients admitted with the diagnosis of AC who underwent cholecystectomy during the same hospitalization.
defined as a WBC count of 11,000/mm 3 or greater recorded during the same period. The HIDA scan was interpreted by a nuclear medicine radiologist; it was considered diagnostic of AC if the gallbladder was not visualized by the time of clearance of radioactivity from the liver and uptake was seen in the gut to a maximum of 4 hours. The pathologist diagnosed AC if neutrophils were present; the diagnosis of chronic cholecystitis required the presence of at least one of the following factors: lymphocytes, subepithelial fibrosis, Rokitansky-Aschoff sinuses, and epithelial atrophy or flattening. Gangrenous cholecystitis was diagnosed if necrosis of the mucosa was detected. We used Student's t test or the %2 test to detect differences between groups. Stepwise logistic regression was used to determine the influence of other variables such as age, sex, duration of symptoms before arrival, and time elapsed before surgery We considered P values less than .05 significant.
MATERIALS AND METHODS
RESULTS
We carried out a retrospective chart review of patients 18 years or older who presented to the ED of the Long Island Jewish Medical Center between the years 1990 and 1993. Patients were initially identified through records of positive hepato-iminodiacetic acid (HIDA) scans obtained from the radiology department. At this institution, the HIDA scan is typically performed to assist in establishing the diagnosis of AC. Patients were included in the study if their ED diagnosis was AC, the HIDA scan was performed within 24 hours of ED arrival, and cholecystectomy was performed during the same hospitalization. For the purposes of data analysis, we defined fever as an oral temperature of 100 ° F (37.7 ° C) or greater or a rectal temperature of 100.4 ° (38.0 ° C) F or greater recorded within 8 hours of ED arrival. Leukocytosis was
The criteria for study inclusion were met by 198 patients. The median age was 59 years (range, 18 to 92 years); 58% of the patients were women. History of diabetes was noted in 5% of patients, cancer in 2%, and long-term oral steroid use in 1%. Of the 198 patients, 154 (78%) were determined on the basis of findings from pathologic examination to have AC, whereas 44 of patients (22%) had chronic cholecystitis. Of the 154 patients with AC, 51 (34%) were found to have gangrenous cholecystitis. The mean temperature for all patients was 99.9 ° F (37.2 ° C) and the mean WBC was 12,600/mm 3 (Table 1). Fever was present in 32% of patients, whereas 61% of patients had leukocytosis. Neither fever nor leukocytosis was found in 31% of patients (Table 2). Of the 135 patients without fever, 23 (17%) had their temperature recorded
Table 1.
Table 2.
Comparison of subgroups, by mean temperature and WBC count in the 8 hours after ED arrival. Type of Cholecystitis All (N=198) NongangrenousAC (n=103) Gangrenous(n=51) Chronic(n=44)
2 74
Temperature (°F) [Mean_+SD]
WBC Count/mm 3 (Mean-+SD)
99.9+1.5 99.7+1.4
12,600+4,300 12,700+3,900
100.1+1.6 99.9_+1.4
14,500+4,600 10,100+3,700
Patients with fever and leukocytosis within 8 hours of ED arrival. Type of Cholecystitis All (N=198) Nongangrenous AC (n=103) Gangrenous (n=51) Chronic(n=44)
% With Fever
% With Leukocytosis
% With Both
% With Neither
32 29
61 68
24 25
31 28
41
73
29
16
27
32
14
55
ANNALS OF EMERGENCYMEDICINE 28:3 SEPTEMBER 1996
CHOLECYSTITIS
Gruber et al
only once within 8 hours of hospital arrival. Two or more temperature readings were documented for the rest of the patients without fever during this period. The presence of fever or leukocytosis was not related to duration of symptoms, time elapsed before surgery, or sex. The occurrence of fever was not related to the occurrence of leukocytosis. The mean temperatures and WBC counts for the pathologic subgroups are shown in Table 1 and the Figure. We noted no significant difference in temperature among the subgroups. Although a significant difference in WBC count was detected among the three subgroups (P=.O001) overlap was considerable. We found no significant difference in temperature when all patients 60 years or older (100.0 ° F [37.7 ° C])
Figure. MaximumWBCcount in the 8 hours@ergDarrival. WBgs/mm 3
were compared with patients below the age of 60 (99.6°F [37.5 ° C]). When leukocytosis was evaluated for all patients, the older population had a higher mean WBC count (13,300/mm 3) than the younger patients (12,000~ram 3) (P=.03). When we made comparisons on the basis of specific pathologic subgroups, which contained smaller numbers of patients, no significant difference in WBC count appeared. The maximum temperature and WBC count in the 24 hours after hospital arrival were also recorded. Fever developed in the first 24 hours in 66% of the patients; leukocytosis developed in 76%. The average time from initial evaluation to cholecystectomy was significantly longer in patients with chronic cholecystitis than it was in patients with nongangrenous AC (101 versus 68 hours, P=.002). Time elapsed before surgery was similar in patients with gangrenous cholecystitis and with acute nongangrenous cholecystitis (61 versus 71 hours, P=NS). The amount of time elapsed before surgery was not related to sex or age.
