Acute Calculous Cholecystitis with Laparoscopic Cholecystectomy as the Primary

Surgical Management of the Disease: A Case Report

Junery G. Bagunas Jr., M.D.

Department of Surgery, Makati Medical Center, Makati City, Philippines

Correspondence Address

Charity Lane, Mountainside Subd., Brgy. 92 Apitong

Tacloban City, Leyte, Philippines

Mobile: 63-(9)-264272657

Email: junerybagunas@gmail.com

Source of support: None

Conflict of interest: None

ABSTRACT

1
 This is the case of a 26 year old female who came in for epigastric pain a few hours

prior to admission. History and physical examination of the patient lead to an admitting

diagnosis of acute calculous cholecystitis. Laboratory results revealed a mildly elevated

WBC count and AST levels, while ultrasound of the whole abdomen showed a mildly

thickened gallbladder wall with presence of sludge in the lumen, thereby confirming the

primary impression. A day after admission, the patient was scheduled for laparoscopic

cholecystectomy. The procedure proceeded without any complications and 3 days later, the

patient was discharged from the hospital. Cholelithiasis or gallstones is one of the more

common diseases which affect the digestive tract. Stones in the gallbladder form as a result

of supersaturation of organic solutes in bile. Patients are generally asymptomatic

throughout their lifetime, but once the stone lodges in the cystic duct, symptoms ensue with

biliary colic as the main complaint. Laparoscopic cholecystectomy is the mainstay

management of gallstones, replacing open cholecystectomy after more than 100 years of

use. Risks of complications still accompany the procedure, with bleeding and infection of

the wound site being the most common ones, but their prevalence of 1.05 and 1.11 percent

respectively further strengthens the claim of surgeons regarding the procedures relative

safety in the hospital setting.

Key words: cholelithiasis, acute calculous cholecystitis, laparoscopic cholecystectomy

2
LIST OF ABBREVIATIONS

1. WBC - White blood cells

2. AST - Aspartate aminotransferase

3. ALT - Alanine transaminase

4. PT - Prothrombin time

5. PTT - Partial thromboplastin time

3
INTRODUCTION

Gallstones or cholelithiasis is among the more common conditions which tend to

affect the digestive tract. They are usually created when the bile becomes supersaturated

with organic solutes which include but are not limited to cholesterol. More often than not,

patients are asymptomatic throughout their lifetimes despite the presence of stones in the

gallbladder. However, there are instances wherein individuals develop colicky pain in the

epigastric area. This is usually a direct result of obstruction of the cystic duct by the

gallstone thereby increasing tension in the gallbladder walls. When patients become

symptomatic, cholecystectomy or surgical removal of the gallbladder is usually warranted.

For the longest time, open cholecystectomy was the procedure of choice for most

surgeons. In 1882, Carl Langenbuch performed the very first successful cholecystectomy,

and for more than a century, fellow surgeons followed suit (1). When Philippe Mouret of

France introduced laparoscopic cholecystectomy in 1987, the treatment of gallstones was

revolutionized. It replaced open cholecystectomy as the main management for symptomatic

gallstones and also ended further attempts for the development of noninvasive procedures

such as extracorporeal shock wave and bile salt therapy. Today, laparoscopic

cholecystectomy is the treatment of choice for cholelithiasis.

4
CASE REPORT

This is a case of D.E.J.B, a 26-year old female, Filipino, Catholic, single, who came

in with a chief complaint of pain in the epigastric area.

Few hours prior to admission, patient experienced pain in the epigastric region,

burning in character, with a severity of 5 out of 10 on the pain scale. Associated symptoms

included bloatedness and frequent belching. However, the patient did not present with

fever, vomiting, nor diarrhea. Because of its persistence, patient sought consult at the

emergency room and was therefore admitted.

Review of systems was unremarkable. Past medical history revealed an instance of

gastritis in 2016. The patient is currently not on any maintenance medications and has no

known allergies. The family history of the patient was positive for hypertension and cancer.

