Choledocholithiasis and gallstone pancreatitis

Frequency of symptoms associated with gallstone disease: a hospital-based cross sectional study

This study investigated the likely outcomes of gallstone disease and frequency of symptoms associated with this. This cross sectional study was performed at the Aliebn Abitaleb hospital in Rafsanjan over a period of twelve months from 2000 to 2001. A total sample of 70 individuals were included in the study, interviewing them using of a questionnaire covering data in terms of demographic features and medical history.The majority of patients belonged to the age group of 41 to 60 years (44.3% of all patients), while the lowest frequency was in the age group of 20 years or less. Frequency of females was higher than males. The frequency of female patients increased with the number of child birth, the highest being in women who had more than 5 child births. The most common complaint of pain was revealed as upper right abdominal quadrant (RUQ), which accounted for 95.7% of cases. Vomiting was observed in 52.9% of patients. In addition, the frequency of patients with chronic pain initiation was more than those with acute pain initiation. Among women, 17.5% had oral contraceptive pill constipation. It is worth noting that ultrasonography was the best diagnostic tool for evaluating patients. It is noteworthy that the most common symptom was right upper quadrant tenderness. Our data indicate that diabetes was the most common illness associated with gallstone disease and that 8.6% of patients had a family history of gallstone disease.

Biliary tract emergencies

Gallstones are responsible for the majority of biliary tract emergencies and will be the main focus of this article. Gallstones present with features related to the site of the calculi and are therefore considered separately. Cholecystolithiasis refers to gallstones confined to the gallbladder, whereas choledocholithiasis refers to gallstones within the common bile duct.

Etiology and pathogenesis of acute pancreatitis: current concepts

Acute pancreatitis is a disorder that has numerous causes and an obscure pathogenesis. Bile duct stones and alcohol abuse together account for about 80% of acute pancreatitis. Most episodes of biliary pancreatitis are associated with transient impaction of the stone in the ampulla (that causes obstruction of the pancreatic duct, with ductal hypertension) or passage of the stone though and into the duodenum. Other causes of acute pancreatitis are various toxins, drugs, other obstructive causes (such as malignancy or fibrotic sphincter of Oddi), metabolic abnormalities, trauma, ischemia, infection, autoimmune diseases, etc. In 10% of cases of acute pancreatitis, no underlying cause can be identified; this is idiopathic pancreatitis. Occult biliary microlithiasis may be the cause of two thirds of the cases of "idiopathic" acute pancreatitis. Intra-acinar activation of trypsinogen plays a central role in the pathogenesis of acute pancreatitis, resulting in subsequent activation of other proteases causing the subsequent cell damage. Ischemia/reperfusion injury is increasingly recognized as a common and important mechanism in the pathogenesis of acute pancreatitis and especially in the progression from mild edematous to severe necrotizing form. Increased intracellular calcium concentration also mediates acinar cell damage. Oxygen-derived free radicals and many cytokines (e.g., interleukin [IL]-1, IL-6, IL-8, tumor necrosis factor-alpha, platelet activating factor) are considered to be principal mediators in the transformation of acute pancreatitis from a local inflammatory process into a multiorgan illness.

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study

OBJECTIVE

We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy.

SUBJECTS AND METHODS

Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room.

RESULTS

Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%.

CONCLUSION

On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.