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A number of complications have been associated with acute and chronic cholecystitis:• Empyema – occurs when super-infection of stagnant bile leads to pus filling the gallbladder. This complication carries a high risk of gram-negative sepsis.• Gangrene – results from chronic ischemia of the gallbladder wall leading to complete tissue necrosis. There is a high risk of perforation associated with this complication.• Perforation (with or without peritonitis) – may be either localized (contained by the omentum and serosa of contiguous organs) or free (frank rupture of the gallbladder into the peritoneal cavity). Fever and a palpable RUQ mass may be present when a localized perforation has occurred. A free perforation produces the clinical findings of diffuse peritonitis.• Emphysematous cholecystitis – occurs when gas-producing bacteria invade a gangrenous gallbladder wall. The clinical manifestations are usually more severe but may be indistinguishable from nongaseous cholecystitis. An abdominal plain radiograph may reveal gas within the gallbladder lumen, gas in a ring along the contours of the gallbladder wall, or a gas-fluid level in the gallbladder.• Cholecystenteric fistulas – can form with chronic inflammation and can connect areas of bowel adjacent to the gallbladder wall. Fistulas from the gallbladder to the duodenum are the most common.• Gallstone ileus – refers to the mechanical intestinal obstruction resulting from passage of a large gallstone through the bowel lumen. If a significantly sized gallstone (>2.5 cm in diameter) passes through a fistula into the intestines, it can cause obstruction, typically at the ileocecal valve. An abdominal plain radiograph reveals intestinal obstruction, gas in the biliary tree, and a calcified gallstone in the bowel lumen.• Porcelain gallbladder – can occur in the setting of chronic cholecystitis when calcium salts deposit within the chronically inflamed gallbladder wall. Cholecystectomy is recommended in these cases because of the association of carcinoma of the gallbladder.• Pericholecystic abscess – consists of a localized pus collection adjacent to the gallbladder.• Intra-abdominal abscess – can occur following a perforation of the gallbladder (usually a free perforation).• Bacteremia – results from translocation of bacteria from the gallbladder into the bloodstream.*105/348/5*

Worldwide, acute infectious diarrhea is the second leading cause of morbidity and mortality. An overwhelming majority of the 3 to 5 billion episodes of diarrhea and more than 3 millions deaths per year occur in developing countries. In the developed world, more than 350,000 episodes of diarrhea require hospital admission, incurring nearly 800,000 dollars in medical costs and lost productivity each year. Many more patients visit outpatient practices or do not seek medical attention at all. The prevalence of acute diarrheal illness is estimated at 1 to 1.5 episodes per person per year, and although most cases are self-limited, the severity of illness can vary markedly depending on characteristics of both the pathogen and the host. Management of each episode, therefore, varies based on cause, severity of illness, the host, and the host’s comorbid illnesses.Prompt recognition, diagnosis, and treatment of infectious diarrhea may have public health implications. The primary care physician is instrumental in early control of local outbreaks as well as in preventing secondary transmission, most importantly in health care workers, day care workers, and food handlers. Stool testing for diagnosis of specific pathogens can abbreviate illness, reduce morbidity, decrease development of antimicrobial resistance through pathogen-directed treatment, and help identify and trace public health outbreaks. However, because the vast majority of patients with acute diarrhea have a self-limited illness that requires only supportive therapy, laboratory testing and antimicrobial treatment in such cases can be fruitless and costly. Additionally, inappropriate treatment can be detrimental through promotion of antimicrobial resistance and, in some cases, prolonged infectivity. Only 1.5% to 5.8% of all submitted stool cultures are positive, making the cost per positive test around 1000 dollars. Pursuit of a microbiologic diagnosis, therefore, must be initiated on a case-by-case basis. *65/348/5*