Bile Peritonitis in Acute Cholecystitis

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BILE

PERITONITIS IN ACUTE

CHOLECYSTITIS

ROLAND

ANDERSSON,

KARL-GORAN

TRANBERGand

STIG BENGMARK

Department

_of

Surgery,Lund University, S-221 85Lund,Sweden

(Received16 November1988)

Areviewofall patients treated foracutecholecystitis(n 5848)during an18-year period(1969-1986)attwo hospitals(onepractisingearly surgeryinpatientswith acutecholecystitis and the othernot)disclosed that 104(1.8%)hadbilewithintheabdominalcavityatsurgery; 71with a visibleperforation of thegallbladder

and 33 without. The bile wasinfectedin82% ofperformedcultures(mostcommonlywithEscherichiacoli).

Mortality was7.7%(8/104patients), being 20%(4/20)inthe hospital practisingdelayedsurgery and 5%(4/ 84)in the hospital practisingearly surgery(p<0.10). Infectious complications were responsible for the deaths by leadingto multiple organ failure with pulmonaryor renal insufficiency or gastro-intestinal bleeding. The timing of surgery was the only factor that had prognostic significance,i.e. thelongerthe hospitaldelay beforesurgerythe higher the mortality,althoughelderly patients or patientswithperforation tendedtohaveaworse prognosis.Inconclusion, the results of thisstudy indicated that earlysurgeryis important in patientswithacute cholecystitisasa meansof lowering mortality inbileperitonitisin this condition.

KEYWORDS: Bileperitonitis,acutecholecystitis, perforation, surgery, complications.

INTRODUCTION

Thefirstreportonperforationofthegallbladderwaspublishedin 18441 andhasbeen

followedbyanumberof reports documentingitsseverity, especially whenassociated

with acutecholecystitis. Morbidityandmortalitycontinuestobe high even in fairly

recentstudies, despite improvements indiagnostic facilities,antibioticsand intensive

care2-4.Thisstudyreviewsourexperience ofbileperitonitisinacutecholecystitisand

aimsatdefiningfactorsof prognosticimportance.

MATERIAL

Duringthe 18-year period1969 to1986,5848patientsweretreated with adiagnosisof

acute cholecystitis at the Departments ofSurgery, Lund University (n 4940) and

Ystad GeneralHospital (n 908). This retrospective studywas focussed onthe 104

patients(1.8%of allpatients) that hadbile withintheabdomenatoperation;71(68%)

patients had a perforated gallbladder, whereas 33 (32%) patients did not have an

obviousperforation. InLund bileperitonitis wasfound in 84 patients (1.7% of all

patients) and in Ystadin20patients(2.2%of allpatients).

There were 47 women(Lund38,Ystad9)and57 men(Lund46, Ystad 11)with a

meanageof 72

+__

(SEM)years(Lund72 I,Ystad75

+_

3)and arange of 22to94

years.Forty-four(42%)patientshadaprevioushistoryofgallbladder disease,verified

by cholecystographyorultrasonographyin 18 patients. Year-by-yeardistributionof

(2)

8

studied, though there was a tendency towardsa lower numberof patientswith bile

peritonitis during thelatterhalf of the study(n 48)ascomparedtothe first(n 56).

Treatment policy in patients with acute cholecystitis differed between the two

hospitals.InLund,

"emergency"

surgery,i.e., withtheaimof operatingwithin24hr.

after admission, was practised between 1980 1986, whereas during theprevious

period(1969-1979),earlysurgerywasadvocated, butthetimingwaslesswell defined.

Diagnostic ultrasonographywasintroducedduringthelaterhalfof the study period

and was routinely used as an

"emergency"

diagnostic procedure in patients with

clinicalsigns ofacutecholecystitis after1982.

InYstad,treatment wasmoreexpectant duringthewhole period studied, aimingat

avoidingearlysurgeryduringthe acuteepisode ofcholecystitis, and operatingatalater

occasion.Ultrasonographywasnotavailable as anemergency investigation.

StatisticalMethods

TheMann-Whitneyandchi-squaretestswereused for standardcomparisonbetween

groups. Analysis ofvariancewithhierarchialclassificationand analysis of interaction,

or,whenappropriate,theMantel-Haenszel test,wereused for evaluatingthepossible

influenceofvariousfactorsonmortality orperforation,whiletakingintoaccountthe

variation between the two hospitals. Since mortality and morbidity were almost

identicalinpatients receiving cholecystostomyorcholecystectomy, results from these

twoprocedureswerepooledin thefollowing analysis.Values are means

+__

SEM.

