[Inflammatory diseases of the gall bladder and biliary system. I. Imaging--cholelithasis--inflammation of the gall bladder]

Cholelithiasis is the most common affliction of the gallbladder and biliary tract. Including its complications, gallstone disease represents the basis for cholecystitis and cholangitis in the majority of cases. Inflammatory diseases of the biliary system are divided into acute and chronic forms originating from the gallbladder as well as from the biliary tract. Although acute calculous cholecystitis is the most common form, gangrenous, and emphysematous inflammation of the gallbladder as well as gallbladder empyema are included in this group of diseases. In the chronic forms, calculous and acalculous inflammation is also differentiated. Recent developments in cross-sectional imaging in sonography, computed tomography, and magnetic resonance imaging offer numerous tools for depicting the biliary system with high diagnostic accuracy. Invasive imaging modalities of the biliary system are mainly used for therapeutic aspects.

Limy bile syndrome: review of seven cases

BACKGROUND

Milk of calcium bile or limy bile is a rare disorder in which the gall bladder is filled with a thick, paste-like, radiopaque material.

METHODS

Seven patients with limy bile syndrome were treated in our department from 1980 to 2003. There were five women and two men, and their age ranged from 30 to 64 years. A retrospective analysis of clinical symptoms, diagnostic work-up, treatment approach and operative findings was performed.

RESULTS

All patients presented with intermittent right upper abdominal quadrant pain. Three of the seven patients (42.85%) presented with complications like acute cholecystitis (two of seven patients) and obstructive jaundice (one of seven patients). Diagnosis was based on clinical findings, plain abdominal X-rays, ultrasonography and computed tomography scanning. Surgery was the treatment of choice and cholecystectomy alone or in combination with common bile duct exploration and drainage (if needed) was performed.

CONCLUSION

The clinical aspect of the disease is similar to that of biliary lithiasis and the diagnosis is easily made by the characteristic spontaneous opacification of the gall bladder on plain abdominal X-rays. Complications such as acute cholecystitis, pancreatitis or obstructive jaundice can also be present. Although some cases of conservative pharmaceutical treatment as well as cases of spontaneous disappearance of limy bile have been reported, surgical treatment remains the treatment of choice.

[Cholecystobiliary fistula: laparoscopic treatment with an endostapler]

The Authors report a case of cholecystobiliary fistula due to cholelithiasis and bile duct lithiasis, treated laparoscopically with an endostapler. In view of the rarity of this condition, we believe it may be useful to discuss the diagnostic work-up in the light of the diagnostic and therapeutic measures currently available. We also review the literature with a view to defining the existing classifications of cholecystobiliary fistulas. We conclude by stressing the importance the endoscopic placement of nasobiliary catheters preoperatively to facilitate laparoscopic treatment.

Spontaneous gallbladder perforation in a neonate

We describe the case of a 700-g neonate who presented with abdominal discolouration, distension, and rapid clinical deterioration. At laparotomy, a perforation in the neck of the gallbladder was found, which was simply over-seen. Perforation of the gallbladder should be considered in the differential diagnosis in such neonates. The surgical management should be direct repair, without resorting to a cholecystectomy.

Ischemic-type biliary lesions in liver transplant recipients: evaluation with magnetic resonance cholangiography

We assessed the diagnostic value of magnetic resonance cholangiography (MRC) when evaluating ischemic-type biliary lesions in the follow-up of liver transplant patients. We retrospectively reviewed magnetic resonance imaging and MRC of 28 liver transplant recipients with ischemic changes of the biliary tree. The MR examinations were performed at 1.5 T. After the acquisition of axial T1w and T2w sequences, MRC involved a coronal respiratory-triggered, fat-suppressed, two-dimensional, thin-slab, heavily T2w fast spin-echo sequence, and/or a coronal breath-hold, thin- and thick-slab, single-shot T2w sequence. Eleven patients underwent either surgical reconstruction of the biliary system (n = 4) or liver retransplantation (n = 7); the pathologic specimens were employed as standard of reference. The final diagnosis was obtained through direct cholangiography in the remaining cases. Without knowledge of the surgical, pathologic, and cholangiographic findings, two experienced investigators evaluated in conference the MR images to determine the presence of biliary tract abnormalities. MRC demonstrated strictures involving the hepatic bifurcation and the extrahepatic bile duct of the graft in 26 patients; a concomitant thickening of the biliary wall was described in 18 out of these 26 subjects. MRC also showed sludge or stones formation in the donor common bile duct in 16 out of these patients. In conclusion, MRC allows noninvasive, reliable, assessment of ischemic-type biliary lesions in liver transplant recipients.

