A Duplicated Gallbladder in a Patient Presenting with Acute Cholangitis. A Case Study and a Literature Review

Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.

Acute cholecystitis and gallbladder perforation leading to massive haemoperitoneum in a patient taking rivaroxaban

We present the case of an 80-year old man taking rivaroxaban for atrial fibrillation who sustained massive intra-abdominal bleeding in the setting of acute cholecystitis. CT scan on admission revealed evidence of active bleeding into the gallbladder lumen and gallbladder perforation. Immediate resuscitation was commenced with intravenous fluids, antibiotics and blood products. Despite attempts to correct coagulopathy, the patient's haemodynamic status deteriorated and an emergency laparotomy was performed, with open cholecystectomy, washout and haemostasis. The patient had a largely uneventful recovery and was discharged on day 11 of admission. Patients with coagulopathies, whether pharmacological or due to underlying disease processes, are at very high risk of severe haemorrhagic complications and subsequent morbidity. As such, prompt recognition and operative management of haemorrhagic perforated cholecystitis is of crucial importance.

Association between dietary intake and postlaparoscopic cholecystectomic symptoms in patients with gallbladder disease

BACKGROUND/AIMS

After cholecystectomy, patients have reported postcholecystectomic syndromes such as abdominal symptoms, dyspepsia, and diarrhea, which suggest a relationship between cholecystectomic symptoms and diet, although the details of this association remain unclear. The present study investigated the hypothesis that dietary intake of nutrients and foods was significantly associated with postcholecystectomic syndromes.

METHODS

Gallstone patients (n = 59) who underwent laparoscopic cholecystectomy were enrolled, and dietary intake and clinical parameters were assessed immediately postcholecystectomy and 3 months later.

RESULTS

There were no significant differences in biochemical measurements or characteristics between symptomatic and asymptomatic patients. Immediately postcholecystectomy, there were no significant differences in consumption of nutrients or foods between symptomatic and asymptomatic patients. However, 3 months after cholecystectomy, symptomatic patients consumed more animal protein, cholesterol, and eggs, and fewer vegetables than did asymptomatic patients. Multivariable-adjusted regression analyses also indicated that the risk for symptoms was positively associated with intake of animal protein, cholesterol, and eggs, but negatively associated with intake of vegetables after adjusting for confounders. In addition, symptomatic patients consumed more bread-based breakfast foods, while asymptomatic patients consumed more rice.

CONCLUSIONS

Postcholecystectomic syndromes were positively associated with intake of cholesterol, animal protein, and eggs, and negatively associated with intake of vegetables, suggesting that diet was plays a role in postcholecystectomic syndromes.

Sex and ethnic/racial-specific risk factors for gallbladder disease

BACKGROUND

Gallbladder disease (GBD) is a highly prevalent condition; however, little is known about potential differences in risk factors by sex and ethnicity/race. Our aim was to evaluate dietary, reproductive and obesity-related factors and GBD in multiethnic populations.

METHODS

We performed a prospective analysis from the Multiethnic Cohort study who self-identified as non-Hispanic White (n = 32,103), African American (n = 30,209), Japanese (n = 35,987), Native Hawaiian (n = 6942) and Latino (n = 39,168). GBD cases were identified using Medicare and California hospital discharge files (1993-2012) and self-completed questionnaires. We used exposure information on the baseline questionnaire to identify exposures of interest. Associations were estimated by hazard ratios and 95% confidence intervals using Cox models adjusted for confounders.

RESULT

After a median 10.7 years of follow-up, there were 13,437 GBD cases. BMI over 25 kg/m2, diabetes, past and current smoking, red meat consumption, saturated fat and cholesterol were significant risk factors across ethnic/racial populations (p-trends < 0.01). Protective factors included vigorous physical activity, alcohol use, fruits, vegetables and foods rich in dietary fiber (p-trends < 0.01). Carbohydrates were inversely associated with GBD risk only among women and Latinos born in South America/Mexico (p-trend < 0.003). Parity was a significant risk factor among women; post-menopausal hormones use was only associated with an increased risk among White women (estrogen-only: HR = 1.24; 95% CI = 1.07-1.43 and estrogen + progesterone: HR = 1.23; 95% CI = 1.06-1.42).

CONCLUSION

Overall, dietary, reproductive and obesity-related factors are strong risk factors for GBD affecting men and women of different ethnicities/races; however some risk factors appear stronger in women and certain ethnic groups.

