Gallstones top to toe: what the radiologist needs to know

Helicobacter pylori infection is associated with the risk and phenotypes of cholelithiasis: A multi-center study and meta-analysis

BACKGROUND

Helicobacter pylori (H. pylori) is a prevalent pathogen associated with various diseases. Cholelithiasis is also a common condition. H. pylori infection has been identified in the biliary system, suggesting its potential involvement in biliary diseases. However, the specific role of H. pylori in the development of cholelithiasis remains inconclusive.

AIM

To investigate the potential association between H. pylori infection and the development of cholelithiasis.

METHODS

We performed a retrospective study in more than 70000 subjects in health examination center from 3 institutions in the middle, northern and eastern China, from October 2018 to December 2021, to explore the potential association between H. pylori and cholelithiasis through univariate and multivariate analysis. Meanwhile, the influence of H. pylori on biliary-related parameters was investigated. A comprehensive analysis of previous studies concerned about H. pylori and cholelithiasis was also executed.

RESULTS

In our multi-center study, H. pylori was positively associated with cholelithiasis [odds ratio (OR) = 1.103, 95% confidence interval (CI): 1.001-1.216, P = 0.049]. Furthermore, H. pylori patients had less total and direct bilirubin than uninfected patients, while the total cholesterol and low-density lipoprotein cholesterol were more in H. pylori-positive participants (P < 0.05). In the published articles, the cohort studies indicated H. pylori was a risk factor of cholelithiasis (hazard ratio =1.3280, 95%CI: 1.1810-1.4933, P < 0.0001). The pooled results of case-control and cross-sectional studies showed positive association between H. pylori and cholelithiasis in Asia (OR = 1.5993, 95%CI: 1.0353-2.4706, P = 0.034) but not in Europe (OR = 1.2770, 95%CI: 0.8446-1.9308, P = 0.246). Besides, H. pylori was related to a higher choledocholithiasis/cholecystolithiasis ratio (OR = 3.3215, 95%CI: 1.1034-9.9986, P = 0.033).

CONCLUSION

H. pylori is positively correlated with cholelithiasis, choledocholithiasis phenotype particularly, especially in Asia, which may be relevant to bilirubin/cholesterol metabolism. Cohort studies confirm an increased risk of cholelithiasis in H. pylori patients.

Bouveret syndrome managed conservatively with the insertion of a double pigtail stent between the stomach and the gallbladder

A woman in her early 90s presented to the acute surgical take with a 3-day history of worsening reflux, vomiting, epigastric pain and constipation. Subsequent imaging demonstrated two large, impacted gallstones in the pylorus and proximal jejunum secondary to a cholecystoduodenal fistula. A diagnosis of Bouveret syndrome was made, and endoscopic attempts to break down and remove the stones were unsuccessful. The stones were left in the stomach, with a pigtail stent placed through the fistula between the stomach and gallbladder to prevent the stones impacting again and to allow adequate drainage of the gallbladder to prevent further flare-ups. Due to the patient's comorbidities, it was decided to leave the stent in situ long term as opposed to surgical management. This has shown to be successful in follow-up. Our case highlights that Bouveret syndrome can potentially be managed conservatively long term in patients deemed unfit for major surgical intervention.

Imaging of gallstones and complications

Gallbladder pathologies caused by gallstones are commonly encountered in clinical practice, making accurate diagnosis critical for effective patient management. Radiologists play a key role in differentiating these conditions through imaging interpretation, ensuring that appropriate treatment is initiated. The imaging features of gallstone associated diseases are classified into various categories, such as inflammatory conditions, benign lesions, malignant tumors, and associated complications. A comprehensive understanding of these categories and their radiologic manifestations is essential for accurate diagnosis and management of gallbladder pathology. By integrating clinical knowledge with radiologic findings, clinicians and radiologists will be equipped with practical tools to identify and distinguish between different gallstone causing conditions.

Imaging of Biliary Tree Abnormalities

Pathologic conditions of the biliary system, although common, can be difficult to diagnose clinically. Challenges in biliary imaging include anatomic variants and the dynamic nature of the biliary tract, which can change with age and intervention, blurring the boundaries of normal and abnormal. Choledochal cysts can have numerous appearances and are important to diagnose given the risk of cholangiocarcinoma potentially requiring surgical resection. Choledocholithiasis, the most common cause of biliary dilatation, can be difficult to detect at US and CT, with MRI having the highest sensitivity. However, knowledge of the imaging pitfalls of MRI and MR cholangiopancreatography is crucial to avoid misinterpretation. Newer concepts in biliary tract malignancy include intraductal papillary biliary neoplasms that may develop into cholangiocarcinoma. New paradigms in the classification of cholangiocarcinoma correspond to the wide range of imaging appearances of the disease and have implications for prognosis. Accurately staging cholangiocarcinoma is imperative, given expanding curative options including transplant and more aggressive surgical options. Infections of the biliary tree include acute cholangitis or recurrent pyogenic cholangitis, characterized by obstruction, strictures, and central biliary dilatation. Inflammatory conditions include primary sclerosing cholangitis, which features strictures and fibrosis but can be difficult to differentiate from secondary causes of sclerosing cholangitis, including more recently described entities such as immunoglobulin G4-related sclerosing cholangitis and COVID-19 secondary sclerosing cholangitis. The authors describe a wide variety of benign and malignant biliary tract abnormalities, highlight differentiating features of the cholangitides, provide an approach to interpretation based on the pattern of imaging findings, and discuss pearls and pitfalls of imaging to facilitate accurate diagnosis. ©RSNA, 2024 Supplemental material is available for this article.

