The burden of incidental findings in clinical practice in a tertiary care center

BACKGROUND

To evaluate the prevalence and clinical burden of serendipitously discovered abnormalities in hospitalized patients, unrelated to their presenting symptoms and physical signs.

METHODS

A total of 478 patients consecutively admitted in the Department of Medicine were enrolled in the study. In the end of first diagnostic work-up, the previously undetected imaging or endoscopic asymptomatic abnormalities termed as incidental findings (IFs) were recorded and some of them were further investigated.

RESULTS

One hundred thirty eight (28.8%) patients had IFs. The most common IFs were located in the kidney and genitourinary system followed by liver and gallbladder. The most common method of detection of IFs was ultrasonography (US) of the abdomen. The patients with IFs compared with those without, were older (P=0.007), had no previous hospitalizations (P<0.001) and stayed longer in the hospital (P<0.001). The 25 (18.1%) patients with IFs were not evaluated further. One hundred seventy seven IFs discovered in 113 patients were further evaluated by medical specialists and additional tests were performed if warranted. In the end of the diagnostic work-up, in a total of 113 patients with IFs, 78.7% had insignificant and 21.2% potentially significant IFs. The latter group had higher rate of IFs compared with the former group, usually more than 3 (P=0.017).

CONCLUSIONS

IFs were prevalent in a hospital population. Hospitalized patients with IFs were more than 60 years old and had no previous hospitalization. A large number of IFs were potentially significant deserving further clinical management.

Gallbladder perforation: a rare complication of acute cholecystitis

Gallbladder perforation is a rare but potentially fatal disease and therefore is a dilemma for early diagnosis. It is usually a complication of acute cholecystitis with or without gallstones. We present a case of 70-year-old female with abdominal pain and fever. Initial ultrasound revealed cholelithiasis with possible acute cholecystitis. Clinical condition of the patient worsened and suspicion of gallbladder perforation was entertained. Hence, a repeat ultrasound and CT scan was done. Following this a gallbladder perforation was confirmed intra operatively.

[Features of diagnosis and clinics of gallbladder cholesterosis in children]

Cholesterosis in childhood--this is a new poorly studied disease, which only begins to highlight in current literature. According to this our work was to study the clinical characteristics and to develop diagnostic criteria of gall bladder cholesterosis in children.

MATERIALS AND METHODS

66 children with cholesterosis gall bladder at the age of 1 year to 15 years were under the supervision. There were 30 girls and 36 boys. The diagnosis was confirmed in the performance of transabdominal ultrasound examination and endoscopic (transesophageal) ultrasonography, magnetic resonance tomography. The cholesterosis of the gall bladder was confirmed by histological examination of the gall bladder wall at 41 children. This article describes the clinical course of gall bladder cholesterosis in children. It was shown an importance of laboratory and instrumental methods of investigation. It was presented an algorithm of children diagnostics and monitoring with gallbladder cholesterosis.

[Causes of functional digestive disorders and therapeutic approach in primary care medicine]

Functional diseases of digestive tract are an ubiquitary problem of diagnosis and treatment for ambulatory care services. Its evolution is chronicle but there are no organic lesions for the beginning. Nevertheless, it impairs quality of life and creates many days of incapacity of work.

MATERIAL AND METHOD

We studied 1118 cases with digestive malfunctions, selected from the patients consulted on Ambulatory Care Unit--Internal Medicine, 2007-2008.

RESULTS

Basal clinical and laboratory explorations classified the type of digestive malfunctions according to international criteria. So we found these types of anomalies: gastro-oesofagial reflux--788 cases; peptic-like syndrome--752 cases; pyloric functional spasm--385 cases; helicobacter pyloridi positive--632 cases; gallblader dysfunction--767 cases; irritable bowel syndrome--872 cases. The treatment was applied pursued the pathological status. Most of cases had un diagnosticated diseases as peptic ulcer, gastritis, gallbladder diseases.