27,500
DISCUSSION 25,000
22,500
20,000 -
17,500 -
~r . . . . .
15,000 -
'i"
*--4---*
12,500 -
FTq
10,000"
* . . . . .
"k
I
I
2t 2,5001
i
i
Acute Acute gangrenous nongangrenaus
I
Chronic
The plus sign representsthe mean,the hatched line the median. The lower and upper ends of the box representthe 25th and 75th interquartiles.The central vertical lines represent 2 SD from the mean.
SEPTEMBER
1996
28:3
ANNALS OF EMERSENCY MEDIOINff
AC is associated with gallstones in more than 90% of cases. Typically, the cystic duct becomes obstructed by a calculus, localized edema, or biliary sludge. This blockage produces gallbladder distention, inflammation, and the symptoms of acute gallbladder disease. 1,2 If the obstruction resolves, the symptoms may subside. If the inflammation progresses, complications such as gangrenous gallbladder and perforation may occur. Early surgery has become the treatment of choice for most patients with AC because delays are associated with greater morbidity and mortality, as well as with increased medical costs. 6 In our study, we found that patients admitted to the hospital with the presumptive diagnosis of AC had a median age of 59 years and that 58% of the population was female. These demographic findings are different from those of the typical AC patient, a woman in the fourth decade of life. s Our patients otherwise had typical clinical presentations, all with history of abdominal pain or pain on examination and most with history of nausea or vomiting. Fever and leukocytosis have been described as typical in patients with AC. Because these signs may be used to assess likelihood of illness, we focused our attention on their presence. We found that most patients with nongangrenous cholecystitis did not have fever, that 32% lacked leukocytosis, and that 28% of patients had neither fever nor leukocytosis during the first 8 hours of hospitalization.