RESULTS

FindingsatAdmission

All patients had abdominal pain at admission. In patients with a perforated

gallbladder, peritonitis was localized in 83% and generalized in 17%; the

corresponding figures for patientswithoutobviousgallbladder perforationwas82 and

18%, respectively.Most (78%)patients had fever(above 38"C),whereas onlyafewhad

jaundice(12%)or apalpablemass(8 %).The whitebloodcellcount(13.7

+

0.6x _109/1;

normalrange4.0-10.0x

_109/1)

andbilirubin(33.1+4.8 umol/1; normalrange3-20

umo1/1)were elevatedatadmission.

Patient’sDelay

Patient’sdelaywassignificantlylongerinpatientswithgallbladder perforationthan in

patients without obviousperforation(p<0.05).Patient’sdelaywas alsosignificantly

longerinYstadthan in Lund(p<0.05),andwhenthiswastaken into account patient’s

delay couldnotbe demonstratedtovarywithperforation(p>0.05).Fifty-twopercent

of patients withgallbladder perforation presentedwithin24hours,28% between 1-3

daysand 20% after morethan3days. The corresponding figures for patientswithout

visibleperforationwere70, 21 and9%,respectively.

Hospital Delay

Seventypatients (67%)were operated uponwithin 24 hr. afteradmission. Hospital

(3)

BILE 9

p<0.05). The interval between admission and surgery did not differ between the

perforatedandnon-perforated groups (p> 0.05), regardlessof whetherthe difference

between thetwohospitalswasaccounted foror not.

DiagnosticProcedures

All23ultrasonographicexaminationsshowed signs of cholecystitis, and 9

examina-tionsdemonstrated freefluid withintheabdominalcavityor localized accumulationof

fluidclosetothegallbladder.Perforationof thegallbladderwas evident inonlyoneof

the ultrasoundexaminations.

The introduction ofultrasonographywas associated with ashorter hospital delay

(comparison between patients undergoing acute ultrasonography or not in Lund;

p<0.05). Twenty ofthe 23 (87%) patients investigated with ultrasonographywere

operatedwithin 24 hr. The ratio ofperforated/non-perforated gallbladdersdid not

change with the introduction of ultrasonography and more aggressive surgery in

patientswith acutecholecystitis.

Treatment

Eleven patients received a cholecystostomy during the first two years ofthe study;

otherwise cholecystectomywas performed. Choledocholithotomy was added in 21

patients. All patientsreceivedantibiotics,treatmentbeing started before operationin

47%

of

the patients, during operationin 11% and after operationin42%.

Operative Findings

At

operation, 375

₊

40(mean

+_

SEM,range 100-2000)mlbilestained fluid wasfound

within theperitoneal cavity; 485+55 (range 100-2000) ml inperforated cases and

175

+

20(range 100-500)mlinpatientswithout obviousperforation.The abdominal

fluid wascultured aerobically and anaerobicallyin60patients andbacterialgrowth

wasdemonstratedin49(82%).Cultures werepositive in 87% of patientswithand in

73% of patients without perforation (p>0.05). The most commonly isolated

microorganism was Escherichia coli (43%), followed by streptococci (10%) and

lostridiumperfringens(8%).

Theperforationwassituated inthefundus, corpus andneck of thegallbladderin45,

40 and 15% ofpatients, respectively. Acalculous cholecystitiswasfoundin 10patients,

a singlestonein 37 andmultiplestonesin57.Seventeenpatients hadanimpactedstone

intheinfundibular area.

Perforation was obvious in 53 (63%)of the 84patients treatedin Lund andin 18

(90%) ofthe 20 patients treated in Ystad, the difference in perforation rate being

statistically significant (p<0.05). Also, perforation was more common in elderly

patients thaninyoung patients (p<0.05).

PostoperativeComplicationsand Mortality(Tables 1-2)

Infectiouscomplications dominated thepostoperative morbidity and seemedto be

responsible for the postoperative deaths by leading to multiple organ failure with

pulmonaryorrenal failure,orgastrointestinal bleeding.Themortalitywas20%(4/20)

.in Ystad and 4.8% (4/84) in Lurid, a difference not reaching statistical difference

(4)

TableI Complications

SURVIVORS

Pulmonary pneumonia

atelectasis

pleuraleffusion embolius Woundinfection/abscess

Urinary infection

Cardiacarrest- ventricular fibrillation

Renalfailure

Biliary cutaneousfistula

No

Perforation perforation Total

(n= 71) (n=33) (n=104)