Risk Factors and Prognostic Factors in GBC

Background: Gallbladder cancer (GBC) is a rare entity with a poor prognosis, usually discovered late due to nonspecific symptoms; therefore, over the last years, attention has been focused on identifying the risk factors for developing this malignancy in order to provide an early diagnosis, as well as new prognostic factors in order to modulate the long-term evolution of such cases. The aim of this review is to discuss both major risk factors and prognostic factors in GBC for a better understanding and integration of relevant and currently available information. Methods: A literature search was performed using Cochrane Library, PubMed, Google Scholar, Elsevier, and Web of Science; studies published after the year of 2000, in English, were reviewed. Results: Over time, risk factors associated with the development of GBC have been identified, which outline the profile of patients with this disease. The most important prognostic factors in GBC remain TNM staging, safety margin, and R0 status, along with perineural invasion and lymphovascular invasion. Both the technique and experience of the surgeons and a pathological examination that ensures final staging are particularly important and increase the chances of survival of the patients. Conclusions: improvements in surgical techniques and pathological analyses might provide better and more consistent guidance for medical staff in the management of patients with GBC.

Cholesterol Gallstones and Long-Term Use of Statins: Is Gut Microbiota Dysbiosis Bridging over Uncertainties?

A total of 300 research participants-200 consecutive patients diagnosed with dyslipidemia (100 statin (+), treated for at least five years, and 100 statin (-)) and 100 healthy controls-were included in this observational study. The aim of the study was to deliver insights into the relationship between the long-term use of statins for dyslipidemia and gallstone disease (GSD), as well as insights into the background particularities of the gut microbiota. All study participants underwent clinical examination, laboratory workups, stool microbiology/stool 16S r RNA, next-generation sequencing, and abdominal ultrasound/CT exams. Results: The research participants presented with similarities related to age, gender, and location. Patients displayed comparable heredity for GSs, metabolic issues, and related co-morbidities. Gut dysbiosis (DB) was present in 54% of the statin (-) patients vs. 35% of the statin (+) patients (p = 0.0070). GSs were present in 14% of patients in the statin (-) group vs. 5% of patients in the statin (+) group (p = 0.0304). Severe dysbiosis, with a significant reduction in biodiversity, an increase in LPS (+) bacteria, and a notable decrease in mucin-degrading bacteria, mucosa-protective bacteria, and butyrate-producing bacteria were observed in the statin (-) group. Strong positive correlations between GSD and diabetes/impaired glucose tolerance (r = 0.3368, p = 0.0006), obesity (r = 0.3923, p < 0.0001), nonalcoholic fatty liver disease (r = 0.3219, p = 0.0011), and DB (r = 0.7343, p < 0.0001), as well as significant negative correlations between GSD and alcohol use (r = -0.2305, p = 0.0211), were observed. The multiple regression equation demonstrated that only DB (95% CI: 0.3163 to 0.5670; p < 0.0001) and obesity (95% CI: 0.01431 to 0.2578; p = 0.0289) were independent risk factors predicting GSD in the group of patients treated with statins. Conclusion: The long-term use of statins in dyslipidemic patients was associated with a low risk of developing GSs. The gut microbiota associated with a long-term use of statins in dyslipidemic patients was characterized by a low risk of developing an imbalance of various functional bacteria and alterations in the metabolic microbiota. DB and obesity were found to be independent risk factors predicting GSD in statin (+) patients.

Aetiological Spectrum of Pancreaticobiliary Diseases in Adult Nigerians on Magnetic Resonance Cholangiopancreatography

BACKGROUND

Imaging is vital for assessing pancreaticobiliary diseases.

AIM

The aim of the study was to investigate the spectrum and pattern of pancreaticobiliary diseases in adult Nigerians using magnetic resonance cholangiopancreatography (MRCP).

METHODS

This was a retrospective, descriptive cross-sectional study. The electronic radiological records of 110 adult Nigerians who had undergone MRCP were reviewed. The MRCP images were evaluated for bile duct dilatation, intraluminal filling defects, strictures, calculi, and other abnormalities.

