Massive hemobilia and acalculous cholecystitis due to benign gallbladder polyp

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Undiagnosed Metachromatic Leukodystrophy Presenting as Severe Gastrointestinal Bleeding and Cholestasis from Hemobilia

Metachromatic leukodystrophy (MLD) is a neurodegenerative disorder caused by the accumulation of lipids called sulfatides throughout the nervous system. Sulfatides can also collect in other organs throughout the body including the gallbladder where they form polyps. Gallbladder polyps rarely have been found to bleed in patients with known MLD, presumably due to polyp shearing. Here we present a case of a child with autism presenting with severe gastrointestinal bleeding and direct hyperbilirubinemia, requiring significant resuscitation and biliary drain placement to tamponade ongoing bleeding. Subsequent neurologic and genetic investigation led to the diagnosis of MLD, with laparoscopic cholecystectomy revealing extensive, elongated gallbladder polyps. Clinicians who care for patients with MLD, including gastroenterologists who manage their progressive oropharyngeal dysphagia, should be aware of the risk for this life-threatening complication. Moreover, pediatric gastroenterologists and hepatologists should maintain a high index of suspicion for MLD in new patients presenting with developmental regression and gastrointestinal bleeding.

Intestinal involvement in metachromatic leukodystrophy

Metachromatic leukodystrophy is a lysosomal storage disease caused by the deficiency of the enzyme arylsulfatase A. If arylsulfatase A is deficient, sulfatide accumulates. Functionally, this accumulation results in progressive neurological deterioration. The reports about the extra nervous system manifestations of metachromatic leukodystrophy are related to the gallbladder involvement such as polyposis. Unexplained vomiting began in a 5½-year-old girl with late infantile metachromatic leukodystrophy. Endoscopy showed multiple polypoid masses in the pylor of the stomach and duodenum. Severe gastrointestinal bleedings occurred during nasogastric feeding. Intestinal intussusception developed later. To the authors' knowledge, intestinal polypoid masses and obstruction with metachromatic leukodystrophy have not previously been reported. The persistent vomiting may be a symptom of intestinal obstruction due to intestinal polypoid masses with metachromatic leukodystrophy. There may be a trend for the development of polypoid masses in intestine as well as in the gallbladder in metachromatic leukodystrophy.

Case report: acute pancreatitis caused by postcholecystectomic hemobilia

Background

Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described.

Case Presentation

We presented the case of a 32-year-old female, admitted to our emergency surgery clinic with hematemesis, jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 4 months ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. Afterwards she is successfully treated by ERCP, angiographic identification and embolization of right hepatic artery pseudoaneurysm.

Conclusions

We presented that postcholecystectomic hemobilia may cause acute pancreatitis and acute pancreatitis caused by postcholecystectomic hemobilia should also be included to the rare complications which may occur following cholecystectomy.

Diagnosis and management of gallbladder polyps

Gallbladder polyps are frequently encountered on cross-sectional imaging, often in asymptomatic patients. Most are benign and of little clinical importance. However, some polyps do have a malignant potential. This article discusses the clinical presentation, diagnosis, and natural history of gallbladder polyps and risk factors for malignant polyps and indications for cholecystectomy.

Cholecystitis

Cholecystitis is the most prevalent surgical condition affecting populations in industrialized countries. Rather than a single clinical entity, cholecystitis is a class of related disease states with different causes, degrees of severity, clinical courses, and management strategies. Appropriate care of the patient who has a diseased gallbladder requires a broad understanding of the acute, chronic, and acalculous cholecystitis syndromes, and awareness of their particular clinical nuances and potential complications.

Incidental Findings During Routine Antepartum Obstetrical Sonography

The standard for performing an antepartum obstetrical sonogram primarily involves the examination of the fetus; however, both the American Institute of Ultrasound in Medicine (AIUM) and American College of Radiology (ACR) guidelines suggest the evaluation of maternal structures as well. The authors present 35 incidental findings that were discovered on routine antepartum obstetrical sonography. These include abdominal wall, gastrointestinal, reproductive, urinary, and vascular anomalies in the maternal structures. A review of the literature demonstrates that many of these findings have clinical significance, which highlights the wisdom of the AIUM and ACR guidelines, and it also stresses the importance of seeking and reporting them.

[Alithiasic cholecystitis in the adult: etiologies, diagnosis and treatment]

Acalculous cholecystitis represents 2% to 14% of cholecystectomies performed for acute cholecystitis. Its main etiology is ischemia of the gallbladder wall, which mainly occurs in critically ill patients, particularly in case of cardiovascular previous disease or diabetes. Acalculous cholecystitis associated with VIH are rare and have a better prognosis. Other etiologies are exceptional. Diagnosis of acalculous cholecystitis is difficult, with a lack of specificity of abdominal ultrasound for the diagnosis of ischemic cholecystitis. In all cases, cholecystectomy is a definitive treatment allowing certain diagnosis. Percutaneous drainage must be reserved to patients whose general condition does not allow general anesthesia. Medical treatment alone is not indicated in acalculous cholecystitis.

Late follow-up of polypoid lesions of the gallbladder smaller than 10 mm

OBJECTIVE

To determine the variation in number, size, and symptoms in patients with polypoid lesions of the gallbladder.

