Challenges in Accurate Clinical Prediction of Gangrenous Cholecystitis: A Single-Centre Retrospective Analysis of Operative Cases

Abstract Introduction: Gangrenous cholecystitis is a severe form of acute cholecystitis with significantly higher mortality. However, preoperative diagnosis remains challenging. Greater understanding of the clinical presentation and associated risk factors is likely to aid surgical teams in early recognition and expedient operative management to improve outcomes. Method: Retrospective data on presentation, investigations and outcomes was collected for patients with a histological diagnosis of gangrenous cholecystitis. Comparative analysis using data from patients with non-gangrenous acute cholecystitis was peformed to identify relevant risk factors. Results: 61 patients with gangrenous cholecystitis were identified over a 5 year period. Most common symptoms were pain (98.4%), nausea or vomiting (70.5%) and subjective fevers (26.2%). Radiological findings included a thickened gallbladder wall (83.6%), pericholecystic fluid (63.9%) and cholelithiasis (60.7%). Pericholecystic fluid (63.9% vs 36.0%, p<0.05) or an irregular wall (16.4% vs 0.0%, p<0.05) were findings significantly higher in those with gangrenous cholecystitis. Patients with gangrenous cholecystitis were more likely to be male (57.4% vs 39.3%, p <0.05), report subjective fevers (26.2% vs 9.5%, p <0.05) and had a higher WCC (14.5 vs 11.3, p<0.0001) or CRP (139.8 vs 50.0, p<0.0001). These patients were also operated on sooner (1.7 days vs 2.3 days, p <0.05). Conclusion: Gangrenous cholecystitis should be suspected in males with markedly elevated inflammatory markers, particularly when radiological investigations suggest an irregular wall or pericholecystic fluid. However, no specific risk factors, clinical features, or investigations can reliably identify this entity and surgical teams should have high suspicion with a low threshold for expedient operative intervention regardless.