She is a non-smoker but an occasional alcoholic beverage drinker. Any use of prohibited

drugs was denied as well as oral contraceptives or hormonal replacement therapies.

Physical examination of the patient was unremarkable as well, apart from the

abdomen. It was soft and presented with direct tenderness in the right upper quadrant but no

rebound tenderness. The bowel sounds were normoactive and guarding did not manifest.

In the emergency room, the patient was subjected to laboratory workups and

diagnostic imaging studies. The patients complete blood count revealed an elevated WBC

count at approximately 14.4x103/uL with predominance of segmenters amounting to 88

percent of the total count. The liver function tests also revealed an elevated AST at 74.64

U/L, but her ALT levels were within normal range. Otherwise, the patients lipase, serum

sodium and potassium, urinalysis, PT and PTT values were essentially normal. When she

was subjected to chest radiography, there were no evidence of lung lesions. However,

5
ultrasound of the whole abdomen showed a thickened gallbladder wall with the presence of

biliary sludge. She was therefore diagnosed with acute calculous cholecystitis.

One day after being admitted, she was scheduled for laparoscopic cholecystectomy.

The surgery lasted for approximately 4 hours and proceeded without any complications.

She was then prescribed with Cefuroxime 500 mg per tab one tab once a day for one week

for her take home medication. Three days after her surgery, she was discharged from the

hospital in stable condition.

6
DISCUSSION

Cholelithiasis or gallstones is one of the more common problems which affect the

digestive tract. In the United states, 11% to as much as 36% of natives are affected by

gallstones (2). Some people are more predisposed to developing the disease altogether as

compared to others. Genetic illnesses such as thalassemia, sickle cell disease, and

hereditary spherocytosis; prior surgeries including gastric surgery and terminal ileal

resection; and other modifiable factors such as obesity and pregnancy all contribute to an

increased risk (3). Between men and women, the latter are three times more likely to

develop gallstones, while first-degree relatives are presented with a two-fold greater

preponderance (4).

Gallstones form when the solids in the bile settle out of its solution. Bile is mainly

composed of organic solutes such as bilirubin, cholesterol, bile salts, and phospholipids.

Stones are classified as either cholesterol stones or pigment stones. Pigment stones are

further divided into black or brown. In the West, the most common type of gallstones are

cholesterol stones. In Asia, pigment stones, black pigment stones to be more specific, make

up the majority. Cholesterol stones are created when the bile is supersaturated with

cholesterol. By nature, cholesterol is nonpolar and insoluble in water and bile.

Hypersecretion therefore leads to supersaturation. Pigment stones on the other hand owe

their dark color to calcium bilirubinate. Black pigment stones are formed when the bile is

supersaturated with calcium bilirubinate, carbonate, and phosphate. Oftentimes

supersaturation occurs secondarily to hemolytic disorders such as sickle cell disease and

hereditary spherocytosis. Grossly, black stones are small, brittle, and sometimes spiculated.

As for brown stones, they form as a result of precipitated calcium bilirubinate and bacterial

7
cell bodies. Therefore, brown pigment stones occur secondarily to bacterial infection

caused by bile stasis. They are less than 1 cm in diameter, yellow, and soft (1).

More often than not, patients with gallstones are asymptomatic throughout their

lifetime. Because of their asymptomatic nature, patients without biliary symptoms are often

diagnosed incidentally through abdominal radiography, ultrasonography, CT scans, or

laparotomy. Complications also rarely develop in asymptomatic patients. That is why

prophylactic cholecystectomy is almost never indicated. However, if the person is an

elderly individual with diabetes, or if they will be isolated from medical care for an

extended period of time, or if they have an increased risk of developing gallbladder cancer,

then prophylactic removal of the gallbladder is advisable. Porcelain gallbladder is another

indication for removal of the gallbladder. It is a rare premalignant condition in which the

walls of the gallbladder become calcified.