MR Imaging of the Gallbladder and Biliary System

MR imaging is an established technique for the diagnosis of a spectrum of biliary and gallbladder pathologies and continues to improve with the advent of technologic advances, including new contrast agents and new sequences that are capable of improving upon the contrast resolution and signal-to-noise that are afforded by conventional MR imaging. These improvements already have shown promise for the increasing role of MRC as the initial modality in assessing living liver donors and evaluating post-operative hepato-biliary complications. Improved spatial resolution and the added functional or physiologic information afforded by MR imaging promise ever expanding clinical applicability and usefulness.

Magnetic resonace appearance of gall bladder ascariasis

Ascariasis is a common disease in many developing countries and is a common cause of biliary and pancreatic diseases in endemic areas. Numerous studies have been published on biliary tract ascariasis. All these have documented ultrasonography as the primary imaging modality for biliary tract ascariasis. Magnetic Resonance Cholangiopancreatography (MRCP) has been the latest entrant for the study of bilary tract. MRCP findings of biliary tract ascariasis have been scarcely documented. MRCP is a unique non-invasive investigation for demonstrating ascariasis in gall bladder and bilary tract clearly. We present MR appearances of gall bladder and biliary tract in a proven case of biliary ascariasis.

Functional MR Cholangiography: Diagnosis of Functional Abnormalities of the Gallbladder and Biliary Tree

OBJECTIVE

Our objective was to describe the technique and utility of functional MR cholangiography (fMRC) in the evaluation of the gallbladder and biliary tree.

CONCLUSION

FMRC has the potential to provide a comprehensive examination for the anatomic and functional assessment of the gallbladder and biliary tree. Complex anatomic abnormalities and functional disorders can be shown by fMRC, including biliary obstruction and extravasation.

Volvulus de la vésicule biliaire : à propos de deux cas

The authors report two cases of gallbladder volvulus. The diagnosis of this rare pathology is mainly identified preoperatively. Ultrasonographic findings include a "floating gallbladder" with thickened hypoechoic walls. The treatment is emergency cholecystectomy.

Complete gallbladder and cystic pedicle torsion. Laparoscopic diagnosis and treatment

Complete gallbladder torsion is an unusual emergency that requires immediate surgical treatment. Since it was first reported in 1898, <400 cases have been described in the literature, and only three of them were diagnosed and treated by laparoscopic cholecystectomy. Our objective here is to describe an approach that allows a definitive diagnosis and treatment. First we present the case of a febrile 81-year-old woman with acute right upper quadrant pain. Ultrasound showed an alithiasic distended gallbladder with a multilayered wall and a transverse orientation. When exploratory laparoscopy was performed, a gangrenous gallbladder secondary to a 360 degrees clockwise cystic pedicle torsion was found. Laparoscopic decompression, detorsion, and cholecystectomy with an intraoperative cholangiogram were completed. The patient was discharged 72 h later. Next, several preoperative diagnostic methods are reviewed. We conclude that the laparoscopic treatment of this entity is feasible and obviates the performance of unnecessary and nonspecific tests. It offers a favorable and rapid postoperative recovery, in addition to the other well-known advantages of the minimally invasive surgical approach.