CONCLUSIONS

Our conclusions are that the whole tract has continuity and the site of dysfunction is difficult to diagnose from the beginning. Pro-kinetic drugs and inhibitory of gastric secretion have very good results. The same time we must treat the "background"--extra digestive factors (i.e., Helicobacter pylori infection).

[Torsion of the gallbladder]

An 18-year-old male presented at the casualty department with acute right upper abdominal pain. Laboratory examinations showed no abnormalities apart from a mildly elevated leukocyte count. Ultrasound examination revealed hydrops of the gallbladder, with thickening of the wall, with no indication of gallstones. Laparoscopy revealed a necrotic gallbladder due to torsion. The gallbladder was successfully removed. Torsion of the gallbladder is a rare condition, in which the organ twists on its longitudinal axis. It is found primarily in patients under 18 years or over 65 years of age. Laboratory and radiological investigations usually reveal non-specific abnormalities, which means that a correct diagnosis is made preoperatively in < 10% of patients. Treatment of choice is an emergency cholecystectomy. The prognosis is excellent with adequate treatment.

Diagnosis and laparoscopic approach to gallbladder torsion and cholelithiasis

Torsion of the gallbladder is common in elderly women. Different causes have been proposed for this rare condition. The presence of a long mesentery and loss of visceral fat are the main causes for the development of torsion. Patients present with a sudden, acute pain in the right upper quadrant, suggesting cholecystitis. Different imaging methods have shown particular findings, but the diagnosis is still complex. Today, just a few cases have been reported in the literature. The treatment for this condition consists of surgical detorsion and cholecystectomy. Gallbladder torsion is a very rare entity and should be suspected when these clinical findings are present.

[Clinical and morphological features of gallbladder cholesterosis in children]

Although that the first reports of cholesterosis gall bladder were in the second half of the XIX century, there is still insufficient information about the frequency of its detection in children. According to some researchers, this disease was detected in patients aged 13 to 14 years. In other periods of childhood gallbladder cholesterosis is considered to be casuistic rarity. Multiyear study conducted by the authors in the study of diseases of biliary tract showed that almost a third of children had combined with cholelithiasis with gallbladder cholesterosis. However, prior to cholecystectomy is diagnosed only 5% of children. In connection with this the aim of our work was to learn the peculiarities of the clinical picture and morphological changes in children at gallbladder cholesterosis. Material and methods. There were observed 54 children with gallbladder cholesterosis (GBC) aged from 1 year to 15 years (20 girls, 34 boys) . The diagnosis was confirmed histologically in the walls of GB. Gallbladder cholesterosis was differentiated from polyps and concrements of GB in the performance of traditional and endoscopic ultrasound. According to testimony performed endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging of the abdominal cavity. The material was processed statistically using a specially program developed by Medstat. Results. There were showed clinical course features and morphological picture of the gallbladder wall. There were brought the attention of pediatricians to the reversibility of the pathological process in childhood, which suggests alternative methods of treatment in gallbladder cholesterosis the in children--traditional treatment.

Laparoscopic management of cholecystoenteric fistulas

BACKGROUND

Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-5% of patients with cholelithiasis. Most fistulas are diagnosed intraoperatively.

MATERIALS AND METHODS

Between January 1997 and June 2003, 12428 patients underwent laparoscopic cholecystectomy at our department. Cholecystoenteric fistula was diagnosed intraoperatively and treated in 63 patients: 45 patients (71.4%) had cholecystoduodenal fistulas, while cholecystogastric and cholecystocolic fistulas were found in 9 patients (14.3%) and 4 patients (6.3%), respectively; and 5 patients (7.9%) were found to have Mirizzi syndrome type I along with a cholecytoenteric fistula. The operation could be completed laparoscopically in 59 patients. An endostapler was used in 47 patients to transect the fistula and in 12 patients the defect in the bowel was repaired with intracorporeal sutures.

RESULTS

Major morbidity occurred in 3 patients (4.76%). One patient developed a loculated subdiaphragmatic collection which was treated by ultrasound guided aspiration and antibiotic therapy. Prolonged biliary drainage occurred in 2 patients. In addition, 7 patients (11.11%) had minor postoperative complications. The mean postoperative hospital stay was 5.2 days. All the patients are asymptomatic at a mean follow-up of 2.4 years.