275
CHOLECYSTITIS Gruber et al
It is interesting that even in the subgroup of patients with gangrenous cholecystitis, a more severe form of the disease, 59% of did not have fever and 27% lacked leukocytosis. The authors of previous studies have noted that the overall clinical presentation of gangrenous cholecystitis is similar to that of acute, nongangrenous cholecystitis, r,8 However, the morbidity and mortality rates of gangrenous diseases are higher, possibly as a result of delay in diagnosis. r,s These higher rates of morbidity and mortality emphasize the need for clinicians to not rely on the traditional signs of fever or leukocytosis in patients with suspected acute cholecystitis. Although the authors of textbooks of surgery and emergency medicine note that fever is frequently present and that increased WBC count is a constant finding in patients with AC, our literature review revealed no study demonstrating this claim. ~,2,5 In contrast, it was reported that 32% to 53% of AC patients had fever and that 51% to 53% had leukocytosis. 9,1° Previous studies differed from ours in the use of different definitions for fever and leukocytosis. Also, the exact times at which data were collected during hospitalization were not noted. However, other authors' relative findings of fever and leukocytosis are similar to the ones we documented during the initial ED evaluation. The authors of previous studies have reported that fever is less common in older patients and debilitated patients with infection. 1>12 In our study, absence of fever was as likely in patients younger than 60 years as it was in patients older than 60. When we examined the cases of patients older than 70 years, we found similar results. Neither time to surgery nor duration of pain was associated with the presence of fever in the different age groups' results. Our findings may be interpreted as indicating that age does not influence the ability to generate a fever in AC. It is also possible that we had fewer older patients who were chronically ill or debilitated, although we did not collect data with which to evaluate this possibility We identified a small number of patients with diabetes. Of the nine diabetic patients, six had gangrenous cholecystitis, two had nongangrenous AC, and one had chronic cholecystitis. The only diabetic with fever was found to have chronic cholecystitis. The authors of a previous study reported a higher rate of gallbladder perforation in diabetic patients than in nondiabetic ones. t3 This finding is not surprising because diabetic patients may have impaired ability to limit infection. Although our findings suggest that caution should be exercised in the evaluation of patients with diabetes, they are limited by the small number of patients.
276
Our study was designed to identifypatients with AC through the selection of positive HIDA scans. However, 22% of our patients were found at surgery to have chronic, not acute, cholecystitis. Although we could not evaluate specificity and sensitivity in our study, a recent metaanalysis noted the specificity of the HIDA in the diagnosis of AC to be 90% (95% confidence interval [CI], 86% to 95%) and the sensitivity 97% (95% CI, 96% to 98%).14 Persistent nonvisualization of the gallbladder in patients with chronic cholecystitis has been reported to account in part for the false-positive findings of HIDA scans. ~5 In a study of 156 patients admitted with the diagnosis of AC in whom HIDA scanning was not performed, Raine and Gunn reported a rate of chronic cholecystitis at pathology identical to the one we found. 9 These results are not surprising; patients with acute right-upper-quadrant pain may have transient cystic duct obstruction without acute inflammation. Given the similar symptoms and signs in acute and chronic cholecystitis, in some patients the distinction between these two diagnoses can only be made by the pathologist. At our institution, the HIDA scan is typically performed to confirm the diagnosis of AC. We recognize that this practice varies from institution to institution. Concern exists that a patient in whom HIDA scanning is ordered has a different clinical presentation than that of a patient sent straight to the operating room or ordered to undergo ultrasound rather than HIDA scanning. To address this question, we reviewed the charts of all patients who presented to the ED over an 18-month period for whom the diagnosis of AC was confirmed on the pathology report. Of the 82 patients with AC, 64 (78%) underwent HIDA scanning before surgery, whereas 18 (22%) underwent only ultrasound or were sent straight to the operating room first without an ED or in-hospital study. Of the patients in whom HIDA scanning was not performed, 61% lacked fever and 33% lacked leukocytosis. These findings are similar to what we found in the patients with AC in our study who were selected on the basis of a positive HIDA scan. This similarity suggests that our conclusion is applicable to the entire population of patients presenting to the ED with AC, regardless of whether they underwent HIDA scanning. Patients who present to the ED with AC frequently lack fever or leukocytosis. This includes patients with gangrenous gallbladder, a more severe form of the disease. The clinician should not rely on the presence of these signs in diagnosing AC.