Intramural gallbladder hematoma mimicking gallbladder neoplasm in a 33-year-old male

We report a case of intramural gallbladder hematoma mimicking gallbladder neoplasm in a 33-year-old male; bleeding was confined to the gallbladder wall without rupture into the lumen. The patient presented with sudden onset of right upper quadrant pain, with no history of abdominal trauma. The abdomen was soft, with mild tenderness over the right upper quadrant, and a positive Murphy's sign. Abdominal sonography, computed tomography, and endoscopic retrograde cholangiopancreatography all revealed the presence of a mass lesion in the gallbladder wall. Thus, a gallbladder tumor was highly suspected. Laparoscopic cholecystectomy was performed, and intramural hematoma was found intraoperatively. The cause of intramural hemorrhage was obscure.

Gall bladder perforation: report of 3 cases

We report 3 cases of gall bladder perforation treated in this centre between January 1996 and June 2001. These were compared with Neimier's original classification of types of gall bladder perforation and areas of difficulty in management emphasised. The literature was also reviewed.

[Laparoscopic cholecystectomy for porcelain gallbladder]

The porcelain gallbladder is uncommon type of chronically inflamed gallbladder wall considered to be associated with a high frequency of adenocarcinoma and subsequently not suitable for a laparoscopic approach. In 12,000 patients chosen for a laparoscopic cholecystectomy 4 porcelain gallbladders were diagnosed. In 2 cases the laparoscopic approach was successful. One conversion was due to an unconfirmed suspicion of gallbladder cancer and the other one to a fistula between the gallbladder and the common bile duct. Patients with a preoperative diagnosis of porcelain gallbladder must not be excluded from the laparoscopic approach yet a low threshold for conversion must be maintained in those with a cancer suspicion.

From the RSNA refresher courses: imaging evaluation for acute pain in the right upper quadrant

Acute cholecystitis is the most common cause of acute pain in the right upper quadrant (RUQ), and urgent surgical removal of the gallbladder is the treatment of choice for uncomplicated disease. However, cross-sectional imaging is essential because more than one-third of patients with acute RUQ pain do not have acute cholecystitis. In addition, patients with complications of acute cholecystitis, such as perforation, are often best treated with supportive measures initially and elective cholecystectomy at a later date. Ultrasound (US) is the primary imaging modality for assessment of acute RUQ pain; US is both sensitive and specific in demonstrating gallstones, biliary dilatation, and features that suggest acute inflammatory disease. Occasionally, additional imaging modalities are indicated. Computed tomography is valuable, especially for confirming the extent and nature of the complications of acute cholecystitis. Magnetic resonance cholangiopancreatography is helpful in complicated ductal disease (eg, recurrent pyogenic cholangiohepatitis) when more detailed diagnostic information is required for treatment planning, whereas endoscopic retrograde cholangiopancreatography is used when biliary intervention is required (eg, treatment of choledocholithiasis). Successful imaging with all modalities requires familiarity with both the characteristic and the unusual features of a wide variety of pathologic conditions. In addition, potential pitfalls must be recognized and avoided.

Current management of gall bladder perforations

BACKGROUND

Gall bladder perforation is a serious complication of acute cholecystitis. The purpose of the present study is to evaluate the presenting symptoms, diagnosis and management of patients with gall bladder perforations.

METHODS

A retrospective study was undertaken of 31 consecutive patients with gall bladder perforation in a single unit of a tertiary referral hospital, between January 1996 and December 2001.

RESULTS

The incidence of gall bladder perforation was 5.9% of all cases of acute cholecystitis. Associated comorbidity was quite common (58%). Ultrasound and computed tomography scans of the abdomen are sensitive investigations. Ultrasound guided percutaneous drainage helps in tiding over the emergency. The morbidity (35%) and mortality (9.6%) is considerable.

CONCLUSION

The patterns of presentations, diagnosis and management of gall bladder perforation are changing. But there is scope for improvement.

Endoscopic stent insertion into the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease

BACKGROUND

Endoscopic stent insertion into the gallbladder entails placement of a double-pigtail polyethylene stent between the gallbladder and the duodenum at ERCP. This procedure may be an effective temporary measure in patients with severe comorbid conditions, especially end-stage liver disease, that subsequently allows more definitive therapy, including liver transplantation.

