Successful removal of massive intragastric gallstones by endoscopic electrohydraulic lithotripsy and mechanical lithotripsy

We describe a case of massive gallstones discharged into the stomach through a cholecystoduodenal fistula and the successful removal of these stones by endoscopic electrohydraulic lithotripsy (EEHL) and endoscopic mechanical lithotripsy (EML) for the prevention of gallstone ileus. A 60-yr-old woman was admitted with epigastric pain and nausea. Upper gastrointestinal tract examination demonstrated backflow of contrast medium from the duodenal bulb into the gallbladder. Endoscopic examination revealed a large fistula on the anterior wall of the duodenal bulb, and two brown stones (about 3 cm in diameter) were found in the stomach. To prevent gallstone ileus, removal of these stones was attempted. They were broken into pieces by EEHL, then crushed into smaller pieces by EML and removed orally. Chemical analysis showed the composition of the gallstones to be at least 98% cholesterol. The patient was discharged one month after removal of the gallstones and has remained asymptomatic.

Cholecysto-cardiac link

Thirty normotensive patients (ASA class I) and 30 treated hypertensives without any cardiac problem (ASA class II) were subjected to elective cholecystectomy under general anaesthesia. Patients' age ranged from 25-50 yr, and male:female ratio was 1:11. There were significant increases in heart rate and mean arterial pressure in both the groups (P less than 0.05) during surgical manipulations for removal of the diseased gall bladders. The alterations in the treated hypertensive patients were not only much more than in the normotensives, but also were associated with tachyarrhythmias in 33.33 per cent of hypertensive patients. All changes returned to the pre-induction level at the end of the surgery. Mediation through fifth thoracic spinal segment, a common source of sympathetic supply to heart and gallbladder, explained the observed cholecystocardiac link. Anaesthetists therefore need to be vigilant during cholecystectomies.

Ultrasonically guided percutaneous drainage of abdominal fluid collections: a long-term study of its therapeutic efficacy

Fifty patients underwent ultrasonically guided percutaneous drainage (US-GPD) either with needle aspiration or catheter drainage. The procedures resulted in 70% complete recovery, 20% partial success and 10% of failures. The same patients were followed with clinical examination and sonography for a mean time of 36.3 months (minimum follow-up: 12 months). During the follow up period, 10 relapses occurred and one patient, considered for surgery after partial percutaneous treatment of a pyogenic liver abscess, recovered completely under conservative treatment. An analysis of the factors potentially related to the recurrence was made. It was found that one-step needle aspiration of abdominal abscesses and percutaneous treatment of chronic pancreatic pseudocysts are more prone to relapses. We conclude that US-GPD is an efficacious therapy for abdominal fluid collections, but an adequate drainage technique and a careful selection of the patients is crucial to avoid the possibility of relapse.

Empyema of gallbladder in a child with homozygous sickle-cell disease

A 13-year-old boy with homozygous sickle-cell (SS) disease followed from birth in a cohort study of sickle-cell disease developed empyema of the gallbladder after a known 3-year history of gallstones. At this age, gallstones occur in 30% of cohort study children with SS disease but this is the first patient with specific symptoms.

[Hemocholecyst: a rare cause of hemoperitoneum]

A rare case of haemoperitoneum due to gallbladder rupture with intraluminal bleeding is reported. The importance of a coagulopathy in the etiology of the disease is pointed out: in the present case it was related to cirrhosis and anticoagulant treatment during dialysis sessions.

[Porto-cholecysto-duodenal fistula as an infrequent cause of upper gastrointestinal hemorrhage]

A case of porto-cholecysto-duodenal fistula which caused a severe upper gastrointestinal haemorrhage is presented. The difficulties involved in diagnosis and surgical treatment are discussed.