CONCLUSION

Cholecystoenteric fistula is a difficult problem usually diagnosed intraoperatively. A high degree of suspicion at operation is mandatory. A stapled cholecystofistulectomy may be the procedure of choice since it avoids contamination of the peritoneal cavity. Complete laparoscopic management of cholecystoenteric fistulas is possible in well-equipped high-volume centers.

Heterotopic pancreatic tissue obstructing the gallbladder neck: a case report

CONTEXT

Heterotopic pancreatic tissue is defined as pancreatic tissue outside the boundaries of the pancreas that has neither anatomic nor vascular continuity with the pancreas. Heterotopic pancreatic tissue in the gallbladder is uncommon and has rarely been reported to cause symptoms. We report a case of heterotopic pancreatic tissue obstructing the gallbladder neck resulting in cholecystitis.

CASE REPORT

A 26-year-old female presented with right upper quadrant abdominal pain and fever. On physical examination the right upper quadrant was tender to palpation with a positive Murphy's sign. Laboratory tests were significant for elevated aspartate aminotransferase and alanine aminotransferase. Transabdominal sonography showed gallbladder wall thickening, a positive sonographic Murphy's sign, and an apparent large non-mobile stone at the gallbladder neck. Pathologic examination revealed cholecystitis but instead of a large stone there was a tan-yellow necrotic mass at the gallbladder neck. Microscopically, the mass consisted of heterotopic pancreatic tissue containing exocrine pancreatic acini, ducts, and islets of Langerhans. The final diagnosis was acute cholecystitis secondary to obstruction by heterotopic pancreatic tissue.

CONCLUSION

Although heterotopic pancreatic tissue is usually an incidental finding on pathologic exam, one should not exclude it in the differential diagnosis of symptomatic gallbladder disease of indefinite etiology.

Should we perform surgical management in all patients with suspected porcelain gallbladder?

BACKGROUND/AIMS

Porcelain gallbladder has generally been regarded as a risk factor for gallbladder cancer. This study was designed to clarify the association between porcelain gallbladder and cancer by analysis of clinicopathological features of patients who underwent surgery for suspected porcelain gallbladder.

METHODOLOGY

From January 2002 to December 2008, 3159 cholecystectomies were performed at Ajou University Medical Center. Twelve patients were preoperatively diagnosed with suspected porcelain gallbladder. To examine the association between gallbladder calcification and cancer, patients who were histopathologically diagnosed with either gallbladder calcification or cancer were also reviewed.

RESULTS

According to final pathology, 44.3% of patients showed porcelain gallbladder. During the study period, calcification of gallbladder wall was identified in 9 patients (0.2%). The mean age was 54.6 +/- 15.0 years (range, 30-75). The female-to-male ratio was 3.5:1. However, preoperative porcelain gallbladder was diagnosed in 5 patients. Eight of 9 patients underwent LC, whereas the remaining one patient underwent laparoscopic-assisted distal gastrectomy. Interestingly, there was no patient with a diagnosis of both porcelain gallbladder and cancer.

CONCLUSIONS

We found that preoperative diagnosis of porcelain gallbladder was difficult. Moreover, there was no association between porcelain gallbladder and cancer. Therefore, when porcelain gallbladder is suspected, surgeons should decide operation, based on the symptoms rather than the possibility of coexistence of gallbladder cancer.

[Acute torsion of the gallbladder--case report]

Torsion of gallbladder is simply defined as a rotation of the gallbladder on its mesentery along the axis of the cystic duct and the cystic artery. It is rare disease which etiology it's still unknown. However we can point some factors postulated as playing causative roles. This disease symptoms mimic acute cholecystitis. In spite of advanced radiological imaging technics there are still problems to set up correct preoperative diagnosis of gallbladder torsion.