METHODS

The records for 29 patients who underwent attempted endoscopic gallbladder stent insertion between May 1999 and May 2004 were reviewed retrospectively.

RESULTS

Mean patient age was 47 years; 86% of the patients were listed for liver transplantation, with a mean model for end-stage liver disease score of 15; 72% had Child's class B cirrhosis. Indications for gallbladder stent placement included recurrent biliary colic (69%), acute cholecystitis (17%), acalculous cholecystitis (7%), and gallstone pancreatitis (7%). Of the 29 patients who underwent ERCP, stent placement was successful in 26 (90%). Median follow-up was 9.4 months (range 0.1-40.5 months). Of those who had a stent placed, 6 (22%) subsequently underwent liver transplantation and another 15 (56%) were alive, most awaiting liver transplantation. Only 3 patients had late a complication or recurrence of biliary symptoms after stent placement.

CONCLUSIONS

Endoscopic stent placement in the gallbladder is a safe and an effective palliative treatment for patients with symptoms caused by gallbladder disease who are poor surgical candidates.

Heterotopic gastric mucosa in the gallbladder: case report and literature review

INTRODUCTION

we report on a case of heterotopic gastric mucosa in the neck of the gallbladder and we also review 95 other reports of HGM in the gallbladder in the international medical literature from 1977.

AIM

to evaluate the gold standard treatment in heterotopic gastric mucosa of the gallbladder by the analysis of literature, compared with our anecdotal experience.

PATIENT AND METHOD

a 43-year-old man, who was recently symptomatic, visited our hospital to submit to laparoscopic cholecistectomy for cholelithiasis. Ultrasonography revealed a broad-based polypoid lesion in the gallbladder (2.5 cm in diameter in the neck of the gallbladder), with multiple gallstones.

RESULTS

standard laparoscopic cholecystectomy was performed. The specimen revealed a 2.5 x 1.7 x 0.5 cm polypoid lesion with deep in the body, with many gallstones in the gallbladder. Histologically, the polypoid lesion consisted of gastric fundic glands located only in the mucosa of the gallbladder. The surrounding mucosa consisted of almost normal epithelium without any metaplastic changes. Postoperative technetium 99m-pertechnetate scintigraphy demonstrated no evidence of gastric heterotopia elsewhere in the body. Actually the patient is in long-time follow-up, asymptomatic.

CONCLUSIONS

for its extreme difficult to make a conclusive diagnosis and thereby rule out the possibility of cancer, it appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.

Gallbladder volvulus: report of two original cases and review of the literature

Gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. It is an unusual and rare occurrence with a predilection for women in their seventh or eight decades of life. Only about 300 cases have been reported in the literature ranging from ages 2 to 100 years old. The etiology of gallbladder volvulus remains speculative; however, the presence of a redundant mesentery is a prerequisite for torsion. Gall-bladder volvulus leads to occlusive obstruction of biliary drainage and blood flow. With early diagnosis and surgical intervention, the disease maintains a low mortality of approximately 5 per cent. We present two original cases of acute gallbladder volvulus successfully treated with cholecystectomy, as well as a review of the literature.

Gallbladder involvement of Henoch-Schönlein purpura mimicking acute acalculous cholecystitis

BACKGROUND/AIMS

We report the case of a 53-year-old man with fever and severe abdominal pain following an upper respiratory tract infection.

METHODS/RESULTS

The clinical signs, the laboratory markers, and the ultrasound findings were consistent with acute acalculous cholecystitis and he underwent cholecystectomy. Histologically the gallbladder showed vasculitis and the patient developed postoperatively a purpuric rash of the legs with transient ankle arthritis. Gastroscopy revealed prepyloric ulcers consistent with vasculitis. The patient was diagnosed as having Henoch-Schönlein purpura. Gastric ulcers as well as arthritis disappeared upon treatment with corticosteroids and proton pump inhibitors.

CONCLUSION

Taken together, Henoch-Schönlein purpura can mimic acute cholecystitis and should be considered as a rare differential diagnosis of acute cholecystitis.