ANNALS OF EMERGENCY MEDICINE
2 8 : 3 SEPTEMBER 1996
CHOLECYSTITIS Gruber et aI
REFERENCES 1. Nah~old DL: Acute cholecystitis. In: Sabiston DC Jr (ed): Textbookof Surgery,ed 14. Philadelphia: Sounders, 1991:1050- 1052. 2. Zinner Mr, Ros[ynJr: Gallbladder and extrahepatobiliary system. In: Schwartz SI, Shires GT. Spencer FC, et al (eds): Principlesof Surgery,ed 6. New York: McGraw-Hill, 1994:1379-1380. 3. Stainer CA, Bass ED, Talamini MA, et al: Surgical rates and operative mortality for open and laparoscopic cholecystectornyin Maryland. N EngtJ Med 1994;330:403-408. 4. ReslynJr, Binns GS, Hughes EF, et al: Open cholecystectemy:A contemporary analysis of 42,474 patients. Ann Surg1993;218:129-137. 5. Guss DA: Disorders of the liver, biliary tract and pancreas. In: Rosen P, Boutin RM. Braen GR, et al (eds): EmergencyMed/eine,ed 3. St Louis: Mosby-Year Book, 1992:1616. 6. Addison NV, Finan PJ: Urgent and early cholecystectomy for acute gallbladder disease. Br J Surg1988;75:141-143.
The authors thank Noel Mancherje, MD, for his help in preparing the manuscript.
Reprint no, 47/1/75266 Address for reprints: Peter Gruber, ME; Emergency Department Jacobi Medical Center 1 W2O Pelham Parkway and East Chester Road Bronx, New York 10461 718-918-5820 Fax 718-918-7459
7. Wilson AK, Kozol RA, Salwen WA, et ah Gangrenouscholecystitis in an urban VA hospital. J SurgResI994;56:402-404, 8. Fry DE, Cex RA, Harbrecht PJ: Gangreneof the gallbladder: A complication of acute cho[ecystitis. SouthMealJ 1981;74:666-688. 9. Baine AM, Gunn AA: Acute cholecystitis. BrJ Surg1975;62:697~700. 10. Hafif A, Gutman, Kaplan O, et ah The management of acute cholecystitis in elderly patients. Am Surg1991;57;948-652. 11. Berman P, Hogan DB: The atypical presentation of infection in old age. AgeAgiog 1987;16:201-207. 12. Darowski A, Najim J, Weinberg A, et ah The increase in body temperature of elderly patients in the first twenty-four hours foJlowing admission to the hospital. Age Aging 1991;20:107-112. 13. Turner RJ, BeckerWF, Coleman WO, at ah Acute cholecystitis in the diabetic. SouthMedJ 1969;62:228-231. 14. Shea J, Berlin JA, EscarceJr, et ah Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch InternMed 1994;I 54:2573-2581. 15. Freitas rE, Mirkes SH, FinbBennett DM: Suspected acute cholecystitis: Comparisonof hepatobi]iary scintigraphy versus ultrasonegraphy. C/inNuclMed 1982;7:364-387.
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277
Presence of Fever and Leukocytosis in Acute Cholecystitis From the Divisionof Emergency Medicine, LongIslandJewish Medical Center, Albert Einstein Collegeof Medicine, brewHyde Park, New York~;and Winthrop University Hospital, Mineola, New York.~
Peter J Gruber, MD* Robert A Silverman, MD ~ Steven Gottesfeld, DO* Edith Flaster, MS*
Receivedfor publication November 13, 1995. Revision received May 10, 1996. Acceptedfor publication May 21, i996. Presented at the Societyfor Academic Emergency MedicineAnnual Meeting, Washington DC, May I994. Copyright © by the American College of Emergency Physicians.
See related editorial, p 347.
Study objective: To determine the frequency of fever and leukocytosis in patients presenting to the emergency department with acute cholecystitis {AC). Methods: We carried out a retrospective review of charts from 1990 to 1993 at a university-affiliated hospital. Our subjects were ED patients with hepato-iminodiacetic acid (HIDA) scans interpreted as showing AC and who had undergoneCholecystectomy during hospitalization. Final diagnosis was determined on the basis of the pathology report. Feverwas defined as an oral temperature of I00 ° F (37.7° C) or greater or a rectal temperature of 100.4° F (38.0° C)or greater. Leukocytosiswas defined as a WBC count of 11,000/mm3 or greater. Results: Of the 198 cases studied, the pathologic diagnosis of nongangrenousAC was made in 103 (52%), gangrenousAC was diagnosed in 51 (26%), and chronic cholecystitis was diagnosed in 44 (22%). In patients with nongangrenousAC, 71% were afeNile, 32% lacked leukocytosis, and 28% lackedfever and leukocytosis. In patients with gangrenousAC, 59% were afebrile, 27% lacked leukocytosis,and 16% lackedfever and leukocytosis.