Rupture of hepatic hemangioma with hemoperitoneum due to spontaneous gallbladder perforation: A unique case report

INTRODUCTION

Hemangiomas are common benign tumors of the liver. Spontaneous rupture is a rare complication, occurring most commonly in giant hemangiomas. Rupture of a hemangioma with hemoperitoneum is a serious development and can be fatal if not managed promptly.The present study reports the unique case of a man who experienced rupture and hemorrhage of a hepatic hemangioma (HH) due to perforation of the gallbladder fundus. After en block resection of the hemangioma and gallbladder using the Pringle maneuver, the patient made an uneventful recovery without complications.To our knowledge, spontaneous rupture of HH secondary to gallbladder perforation has not been reported in the literature. This case highlights a unique, rare cause of ruptured HH and the need to consider appropriate treatment for some hemangiomas to avoid this potentially fatal complication.

CONCLUSION

The current case may provide additional support for treatment of HH due to the potential for spontaneous rupture. For patients with ruptured HH, enucleation with the Pringle maneuver is recommended.

Portal biliopathy

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).

Diagnosis of fasciola hepatica cases in an operating room

Fascioliasis is a zoonotic disease that is acquired by ingestion of the metacercaria form on uncooked aquatic plants, and humans act as an accidental host. Diagnosis is confirmed by the demonstration of the parasites or evidence of them in faeces and serology. In the absence of these data, delays or misdiagnosis may occur since it may mimic many diseases. In this study, we present three cases, among them two were similar to the above-mentioned statement. The first case, to the best of our knowledge, is the first case with adult-type living fluke in the gall bladder, diagnosed by laparoscopic cholecystectomy.

Gallbladder bleeding-related severe gastrointestinal bleeding and shock in a case with end-stage renal disease: A case report

Gallbladder (GB) bleeding is very rare and it is caused by cystic artery aneurysm and rupture, or GB wall rupture. For GB rupture, the typical findings are positive Murphy's sign and jaundice. GB bleeding mostly presented as hemobilia. This is the first case presented with severe GI bleeding because of GB rupture-related GB bleeding. After comparing computed tomography, one gallstone spillage was noticed. In addition to gallstones, uremic coagulopathy also worsens the bleeding condition. This is also the first case that patients with GB spillage-related rupture and bleeding were successfully treated by nonsurgical management. Clinicians should bear in mind the rare causes of GI bleeding. Embolization of the bleeding artery should be attempted as soon as possible.

TOTAL COST OF HOSPITALIZATION OF PATIENTS UNDERGOING ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY RELATED TO NUTRITIONAL STATUS

BACKGROUND

In the Western world, the population developed an overweight profile. The morbidly obese generate higher cost to the health system. However, there is a gap in this approach with regard to individuals above the eutrofic pattern, who are not considered as morbidly obese.

AIM

To correlate nutritional status according to BMI with the costs of laparoscopic cholecystectomy in a public hospital.

METHOD

Data were collected from medical records about: nutritional risk assessment, nutricional state and hospital cost in patients undergoing elective laparoscopic cholecystectomy.

RESULTS

Were enrolled 814 procedures. Average age was 39.15 (±12.16) years; 47 subjects (78.3%) were women. The cost was on average R$ 6,167.32 (±1830.85) to 4.06 (±2.76) days of hospitalization; 41 (68.4%) presented some degree of overweight; mean BMI was 28.07 (±5.41) kg/m²; six (10%) individuals presented nutritional risk ≥3. There was a weak correlation (r=0.2) and not significant (p <0.08) between the cost of hospitalization of the sample and length of stay; however, in individuals with normal BMI, the correlation was strong (r=0,57) and significant (p<0.01).

CONCLUSION

Overweight showed no correlation between cost and length of stay. However, overweight individuals had higher cost of hospitalization than those who had no complications, but with no correlation with nutritional status. Compared to those with normal BMI, there was a strong and statistically significant correlation with the cost of hospital stay, stressing that there is normal distribution involving adequate nutritional status and success of the surgical procedure with the consequent impact on the cost of hospitalization.

Diabetes mellitus and the risk of gallbladder disease: A systematic review and meta-analysis of prospective studies

BACKGROUND

Diabetes has been hypothesized to increase the risk of gallbladder disease based on the observation that obesity and insulin resistance are associated with gallbladder disease. Although several studies have investigated the association between a diabetes diagnosis and risk of gallbladder disease, the results have not been entirely consistent. For this reason we conducted a systematic review and meta-analysis of the available cohort studies.

