2.1. Epidemiology and Clinical Relevance
The most common cause for surgical intraabdominal infections in the elderly is acute cholecystitis, and the number of cholecystectomies in the elderly is increasing (6). The incidence of this disease is higher in the female. However, the female-to-male ratio lowers from 3:1 in younger adults to 1.5:1 in patients older than 50. Cholelithiasis accounts for 95% of acute cholecystitis, with the other 5% termed acalculous cholecystitis. The incidence of cholelithiasis increases with age, ranging from 25-40% for those in their sixties to over 50% in those 70 yr and older (7). Acute cholecystitis appears to be caused by obstruction of the cystic duct by an impacted stone. The sequelae of this may be simple acute cholecystitis, gangrenous cholecystitis, perforation of the gallbladder with possible bile peritonitis, or cholecystoenteric fistula. If a cholecystoenteric fistula is found in the presence of small bowel obstruction, the possibility of a gallstone lodged in the distal ileum should be considered.
In the elderly, biliary disease should be considered foremost in the differential diagnosis of the physician when eliciting the history of upper abdominal pain. The pain may be steady and persistent in the right subcostal, epigastric region or both. Often the pain may develop after ingestion of a meal. Radiation of this pain may be to the back or to the tip of the right scapula. Also, irritation of the diaphragm may cause right shoulder pain. Nausea and vomiting are common in about 65% of patients. Fever, which is found in 80% of all acute cholecystitis patients, may be absent in the elderly, especially if they are taking nonsteroidal anti-inflammatory drugs. The physical examination should elicit tenderness in the right upper quadrant, epigastrium, or both. A common physical finding is inspiratory arrest during deep palpation of the right upper quadrant, which is called Murphy's sign. Rigidity, rebound tenderness, and/or a palpable mass may be found as well. In 10% of patients with acute cholecystitis, jaundice can occur due to bile pigments entering into the circulation from the damaged mucosa of the gallbladder (8). Choledocholithiasis should always be suspected in the presence ofjaun-dice. This is because the incidence of common bile duct stones increases with age to about 20% in the elderly patient with acute cholecystitis.
Laboratory studies may show increased leukocytosis, increase in serum bilirubin, and/or an increase in serum amylase. Ultrasound examination of the right upper quadrant is highly sensitive, approximately 95%, in showing gallstones. Other findings of acute cholecystitis with ultrasonography are dilated and thickened gallbladder wall, pericholecystic fluid, and or ultrasonographic Murphy's sign. When the diagnosis is still in question, a cholescintigraphic study using 99m-labeled derivative of iminodiacetic acid (HIDA) may be used. In the presence of acute cholecystitis, the gallbladder will not be seen. This indicates cystic duct obstruction. The HIDA scan is 100% sensitive and 95% specific for the diagnosis of acute cholecystitis (9).
In the presence of symptomatic cholelithiasis, elective laparoscopic cholecystec-tomy is associated with reduced morbidity and mortality when compared with emergent surgery. Acute cholecystitis in the elderly is associated with a higher morbidity when compared with the general population with the same disease. Emergent chole-cystectomy is associated with a mortality rate of 10% in the elderly. Furthermore, the conversion rate of laparoscopic cholecystectomy to open cholecystectomy can be as high as 50% (10). In the majority of elderly patients, medical therapies for acute cholecystitis will fail (11). Early cholecystectomy has a lower morbidity and mortality than medical management with elective cholecystectomy (12). Intraoperative cholangiography is encouraged in the elderly due to the increased risk of concomitant common bile duct stones. In the unstable patient, cholecystostomy may be an immediate alternative to emergent cholecystectomy. This may be performed through a limited incision under local or general anesthesia, or by image-guided percutaneous catheter placement.
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One of the main home remedies that you need to follow to prevent gallstones is a healthy lifestyle. You need to maintain a healthy body weight to prevent gallstones. The following are the best home remedies that will help you to treat and prevent gallstones.