RESULTS

There were 45 males (40.9%) and 65 females (59.1%) aged 18-83 years, with a mean age of 51.93 ± 15.22 years. Jaundice (59.1%) and right hypochondrial pain (31.8%) were the most common presenting complaints. Gallstones (32.7%), common bile duct strictures (15.5%), choledocholithiasis (11.8%), pancreatic head carcinoma (10.9%), and gallbladder carcinoma (2.7%) were the most frequent abnormalities. There was biliary obstruction in 56.4% of participants, mostly at the distal and proximal common bile duct. Other findings include hepatomegaly (23.6%), hepatic cysts (6.4%), hepatic steatosis (0.9%), duodenal wall thickening (1.8%), and ascites (5.5%). MRCP was normal in 25 (22.7%) participants.

CONCLUSION

Gallstones were the predominant pathology of the various pancreaticobiliary diseases, while Pancreatic head and gallbladder carcinoma were the most common malignant diseases.

Impact of Imaging Techniques in the Assessment of Gallstone Pancreatitis

From the category of biliary disease, gallstones registered an increase during the last years, approximately 6% of men and 9% of women being affected by the pathology in the United States only. In western countries between 10-20% of the adult population is suffering from cholelithiasis. Although increasing age is a major risk factor for their formation, late studies correlate gallstones appearance with an age decrease for the onset of symptoms. We therefore face a younger population manifesting pain and sometimes functional disability. In accordance with statistical analysis, the economic impact of gallstones in highly industrialized countries such as United States produces costs of up to 6.5 billion dollars annually. In this context, the appropriate timing for intervention becomes a factor of major interest. The present review uses 28 articles and specialized literature. Article selection was based on keywords and followed the effectiveness of imaging investigation such as ultrasound, CT and MRI for patients diagnosed with cholelithiasis. Since a direct comparison between the imaging investigation techniques is not concluding we have tried to establish the sensitivity and specificity offered by each imaging assessment. The comparative analysis revealed a p Kruskal-Wallis <0.001 for sensitivity and p Kruskal-Wallis=0.474 for specificity.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

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.

Prevalence of extra-hepatic incidental findings on ultrasound screening for hepatocellular carcinoma

PURPOSE

Abdominal ultrasound is a cost-effective method for screening for hepatocellular carcinoma (HCC) in high-risk individuals. Currently, at many institutions the protocol for obtaining HCC screening ultrasounds includes a traditional examination of the right upper quadrant, including the pancreas and right kidney. There is no consensus on the role of imaging of extra-hepatic structures and there are limited data describing the frequency and clinical significance of incidental findings discovered during HCC screening. The purpose of this retrospective study is to assess the prevalence and significance of extra-hepatic incidental findings during HCC screening ultrasounds.

METHODS

A single-center retrospective review of all right upper quadrant HCC screening ultrasounds identified 432 HCC screening ultrasounds performed on 294 adults over a 2.5-year period. Findings in all organs evaluated were recorded. Any incidental finding was classified as minor, moderate, or major clinical significance.

RESULTS

At least one extra-hepatic finding was documented in 57.4% of examinations. The most common extra-hepatic findings occurred in the gallbladder (40.3%), most commonly gallstones (25.4%). Four moderate clinically significant incidental findings were recorded (0.9%). Only one of these incidental findings required specific imaging follow up (0.2%). No major clinical significance incidental findings were identified.

CONCLUSIONS

Potentially clinically significant incidental findings during ultrasound HCC screenings are rare. Incidental findings identified on HCC screening did not result in significant additional follow-up imaging or interventions.

Physical activity and risk of gallstone disease: A Mendelian randomization study

Objective: Given the association between physical activity and the reduced risk of gallstone disease as suggested in observational studies, a Mendelian randomization study was conducted to evaluate the causal nature of this association in genetic epidemiology. Study: Including self-reported and accelerometer-based physical activity traits, the independent genetic variants associated with physical activity were selected from the corresponding genome-wide association studies as instrumental variables. The summary-level data for gallstone disease were sourced from the UK Biobank (7,682 cases and 455,251 non-cases) and FinnGen consortium (23,089 cases and 231,644 non-cases). Then, two-sample Mendelian randomization analysis was conducted. Inverse-variance weight (IVW), weighted median, and Mendelian randomization-Egger regression were determined through Mendelian randomization analyses. To ensure the robustness of the results, sensitivity analyses were also carried out in the study. Results: The negative causality between the genetically predicted accelerometer-based "average acceleration" physical activity and the risk of gallstone disease was suggested in the UK Biobank study (p = 0.023, OR = 0.93, 95% CI: 0.87-0.99), and accelerometer-based "overall activity" physical activity and the risk of gallstone disease in the UK Biobank study (p = 0.017, OR = 0.38, 95% CI: 0.17-0.84). With accelerometer-based "average acceleration" physical activity negatively correlated with gallstone disease in the FinnGen consortium data (p = 0.001, OR = 0.94, 95% CI: 0.90-0.97). As for self-reported moderate-to-vigorous physical activity, however, there was no causality observed in both pieces of data. Conclusion: Our studies provide the evidence suggesting a casual association between physical activities and gallstone disease through analysis of genetic data. As indicated by the research results, there is a possibility that a higher level of physical activities could mitigate the risk of gallstone disease.