Tension and stress calculations in a 3-D Fourier model of gall bladder geometry obtained from MR images

Biliary tract obstruction results in dilatation of the biliary tract including the gall bladder and induction of symptoms such as abdominal pain. Since the pain receptors are likely mechano-sensitive receptors, it is important to develop tools for studying the distributions of tension and stress in the wall of the gall bladder. Wall tension and stress can be determined using Laplace's equation and the three-dimensional (3-D) geometry of a thin walled organ under equilibrium conditions. The objective of this study was to develop an analytical method to describe the 3-D geometry of the porcine gall bladder. The Fourier series method was used to describe the organ surface geometry obtained from magnetic resonance (MR) images. MR images of nine normal and three obstructed porcine gall bladders were analyzed. The curvature was computed throughout the gall bladder surface and the wall tension was computed using Laplace's equation. The spatial distributions of principal curvatures, tensions, and stresses were nonhomogeneous in the gall bladder because of its complex geometry. The extremum values of curvatures did not differ between normal and 2-day obstructed gall bladders. The pressure, tension, and stress were significantly higher, however, in the obstructed gall bladders (p < 0.05). This study provides an analytical tool for characterizing the complex 3-D geometry of an organ obtained from a clinical imaging modality.

Diagnosis and treatment of polypoid lesions of the gallbladder: report of 194 cases

BACKGROUND

With the wide use of B-ultrasonography in recent years, the polypoid lesion of the gallbladder (PLG) has been one of the most common diseases detected in biliary surgery. This study was to investigate the diagnostic method and operative indications of PLG.

METHODS

The clinical and pathological data of 194 patients with PLG who had received operation at our hospital from January 1994 to September 2002 were analyzed retrospectively. Categorized data were analyzed by the chi-square test.

RESULTS

All the patients received preoperative B-ultrasonography. 185 of the 194 PLG patients were diagnosed as having cholecystic polyp, and 9 adenomas. Among the 42 patients who received CT, 6 showed early gallbladder cancer. Pathologically, cholesterol polyps were mostly multiple lesions (64.7%) with a mean diameter of 3.86+/-2.2 mm in 136 patients. Of 16 patients with adenomas, 10 had a tumor diameter of more than 10 mm (62.5%). In 11 patients with gallbladder carcinoma, 7 were accompanied with gallbladder stone (63.6%). In addition, inflammatory polyps and adenomyomas were found in 25 and 6 patients respectively.

CONCLUSIONS

B-ultrasonography is the most effective diagnostic method for detecting PLG. When large or irregular lesions are found, CT should be performed in order to avoid missing of gallbladder carcinoma. Operative indications for PLG include: a maximal tumor diameter of more than 10 mm; an over 50-year-old patient with a widebase and a single polyp lesion; a wide-base lesion or a lesion showing a tendency to enlargement; co-existing gallbladder stone or cholecystitis; a patient without other diseases but obvious clinical features and failure of general management; big or long pedicels or polyps at the neck of the gallbladder for preventing the empty of the gallbladder and a history of biliary colic; and PLG with irregularly thickened local gallbladder wall.

[Aerobilia as an initial sign of a cholecystoduodenal fistula--a case report]

An 82 year old female patient has the following medical history: repeated chemotherapy and radiation therapy for non-Hodgkin's lymphoma, a radiation-induced osteoblastic osteosarcoma and a longstanding cholecystolithiasis with sclero-atrophic cholecystitis. She appeared at the practice and complained about a dull food-dependent mesogastric and epigastric pain as well as a discrete scleral jaundice. Sonography and CT showed air inclusions in the bile ducts. Subsequently, a cholecystoduodenal fistula was found intraoperatively. The cause could be the long-existing cholecystolithiasis.

Chronic acalculous gallbladder disease: outcomes of treatment by laparoscopic cholecystectomy

BACKGROUND AND AIMS

The diagnosis and treatment of chronic acalculous gallbladder disease (CAGD) remains controversial. Laparoscopic cholecystectomy (LC) is increasingly accepted as the treatment of choice for this condition. The purpose of this study was to analyse the outcomes from LC for CAGD and to identify potential prognostic factors.