Increased prevalence of clinical gallbladder disease in subjects with non-insulin-dependent diabetes mellitus

The association between non-insulin-dependent diabetes mellitus (NIDDM) and the prevalence of gallbladder disease remains controversial. The authors investigated this association in 1,250 men and 1,656 women from the San Antonio Heart Study (1984-1988) a population-based study of diabetes and cardiovascular disease. A total of 68% of the subjects were Mexican American, a population at high risk for both gallbladder disease and NIDDM. Gallbladder disease was assessed by self-report, and the prevalence of diabetes was determined using National Diabetes Data Group criteria. NIDDM was significantly associated with gallbladder disease in Mexican-American men and women and in non-Hispanic white women. After adjustment for age, body mass index, ratio of waist-to-hip circumference, and ethnicity, using multiple logistic regression, the odds of gallbladder disease in women was 1.6 times higher if NIDDM was present (odds ratio = 1.60, 95% confidence interval 1.08-2.37). Mexican-American women also had a significantly increased prevalence of gallbladder disease relative to non-Hispanic white women (odds ratio = 2.21, 95% confidence interval 1.50-3.28). In nondiabetic women, fasting insulin was significantly related to prevalence of gallbladder disease in univariate analyses, but not in multivariate analyses. The authors conclude that women with diabetes have an increased prevalence of gallbladder disease relative to nondiabetic women and that this association is not explained by the greater adiposity or unfavorable body fat distribution of the diabetic subjects.

Natural history of peptic ulcer disease in Poland. Part VIII. Peptic ulcer disease and diseases of the liver, bile ducts and gallbladder

The data obtained from the databank Ulcer showed that among 5813 patients with peptic ulcer 472 (8.11%) had concomitant liver diseases, and 540 (9.28%) had concomitant disease of the bile ducts. A detailed analysis of the data confirmed the presence of symptoms and signs known to occur in these diseases.

Cholecystocolonic fistula: malabsorptive consequences of lost bile acids

A patient with the painless onset of a cholecystocolonic fistula associated with virtually complete common bile duct obstruction due to stones provided a unique opportunity to assess the consequences of prolonged bile acid depletion on the digestion and absorption of nutrients. Over 2 years, the patient insidiously developed steatorrhea, osteomalacia with an atraumatic pelvic fracture, and congestive heart failure complicated by polymorphic ventricular tachycardia (torsade de pointes) all of which could be attributed to malabsorption of fat and fat-soluble vitamins.

[Bilateral gallbladder rupture after blunt abdominal trauma]

A 65-year-old man under the influence of alcohol sustained blunt trauma to the abdomen in an accident while riding a motorcycle. An intramural haematoma of the gall-bladder was demonstrated by computed tomography: peritoneal lavage was negative. About five hours later the gall-bladder ruptured, as confirmed at laparotomy. The postoperative course after cholecystectomy was uneventful.

[Complicated torsion of the gallbladder. Presentation of a clinical case]

A case of gallbladder torsion complicated by sigmoid volvulus and sub-torsion of the ileus is reported because of the difficulty of diagnosis, conditioned by polymorphic symptomatology, the expression of a variety of causes and contributing causes that play an important role in the greater or less onset of dramatic symptomatology, and because of the rarity of the pathology.

Dysplasia of the gallbladder. Its histogenesis and correlation to gallbladder adenocarcinoma

A total of 50 cases of gallbladder dysplasia found adjacent to carcinoma were examined histologically and immunohistochemically for metaplastic changes in order to elucidate the characteristics of the dysplasia of the gallbladder. The incidence of metaplastic changes in the dysplastic mucosa such as the occurrence of endocrine cells, lysozyme-immunoreactive cells, goblet cells, and Paneth cells were 58%, 74%, 32%, and 22%, respectively. Based on the presence or absence of metaplastic changes, these 50 cases of dysplasia were divided into 40 cases (80%) of metaplastic type dysplasia showing at least one marker of metaplasia and 10 cases (20%) of non-metaplastic type dysplasia showing no metaplasia. On the other hand, these 50 cases of carcinoma were divided into 10 cases of non-metaplastic type carcinoma and 40 cases of metaplastic type carcinoma based on the presence or absence of metaplasia in the tumor tissue. The incidence of metaplastic changes in the dysplastic lesions was compared between the dysplasia adjacent to non-metaplastic type carcinoma and that adjacent to metaplastic type carcinoma. The incidence of metaplasia in the dysplastic mucosa adjacent to metaplastic type carcinoma was higher than that adjacent to non-metaplastic type carcinoma with a statistically significant difference. Moreover, the presence or absence of metaplastic changes was also examined in the surrounding dysplasia and non-tumorous mucosa in each case. Most cases of metaplastic type carcinoma were surrounded by dysplasia with metaplastic changes and by metaplastic epithelium, whereas most cases of non-metaplastic type carcinoma were surrounded by dysplasia without metaplasia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Massive hemoperitoneum caused by spontaneous rupture of the gallbladder during anticoagulant treatment]

The Authors report main complications of anticoagulant treatment. Particularly, they describe a rare case of hemoperitoneum by spontaneous rupture of the gallbladder. They discuss etiopathogenesis and consequent clinico-therapeutic implications.