Conclusion: We found that patients with AC diagnosed in the ED frequently lacked fever or leukocytosis. The clinician should not rely on the presence of these signs in making the diagnosis of acute cholecystitis. [Gruber PJ, Silverman RA, Gottesfeld S, Flaster E: Presenceof fever and leukocytosis in acute cholecystitis. Ann ErnergMed September 1996;28:273-277.]
SEPTEMBER 1996 2 8 : 3 ANNALS OF EMERGENCY MEDICINE
273
CHOLECYSTITIS
Gruberet al
INTRODUCTION
Acute cholecystitis (AC) is a common abdominal emergency that results from chemical or bacterial inflammation of the gallbladder. 1,2 Of the approximately 500,000 gallbladder operations performed yearly in the United States, 17% to 31% are for acute cholecystitis. 3'4 The clinical presentation of AC is characterized by abdominal pain, anorexia, nausea, and vomiting. Textbooks of surgery and emergency medicine note that AC patients typically have fever and leukocytosis. 1,2,5 In our experience, however, many patients found in the emergency department to have AC lack fever, increased WBC count, or both. For the clinician who initially evaluates such patients, knowledge of the frequency of these signs on hospital presentation may be of assistance in the diagnosis. Our objective, therefore, was to determine the frequency of fever and leukocytosis in patients admitted with the diagnosis of AC who underwent cholecystectomy during the same hospitalization.
defined as a WBC count of 11,000/mm 3 or greater recorded during the same period. The HIDA scan was interpreted by a nuclear medicine radiologist; it was considered diagnostic of AC if the gallbladder was not visualized by the time of clearance of radioactivity from the liver and uptake was seen in the gut to a maximum of 4 hours. The pathologist diagnosed AC if neutrophils were present; the diagnosis of chronic cholecystitis required the presence of at least one of the following factors: lymphocytes, subepithelial fibrosis, Rokitansky-Aschoff sinuses, and epithelial atrophy or flattening. Gangrenous cholecystitis was diagnosed if necrosis of the mucosa was detected. We used Student's t test or the %2 test to detect differences between groups. Stepwise logistic regression was used to determine the influence of other variables such as age, sex, duration of symptoms before arrival, and time elapsed before surgery We considered P values less than .05 significant.
MATERIALS AND METHODS
RESULTS
We carried out a retrospective chart review of patients 18 years or older who presented to the ED of the Long Island Jewish Medical Center between the years 1990 and 1993. Patients were initially identified through records of positive hepato-iminodiacetic acid (HIDA) scans obtained from the radiology department. At this institution, the HIDA scan is typically performed to assist in establishing the diagnosis of AC. Patients were included in the study if their ED diagnosis was AC, the HIDA scan was performed within 24 hours of ED arrival, and cholecystectomy was performed during the same hospitalization. For the purposes of data analysis, we defined fever as an oral temperature of 100 ° F (37.7 ° C) or greater or a rectal temperature of 100.4 ° (38.0 ° C) F or greater recorded within 8 hours of ED arrival. Leukocytosis was
The criteria for study inclusion were met by 198 patients. The median age was 59 years (range, 18 to 92 years); 58% of the patients were women. History of diabetes was noted in 5% of patients, cancer in 2%, and long-term oral steroid use in 1%. Of the 198 patients, 154 (78%) were determined on the basis of findings from pathologic examination to have AC, whereas 44 of patients (22%) had chronic cholecystitis. Of the 154 patients with AC, 51 (34%) were found to have gangrenous cholecystitis. The mean temperature for all patients was 99.9 ° F (37.2 ° C) and the mean WBC was 12,600/mm 3 (Table 1). Fever was present in 32% of patients, whereas 61% of patients had leukocytosis. Neither fever nor leukocytosis was found in 31% of patients (Table 2). Of the 135 patients without fever, 23 (17%) had their temperature recorded
Table 1.