[Xanthogranulomatous cholecystitis associated with a suspicious colonic fistula and its spontaneous resolution]

Fistula between the gallbladder and colon is a rare condition. Even more infrequent is spontaneous resolution of the fistula. We encountered a case of cholecystocolic fistula associated with xanthogranulomatous cholecystitis (XGC) that was diagnosed definitively using CT, MRI, and colonoscopy. An 82-year-old woman with no remarkable medical history presented with fever and right hypochondralgia that had continued for 8 days. Abdominal ultrasound showed a hyperechoic area as air in the lumen of the gallbladder with a hypertrophic wall. Contrast-enhanced CT, with the peripheral layer enhanced homogeneously by contrast medium, indicated air in the gallbladder with a thickened wall. Furthermore, MRI and colonoscopy revealed a fistula between the gallbladder and transverse colon strongly suggested. Those findings suggested cholecystocolic fistula associated with XGC. The patient was treated initially by administration of antibiotics, while fasting. Unfortunately, surgical specimens did not show the fistula, thus it was decided that the existence of cholecystocolic fistula with spontaneous resolution were highly suspected by the clinical course and imaging in this patient.

Emergent right upper quadrant sonography

OBJECTIVE

The purpose of this presentation is to review the sonographic spectrum of disease entities evaluated by right upper quadrant (RUQ) sonography on an emergent basis.

METHODS

Right upper quadrant sonography was performed on an emergent basis in patients who came to the emergency department with signs and symptoms suspicious for or simulating acute cholecystitis or diseases of the liver and biliary tree.

RESULTS

A wide gamut of acute and chronic cholecystitis and diseases of the liver and biliary tree were visualized on RUQ sonography. Several other entities in addition to hepatic and biliary disease were also suspected on sonography and further evaluated by computed tomography.

CONCLUSIONS

Right upper quadrant sonography is the first line of imaging in patients with signs and symptoms of hepatic, gallbladder, or biliary disease as well as RUQ pain. Patient triage or additional imaging may be obtained on the basis of emergent RUQ sonographic findings.

Gallbladder edema in type 1 diabetic patient due to delayed-type insulin allergy

A 29-year-old woman was diagnosed as having type 1 diabetes mellitus and received insulin aspart and NPH insulin (NovolinN). On day 22, she had leg edema and right abdominal pain. The serum hepatobiliary enzyme levels were markedly elevated. Computed tomography revealed gallbladder edema. After an injection of human regular insulin and NPH insulin (HumacartN), the elevated liver enzyme levels were no longer observed. Challenge testing demonstrated that protamine was the cause of her allergy. Furthermore, tests revealed increased VEGF levels. This is an extremely rare case with a delayed-type protamine allergy caused by NovolinN resulting in gallbladder edema.

Does cholecystectomy prior to the diagnosis of pancreatic cancer affect outcome?

Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7% ; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58-0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.

Gallbladder torsion: preoperative diagnosis by MDCT

The patient was a 80-year-old female who was diagnosed as having gallbladder torsion preoperatively. To out knowledge, this is the first reported case diagnosed by CT with a multidetector CT scanner. The abdominal CT showed a V-shape distortion of the extrahepatic ducts, twisting cystic artery with "Whirl's sign", distended and enlarged gallbladder with wall hemorrhage. A definitive diagnosis of gallbladder torsion was made by CT preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute abdominal pain of unknown origin, and MDCT with multiplanar reformation is very useful in making a definitive diagnosis.

Perforation of gallbladder

OBJECTIVE

Gallbladder perforation is a rare but life threatening complication of acute cholecystitis. Aim of this study is to present our clinical experience with gallbladder perforation.

MATERIAL AND METHODS

Thirty-seven of retrospectively reviewed 1042 acute cholecystitis patients were found to have gallbladder (GB) perforation. Perforations due to trauma, iatrogenic causes, and gallbladder carcinoma were excluded.

