Diagnosi e terapia della colecistite acuta

Acute cholecystitis is a serious inflammatory disease which requires immediate diagnosis and early surgical treatment. With the aim of identifying whether the urgent ultrasound (US) and the surgical approach within 72 hours can positively affect the course of the illness, we report our experience carried out on 100 patients (54 males and 46 females with an average age of 65 years ranging between 30 and 90) reaching our department in the period between January 1988 and October 1991. The US carried out on admission demonstrated a diagnostic sensitivity of 74%; while if considering the cases in which the histopathological report outlined a serious event (empyema or gangrene 21/100) the US sensitivity increased to 84.2%. It was also useful in patients without leucocytosis (15/100; sensitivity of 78.6%) and in those with marked leucocytosis (9/100) where the diagnostic sensitivity reaches a 100%. A cholecystectomy operation was carried out in all the patients within the first 72 hours; in 13 cases with bile duct exploration. During the last 18 months a new approach was applied on the 16 patients who showed evidence of acute cholecystitis with a stone in the common bile duct: that of performing an urgent ERC followed by sphincterotomy and extraction of the stone/s followed by cholecystectomy the day after (always within the 72 hours). The overall mortality rate was 2%. The early cholecystectomy carries a morbidity rate of 18% which increases to 31% if associated with exploration of the common bile duct; the use of the alternative early endoscopic-surgical approach by us followed for cholecystitis with bile duct stone/s does not increase the morbidity rate of the cholecystectomy, while it permits a shorter hospital stay. We retain that the principle urgent diagnostic means for acute cholecystitis is the ultrasonography. It yields a correct diagnosis in almost 8 out of 10 cases and can determine the right moment for carrying out the cholecystectomy which must always be, when possible, within the 72 hours from the occurance of the symptomatology. Finally we consider the endoscopic-surgical approach as a valid alternative to the traditional bile duct exploration for cholecystitis with bile duct stone/s.