64 32 96

5 5

2

3 4

2 3

2 2

2

NON-SURVIVORS 7 8

Multiple organfailure 6 7

Respiratory failure 5 6

Renalfailure 2

Cardiac failure 3 4

UpperG-Ibleeding 2 3

Table2 Mortality

Age

Year (years) _Perforation Pat delay Hospdelay

I.1969 76 Y 48h 6h

2.1972 73 N 12 h 3d

3.1973 91 Y 24 h 2 d

4.1976 84 Y 3d 2d

5. 1978 66 Y 12 h 2 d

6. 1978 70 Y 12 h 3d

7. 1979 89 Y 24 h 24h

8. 1985 91 Y 14 d 3d

PrognosticFactors

Theriskof postoperative deathwaslargerthelongerthe interval between admission

andsurgery (p<0.01). However,after eliminating the effect of difference in hospital

delaybetween Lund andYstad, hospital delaycouldnotbe demonstratedtobelonger

in dying patients (p>0.05). No other factor could be demonstrated to vary with

prognosis, although perforation and high age tendedtobeassociated with increased

mortality.Sevenof the eightdeaths occurredin patients with aperforated gallbladder;

mortality was9.9%whenperforationwas obvious and3.0% whennoperforationwas

found (p>00.5). The age of dying patientswas80

+

3 years ascomparedto 72

₊

11

yearsinsurviving patients (p> 0.05).Mortality rate did notvarywith patient’sdelay,

physical or laboratory findings at admission or the presence of bacteria in the

abdominalcavity(asdeterminedbystandard bacterialculture)(p

>

0.05).

(5)

during the last 7 years of the study periodinLund.Atthishospital, mortalitywasnil

during thesameperiodof time.

DISCUSSION

Weconcludefromthisstudy that early surgeryinacutecholecystitisisimportant for

decreasing mortalityin bileperitonitisassociated with this condition.Although this

conclusion cannotbe unequivocally provenby thedataobtained, theevidence isquite

strong.Asfaras weknow, the management of patientswith acutecholecystitisatthe

twohospitals differedonlywithrespecttothe timing of surgery(earlyvsdelayed). If

this istrue,datafromthe twohospitalsarecomparable andcanbecombined.Under

thisassumption,itwasfoundthatmortalitywaslarger thelongerthe intervalbetween

admission and surgery (p<0.01). In addition, the lower relative frequency of

perforated gallbladders (p<0.05) and the tendency towards decreased mortality

(p<0.10)in thehospital practisingearly

surgery,

supportthe idea thatearly surgeryis

important for avoiding deathin bileperitonitis. When the effect ofthe (significant)

difference inhospital delay between the twohospitals was eliminated(statistically),

hospital delay could not be demonstrated to vary with mortality. This may be

interpretedas showing that hospital delaywas not animportant factor

and/or

that

anotherfactor(s) was a moreimportant determinantof mortality.

However,

this is

unlikelybecause

a/the

basis of thestudywasthepresence oftwohospitalsin which the

treatmentwasthesameexcept for thetiming ofsurgery,and

b/no

otherfactor couldbe

foundtovary with mortality(e.g., patient’s delayvariedbetween thehospitalsbut did

notvarywith mortality).

In the hospital practising early surgery, the transition from early to emergency

surgeryinpatientswith acutecholecystitis, andthe increased routine use ofemergency

ultrasonography, duringthe last7 yearsof thestudy periodwas associated with zero

mortality in cases of bile peritonitis. Postoperative morbidity and mortality is

multifactorial,butit is conceivable that theaggressive surgicalattitude contributedto

the absent mortality. Also, it appears likely that emergency ultrasonography in

patients with suspect acute cholecystitis is helpful in somepatients by establishing

a definitive diagnosis and by demonstrating signs of imminent or established

perforation

Bile peritonitis associated with acute cholecystitis has been reported to have a

mortality0f20-40%2’4’6’7.InarecentstudyfromFinland,Larmietal.reportedthatthe

mortality inacutecholecystitis with freeperforationdeclinedfrom55% in 1946-1956

to8% in 1969-19803. Theyattributed thisimprovementto ageneral improvementin

pre- and postoperative care, more effective antibiotic therapy and a change from

delayedtoearly (operationwithin3-7days) surgery.

However,

the importance of the

timingof surgeryisdifficultto determinefrom theirstudy because they comparedtwo

widely different timeperiods.Ourstudy compareddifferentpolicies duringthe same

period of timeat two hospitals havingthe same management capacities except for

diagnosticultrasound.

A

numberof otherconsiderations indicatesthatearly rather

s9

than delayed cholecystectomy is the method ofchoice in acute cholecystitis’. The

results ofour study support this idea andemphasize the importanceofemergency

surgery,i.e.surgerywithin24hr.

Itshouldbenoted that theincidenceofbileperitonitiswas notappreciably affected

by emergency surgery and that perforation of the gallbladderwasequallycommonat

(6)

the process of cholecystitis and that emergency surgery is advantageous mainly

becauseitshortens the period of freebile intheabdomen. Also, these findings may

suggest that intraperitoneal accumulation ofbile without obvious perforation is a

separatecondition.

However,

it is morelikely thatitsimply representsan earlierstage

of the inflammatory process.Thisinterpretationissupportedby the finding that the

percentage ofperforated gallbladderswaslargerinthe hospitalwithlonger patient’s

and hospitaldelays.