METHODS

We retrospectively analysed 54 patients with a clinical diagnosis of CAGD. All patients underwent LC. The outcomes were evaluated at 12 months. Outcomes from surgery were graded on a predetermined scoring system (score 1-6) reflecting the effect of surgery on symptomatology. Histopathological analysis was systematically performed on the resection specimens.

RESULTS

Post-operatively, 90.8% of patients (49/54) were satisfied with the operation (outcome score 1-2). A pathological abnormality was detected in 40 patients (74.1%). Of those in whom no abnormality detected on histopathological examination, LC achieved a successful outcome (score 1-2) in 85.7% of patients (12/14). The worst outcomes (score 5-6) were observed in 2 patients with a pathological abnormality of the gallbladder. For the 5 patients with outcome scores of 3 to 6 (poor outcome), the mean duration of symptoms was 7.1 months compared to 18.2 months for patients with score of 1 and 2 (good outcome).

CONCLUSIONS

There is no significant correlation between outcomes from LC for CAGD and the existence of a definable underlying pathology (p>0.05). Patients with long-standing symptoms were more likely to benefit from LC (p=0.039). LC is an appropriate treatment option for CAGD.

Polypoid lesions of the gallbladder

BACKGROUND

Polypoid lesions of the gallbladder encompass a wide variety of pathology. Although most of these lesions are benign, some early carcinomas of the gallbladder do present as polypoid lesions. Problems remain in selecting patients with polypoid lesions of the gallbladder for surgery, the operative approach, and the method of follow-up of those deemed not needing surgery.

DATA SOURCES

This review was done by Medline search of the English literature by the keywords "polypoid lesions of gallbladder," "gallbladder polyps," "carcinoma of gallbladder," and "benign tumors of gallbladder."

CONCLUSIONS

Most small polypoid lesions of the gallbladder are benign and remain static for years. Three- to six-monthly ultrasonography examination is warranted in the initial follow-up period but it is probably unnecessary after 1 or 2 years. Age more than 50 years and size of polyp more than 1 cm are the two most important factors predicting malignancy in polypoid lesions of the gallbladder. Other risk factors include concurrent gallstones, solitary polyp, and symptomatic polyp. Laparoscopic cholecystectomy is the treatment of choice unless the suspicion of malignancy is high, in which case it is advisable to have open exploration, intraoperative frozen section, and preparation for extended resection.

Cholecysto-hydatid cyst fistula

A 27-year-old woman developed recurrent hydatid of liver. CT scan showed unilocular cysts in segments IV and VII. Intraoperatively, there was a fistulous communication between the gall bladder and the cyst in segment IV. Partial pericystectomy along with cholecystectomy was done for the segment IV cyst; percutaneous aspiration, instillation and re-aspiration using hypertonic saline was done for the cyst in segment VII. This was followed by albendazole treatment.

Spontaneous gall bladder perforation: a rare entity in infants

Spontaneous gall bladder perforation in infants is rare. We report a 3-month-old male infant who presented with progressive abdominal distension, low-grade fever, bilateral hydrocele and acholic stools. Ultrasonography showed free fluid in the peritoneal cavity, which was bile-stained on paracentesis. Surgical exploration revealed sterile biliary peritonitis and a gangrenous gall bladder. Partial cholecystectomy with external biliary drainage resulted in satisfactory recovery.

[Diagnostic image (193). A man with a palpable mass in the upper abdomen. Porcelain gallbladder]

In a 73-year-old man with a non-tender palpable mass in the right part of the upper abdomen and soft stool a porcelain gallbladder was observed at radiological examination.

A case of spontaneous gallbladder perforation

Gallbladder perforation is an almost exclusive complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Whether it is of a calculous or acalculous origin, gallbladder perforation, as a complication of acute cholecystitis, has common symptoms, signs, laboratory data, radiological findings and treatment modalities. Even though many reports of gallbladder perforation have been published, there are few reports of gallbladder perforation without any clinical and radiological indications. We experienced a case of a 70-year-old woman with acute abdomen, which was found to be peritonitis caused by spontaneous gallbladder perforation that was devoid of clues suggesting this condition. Although rare and unusual, this case shows that this disorder should be considered in elderly patients presenting with peritonitis with an unknown etiology.