Table 2.
Comparison of subgroups, by mean temperature and WBC count in the 8 hours after ED arrival. Type of Cholecystitis All (N=198) NongangrenousAC (n=103) Gangrenous(n=51) Chronic(n=44)
2 74
Temperature (°F) [Mean_+SD]
WBC Count/mm 3 (Mean-+SD)
99.9+1.5 99.7+1.4
12,600+4,300 12,700+3,900
100.1+1.6 99.9_+1.4
14,500+4,600 10,100+3,700
Patients with fever and leukocytosis within 8 hours of ED arrival. Type of Cholecystitis All (N=198) Nongangrenous AC (n=103) Gangrenous (n=51) Chronic(n=44)
% With Fever
% With Leukocytosis
% With Both
% With Neither
32 29
61 68
24 25
31 28
41
73
29
16
27
32
14
55
ANNALS OF EMERGENCYMEDICINE 28:3 SEPTEMBER 1996
CHOLECYSTITIS
Gruber et al
only once within 8 hours of hospital arrival. Two or more temperature readings were documented for the rest of the patients without fever during this period. The presence of fever or leukocytosis was not related to duration of symptoms, time elapsed before surgery, or sex. The occurrence of fever was not related to the occurrence of leukocytosis. The mean temperatures and WBC counts for the pathologic subgroups are shown in Table 1 and the Figure. We noted no significant difference in temperature among the subgroups. Although a significant difference in WBC count was detected among the three subgroups (P=.O001) overlap was considerable. We found no significant difference in temperature when all patients 60 years or older (100.0 ° F [37.7 ° C])
Figure. MaximumWBCcount in the 8 hours@ergDarrival. WBgs/mm 3
were compared with patients below the age of 60 (99.6°F [37.5 ° C]). When leukocytosis was evaluated for all patients, the older population had a higher mean WBC count (13,300/mm 3) than the younger patients (12,000~ram 3) (P=.03). When we made comparisons on the basis of specific pathologic subgroups, which contained smaller numbers of patients, no significant difference in WBC count appeared. The maximum temperature and WBC count in the 24 hours after hospital arrival were also recorded. Fever developed in the first 24 hours in 66% of the patients; leukocytosis developed in 76%. The average time from initial evaluation to cholecystectomy was significantly longer in patients with chronic cholecystitis than it was in patients with nongangrenous AC (101 versus 68 hours, P=.002). Time elapsed before surgery was similar in patients with gangrenous cholecystitis and with acute nongangrenous cholecystitis (61 versus 71 hours, P=NS). The amount of time elapsed before surgery was not related to sex or age.
27,500
DISCUSSION 25,000
22,500
20,000 -
17,500 -
~r . . . . .
15,000 -
'i"
*--4---*
12,500 -
FTq
10,000"
* . . . . .
"k
I
I
2t 2,5001
i
i
Acute Acute gangrenous nongangrenaus
I
Chronic
The plus sign representsthe mean,the hatched line the median. The lower and upper ends of the box representthe 25th and 75th interquartiles.The central vertical lines represent 2 SD from the mean.
SEPTEMBER
1996
28:3
ANNALS OF EMERSENCY MEDIOINff
AC is associated with gallstones in more than 90% of cases. Typically, the cystic duct becomes obstructed by a calculus, localized edema, or biliary sludge. This blockage produces gallbladder distention, inflammation, and the symptoms of acute gallbladder disease. 1,2 If the obstruction resolves, the symptoms may subside. If the inflammation progresses, complications such as gangrenous gallbladder and perforation may occur. Early surgery has become the treatment of choice for most patients with AC because delays are associated with greater morbidity and mortality, as well as with increased medical costs. 6 In our study, we found that patients admitted to the hospital with the presumptive diagnosis of AC had a median age of 59 years and that 58% of the population was female. These demographic findings are different from those of the typical AC patient, a woman in the fourth decade of life. s Our patients otherwise had typical clinical presentations, all with history of abdominal pain or pain on examination and most with history of nausea or vomiting. Fever and leukocytosis have been described as typical in patients with AC. Because these signs may be used to assess likelihood of illness, we focused our attention on their presence. We found that most patients with nongangrenous cholecystitis did not have fever, that 32% lacked leukocytosis, and that 28% of patients had neither fever nor leukocytosis during the first 8 hours of hospitalization.