[Computed tomography of complications of cholecystitis]

In cases of acute cholecystitis, especially with cholecystolithiasis, the diagnosis is usually quickly made. In contrast, the symptoms in the presence of such complications as penetration, perforation and local abscess are often unspecific, and diagnostic procedures may be time-consuming, extending into weeks. One reason for this is the rareness of the entity. The same is true for emphysematous cholecystitis, although this presents with more acute symptoms. Computed tomography seems to be the most effective imaging method. Therefore, it should be used in cases of nonspecific problems in the upper abdomen.

Operative therapy of gallbladder disease in patients with cystic fibrosis

We retrospectively studied 20 patients with cystic fibrosis who underwent surgery for gallbladder disease from 1973 to 1986. A long delay between the onset of symptoms and the diagnosis was noted (mean 7.4 months). This delay was attributed to masking of the symptoms of biliary disease by the malabsorption and pulmonary symptoms seen in this patient population. There was a notable lack of common bile duct disease in our patients as well as in those reported in the literature. This may have been due to a combination of factors: the increased viscosity of the mucus, the small caliber of the gallbladder and ductal system, and the hypotonicity of the gallbladder. We do not recommend routine intraoperative cholangiography in patients with cystic fibrosis and gallbladder disease. Cystic fibrosis is a disease with progressive pulmonary deterioration. Cholecystectomy can be performed in these patients with relative safety if careful preoperative and postoperative care is provided. We recommend early operative intervention in the patient with gallbladder disease and cystic fibrosis.

[Acute obstruction of the pylorus by a gallstone]

The authors describe a case of spontaneous cholecystoduodenal fistula with passage of a stone which caused acute pyloric obliteration. Based on their own experience, they draw attention to some pitfalls of diagnosis and therapy in this relatively rare complication of biliary surgery.

Massive hemoperitoneum from transhepatic perforation of the gallbladder: a rare complication of cholelithiasis

A 74-year-old woman with known cholelithiasis arrived at our emergency department with mild abdominal pain. During investigation she collapsed with abrupt hypotension. A peritoneal tap revealed frank blood. At urgent laparotomy, there were several liters of blood in the peritoneal cavity and two free gallstones, despite an apparently intact gallbladder. We report the second recorded instance of transhepatic perforation of the gallbladder presenting as massive hemoperitoneum.

Bilirubinuria: an early indicator of gallbladder hydrops associated with Kawasaki disease

We report four cases of gallbladder hydrops associated with Kawasaki disease diagnosed over a 7.5 year period. Despite varying clinical presentations, all four of these patients had the common finding of bilirubinuria prior to clinical symptoms or at the time of admission. Review of 40 other cases of Kawasaki disease without evidence of hydrops over this time period revealed that urinalysis had been performed in each and bilirubinuria was present in only one case. Bilirubinuria appears to be an early indicator of hydrops in these patients.

[Percutaneous drainage of fistula-associated abscesses and biliary fistulas]

33 abdominal abscesses associated with fistulae in 31 patients were treated by percutaneous drainage. 19 of these patients had had surgery immediately preceding the drainage. In 64% the percutaneous drainage led to a diagnosis of an internal fistula. Additional therapeutic measures, because of the fistula, were necessary in 45% (operation, biliary drainage, repositioning of catheter). The average duration of drainage was 29 days. 77% of those abscesses which could be drained were treated successfully. Mortality in the entire series was 19%.

[Spontaneous cholecystocolonic fistulas. Presentation of 5 cases]

From 1979 to 1987, 5 patients with cholecystocolonic fistula were operated on in our service, which represents 25% of a total of 20 external biliodigestive fistulas complied over this period. Admission was as an emergency in 4 of the 5 patients (80%), and in one for elective programmed surgery. External biliodigestive fistula was suspected in 3 patients (60%) and biliocolonic fistula in one (20%), on observing aerobilia and leakage of contrast into the hepatic angle of the colon. On two occasions (40%) associated choledocholithiasis was detected, by means of echographic study in one case and intraoperative cholangiography in the other. Antecedents of biliary pathology were present in 3 of our 5 observations (60%), with a mean time of evolution of 12 years.