Reply to S. V. Murugesan, C. B. Babbs

We appreciate the interest of Drs. Senthil Murugesan and Chris Babbs in our study of acute cholecystitis, published in the August 2006 issue of Endoscopy, that introduced a new indication for early endoscopic sphincterotomy (ES) in elderly patients at high surgical risk who were suffering from acute cholecystitis, We take the opportunity to comment on their letter and to add further explanation.

We are dealing with the interdependent pancreaticobiliary system: two organs - gallbladder and pancreas - connected via the common channel. To quote Sir Alfred Cuschieri: “It is important to stress that acute cholecystitis and acute pancreatitis frequently coexist and it may be impossible to differentiate one from the other, even at operation” [1].

As surgeons skilled in the management of patients suffering from acute cholecystitis, stones in the bile ducts with or without cholangitis, and acute biliary pancreatitis, we would like to refer to our earlier report on common channel obstruction [2]. Independently of whether the obstruction is caused by a present or previously passed small gallstone, or edema, or dysfunction of the sphincter of Oddi, it will lead to reflux of pancreatic juice into the biliary tree and gallbladder with consequent cholangitis of specifically enzymatic origin [3], inflammation of the cystic duct [4], and gallbladder wall edema [2]. This is valid, specifically, in the early course of acute cholecystitis, when the bile from the common bile duct activates the pancreatic enzymes to form a pronouncedly proteolytic mixture. The gallbladder edema with or without mild symptoms, may range from slight to pronounced, with or without necrotic areas in the gallbladder wall. This edema will gradually compress either a large stone or a group of small stones into the gallbladder neck - a stone impaction [2]. The opposite course, stone compression in the gallbladder neck causing a gallbladder wall edema seems to us to be less likely [2]. The increased presence of pancreatic enzymes in the gallbladder bile, as confirmed by radioimmunoassay [2], is the primary cause of acute cholecystitis that 3-5 days later may become infected by bacteria. It is essential to distinguish between the early enzymatic stage in acute cholecystitis with sterile bile [2] within the first 48 hours after onset of the initial symptoms, and the later possible infected secondary stage. These pathophysiological events are fundamental facts forming a basis for the recommended early ES in elderly, high surgical risk patients suffering from acute cholecystitis. Sphincterotomy is indicated and can be effective only in the early course of this acute disease. Therefore, we agree with the guidance of the British Society of Gastroenterology [5].

As Drs. Murugesan and Babbs probably know from their everyday clinical practice, endoscopic retrograde cholangiopancreatography (ERCP) in some patients who have been admitted to hospital in a jaundiced state, may show a stonefree common channel as the stones may have passed into the duodenum. The edema in the papilla of Vater subsides in the course of time and the patients recover.

Hui et al. from Queen Mary Hospital, Hong Kong, reported a decreased duration of cholangitis (P < 0.001) and a reduced hospital stay (P < 0.04) after ES compared with a non-ES group in patients with acute cholangitis without common bile duct stones [6]. Thus, ES is beneficial in such patients. However, to asses the long-term outcome regarding recurrent acute cholangitis in their study (14/50 or 12.5 % after ES vs. 9/61 or 8.1 % without ES) [6], a larger group of patients would have been needed to reach statistical power.

Acute cholecystitis per se does not exist. It is associated with previous or present common channel obstruction, that causes reflux of the pancreatic juice into the bile ducts and gallbladder. Therefore, for adequate treatment it is essential to secure free delivery of the proteolytic mixture of bile and pancreatic juice from the bile ducts early in the course of this acute disease.

Competing interests: None

References

• 1 Cuschieri A, Bouchier A D. The biliary tract.  In: Cuschieri A, Giles GR, Moosa AR (eds.) Essential surgical practice. London; John Wright & Sons 1982: 1039-1073
• 2 Vracko J, Wiechel K L. Increased gallbladder trypsin in acute cholecystitis indicates functional disorder in the sphincter of Oddi and could make EPT a logical procedure.  Surg Laparosc Endosc Percutan Tech. 2003;  13 308-313
• 3 Vracko J, Wiechel K l. The laparoscopic finding of pericholedochitis at cholecystectomy predicts the presence of unsuspected bile duct stones.  Surg Laparosc Endosc Percutan Tech. 2000;  10 120-126
• 4 Vracko J, Wiechel K L. Trypsin level in gallbladder bile and ductitis and width of the cystic duct.  Hepatogastroenterology. 2000;  47 115-20
• 5 UK Working Party on Acute Pancreatitis . UK guidelines for the management of acute pancreatitis.  Gut. 2005;  54 (Suppl III) iii1-iii9
• 6 Hui C K, Lai K C, Wong W M. et al . A randomised controlled trial of endoscopic sphincterotomy in acute cholangitis without common bile duct stones.  Gut. 2002;  51 245-247