Patients with gallstones then proceed to presenting with symptoms if the stones

themselves become lodged in the cystic duct. The primary manifestation of the obstruction

is biliary colic. Because of the obstruction, tension increases in the gallbladder wall,

thereby causing pain. When enough time has elapsed, the seemingly normal gallbladder

with a minor inflamed mucosa can deteriorate to a shrunken nonfunctioning gallbladder

laden with fibrosis and adhesions to nearby structures. Atrophy of the mucosa will also lead

to the epithelium protruding into the muscle coat, thereby giving rise to the so-called

Aschoff-Rokitansky sinuses (1).

Clinically, patients with symptomatic cholelithiasis primarily complain of pain. It is

most commonly located in the epigastric region of the abdomen and lasts anywhere

between 1 to 5 hours. From the epigastrium, the pain commonly radiates to the right upper

8
back or between the scapula. It usually comes abruptly, oftentimes at night or after a fatty

meal. Associated symptoms include nausea and sometimes vomiting and anorexia. Bloating

and belching are other manifestations which occur in conjunction with the pain. There are

also cases wherein the patient becomes febrile. Furthermore, the affected individual

becomes reluctant to move about because the inflammatory process affects the parietal

peritoneum. Between episodes of colickly pain, the patient generally feels well. During the

physical examination of the abdominal region, there is tenderness in the right upper

quadrant once palpated. Guarding can also be observed as well. A Murphys sign, or an

inspiratory arrest with deep palpation of the right subcostal area, can also be elicited. If

severe jaundice develops, the gallstone might have already obstructed the common bile

duct. Mirizzis syndrome occurs when the primary cause of the obstruction of the bile ducts

is severe pericholecystic inflammation due to a stone in the infundibulum of the

gallbladder. When the pain already lasts for more than 24 hours, then acute

cholecystolithiasis or an impacted gallstone in the cystic duct is highly suspected (1).

Upon obstruction of the cystic duct by the gallstone, gallbladder distention,

inflammation, and gallbladder wall edema ensues. The inflammation that occurs during the

disease is probably mediated by the mucosal toxin lysolecithin, which is a product of

lecithin, bile salts, and platelet-activating factor. Amplification of the inflammatory process

occurs when prostaglandins are further synthesized. There is thickening and reddening of

the gallbladder wall accompanied with subserosal hemorrhages. Pericholecystic fluid is

often present as well. As for the mucosa, it may show patchy necrosis and hyperemia. In

one-third of cases, there is secondary bacterial contamination. Once the stone is dislodged

from the cystic duct, the inflammation resolves as well (5). However, failure to do so will

9
lead to the progression of ischemia and necrosis of the gallbladder wall. Secondary

bacterial infection will then supervene, and an abscess or empyema will form within the

gallbladder. If gas-forming organisms are ruled in to the equation, gas may be seen in the

lumen on abdominal radiographs and CT scans. This condition is referred to as

emphysematous gallbladder (1).

Laboratory tests usually reveal a mild to moderate leukocytosis at 12,000-15,000

cells/mm3. However, there are also patients wherein their WBC count remains normal

throughout the course of the disease. When the count reaches the 20,000 threshold, a

complicated case should be suspected. It is likely that gangrenous cholecystitis, perforation,

or cholangitis, an ascending bacterial infection and contamination of the bile associated

with partial or complete obstruction of the gallbladder, has already developed. Serum liver

chemistries are often unremarkable, but there are instances wherein there is mild elevation

of serum bilirubin, alkaline phosphatase, transaminase, and amylase (6).

When diagnosing cholelithiasis, ultrasonography is usually the most useful tool. Its

sensitivity and sensitivity is valued at 95 percent. One can usually observe the presence or

absence of stones in the gallbladder with an ultrasound. Furthermore, one can appreciate

the thickening of the gallbladder the the accumulation of pericholecystic fluid. A

sonographic Murphys sign or focal tenderness over the gallbladder once compressed with

a sonographic probe can also be elicited. There are instances wherein biliary sludge is

found upon sonography in place of the stones. Recurrent attacks of typical biliary pain will

also warrant surgical management. During atypical cases of cholecystitis, a biliary

radionuclide scan or HIDA scan can be used. If there is lack of filling of the gallbladder

after 4 hours, an obstructed cystic duct should be suspected. CT scan can also demonstrate

10
thickening of the gallbladder wall, pericholecystic fluid, and presences of gallstones and air

in the gallbladder wall. However, it is usually less sensitive as compared to ultrasonography

(1).