MATERIALS AND METHODS

We searched the PubMed and Embase databases for studies of diabetes and gallbladder disease (defined as gallstones, cholecystectomy, or cholecystitis) up to January 9th 2015. Prospective studies were included if they reported relative risk estimates and 95% confidence intervals of gallbladder disease associated with a diabetes diagnosis. Summary relative risks were estimated by use of a random effects model.

RESULTS

We identified 10 prospective studies that could be included in the meta-analysis which included 223,651 cases among 7,365,198 participants. The summary RR for diabetes patients was 1.56 (95% CI: 1.26-1.93, I(2)=99.4%, pheterogeneity<0.0001). The results persisted when stratified by gender, and in most subgroup analyses and there was no heterogeneity among studies with more than 10 years duration of follow-up. There was no evidence of publication bias.

CONCLUSIONS

Our analysis provides further support for an increased risk of gallbladder disease among diabetes patients.

[Renal hemodynamic in hydronephrosis concurrent with hepatobiliary system disorders, its dynamics in the course of treatment]

This article examines measurements of renal vascular ultrasound in 85 patients with hydronephrosis concurrent with disorders of the gallbladder and biliary tract, depending on severity and dynamics during treatment. The estimation of blood flow changes depending on applied renoprotective and hepatoprotective therapy is provided.

[Coincidence of colonic lymphoma and gallstone ileus - case report]

INTRODUCTION

Primary colonic lymphoma is a very rare malignant disease of the gastrointestinal tract, accounting for 14% of all malignant diseases in this location. It is classified in the group of extranodal lymphomas; its long-term asymptomatic progression makes it different from common colorectal carcinomas making its diagnosis very difficult, more often accidental. Gallstone ileus is quite an uncommon complication of cholecystolithiasis diagnosed with difficulty. Up to 50% of cases are diagnosed during surgery. The obturated location depends on the size of the stone, location of the conjunction between the biliary and gastrointestinal tracts, and also on any preexisting stenosis due to another unknown pathology.

CASE REPORT

We present a case of an 86-year-old man treated for acute diverticulitis with typical clinical symptoms. Following further examination (colonoscopy, computed tomography) revealed a tumour-like infiltration in the sigmoid colon wall and a voluminous polyp was suspected according to the colonoscopy. Computed tomography described an obstruction by a biliary stone tumbling through the cholecystocolonic fistula. Subsequent biopsy supported the suspected malignant etiology. The patient underwent resection of the sigmoid colon sec. Hartmann; an infiltration was found in the subhepatic space, which corresponded to the described fistulisation between the biliary tract and the colon. A large 40 mm gallstone was found in the resected sigmoid colon over the stenosis and the bowel wall showed diffuse thickening with several polyps; final histopathological assessment confirmed malignant lymphoma of the plasmocytoma type. No serious complications occurred in the postoperative period; after healing, the patient was transferred to hematooncology care.

CONCLUSION

The article describes the presence of two rare diseases - colonic lymphoma and gallstone ileus. Clearly, without the biliary stone obstruction in the preexisting tumorous stenosis in the sigmoid colon, the malignant hematooncology disease would not have been diagnosed.

KEY WORDS

primary colonic lymphoma - gallstone ileus - complication of the cholecystolithiasis - extranodal lymphoma - acute diverticulitis.

Left-sided Gallbladder in the Era of Laparoscopic Cholecystectomy: A Single-center Experience

The malposition of gallbladder under the liver segment III, defined as left-sided gallbladder (LSG), is an unexpected situation for the laparoscopic surgeon. The purpose of this study is to present our experience in treating patients with cholecystitis and LSG discovered incidentally during laparoscopic surgical procedure. Between 1993 and 2009, 5569 patients underwent laparoscopic cholecystectomy in our surgical department. Their records were reviewed and seven patients revealed having LSG (0.12%). Analysis parameters included demographic data, diagnostic methods, mode of surgery, and postoperative outcome. Mean follow-up was 140 months. Of the seven patients, five were women. Mean patient age was 56.7 years. All patients were referred to our department with clinical symptoms of classic cholelithiasis and the diagnosis was established in all of them during surgery. Laparoscopic cholecystectomy was successful in five patients, while in two patients, a conversion to open procedure was needed. A postoperative complication, i.e., biliary leakage was registered in one patient, which was treated successfully. Laparoscopic cholecystectomy is safe even in LSG, but the surgeon must consider the possibility for more anatomical anomalies, adjust the technique of dissection, and must not hesitate, if in doubt, to strive for conversion to open procedure to avoid serious complications.