275
CHOLECYSTITIS Gruber et al
It is interesting that even in the subgroup of patients with gangrenous cholecystitis, a more severe form of the disease, 59% of did not have fever and 27% lacked leukocytosis. The authors of previous studies have noted that the overall clinical presentation of gangrenous cholecystitis is similar to that of acute, nongangrenous cholecystitis, r,8 However, the morbidity and mortality rates of gangrenous diseases are higher, possibly as a result of delay in diagnosis. r,s These higher rates of morbidity and mortality emphasize the need for clinicians to not rely on the traditional signs of fever or leukocytosis in patients with suspected acute cholecystitis. Although the authors of textbooks of surgery and emergency medicine note that fever is frequently present and that increased WBC count is a constant finding in patients with AC, our literature review revealed no study demonstrating this claim. ~,2,5 In contrast, it was reported that 32% to 53% of AC patients had fever and that 51% to 53% had leukocytosis. 9,1° Previous studies differed from ours in the use of different definitions for fever and leukocytosis. Also, the exact times at which data were collected during hospitalization were not noted. However, other authors' relative findings of fever and leukocytosis are similar to the ones we documented during the initial ED evaluation. The authors of previous studies have reported that fever is less common in older patients and debilitated patients with infection. 1>12 In our study, absence of fever was as likely in patients younger than 60 years as it was in patients older than 60. When we examined the cases of patients older than 70 years, we found similar results. Neither time to surgery nor duration of pain was associated with the presence of fever in the different age groups' results. Our findings may be interpreted as indicating that age does not influence the ability to generate a fever in AC. It is also possible that we had fewer older patients who were chronically ill or debilitated, although we did not collect data with which to evaluate this possibility We identified a small number of patients with diabetes. Of the nine diabetic patients, six had gangrenous cholecystitis, two had nongangrenous AC, and one had chronic cholecystitis. The only diabetic with fever was found to have chronic cholecystitis. The authors of a previous study reported a higher rate of gallbladder perforation in diabetic patients than in nondiabetic ones. t3 This finding is not surprising because diabetic patients may have impaired ability to limit infection. Although our findings suggest that caution should be exercised in the evaluation of patients with diabetes, they are limited by the small number of patients.
276
Our study was designed to identifypatients with AC through the selection of positive HIDA scans. However, 22% of our patients were found at surgery to have chronic, not acute, cholecystitis. Although we could not evaluate specificity and sensitivity in our study, a recent metaanalysis noted the specificity of the HIDA in the diagnosis of AC to be 90% (95% confidence interval [CI], 86% to 95%) and the sensitivity 97% (95% CI, 96% to 98%).14 Persistent nonvisualization of the gallbladder in patients with chronic cholecystitis has been reported to account in part for the false-positive findings of HIDA scans. ~5 In a study of 156 patients admitted with the diagnosis of AC in whom HIDA scanning was not performed, Raine and Gunn reported a rate of chronic cholecystitis at pathology identical to the one we found. 9 These results are not surprising; patients with acute right-upper-quadrant pain may have transient cystic duct obstruction without acute inflammation. Given the similar symptoms and signs in acute and chronic cholecystitis, in some patients the distinction between these two diagnoses can only be made by the pathologist. At our institution, the HIDA scan is typically performed to confirm the diagnosis of AC. We recognize that this practice varies from institution to institution. Concern exists that a patient in whom HIDA scanning is ordered has a different clinical presentation than that of a patient sent straight to the operating room or ordered to undergo ultrasound rather than HIDA scanning. To address this question, we reviewed the charts of all patients who presented to the ED over an 18-month period for whom the diagnosis of AC was confirmed on the pathology report. Of the 82 patients with AC, 64 (78%) underwent HIDA scanning before surgery, whereas 18 (22%) underwent only ultrasound or were sent straight to the operating room first without an ED or in-hospital study. Of the patients in whom HIDA scanning was not performed, 61% lacked fever and 33% lacked leukocytosis. These findings are similar to what we found in the patients with AC in our study who were selected on the basis of a positive HIDA scan. This similarity suggests that our conclusion is applicable to the entire population of patients presenting to the ED with AC, regardless of whether they underwent HIDA scanning. Patients who present to the ED with AC frequently lack fever or leukocytosis. This includes patients with gangrenous gallbladder, a more severe form of the disease. The clinician should not rely on the presence of these signs in diagnosing AC.
