Although acute acalculous cholecystitis is uncommon in burn patients, this condition can be rapidly fatal due to delays in diagnosis and treatment and should always be considered in the differential diagnosis when burn patients become septic, develop abdominal pain, or have hemodynamic instability. This article reviews the use of percutaneous cholecystostomy in burn patients as both a diagnostic and therapeutic intervention.
Key points
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Plastic surgeons who take care of burn patients must be able to diagnose and treat sepsis, which can include acute acalculous cholecystitis (AAC).
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AAC is uncommon in burn patients but is associated with high mortality, especially when there is a delay in diagnosis and treatment.
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Percutaneous cholecystostomy can be performed for both diagnostic and therapeutic indications, with minimal morbidity, in burn patients.
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Improved survival in burn patients with acute acalculous cholecytitis requires treatment of the underlying conditions that contribute to end-organ hypoperfusion.
Introduction
AAC is an acute, necrotic inflammation of the gallbladder in the absence of gallstones. It is a rare cause of acute cholecystitis, ranging from 2% to 14% of all cases of acute cholecystitis, and AAC affects 0.2% to 0.4% of critically ill patients. Incidence of AAC is higher among burn patients (0.4%–3.5%) and is associated with complications, such as gangrene, perforation, and empyema.
Clinical findings of AAC are indistinguishable from calculous cholecystitis. The clinical signs and laboratory values are nonspecific, especially in burn patients, but include right upper quadrant pain, leukocytosis, fever, and abnormal liver function tests. Further factors complicating the diagnosis include overlying burn, intubation, narcotics, and sedation. Therefore, the diagnosis becomes difficult and often delayed, leading to high mortality ranging from 10% to 90%.
As a follow-up to the authors’ previous study examining the efficacy of percutaneous cholecystostomy tube (PCT) placement in critically ill patients, published in 1996, the authors noted that there had been a gradual decrease in PCT placement over the past few years compared with this same patient population in decades past. The authors hypothesized that this was likely explained by advances in critical care and set out to evaluate institutional data to review the trends in placement, indications, and outcomes.
Introduction
AAC is an acute, necrotic inflammation of the gallbladder in the absence of gallstones. It is a rare cause of acute cholecystitis, ranging from 2% to 14% of all cases of acute cholecystitis, and AAC affects 0.2% to 0.4% of critically ill patients. Incidence of AAC is higher among burn patients (0.4%–3.5%) and is associated with complications, such as gangrene, perforation, and empyema.
Clinical findings of AAC are indistinguishable from calculous cholecystitis. The clinical signs and laboratory values are nonspecific, especially in burn patients, but include right upper quadrant pain, leukocytosis, fever, and abnormal liver function tests. Further factors complicating the diagnosis include overlying burn, intubation, narcotics, and sedation. Therefore, the diagnosis becomes difficult and often delayed, leading to high mortality ranging from 10% to 90%.
As a follow-up to the authors’ previous study examining the efficacy of percutaneous cholecystostomy tube (PCT) placement in critically ill patients, published in 1996, the authors noted that there had been a gradual decrease in PCT placement over the past few years compared with this same patient population in decades past. The authors hypothesized that this was likely explained by advances in critical care and set out to evaluate institutional data to review the trends in placement, indications, and outcomes.
Methods
An institutional interventional radiology (IR) register was queried to identify all patients who had a percutaneous cholecystostomy tube placed over the last 10 years. Cross-referencing the IR database with the institutional American Burn Association (ABA) registry identified the burn-specific cohort. A post hoc review was performed on individual charts to extrapolate data for analysis.
Results
From 2004 to 2014, 21 critically ill burn patients had percutaneous cholecystostomy tubes placed by IR; 15 of the 21 patients had thermal injury, 4 patients had Stevens-Johnson syndrome/toxic epidermal necrolysis, and 2 patients had traumatic injuries with associated burns/degloving. Table 1 provides a summary of patient demographics; outcome measures, such as length of stay and mortality; and clinical response to PCT. The average age of the patients was 49 years old. Charleson comorbidity index scores were calculated on admission for all patients; the mean was 8.2. The average length of stay was 102 days. Mean length of stay in the burn center ICU was 97 days, and the average number of ventilator days was 90. Mean total burn surface area was 47.8%; 80% (12 of 15) of the burn patients also had inhalation injury. Baux scores were also calculated, the average being 104.5. Overall mortality rate was 66.7%. The average length of drainage of the PCT was 70 days. On right upper quadrant ultrasound, all patients had some degree of gallbladder dilation, wall thickening, sludge, and/or pericholecystic fluid; 5 of the 21 patients (23.8%) had incidental gallstones on ultrasound, and there was no obstruction visualized; 4 of the 21 (19.0%) patients had a normal liver function tests prior to PCT placement. The most common abnormal liver function test was gamma-glutamyltransferase (16 patients), followed by alkaline phosphatase (12 patients), aspartate aminotransferase (11 patients), alanine aminotransferase (6 patients), and total bilirubin (6 patients); 13 of the 21 patients (61.9%) had negative bile cultures, 7 patients did not have cultures obtained, and only 1 patient, with Stevens-Johnson syndrome/toxic epidermal necrolysis, had a positive culture, for Enterobacter and Pseudomonas . Two-thirds of the patients, or 7 of 21, had burns/injuries at or near the PCT placement site. Average number of blood transfusions prior to PCT was 18.5 units of packed red blood cells. The average time to defervescence in the 6 patients (28.5%) who responded to PCT placement was 29.6 hours.
| Patient Variables (n = 21) | |
|---|---|
| Average age | 49 y |
| Percentage total burn surface area | 47.8 |
| Length of stay (d) | 102 |
| ICU/ventilator days | 97/90 |
| Average length of drainage (d) | 70 |
| Mortality rate | 66.7% |
| Average number of packed red blood cells transfusions prior to placement | 18.5 |
| Shock/vasopressors during placement | 57% |
| Defervescence after placement | 28.5% |
| Culture performed on fluid | 66.7% |
Fifteen of 21 patients (71.4%), however, did not respond to PCT placement and did not clinically improve, in contrast to the authors’ experience in critically ill patients in the surgery ICU. Defervescence did not predict survival, because 4 of these 6 patients died (66.7%); 12 of the 21 patients were in shock, on vasopressor therapy at the time of PCT placement; 2 of the 21 patients eventually underwent a cholecystectomy; and 14 of the 21 patients died, with 7 surviving to discharge, either to home (n = 5) or rehabilitation (n = 2). The average follow-up time was 14 months, with all 7 patients still alive, more than 1 year from their discharge.
The number of PCTs placed at the authors’ institution decreased considerably from 2004 to 2014 ( Fig. 1 ), with two-thirds placed in the first half of the study period. One was placed in 2004, 14 placed in 2005, 6 placed in 2006, 1 placed in 2007, 1 placed in 2009, 1 placed in 2010, 2 placed in 2011, 3 placed in 2013, and 1 placed in the first 6 months of 2014.
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