Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk.

Background And Study Aims: Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure. The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor. It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course.

Increased gallbladder trypsin in acute cholecystitis indicates functional disorder in the sphincter of oddi and could make EPT a logical procedure.

Clinical and surgical observations confirm that acute cholecystitis (ACh) and acute biliary pancreatitis can coexist and that differentiation may be difficult even at surgery. Synchronous appearance of ACh and acute biliary pancreatitis suggests a similar etiology. Endoscopic sphincterotomy, with relief of the common channel outlet obstruction, has become the established therapeutical modality that improves the outcome in acute biliary pancreatitis.

Why is it necessary to retrieve small bile duct stones at cholecystectomy?

Recovery of gallstones from the stool demonstrates that gallstones pass into the duodenum due to antegrade sphincter of Oddi (SO) activity. However, retrograde SO peristalsis occurs in three-fourths of patients with bile duct stones as shown by SO manometry. The aim of this study was to investigate, by comparing patients with and without bile duct stones, whether reversed SO activity would retain even small stones.