Usefulness of cholescintigraphy with lipid meal loading for diagnosis and determination of cholecystectomy in a patient with gallbladder dysfunction

A 47-year-old woman was admitted to our hospital because of upper abdominal and back pain. Abdominal ultrasonogram, computed tomogram, endoscopic retrograde cholangiopancreatography and arteriography examination did not reveal any abnormalities. As cholescintigraphy after lipid meal loading detected dysfunction of the gallbladder, we diagnosed dyskinesia of the gallbladder. And the output ratio of the gallbladder from scintigraphy was less than 1%. Cholecystectomy completely relived her from symptoms. Histological examination disclosed chronic cholecystitis and arteritis causing dysfunction of the gallbladder. This case suggested the usefulness of cholescintigraphy with lipid meal loading for gallbladder dysfunction in determining whether or not to do cholecystectomy.

Volvulus of the gallbladder: laparoscopic detorsion and removal

A 73-year-old woman who presented with symptoms of acute cholecystitis was found to have a gangrenous gallbladder wrapped in three complete rotations around its pedicle. Detorsion and removal of the gallbladder were accomplished laparoscopically. Our review of the literature found no other case in which this degree of torsion was successfully treated laparoscopically.

[Gallbladder surgery in a district hospital--a prospective registration]

BACKGROUND

Health authorities and patients are expected to be more active in inquiring about the outcome of surgery for each specific hospital. Prospective registration performed in a district hospital has to go on for years until the results can be evaluated. Specific data for gallbladder surgery performed in Norwegian district hospitals have not been reported before.

MATERIAL AND METHODS

All 220 cholecystectomies carried out from May 1993 to March 2001 were registered prospectively.

RESULTS

Two surgeons performed 93% of the operations with an average annual operator volume of 28. The operation rate was 8.5 per 10,000 inhabitants. The need for conversion was 9%. The peri and postoperative complication rate for laparoscopic and converted operations was 11%.

INTERPRETATION

Our operation rate is somewhat higher than the average in Norway. The number of annual operations in a district hospital is somewhat low, but as almost all procedures are carried out by a limited number of surgeons, operator volume is compatible with data from larger hospitals in Norway. The need for conversion and the rate and seriousness of complications peri and postoperatively does not seem to be higher in this district hospital than in county and university hospitals in Norway.

Double gallbladder-a laparoscopic management

A rare case of gallbladder duplication, an unusual biliary anomaly is reported in a young female patient presenting with acute cholecystitis. After a confirmed diagnosis of double gallbladder was made by sonography, endoscopic retrograde cholangio-pancreaticography (ERCP), and magnetic retrograde cholangio-pancreaticography(MRCP), both gallbladders were removed laparoscopically. On histology both gallbladders showed cholesterolosis. Detailed preoperative investigations are required for an accurate preoperative diagnosis before considering laparoscopic cholecystectomy to avoid inadvertent damage to biliary ductal system and overlooking of second gallbladder during surgery.

Hepatobiliary imaging and its pitfalls

In summary, US is the initial imaging modality for the evaluation of acute right upper quadrant pain. It permits accurate diagnosis of acute cholecystitis and successfully identifies multiple other causes of patient symptomatology. Some of these processes lie outside the hepatobiliary system and include renal infection and obstruction, pancreatitis and its sequelae, duodenal or colonic perforation or mass lesions, peritoneal tumor spread, adrenal hemorrhage, and even remote problems, such as pneumonia. The limitations on US include incomplete imaging of the liver, most often at the dome or beneath ribs on the surface, and incomplete visualization of lesion boundaries, particularly with some infections and tumors. For these clinical scenarios, contrast-enhanced CT is complementary to US and should be encouraged. In the biliary tree, US has limitations in situations in which the ducts are not dilated and sometimes with imaging the extra hepaticducts, especially distally. For these patients, CT or MR imaging (MRCP) is especially useful. If one keeps the clinical scenario in mind and always images a patient where he or she hurts, US is a powerful and effective diagnostic method for evaluating acute right upper quadrant pain.