RESULTS

Abdominal ultrasound (US) showed gall stones in all of the patients with type-I and type-II gallbladder perforations (GBP), extensive intraperitoneal free fluid in 9 patients with type-I GBP, and a small amount of pericholecystic free fluid in 7 patients with type-II GBP. Abdominal US did not show GB wall defect in any of the patients, but showed intraperitoneal free gall stone in one type-I and one type-II GBP patients. CT revealed GB wall thickening in all of the patients, gall stones in 7 patients, extensive intraperitoneal free fluid in 7 patients, a small amount of pericholecystic free fluid in 8 patients, and GB perforation sites in 4 patients. Abdominal CT and US detected subhepatic abscesses in 3 patients.

CONCLUSION

Early diagnosis of gallbladder perforation and immediate surgical intervention are of crucial importance. Unfortunately, the limited success of US and CT for detecting the GBP let us advocate early and urgent surgery (Tab. 3, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

[Cholesterosis of the gall bladder and atherogenic dyslipidemia: etiology, pathogenesis, clinical symptoms, diagnosis and treatment]

AIM

To detect specific morphological signs of hepatic lesion in patients with cholesterosis of the gall bladder and atherogenic dyslipidemia in the presence of steatohepatitis.

MATERIAL AND METHODS

Atherogenic dyslipidemia was detected in 150 patients with steatohepatitis. Ultrasound investigation diagnosed cholesterosis of the gall bladder in 51.3% patients. The protocol included the following examinations: analysis of the disease history, physical examination, laboratory, device and morphological tests. Thirty patients received therapy with ursodesoxycholic acid medicine for 3 months.

RESULTS

Basic clinical symptoms of gall bladder cholesterosis (GBC) and its risk factors are defined. The biochemical blood test registered elevated levels of transaminase, alkaline phosphatase and bilirubin. All the patients had an atherogenic type of dyslipidemia. According to USI, a focal-reticular form of GBC prevailed. Histologic examination of the liver detected the following alterations: fat infiltration, portal and intralobular infiltration, hydropic dystrophy, binuclear hepatocytes, lobular hepatitis, fibrosis of the portal tracts, periductular fibrosis, ductual proliferation, ductual epithelium detachment. Histologically, the walls of the gall bladder contain foam cells in the mucous and submucous layer. The same changes were seen in the wall of the hepatic artery as well as cholesterol polyps, epithelial destruction. Ursosan treatment resulted in a significant lowering of total cholesterol.

CONCLUSION

GBC seems to be a chain of successive conditions: lipid disbolism at the level of hepatocyte, development of steatosis, steatohepatitis, fibrosis, involvement of all anatomo-morphological structures of the liver including the biliary tract, GBC.

Torsion of the gallbladder: two case reports

Torsion of the gallbladder is a rare disease. It is simply defined as a rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. The aetiology is unknown. However, several factors are postulated as playing causative roles. The disease symptoms mimic acute cholecystisis. The current value of radiological imaging is limited, but clinically, volvulus of the gallbladder is an acute surgical situation. It may be treated and diagnosed by a laparoscopic approach.

Polypoid lesion of the gallbladder in childhood: case report and literature review

Gallbladder polypoid lesions are rare in the pediatric patient and sometimes represent an incidental finding. A 13 year old male was referred to the Padua Hospital Pediatric Department for an obesity. A routine abdominal ultrasound (US) detected a gallbladder polypoid lesion 6 mm in diameter, initially considered a gallbladder adenoma. Investigation did not detect any other biliary tract abnormality. After seven months, the asymptomatic patient underwent a follow-up US which revealed the disappearance of the polypoid mass. The following concerns are raised: what is the size of the polypoid mass that should be considered for surgery? How does the presence of symptoms worsen the diagnosis and lead to preferring a surgical approach (cholecystectomy) over an echographic follow-up?

