Management ofcrescendo biliary colic 681

pathological lesion was described in seven ognition in view of its high mortality. To the infiltra- pathologist, it is another addition to the

cases; five showed neurofibromatous Postgrad Med J: first published as 10.1136/pgmj.74.877.681 on 1 November 1998. Downloaded from tion or compression. In Miura's case,9 neurofi- ever-lengthening list ofcauses ofsudden death, bromatous infiltration of the subclavian wall but knowledge of the syndrome will help to was not found, but there was evidence of explain an otherwise puzzling accumulation of vascular dysplasia, consisting of decreased blood behind the pleura or within the mediasti- elastic fibres and deranged smooth muscle. In num and guide the search for the cause. For the absence of a demonstrable intrathoracic clinicians, recognition of the syndrome should tumour, we believe that a similar vascular dys- lead to urgent referral to the nearest cardiotho- plasia was responsible for haemorrhage in our racic centre. The configuration of the radio- case. logical opacity and the ease with which frank Out of 18 patients reported in the literature,'9 plus our own case, the four blood is withdrawn on paracentesis should patients who had no surgical intervention died. suggest the diagnosis in a patient with cutane- Of the remaining 15 who underwent thora- ous manifestations of neurofibromatosis. cotomy, nine survived. Von Recklinghausen's disease is a relatively We are grateful to Mrs Gaynor Francis for secretarial assistance, common disorder and this syndrome of and to Dr Kim Harrison, Chest Physician at Morriston Hospi- spontaneous haemothorax deserves wider rec- tal, for drawing our attention to the report by Miura et al.'

1 Lie JT. Vasculitis look-alikes and pseudovasculitis syn- 6 Larrieu AJ, Hashimoto SA, Allen P. Spontaneous massive dromes. Curr Diagn Pathol 1995;2:78-85. haemothorax in von Recklinghausen's disease. Thorax 1982; 2 Greene JF, Fitzwater JE, Burgess J. Arterial lesions 37:151-2. associated with neurofibromatosis. Am Jf Clin Pathol 7 Brady DB, Bolan JC. Neurofibromatosis and spontaneous 1974;62:481-7. hemothorax in pregnancy. Two case reports. Obstet Gynecol 3 Reubi F. Neurofibromatose et lesions vasculaires (Neurofi- bromatosis and vascular lesions). Schweiz Med Wochenschr 1984;63(suppl 3):35-38S. 1945;75:463-5. 8 Fuyuno G, Kobayashi R, Iga R, et al. A case of von 4 Leier CV, DeWan CJ, Anatasia LF. Fatal hemorrhage as a Recklinghausen's disease associated with a hemothorax due complication of neurofibromatosis. Vasc Surg 1972;6:98- to a rapidly growing malignant Schwannoma. _'ap J Thorac 101. Dis 1995;33:682-5. 5 Butchart EG, Grotte GJ, Barnsley WC. Spontaneous 9 Miura H, Taira 0, Uchida 0, Usuda J, Hirai S, Kato H. rupture of an intercostal artery in a patient with neurofi- Spontaneous haemothorax associated with von Reckling- bromatosis and scoliosis. J Thorac Cardiovasc Surg 1975;69: hausen's disease: review of occurrence in Japan. Thorax 919-21. 1997;52:577-8.

The best management for 'crescendo biliary colic' is urgent laparoscopic cholecystectomy http://pmj.bmj.com/

G S M Robertson, S A Wemyss-Holden, G J Maddern

Summary minimising the need for further medical Gallbladder disease due to stones is well involvement. recognised as falling into two categories, on September 27, 2021 by guest. Protected copyright. presenting with either chronic symptoms Keywords: gallstones; biliary colic; laparoscopic chole- or developing acute cholecystitis or other cystectomy complications. We describe an intermedi- ate group of 14 patients (11 women, three men, median age 31 years) presenting Patients with gallstones are usually regarded as with 4-14 days of at least daily attacks of having either intermittent biliary colic resulting resolving biliary colic, who underwent in 'chronic' inflammatory changes or 'acute' Department of such Surgery, Queen early laparoscopic cholecystectomy within complications as cholecystitis.' Most sur- Elizabeth Hospital, 24 hours of presentation. None had any geons and general practitioners will, however, Woodville, South evidence of acute inflammation, either at be familiar with a group of patients developing Australia 5011 laparoscopy or on histology. Their surgery acute cholecystitis or other complications of G S M Robertson gallstones, who give a history of dramatically S A Wemyss-Holden was straightforward with operating times G J Maddern ranging from 35-80 minutes and no com- worsening biliary colic over the preceding cou- plications. Patients with 'crescendo bil- ple of weeks. Such patients have frequently Correspondence to iary colic' are often young women who can seen the emergency services with episodes of Mr GSM Robertson, Clinical Lecturer in Surgery, rarely afford invalidity. Rather than the pain but in the UK are rarely admitted until Department of Surgery, current practice of analgesia for each their pain fails to resolve and acute cholecysti- Clinical Sciences Building, attack and elective surgery weeks later, tis or other complications supervene. Even Leicester Royal Infirmary, Leicester LE2 7LX, UK they are optimally managed by urgent when admitted, they are usually pain-free the laparoscopic cholecystectomy, preventing following day and are discharged pending elec- Accepted 23 April 1998 the development of complications and tive surgery or further emergency admission. 682 Robertson, Wemyss-Holden, Maddern