Ectopic Gallbladder

An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital anomaly was detected on ultrasonography and confirmed by CT scan, MRCP, and ERCP. Laparoscopic cholecystectomy was performed without complications. The importance of proper preoperative investigations is emphasized for accurate diagnosis, to rule out biliary tract anomalies, and to properly plan surgical approach and management.

Ciliated foregut cyst of the gallbladder: report of a case

We report the rare case of a gallbladder cyst arising from the foregut remnants. A 36-year-old woman was referred to our hospital after screening ultrasonography (US) detected a tumor in the gallbladder. On admission, she was well and her blood analyses were all normal. US showed a cystic mass with internal high-echoic lesions, and computed tomography (CT) demonstrated a protruding tumor with slight enhancement in the gallbladder. Angiography provided no additional information; however, sequential CT-arteriography (CTA) clearly demonstrated that this tumor was a cystic lesion. Surgical exploration was performed, first because of the difficulty in establishing a definite diagnosis, and also because the patient wanted the tumor removed. The resected specimen contained a unilocular cystic tumor that looked like a submucosal tumor. Histologically, the wall of the cyst was lined by ciliated stratified columnar epithelium with interspersed goblet cells and underlying smooth muscle fibers. The mass was finally diagnosed as a congenital ciliated foregut cyst of the gallbladder. Cysts of the gallbladder are uncommon and the majority are acquired. To our knowledge, this represents only the fourth report of a ciliated foregut cyst of the gallbladder in the literature. Although rare, an awareness of this entity could allow a preoperative diagnosis to be made, whereby surgical exploration may be avoided. CT-A is a very useful diagnostic tool, especially when the nature of the tumor presents a difficult differential diagnosis.

Imaging diagnosis of pancreato-biliary diseases: A control study

AIM: To evaluate the clinical value of various imageological methods in diagnosing the pancreato-biliary diseases and to seek the optimal procedure.

METHODS: Eighty-two cases of pancreato-biliary diseases confirmed by surgery and pathology were analyzed. There were 38 cases of cholelithiasis, 34 cases of pancreato-biliary tumors and 10 other cases. The imageological methods included B-US, CT, ERCP, PTC, cross-sectional MRI and MR cholangiopancreatography (MRCP).

RESULTS: The accuracy rate of MRCP in detecting the location of pancreato-biliary obstruction was 100%. In differentiating malignant from benign obstruction, the sensitivity of the combination of MRCP and cross-sectional MRI was 82.3%, the specificity was 93.8%, and the accuracy rate was 89.0%. The accuracy rate for determining the nature of obstruction was 87.8%, which was superior to that of B-US (P = 0.0000) and CT (P = 0.0330), but there was no significant difference between direct cholangiopancreatography and the combination of MRCP and conventional MRI (P = 0.6666).

CONCLUSION: In most cases, MRCP can substitute direct cholangiopancreatography for diagnosis. The combination of MRCP and cross-sectional MRI should be considered as an important means in diagnosing the pancreato-biliary diseases, pre-operative assessment and post-operative follow-ups.

[Gallbladder tuberculosis associated with cholelithiasis]

Tuberculosis of the gallbladder is rare, even in our country known for being an endemic area. The positive diagnosis depends on suspicion of tuberculosis, peroperative findings and histological examination. From a review of the literature, the physiopathology of this infection is discussed, emphasizing the role of lithiasis in the development of tuberculous lesions. The authors report a case of gallbladder tuberculosis in a female patient who presented with a clinical picture of chronic cholelithiasis. The diagnosis of gallbladder tuberculosis was reached only after surgery and proven by histopathology. In our case, the presence of stones associated with non specific inflammatory alterations and possibly low resistance against tubercle bacillus, is believed to have been of importance for the development of the tuberculous infection.