[Incidentalomas of the liver and gallbladder. Evaluation and therapeutic procedure]

The expanding use of ultrasound in general practice is leading to an ever increasing rate of detection of true hepatic incidentaloma. The correct diagnosis of hepatic incidentaloma may be made in over 90% with non-invasive means. The questionable diagnosis of "symptomatic" incidentaloma should undergo close scrutiny prior to a decision in favour of surgery. With regard to more recent literature, the former "absolute" requirement for surgical resection in all cases of liver cell adenoma may have to be reappraised. Final inability to rule out malignancy represents an unquestionable indication for surgery in the light of low rates of morbidity and lack of mortality in this otherwise healthy patient group. Percutaneous biopsies should not be performed due to oncological hazards, indeterminate results and potential for acute complications.The stage-oriented radical re-resection following diagnosis of an incidentally detected gallbladder cancer may lead to significantly improved long-term survival, especially in the early tumour stages T1b and T2, which represents the most common stage of gallbladder cancer in incidentaloma. Patients at elevated risk for incidental gallbladder cancer should undergo thorough instruction with regard to the potential hazards of laparoscopic cholecystectomy. Multimodal therapeutic strategies directed at advanced stages of incidentally detected gallbladder cancer should be evaluated in prospective multicentre studies.

[Heterotopic pancreas in the gallbladder. Diagnosis, therapy, and course of a rare developmental anomaly of the pancreas]

Ectopic pancreas is a rare entity but the second most prevalent pancreatic anomaly. Heterotopic pancreas is defined as the presence of pancreatic tissue without any anatomic or vascular continuity with the main body of the pancreas. Its aetiology is not clearly established. In 1916, Poppi published for the first time evidence of heterotopic pancreas in the gallbladder. A review of the literature up to the present showed only 28 more cases worldwide of ectopic pancreas in the gallbladder. Aberrant pancreas is incidentally discovered in 2% of autopsies and has been estimated to occur once in every 500 upper abdominal explorations. Ninety per cent of ectopic pancreas is found in the stomach, duodenum, and jejunum. Mostly it is asymptomatic and benign. For this reason, therapy is indicated only in patients with symptoms such as pyloric obstruction, bleeding, and malignant transformation. Surgical resection or endoscopic mucosal resection as a newer method are recommended.

[A case of incomplete torsion of the gallbladder due to partial torsion of the gallbladder neck]

A 57-year-old man was admitted to our hospital because of low-grade fever and pain in the right hypochondrium. Abdominal ultrasonographic (US) examination revealed a hyperechoic mass in the body of the gallbladder. The wall of the gallbladder towards the fundus was markedly thickened, while the wall near the gallbladder neck showed no abnormality. Power Doppler and contrast-enhanced CT of the abdomen revealed absence of blood flow in the fundic wall of the gallbladder, however, a contrast-enhanced image of the entire wall was obtained by contrast US, although the blood flow to the fundus was decreased. Torsion of the gallbladder was diagnosed and laparoscopic cholecystectomy was performed. The gallbladder was found to be a wandering gallbladder, Gross I type, and slight counterclockwise torsion was found at the neck of the gallbladder. We report a case of partial torsion of the gallbladder neck, in which the details of the ischemic hemodynamic changes could be observed by contrast-enhanced US.

Ectopic liver encountered during laparoscopic cholecystectomy

Ectopic liver is hepatic tissue that histologically resembles the mother tissue but is located at a site away from its usual location. Initially thought to be a rare anatomical anomaly of no clinical significance, it is now increasingly recognised to be capable of causing clinically relevant pathology. More specifically, it has been associated with a higher incidence of hepatocellular carcinoma, cholelithiasis and cholecystitis. Here, we report a case of ectopic liver encountered incidentally during laparoscopic cholecystectomy.

[Biliary ileus--a rare complication of cholecystolithiasis]

The diagnosis of ileus caused by biliary stones occurs very rarely, with the range of 2 % worldwide. This complication of cholecystolithiasis caused by the stone fistulation into gastrointestinal tract and its subsequent obstruction occurs mostly in elderly and has a high mortality rate. During the course of ten years (1996-2006) in the 2nd surgical clinic FNLP in Kosice, 1640 cholecystectomies and 255 operations, due to the obstruction ileus, were performed. Biliary ileus was recorded in four cases. In two cases, the reason being an obstruction caused by a travelled stone into jejunum, one event was caused by a mechanic wedge of a stone in duodenum and in the last event rectosigma was obturated. The diagnostic is relatively difficult because of a nonspecific symptomatology and often negative anamnesis of previous problems with gallstones. According to literature, the most reliable diagnostic method is computer tomography (CT). In our case, abdominal ultrasonography was successful, which pointed out this diagnosis. Gastroscopy localized the place of obstruction, but not its cause and X-ray image showed aerobilia two times. By the use of magnetic resonance cholangiopancreatography (MRCP) the diagnosis was not positively confirmed. Only in one out of four cases, there was a suspicion of the diagnosis of the biliary ileus, which makes its detectability 25%. The aim of this retrospective analysis is the comparison of diagnostic method-options and their range of success in the diagnosis of acute abdomen in our clinic and the entries in the world literature.