In the management of cholelithiasis, elective laparoscopic cholecystectomy is

usually the gold standard (7). During the procedure, the patient is placed supine on the

operating table while the surgeon stands at the left side. A pneumoperitoneum is then

created with carbon dioxide gas. This can be done with either an open technique or a closed

needle technique. The first small incision is made at the upper edge of the umbilicus. The

closed technique utilizes a special insufflation needle called a Veress needle to achieve

pneumoperitoneum. Next, a 10-mm trocar is inserted into the supraumbilical incision. A

Hasson cannula is then inserted into the peritoneal cavity and anchored to the fascia. A

laparoscope with the video camera attached is passed through the umbilical port and the

abdomen is inspected. Three additional ports in the epigastrium, the mid-clavicular line,

and right flank in line with the gallbladder fundus are placed. At the lateral-most port, a

grasper is used to grasp the gallbladder fundus and is retracted over the liver edge upward.

A second grasper is inserted into the midclavicular port which is used to grasp the

gallbladder infundibulum laterally to expose the triangle of Calot. Dissectors, hook cautery,

or scissors are then inserted into the epigastric port, where most of the dissection and

removal of the gallbladder is carried out.

Surgical interventions are never without risk, laparoscopic cholecystectomy

included. Complications of the procedure are variable and may include postoperative bile

leak, urinary tract infection, retained stones, ileus, myocardial infarction, bowel injury,

wound infection, bleeding, subhepatic fluid, wound hematoma, pulmonary edema,

11
postoperative fever, atelectasis, urinary retention, common bile duct injury, and pulmonary

embolism (8). Among the complications, bleeding and wound infection were reported to be

the most common, occurring in 163 and 153 cases out of 15,596 and 13,274 patients

resulting to a conversion rate of 1.05 and 1.1 percent, respectively. Mortality is also a

possible outcome regarding the contemplated procedure. Out of 48,795 patients, 0.091

percent resulted in expiration. Despite the added risk during the postoperative period, one

can confirm the relative safety of the procedure as per suggestion of numerous surgeons

and authors.

ACKNOLWEDGeMENT

To Dr. Benedict Cruz and Dr. Marco Paulo Neri for assisting in the completion of

this paper.

To Makati Medical Center for the opportunity to learn and experience what it means

to provide world-class hospital care.

12
REFERENCES

1. Schwartz, Seymour I.,Brunicardi, F. Charles. (Eds.) (2011) Schwartz's principles of

surgery: 10th Edition. McGraw-Hill Medical.

2. Brett M, Barker DJ. The world distribution of gallstones. Int J Epidemiol.

1976;5:335.

3. Al-Jiffry BO, Shaffer EA, Saccone GT, et al. Changes in gallbladder motility

and gallstone formation following laparoscopic gastric banding for morbid obesity.

Can J Gastroenterol. 2003;17:169.

4. Nakeeb A, Comuzzie AG, Martin L, et al. Gallstones: genetics versus environment.

Ann Surg. 2002;235:842.

5. Strasberg SM. Cholelithiasis and acute cholecystitis. Baillieres Clin Gastroenterol.

1997;11:643.

6. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute

cholecystitis? JAMA. 2003;289:80.

7. Kiviluoto T, Siren J, Luukkonen P, et al. Randomised trial of laparoscopic versus

open cholecystectomy for acute and gangrenous cholecystitis. Lancet.

1998;351:321.

8. Shea, J. A., Healey, M. J., Berlin, J. A., Clarke, J. R., Malet, P. F., Staroscik, R. N.,

... & Williams, S. V. (1996). Mortality and complications associated with

laparoscopic cholecystectomy. A meta-analysis. Annals of surgery, 224(5), 609.

13