Unlike otherauthors3,we didnot findthat high agewas associated withan increased

riskofdying frombileperitonitis.Thismay, however, beatype

II

error,andwe believe

thatearlysurgeryin acutecholecystitisistoberecommendedalsoinelderly patients.

References

1. Duncan, J. (1844-45)Femoralhernia;gangrene of thegallbladder;extravasationofbile;peritonitis; death. North.J.Med.,2,151-153

2 Felice,P.R., Trowbridge,P.E. andFerrara, J.J. (1985) Evolvingchangesinthe pathogenesis and treatmentof theperforated gallbladder. Am. J. Surg., 49,466-473

3. Larmi, T.K.I., Kairaluoma, J.J., Junila, J., Laitinen, S., Shlberg, M. and Fock, H.G. (1984) Perforation of thegallbladder. ActaChit.Scand.,150,557-560

4. Riesenfeld,G.(1969)Perforationofthegallbladder. Int. Surg., 52,218-225

5. Forsberg, L., Andersson. R., Hederstrtm, E. and Tranberg, K.-G. (1988) Ultrasonography and

gallbladderperforation in acute cholecystitis.ActaRadiologica,29, 203-205

6. Dale, G.andSolheim,K. (1975)Bile peritonitis in acutecholecystitis. ActaChir.Scand.,141,746-748 7. Essenhigh,D.M.(1968)Perforationofthegallbladder. Br. J. Surg.,55,175-178

8. Vander Linden,W.andEdlund, G.(1981)Earlyversusdelayed cholecystectomy:theeffect ofa change inmanagement.Br. J. Surg., 68,753-757

9. Norrby, S., Herlin, P., Holmin, T., Sjtdahl, R. and Tagesson, C. (1983) Early or delayed

cholecystectomyinacute cholecystitis;Aclinical trial.Br.J. Surg., 70, 163-165 Accepted by S. Bengmark8June1989

INVITED COMMENTARY

This paper reviews an uncommon complication of acute cholecystitis bile

peritonitis. The authors report a 1.8% incidence ofthis complication which was

associated with acommendably low 8% postoperative mortality. They have shown

that this complication is difficult to diagnose clinically, that the peritoneal bile is

usually infected with gram-negative organisms, and that a delay in surgery may

increaseoperativeriskespecially frominfectivecomplications. They conclude thatthis

experience supportsapolicyofurgent(within24hours ofadmission)surgery foracute

cholecystitis.

Whileearly surgery foracutecholecystitis has been showntobeeffectiveand safein

low risk patients,2. _we_must_be _cautious _{when drawing}_conclusions

for the overall

treatmentofa condition on a basisofaretrospectivereviewofacomplication,albeit a

seriousone,whichoccursinlessthan 2% of patients.This isparticularlysowhena

policy ofearlysurgery aspractisedatLundhashadadisappointing impact on the

incidenceofbileperitonitis foundatoperation.Bileperitonitisis notthe onlycauseof

deathinpatientswith acutecholecystitis and overall mortality and morbiditymustbe

(7)

BILE PERITONITIS 13

Althoughelectivecholecystectomy has beenreportedtobesafeintheelderly

,

acute

cholecystitisin thesepatientscarriesanappreciable mortality much ofitattributed to

concurrent disease’. Patients with acutecholecystitis whoare at ahigh surgicalrisk

may bemanaged non-operativelyatfirst, although early surgeryisrecommended if

they do notimproveover 12-24 hourss. Itwould be interestingtoknow how many

patientsin this series weretreated non-operatively.

References

1. Vandcr Lindcn, W.and Edlund, G. (1981)Early versusdelayed cholccystcctomy. The effect ofa changein managcmnt.Br. J. Surg.68, 753-757

2. Norrby, S., Hedin, P., Holmin, T., Sjodahl, R. and Tagessan, C. (1983) Early or dclayexi cholcystetomy inacutcholccystitis?Aclinicaltrial.Br. J. Surg, 70,163-165

3. Houghton,P.W.J.,Jnkinson,L.R.andDonaldson,L.A. (1985)Cholccystcctomyin theelderly: a prospective study.Br. J. Surg. 72,220-222

4. Hubcr,D.F.,Martin,E.W.Jr.andCoopcrman,M.(1983)Cholecystcctomyinelderlypatients.Am. J. Surgery. 146,719-722

5. Sullivan,D.M.,Hood, T.R.and Griffcn,W.O.(1982)Biliary tractsurgery in theldcdy. Am J.Surg.

143, 218-220

L. Blumgart

Inselspital

CH-3010Bern

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Bile Peritonitis in Acute Cholecystitis

BILE

PERITONITIS IN ACUTE

CHOLECYSTITIS

ANDERSSON,

KARL-GORAN

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References

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References

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