Internal biliary fistula due to cholelithiasis: A single-centre experience

AIM: To discuss about the perioperative problems encountered in patients with internal biliary fistula (IBF) caused by cholelithiasis.

METHODS: In our hospital, 4 130 cholecystectomies were carried out for symptomatic cholelithiasis from January 2000 to March 2004 and only 12 patients were diagnosed with IBF. The perioperative data of these 12 IBF patients were analyzed retrospectively.

RESULTS: The incidence of IBF due to cholelithiasis was nearly 0.3%. The mean age was 57 years. Most of the patients presented with non-specific complaints. Only two patients were considered to have IBF when gallstone ileus was observed during the investigations. Nine patients underwent emergency laparotomy with a pre-operative diagnosis of acute abdomen. In the remaining three patients, elective laparoscopic cholecystectomy was converted to open surgery after identification of IBF. Ten patients had cholecystoduodenal fistula and two patients had cholecystocholedochal fistula. The mean hospital stay was 13 d. Two wound infections, three bile leakages and three mortalities were observed.

CONCLUSION: Cholecystectomy has to be performed in early stage in the patients who were diagnosed as cholelithiasis to prevent the complications like IBF which is seen rarely. Suspicion of IBF should be kept in mind, especially in the case of difficult dissection during cholecystectomy and attention should be paid in order to prevent iatrogenic injuries.

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM

The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared.

RESULTS

A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality.

CONCLUSION

Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.

[Ischemic variant of cholecystocardial syndrome in the diseases of gallbladder]

There were analyzed 14 observations of patients suffering ischemic variant of cholecystocardial syndrome on the background of an acute calculous cholecystitis and cholecalculous disease. The rate of the pseudocoronary syndrome revealing was determined. The coding procedure using Minnesota's code was applied for the first time for ECG estimation in the patients.

Gall bladder torsion and rupture in a dog

A 6-year-old desexed female German Shepherd dog was referred to the Murdoch University Veterinary Hospital for assessment and management of acute onset vomiting, diarrhoea, polydipsia and lethargy of 2 days duration. Surgical, microbiological and histological findings were consistent with necrotising cholecystitis secondary to gall bladder torsion, resulting in gall bladder rupture and secondary non-septic bile peritonitis. A chronic peritoneopleural perforation resulting from an abdominal cavity foreign body and congenital peritoneopericardial hernia were also present. The dog made a full recovery following cholecystectomy, foreign body removal, repair of the peritoneopleural perforation and peritoneopericardial herniorrhaphy. This is the first recorded case of gall bladder torsion in the dog.

Coexistence of Mirizzi syndrome with adenomyomatosis in the gallbladder: report of a case

BACKGROUND

Mirizzi syndrome is a rare complication of cholelithiasis. Adenomyomatosis is a common tumor-like lesion of the gallbladder.

METHODS

A 52-year-old man was admitted to our hospital complaining of right hypochondriac pain and jaundice. Ultrasonography and computed tomography revealed stones in the gallbladder and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography revealed narrowing of the common bile duct caused by compression of the gallbladder. Laparotomy revealed type II Mirizzi syndrome.

RESULTS

Partial cholecystectomy with a Roux-en-Y hepaticojejunostomy reconstruction was performed. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen in the gallbladder. A segmental type of adenomyomatosis of the gallbladder was diagnosed.