SUMMARY BACKGROUND DATA

A polypoid lesion is any elevated lesion of the gallbladder mucosa. Several studies have been reported in patients undergoing cholecystectomy, but little information exits regarding the natural history of these lesions in nonoperated patients.

METHODS

A total of 111 patients with ultrasound diagnosis of polypoid lesions smaller than 10 mm were followed up by clinical evaluation and ultrasonography. Twenty-seven patients underwent cholecystectomy.

RESULTS

There was no difference in terms of gender. Nearly 80% of the lesions were smaller than 5 mm; they were single in 74%. In nonoperated patients, 50% remained of similar size at the late follow-up, 26.5% increased in number and size, and 23.5% shrank or disappeared. Among the operated patients, 70% corresponded to cholesterol polyps. None of the patients developed symptoms of biliary disease or gallstones or adenocarcinoma.

CONCLUSIONS

Ultrasound is useful in the follow-up of patients with polypoid lesions of the gallbladder. Lesions smaller than 10 mm do not progress to malignancy or to development of stones, and none produced symptoms or complications of biliary disease.

Surgical management of polypoid lesions of the gallbladder

BACKGROUND

With improvements in ultrasonography more polypoid lesions of the gallbladder (PLGs) are being detected. The management of these is controversial.

METHODS

The demographic, radiological and pathological data of 38 patients with ultrasonographically detected PLGs were reviewed. A Medline search for such lesions was performed and a review of the literature is presented.

RESULTS

Thirty-four patients underwent cholecystectomy and four were advised against or declined operation. Of the 34 who had cholecystectomy, 11 had macroscopic and histopathologically proven PLGs. Of these, seven had cholesterol polyps, two had adenomas, one had a carcinoid tumour and one had an adenocarcinoma of the gallbladder. One patient had a histopathologically normal gallbladder. The remainder had chronic cholecystitis with or without gallstones. All of the patients with neoplastic lesions of the gallbladder had solitary polyps greater than 1.0 cm in diameter.

CONCLUSION

A protocol for the management of ultrasonographically detected PLGs is proposed. In this protocol it is suggested that patients with a PLG should undergo surgery if they are symptomatic, or if the PLG is 1.0 cm or more in diameter.

Cholecystitis caused by hemocholecyst from underlying malignancy

Massive hemobilia is a well recognized clinical entity, particularly when it presents with jaundice, GI bleeding, and biliary pain. However, occult hemobilia is more difficult to diagnose and has seldom been reported because of its clinically silent nature. In fact, this is usually overlooked until complications arise. Hemocholecyst or clot within the gallbladder may rarely occur in this setting, leading to cystic duct obstruction and cholecystitis. Most previous reports describe cholecystitis resulting from hemocholecyst after iatrogenic trauma. We describe two cases in which hemocholecyst occurred from underlying malignancies, both resulting in cholecystitis (acute or chronic).

Acute cholecystitis secondary to hemobilia

Invasive diagnostic and therapeutic techniques such as percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography (ERCP), transjugular intrahepatic portosystemic shunting, and laparoscopic cholecystectomy have led to a rise in hemobilia. Most complications from hemobilia are attributable to acute blood loss; other complications are secondary to thrombus formation in the biliary tree. We present a case report of acute cholecystitis secondary to hemobilia after percutaneous liver biopsy. The role of ERCP in the diagnosis and treatment of this exceedingly rare event is discussed.

Early carcinoma of the gallbladder accompanied by hemobilia: report of a case

The majority of cases of hemobilia are of traumatic or vascular origin; however, we report herein the rare case of a 51-year-old man with early carcinoma of the gallbladder accompanied by hemobilia. He had been diagnosed as having gallbladder polyps during an admission to a local hospital for treatment of cardiac failure. Preoperative evaluation in our hospital suggested that the polypoid lesion was an advanced carcinoma of the gallbladder. Laparotomy revealed that the gallbladder contained blood clots, and a cholecystectomy was performed. Histological examination confirmed the main lesion to be IIb-type early carcinoma of the gallbladder and proved that the blood clots had been misinterpreted as polyps or advanced carcinoma before the operation. The diagnostic approaches and characteristics of hemobilia in the gallbladder are discussed with a review of the literature.

Chronic cholecystitis following hemobilia due to traumatic intrahepatic injury

We report a patient who presented with colicky abdominal pain, hematemesis, and melena following a blunt abdominal injury sustained in an automobile accident. Serologic tests suggested liver dysfunction and computed tomography (CT) revealed dilatation of the intrahepatic bile duct. Duodenoscopy demonstrated hemobilia originating from the duodenal papilla of Vater. Angiography revealed a pseudoaneurysm of the hepatic artery and angiographic embolization sucessfully stopped the hemorrhaging. However, even following the angiographic embolization, the patient remained symptomatic and repeat CT demonstrated thickening of the gallbladder wall and a lesion resembling a blood clot. We strongly suspected cholecystitis and performed a laparoscopic cholecystectomy. Grossly, the resected specimen revealed wall thickening with a congested mucosa and three blood clots; histologically, these changes were consistent with a diagnosis of chronic cholecystitis. The clinical message of this paper is that patients should be observed for this usual complication of hemobilia after liver injury.