• Initial diagnoses
  • He went to the hospital on Thursday (Dec 7, 2007), presenting with abdominal pain and vomiting, but no jaundice. They did an ultrasound to look for gallstones or kidney stones, followed by a CT scan of the abdomen. Neither turned up any problems, so they sent him home with prescription antibiotics, believing it might be an infection of the peritoneum (the sac that surrounds the instestines), absent any firm information otherwise.
  • He returned to the hospital Friday afternoon, as the pain had gotten worse rather than better. They did an hour-long repetitive perfusion scan with contrast (functional MRI?), and concluded that the gallbladder wasn't taking up any blood, and therefore had to be removed.
• Final diagnosis: acute cholecystitis (inflammation of the gallbladder), caused by obstruction by gallstones
• He had a cholecystectomy (gallbladder removal) performed laparoscopically. [initially scheduled for 7:30am Saturday, but was pushed back to 4pm]
  • They discovered that the gallbladder had several gallstones inside, and was inflamed with puss (empyema). They believe inflammation/puss is the reason the gallstones didn't appear on the initial scans. (because of the gas?, see "emphysematous" below)
  • When they began removing the gallbladder during surgery, it ruptured while still inside (based on various clues, I think this was caused by emphysematous cholecystitis, or infection of the gallbladder wall by gas-forming organisms). For whatever reason (...?), this didn't cause any significant complications, and they were able to complete the laparoscopic procedure without taking noticeably longer. (~one hour for the entire surgery)
    • incidence: "Reports in the surgical literature indicate that emphysematous cholecystitis develops in approximately 1% of all cases of acute cholecystitis [in the US]." *
    • mortality: "Overall mortality rates vary from 15-25%. These rates are 5 times the operative mortality rates for nonemphysematous cholecystitis." *
    • (I lost the reference, and this is my own summary, but...) In patients where the gallbladder perforates before surgery, the mortality rates are sometimes reported to be as high as 40-60%, particularly in cases where the problem isn't able to be quickly diagnosed by a doctor.
      Lesson learned: It's good to have health insurance.

• if the gallbladder was becoming filled with gas, why did that not appear on the initial CT scan?

Risk factors for forming cholesterol gallstones

High-level reasons:

• high concentration of cholesterol in the gallbladder
• incomplete and infrequent emptying of the gallbladder
• presence of proteins that either promote or inhibit cholesterol crystallization into gallstones

Specific reasons:

• inherited body chemistry
• body weight
• gallbladder motility (movement)
• possibly diet — "No clear relationship has been proven between diet and gallstone formation. However, low-fiber, high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate, magnesium, calcium, and vitamin C."