Sonographic pattern of gallbladder disease in children with sickle cell anaemia

A prospective analysis of ultrasound examinations of the gallbladder in 161 children with sickle cell anaemia revealed cholelithiasis in 7 cases (4.2%). Biliary sludge was present in 12 cases (7.5%). The commonest abnormality noted was gallbladder wall thickening seen in 13 patients (8.1%). The age range of patients studied was 2 1/2 months to 16 years with a mean of 7.96 years. The youngest age for development of cholelithiasis was 10 years while biliary sludge was noted earliest at 5 years. Gallbladder wall thickening appeared as early as 4 years. Dietary and environmental factors are probably responsible for the low incidence of cholelithiasis in Africans with sickle cell anaemia. The low incidence of cholelithiasis in the African child with this disease does not justify routine and follow-up ultrasound scans in all cases with sickle cell anaemia.

Chronic acalculous gallbladder disease: a clinical variant

A review of 228 cholecystectomies done over a two-year period revealed 15 cases (6.6%) in which gallstones were absent. These 15 patients were all characterized by colicky abdominal pain in the right upper quadrant, with a mean duration of eight months. Ultrasonographic examination was falsely positive for gallstones in one third (5/15) of the patients, and further diagnostic evaluation in the remaining two thirds (10/15) failed to define a clear-cut surgical problem. All 15 patients ultimately had operation on the basis of symptoms. Every patient reported resolution of preoperative symptoms at short-term follow-up (four to eight weeks). Seven patients available for long-term follow-up (ten to 27 months) reported complete symptomatic resolution. The postoperative outcome failed to correlate reliably with gallbladder histology, bile cultures, and results of diagnostic testing. There was no mortality, and morbidity was limited to three patients. This series confirms previous reports of a small set of relatively young, healthy patients having chronic disabling symptoms of gallbladder disease in the absence of gallstones. Our results suggest that the most reliable factor predicting a successful outcome of cholecystectomy in these patients was the presence of severe biliary colic.

Diffuse papillomatosis of the gallbladder complicated with tuberculosis

A rare case of diffuse papillomatosis of the gallbladder complicated with tuberculosis is reported. The mucosa of the gallbladder displayed a diffuse papillary pattern composed of excrescences that varied in size and height. The proliferative glands contained many Paneth cells, and the diffuse papillomatosis appeared to be derived from metaplastic-type epithelium. Tuberculous granulomas were observed in the serous layer of the gallbladder. The relationship between diffuse papillomatosis and tuberculosis of the gallbladder is discussed.

Carcinoma in a true diverticulum of the gallbladder

Extensive search of the literature reveals the extreme rarity of true diverticulum of the gallbladder. Its frequency varies from 0.0008% of all resected gallbladders at the Mayo Clinic to 0.06% of a series of congenital anomalies of the gallbladder collected from the world literature. We are presenting a case of a true diverticulum of the gallbladder with sonographic demonstration and focal malignant alterations, neither one of which has been reported previously. The difference between true and false diverticula of the gallbladder is discussed.

Hepatobiliary disorders presenting as fever of unknown origin in Cairo, Egypt: the role of diagnostic ultrasonography

Among 130 patients with fever of unknown origin (FUO) studied from 1981 to 1985, 34 were diagnosed as having hepatobiliary disorders: amoebic liver abscess (11), pyogenic liver abscess (4), hepatic hydatid cysts (2), hepatic fascioliasis (2), tuberculous hepatic granulomas (1), chronic calcular cholecystitis with recurrent cholangitis (2), chronic active hepatitis (2), hepatocellular carcinoma (3), lymphoma involving the liver (4) and hepatic metastasis in (3) cases. Hepatobiliary disorders were the cause in 27% of FUO seen during 4 years.

Changing trends in surgery for benign gallbladder disease

Hospital charts and notes of 2181 consecutive cholecystectomies performed between 1969 and 1984 were computer analyzed. They were divided into three categories of patients operated on 5, 10, and 15 yr ago. The trends of change throughout this period were as follows: 1) The population operated on in the last 5 yr is older, the proportion of males, especially over 70-80 yr old, and diabetics, is growing constantly. 2) The frequency of acalculous cholecystitis and gangrenous changes increase; the same is true for common bile duct pathology and positive bile cultures. 3) There is a marked decrease in hospitalization time, postoperatively, without significant increase in rate of wound infection and thromboembolic phenomena, or mortality. It seems that there is no change in the frequency of gallstone-related pancreatitis and perforations of gallbladder. The same is disappointingly true for positive choledochal exploration index. We think that the subcostal approach, with rational prophylactic and therapeutic antibiotic regimen, contribute to the shortening of hospitalization time and the fixed rates of wound infection and herniae in scar. Prophylactic heparin given subcutaneously seems to avoid possible thromboembolic phenomena.

Diagnosis of nontraumatic hematobilia by computerized tomography of the abdomen

Hematobilia was diagnosed by computerized tomography as the cause of gastrointestinal bleeding in a 73-yr-old man. The patient suffered from recurrent abdominal pain for 4 yr and presented with a history of episodic hematochezia over the previous 24 h, suggestive of significant lower gastrointestinal bleeding. Endoscopic evaluation of the lower and upper gastrointestinal tract revealed only blood in the region of a normal ampulla. Computerized tomography demonstrated a thickened gallbladder filled with material the density of blood. A blood-filled gallbladder was removed at cholecystectomy and pathological examination of the excised gallbladder demonstrated ulceration and inflammation of the mucosa. The diagnostic evaluation of hematobilia is discussed.