Over the last 9 months we have prospectively

audited a policy of early laparoscopic cholecys- Learning points Postgrad Med J: first published as 10.1136/pgmj.74.877.681 on 1 November 1998. Downloaded from tectomy in all patients admitted to our Unit as * patients with gallstones can suffer escalating or an emergency with gallstone-related symp- crescendo attacks of biliary colic toms. The majority have been patients with * such patients are often young women with acute cholecystitis (17), empyema of the families to care for gallbladder (eight), or pancreatitis (three), or * laparoscopic cholecystectomy at this stage is have been elective admissions (88). There has straightforward with a short hospital stay also been a group of 14 patients (10%) with * if managed conservatively such patients are likely to develop complications of their gallstones, what we have christened 'crescendo biliary occupy more health service resources before colic', admitted with up to 2 weeks of daily inevitable surgery, and have continuing problems attacks of uncomplicated biliary colic, often on coping with family commitments a background of previous less frequent symp- * the Health Service in the UK needs to adapt to toms. This report reviews their management refer such patients for urgent laparoscopic and its implications based on our experience. cholecystectomy Methods and results Eleven women and three men, median age 31 Discussion (range 23-81) years, were admitted with a median history of 7 (range 4-14) days of at Patients with frequent (crescendo) biliary colic least daily attacks of biliary colic. All of them due to a gallstone recurrently obstructing the had proven gallbladder stones of varying sizes cystic duct or Hartmann's pouch are inevitably on ultrasound with only two showing any at high risk of developing acute cholecystitis or evidence of gallbladder wall thickening. Three more serious complications as the stone is patients had slightly elevated liver function passed into the common bile duct. Laparo- tests, two of whom had a dilated common bile scopic cholecystectomy then becomes more duct (8 and 9.6 mm) on ultrasound. On exam- difficult requiring more surgical experience2 ination, each was apyrexial, with a normal and operating time,3 and carrying a higher rate white cell count, range 4.7-9.2 x 109/l (normal of conversion to open surgery2 3 and a greater 4.0-10.0 x 109/1) and normal amylase levels. risk of complications.3 At laparoscopic cholecystectomy within 24 Our experience suggests that such patients, hours of admission, there was evidence of rather than being managed at home with anal- oedema in the gallbladder wall in four patients gesia, should be admitted for early straightfor- but no other evidence of acute inflammation. ward laparoscopic cholecystectomy the follow- Laparoscopic cholecystectomy was straightfor- ing day. Such a policy is highly acceptable to ward taking a median of 56 (range 35-80) patients who, in our experience, are often minutes, with no gallbladder perforations or women with young families, and should conversions. The three patients with elevated minimise further health service involvement in liver function tests underwent normal perop- a group of patients who inevitably require sur- erative cholangiography. Seven patients were gery sooner or later. Logistically this policy http://pmj.bmj.com/ discharged the following day, the rest stayed a requires the ability to ultrasound the gallblad- further day, there were no complications. der, ideally on the day of admission, and the Histology of the gallbladder showed gallstone- flexibility of theatre services, including sur- related changes in each case with no evidence geons, to accommodate their surgery the of acute inflammation, wall thickness ranged following day. It therefore requires a change in from 3-7 mm (median 3 mm) microscopically. both referral and surgical practice. on September 27, 2021 by guest. Protected copyright.

1 Hermann RE. Surgery for acute and chronic cholecystitis. 3 Kum C-K, Eypasch E, Lefering R, Paul A, Neugebauer E, Surg Clin North Am 1990;70:1263-75. Troidl H. Laparoscopic cholecystectomy for acute 2 Fried GM, Barkun JS, Sigman HH, et al. Factors determin- cholecystitis: is it really safe? WorldJ3 Surg 1996;20:43-9. ing conversion to laparotomy in patients undergoing laparo- scopic cholecystectomy. Am _J Surg 1994;167:35-41.