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CHOLECYSTITIS Gruber et aI
REFERENCES 1. Nah~old DL: Acute cholecystitis. In: Sabiston DC Jr (ed): Textbookof Surgery,ed 14. Philadelphia: Sounders, 1991:1050- 1052. 2. Zinner Mr, Ros[ynJr: Gallbladder and extrahepatobiliary system. In: Schwartz SI, Shires GT. Spencer FC, et al (eds): Principlesof Surgery,ed 6. New York: McGraw-Hill, 1994:1379-1380. 3. Stainer CA, Bass ED, Talamini MA, et al: Surgical rates and operative mortality for open and laparoscopic cholecystectornyin Maryland. N EngtJ Med 1994;330:403-408. 4. ReslynJr, Binns GS, Hughes EF, et al: Open cholecystectemy:A contemporary analysis of 42,474 patients. Ann Surg1993;218:129-137. 5. Guss DA: Disorders of the liver, biliary tract and pancreas. In: Rosen P, Boutin RM. Braen GR, et al (eds): EmergencyMed/eine,ed 3. St Louis: Mosby-Year Book, 1992:1616. 6. Addison NV, Finan PJ: Urgent and early cholecystectomy for acute gallbladder disease. Br J Surg1988;75:141-143.
The authors thank Noel Mancherje, MD, for his help in preparing the manuscript.
Reprint no, 47/1/75266 Address for reprints: Peter Gruber, ME; Emergency Department Jacobi Medical Center 1 W2O Pelham Parkway and East Chester Road Bronx, New York 10461 718-918-5820 Fax 718-918-7459
7. Wilson AK, Kozol RA, Salwen WA, et ah Gangrenouscholecystitis in an urban VA hospital. J SurgResI994;56:402-404, 8. Fry DE, Cex RA, Harbrecht PJ: Gangreneof the gallbladder: A complication of acute cho[ecystitis. SouthMealJ 1981;74:666-688. 9. Baine AM, Gunn AA: Acute cholecystitis. BrJ Surg1975;62:697~700. 10. Hafif A, Gutman, Kaplan O, et ah The management of acute cholecystitis in elderly patients. Am Surg1991;57;948-652. 11. Berman P, Hogan DB: The atypical presentation of infection in old age. AgeAgiog 1987;16:201-207. 12. Darowski A, Najim J, Weinberg A, et ah The increase in body temperature of elderly patients in the first twenty-four hours foJlowing admission to the hospital. Age Aging 1991;20:107-112. 13. Turner RJ, BeckerWF, Coleman WO, at ah Acute cholecystitis in the diabetic. SouthMedJ 1969;62:228-231. 14. Shea J, Berlin JA, EscarceJr, et ah Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch InternMed 1994;I 54:2573-2581. 15. Freitas rE, Mirkes SH, FinbBennett DM: Suspected acute cholecystitis: Comparisonof hepatobi]iary scintigraphy versus ultrasonegraphy. C/inNuclMed 1982;7:364-387.
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