CONCLUSIONS

The pathogenic link between the two peculiar entities is unclear. A possible explanation is considered that the pathogenesis of Mirizzi syndrome is resulted from chronic inflammation due to adenomyomatosis.

[New possibilities to study biliary tree and gallbladder: functional magnetic resonance cholangiography contrast-enhanced with mangafodipir trisodium (Mn DPDP)]

Mangafodipir trisodium (Teslascan) is a hepatobiliary contrast agent that provides noninvasive opacification of the bile ducts. Using this contrast medium combined with a T1-weighted gradient echo enhanced sequence provides functional imaging of the bile ducts. Second-intention MRI was obtained after the usual morphological study of the bile ducts using heavily T2-weighted sequences (SS-FSE Te eff long and SS FSE Te eff short). This method can detect many biliary duct anomalies: biliary leakage in the postoperative context, mapping of bile ducts and the gallbladder in the search for anatomical variants, analysis of biliodigestive or biliobiliary anastomoses, or a dynamic study of bile secretion and excretion. Opacification of the bile ducts has only been possible until now with invasive tests aggravated by a certain co-morbidity rate and their functional study using biliary scintigraphy limited by mediocre spatial resolution. This new possibility provides access not only to morphological imaging, but also to functional imaging with excellent spatial resolution.

Magnetic resonance imaging of the gallbladder: spectrum of abnormalities

Various pathologies involving the gallbladder can manifest clinically, producing nonspecific clinical symptoms and making diagnosis difficult and challenging. Real-time sonography is the most widely used diagnostic study for the gallbladder and the primary screening examination of choice. With increasing use of magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP), gallbladder pathology is frequently seen. Understanding the basic patterns of various disease manifestations and appearance on MRI is the key to making an accurate diagnosis. Given its inherent tissue contrast and contrast sensitivity, MRI in conjunction with MRCP can be a very valuable test in evaluating gallbladder pathology. Gallbladder pathology can be classified into congenital (such as absence), inflammatory (acute, hemorrhagic, and chronic cholecystitis), traumatic, benign (polyps) and malignant tumors (gallbladder carcinoma and lymphoma), and other disease processes can be seen in cholelithiasis, cholesterosis, thickened gallbladder wall, and Mirrizzi syndrome.

Pregnancy and gallbladder disease

Gallbladder disease is a highly prevalent disease in western countries as a consequence of several genetic, biochemical, and environmental factors. Females are a high risk group, and pregnancy increases this risk considerably. In fact, gallbladder diseases are the second most common indication for nonobstetric surgical intervention in pregnancy. In this review, we discuss the most important aspects of gallbladder disease and pregnancy as part of the Symposium on Liver and Pregnancy, co-sponsored by the Mexican Association of Hepatology and the Mexican Association of Gynecologists and Obstetrics.

[Tumors in the gallbladder: a possible differentiation between malignant and benign tumours]

In a 59-year-old woman with pain in the right upper abdomen, echography and CT-scan revealed adenomatosis of the gallbladder. Her symptoms did not disappear after cholecystectomy, even though echography showed no further abnormality. In a 46-year-old man with fever and weight loss, echography revealed two polyps in the gallbladder. Following cholecystectomy, histopathology revealed cholesterol polyps and an infection with Entamoeba coli. In a 63-year-old man with systemic symptoms, a biopsy of the echographically diagnosed tumour of the gallbladder revealed that he had actually had cholecystitis. The management was wait-and-see and the patient recovered completely. In a 68-year-old woman with jaundice and attacks of abdominal pain, a CT-scan revealed gallstones. The symptoms recurred following an ERCP. Following cholecystectomy, an adenocarcinoma of the gallbladder was found. One year later, a contact metastasis developed forwhich she received radiotherapy. After 4 years she was in good condition. Patients with a tumour in the gallbladder are often diagnosed with gallbladder cancer, which has a poor prognosis. Other diseases should also be considered, since the treatment and prognosis differ greatly. It is important to differentiate at an early stage. Ultrasound, CT and MRI have improved the possibility of differentiating and choosing the correct treatment.