Gallbladder disease in patients with primary sclerosing cholangitis

We evaluated the gallbladders of 121 patients who had well-documented primary sclerosing cholangitis. Sonograms, cholangiograms, and CT scans were reviewed, and the findings were correlated with surgical or autopsy findings, when available. Pathologic examination of the gallbladder was available in 55 (45%) of the 121 patients; of these, 49 (89%) had abnormal gallbladders. Ninety-three of the 121 patients had one or more radiologic examinations of the gallbladder: 77 had sonograms, 80 had cholangiograms, and 18 had CT scans. Seventy-five (62%) of the 121 patients had abnormal gallbladders on histologic examination or had positive findings on one or more imaging study. By excluding 25 patients who had histologic changes of borderline significance and/or patients who had thick-walled gallbladders attributable to end-stage liver disease, we concluded that 50 (41%) of the 121 patients had intrinsic abnormalities of the gallbladder. Thirty-two (26%) had gallstones, 18 (15%) had probable primary sclerosing cholangitis involving the gallbladder, and five (4%) had benign or malignant neoplasms. Our study indicates that gallbladder abnormalities are common among patients with primary sclerosing cholangitis, and sonography is the most useful technique for evaluating these conditions.

[Spontaneous bacterial peritonitis in a patient with congenital hepatic fibrosis and Caroli's disease]

The authors describe by the first time in the literature a patient with congenital hepatic fibrosis and Caroli's disease complicated by spontaneous bacterial peritonitis. The possible routes of ascitic infection are discussed.

Gallbladder perforation. An imaging analysis

We evaluated the radiologic studies of 23 patients with surgically or autopsy-documented gallbladder perforation. Extravasation was shown by cholescintigraphy and cholangiography in seven patients and corresponded to free perforation or large pericholecystic loculation. In 16 patients, ultrasonography and computed tomography detected fluid and abscesses outside the gallbladder ranging from 1 to 2 mm pericholecystic fluid collections to large phlegmonous masses. A right, upper-quadrant mass on plain films and scattered calcification in this area suggested perforation. Gallbladder perforation could be diagnosed or suspected preoperatively in ten patients and antemortem in 22 of 23 individuals. This rate of recognition, higher than previously reported, may be ascribed in part to improvements in biliary imaging.

Coexistence of gallbladder disease and morbid obesity

To further investigate the relationship between gallbladder disease and morbid obesity, 92 morbidly obese patients underwent routine cholecystectomy at the time of their bariatric procedures. The preoperative ultrasonographic findings were positive in only 20 patients. Of the 92 patients who underwent cholecystectomy, 87 (95 percent) had pathologic evidence of gallbladder disease. This included cholecystitis, cholesterolosis, cholelithiasis, or some combination of the three. The incidence of postoperative cholecystitis, the technical difficulty of reoperation, the unnecessary expense and exposure to a second hospitalization and a second operation are all completely eliminated when routine cholecystectomy is performed in concert with elective bariatric procedures.

[Intramural diverticulosis and cancer of the gallbladder]

Two cases of gallbladder carcinoma occurring in intramural diverticulosis (adenomyomatosis) are reported. The first was adenocarcinoma associated with cholesterolosis without gallstone formation. The second was squamous cell carcinoma. Four other carcinomas developing on diverticulosis were reported in the literature, none of them being squamous cell carcinoma. Our cases and those of the literature show that diverticulosis, a benign condition, can be associated with carcinoma which can make the pathological diagnosis difficult.

Neonatal gallbladder enlargement and alpha 1-antitrypsin deficiency

Patients with clinical signs of alpha 1-antitrypsin deficiency in the neonatal period usually present with prolonged obstructive jaundice. We report a patient with alpha 1-antitrypsin deficiency who presented with gallbladder enlargement in the neonatal period. This gallbladder enlargement may be due to cystic duct hypoplasia or atresia, which has been reported in association with alpha 1-antitrypsin deficiency. The diagnosis of alpha 1-antitrypsin deficiency should be considered in neonates with gallbladder enlargement and prolonged obstructive jaundice.

Gastric outlet obstruction due to gall stones (Bouveret syndrome)

Gastric outlet obstruction by gall stone is a rare complication of a common disorder. Two cases are reported here. The investigations are conducted along the same lines as for pyloric stenosis. The diagnosis can be made with a barium meal or gastroscopy. Treatment is by surgical intervention after adequate resuscitation.

Somatostatinomas, PPomas, neurotensinomas

We have reviewed data pertinent to three tumor syndromes that derive from overproduction of three GEP peptide hormones. The clinical syndrome of somatostatin excess remains well defined with diabetes, diarrhea, steatorrhea being predominant features. With the availability of assays and increasing awareness, more cases are being diagnosed in the intestine and these differ somewhat in their presentation with cholecystitis, GI bleeding, or a mass as the cardinal features. An unusual association with MEN II pheochromacytoma and neurofibromatosis is emerging. PPomas remain enigmatic. Although diarrhea is a feature, these tumors are usually silent and present with hypatomegally, abdominal pain, and jaundice because of the large size and malignant nature. Neurotensinomas remain rare and truly difficult to separate from the symptom complex produced by VIP excess. Edema, hypotension, cyanosis and flushing should alert one to the possibility of a neurotensin-secreting tumor.

[Extended, combined and associated resection of the liver]

The authors describe their observations of 227 patients after operations for focal lesions of the liver. Radical operations were performed on 93 patients, 61 being subjected to extended, combined and associated resections of the liver. Most operations were made as atypical resections of the liver. In order to reduce the operation blood loss the authors recommend to fulfil temporary exclusion of the liver from blood circulation by compression of the hepato-duodenal ligament. The temporary external drainage of bile ducts is recommended as a preventive measure against post-operative bile peritonitis. Postoperative lethality after extended, combined and associated resections of the liver was 9.8%.