Sonographic Diagnosis of Complicated Cholecystitis

OBJECTIVES

Early detection of the complications of cholecystitis is important for clinical management, yet only a small percentage of patients have a correct diagnosis before surgery. The purpose of our study was to identify sonographic findings that are associated with complicated cholecystitis.

METHODS

Sonographic, surgical, and pathologic reports were reviewed for 70 patients who underwent early cholecystectomies from January 2010 to August 2014. Sonograms were assessed for 16 independent variables. Statistical analyses were performed to evaluate associations between various sonographic features and complicated cholecystitis.

RESULTS

Sonographic signs associated with complicated cholecystitis (P< .05) were a greater short-axis gallbladder diameter (mean, 4.4 versus 4.0 cm), a greater mean wall thickness (5.6 versus 4.2 mm), and the likelihood of wall striations, gallbladder echogenic content, pericholecystic free fluid, and local inflammatory fat changes. Specific sonographic signs, such as sloughed intraluminal membranes, were detected in a small percentage of cases (10%). None of the sonographic features evaluated in this study was found to be sensitive and specific enough to indicate complicated cholecystitis. In most cases, sonograms reflected severe inflammation, with multiple sonographic signs.

CONCLUSIONS

Although multiple sonographic signs are associated with complicated cholecystitis, none of them is sensitive and specific enough to definitively diagnose it. Sonograms usually reflect severe inflammation, with numerous sonographic signs. Thus, in the right clinical context, sonograms of severe cholecystitis should alert radiologists to the possibility of complications.

Safety and efficacy of a laparoscopic cholecystectomy in the morbid and super obese patients

BACKGROUND

Although a laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis, its safety and efficacy in the morbidly/super obese patients is unknown. The aim of this study was to investigate the safety and efficacy of an elective LC in the morbid/super obese patients.

METHODS

A retrospective review of the hospital electronic database and medical records was conducted searching for all elective LC from 2010 to 2013. The data collected included patient demographics and body mass index (BMI), length of hospital stay (LOS), duration of surgery (DOS), intra- and post-operative complications, bile duct injuries, performance of an intra-operative cholangiogram, the incidence of open conversion and the seniority of the operator.

RESULTS

A total of 799 patients (76% female) with a mean age of 46 years and BMI of 31 were included in this study. There were significant differences in the median DOS between the three BMI groups; BMI < 26 [64 min; interquartile range (IQR) 54-83]; BMI 26-40 (72 min, IQR 58-91) and BMI > 40 (82 min, IQR 63-104), P < 0.001. There were no statistically significant differences in the LOS, peri-operative complication rates, open conversions or bile duct injuries among the BMI groups.

CONCLUSIONS

This study showed that LC can be performed safely in the morbid/super obese patients.

True left-sided gallbladder with variations of bile duct and cholecystic vein

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

[Acute abdominal surgery in pregnancy - as viewed by the surgeon]

INTRODUCTION

Acute abdomen during pregnancy presents very specific problem on the boundary of surgery and gynaecology. Although gynaecologists provide healthcare to pregnant women, surgery indication because of acute abdomen during pregnancy should be done by surgeon (who has usually little knowledge and experience regarding pregnant women examination and management). There is therefore real opportunity for possible mistakes origin with serious consequences for mother and foetus.

METHODS

Literature search in PubMed was done aimed at studies within the last 10 years dealing with appendectomy, cholecystectomy and laparoscopy during pregnancy in the context of acute abdomen. Surgical interventions done from obstetrics indications were excluded.

RESULTS

Pregnancy is associated with many anatomical and physiological changes which have to be considered not only during clinical examination, but also when analysing laboratory findings and considering operative tactics. Imaging modalities employment during pregnancy is very limited due to harmful effect of ionising radiation and not clear impact of strong magnetic field on the foetus. Timing of surgical interventions because of acute abdomen during pregnancy should be the same as timing of acute abdomen interventions in non-pregnant patients. Minimally invasive surgery in acute abdomen during pregnancy presents standard technique nowadays. Many advantages of laparoscopic approach (lower rate of surgical site infections, quicker convalescence etc.) are valid also during pregnancy.

CONCLUSION

Acute abdomen during pregnancy should be managed within a multidisciplinary cooperation between gynaecologist, surgeon, anaesthesiologist and neonatologist. With respect to results of published studies, laparoscopic approach in the management of acute abdomen during pregnancy should be considered safe and effective.