Incidental Findings of Gallbladder and Bile Ducts-Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening-A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.

Optimization of Patient Positioning for the Sonographic Evaluation of Gallstone Impaction: Analysis of Gallbladder Orientation Based on Computed Tomography

ABSTRACT

An important sonographic sign of cholecystitis is stone impaction in the gallbladder neck. Demonstration of stone mobility excludes impaction. The purpose of this study is to analyze the orientation of the gallbladder on computed tomography and determine the patient position most likely to facilitate stone mobility. ImageJ processing software was used to determine the x (transverse), y (anterior-posterior), and z (craniocaudal) coordinates for the gallbladder neck and fundus in 544 consecutive computed tomography examinations. The differences in the fundal and neck coordinates were used to determine the likelihood of moving a stone from the neck to the fundus for the left and right lateral decubitus positions ( x coordinates), the prone position ( y coordinates), and the upright position ( z coordinates). The coordinate with the largest difference was considered to predict the position most likely to facilitate stone motion. The difference in position of the fundus and neck was greatest in the y -, z -, and x -axis in 232 (42.6%), 194 (35.7%), and 118 (21.7%) of patients, respectively. For body mass index (BMI) less than 25 kg/m 2 , the difference was greatest in the z -axis (59.8%). For BMI greater than 25 kg/m 2 , the difference was greatest in the y -axis (47.1%). Based on their relative location, the optimal position to facilitate gallstone mobility from the gallbladder neck to fundus was most often prone (especially in high BMI patients), followed by upright (especially in low BMI patients), followed by right lateral decubitus. The left lateral decubitus position was never optimal.

Beyond acute cholecystitis-gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

"Target sign" from dropped gallstones after laparoscopic cholecystectomy

Isolated case reports and small series in radiologic and surgical literature relay the different modes of clinical presentation that arise secondary to spillage of gallstones during surgery. We report a case of a 70-year-old female who presented with a 2-week history of right-sided abdominal pain. CT (computerized tomography) imaging findings demonstrated multiple peripherally enhancing hypoattenuating lesions in the right subphrenic space abutting the hepatic dome, concerning for abscesses. The lesions were found to have a characteristic central hyperattenuating focus (Target Sign) consistent with gallstones, as identified on a pre-cholecystectomy CT, resulting in the early diagnosis and treatment of dropped gallstones from prior laparoscopic cholecystectomy approximately 1 year prior to presentation.

Focal hepatic intrinsically hyperattenuating lesions at unenhanced CT: Not always calcifications

Due to the growing use of CT, there has been an increase in the frequency of detecting focal liver lesions. Intrinsically hyperattenuating hepatic lesions or pseudolesions are not uncommon at unenhanced CT. Hyperattenuating hepatic lesions can be divided into non-calcified and calcified. Causes of intrinsic hyperattenuation include hemorrhage, thrombosis, and calcifications. Focal liver lesions can show hyperattenuation on unenhanced CT in case of severe liver steatosis. Recognition of etiologies associated with hyperattenuation on unenhanced CT can help the radiologist in characterizing focal liver lesions and pseudolesions. In this paper, we describe the spectrum of intrinsically hyperattenuating focal liver lesions and pseudolesions at unenhanced CT.

A unique case of black choledocholithiasis: a video-based case review in the Pancreato-Biliary Division–Endoscopy Unit of National Liver Institute (NLI)

Background

Black gall stones are consistently described in relation to haem turnover and hemolytic disorders. Black gall stones are also a frequent presentation in cirrhotic patients, principally due to hemolysis-related hypersplenism.

Case presentation

Herein, we present a case of an average built 83-year-old lady who was suffering from biliary-type abdominal episodes of pain. Neither clinical nor laboratory evidence of overt biliary obstruction, cholangitis, or pancreatitis was detected. Sonographic examination revealed the presence of calcular gall bladder with many small stones, dilated common bile duct (CBD), and biliary radicles, along with homogenous average-sized liver, average-sized spleen with normal echogenicity and no focal lesions. Endoscopic retrograde cholangiography (ERC) was performed with wide papillotomy which was surprisingly followed by a drift of innumerable intensely black small stones.

Conclusion

In aged population, absence of the full-blown clinical syndrome in relation to complicated CBD stones should not exclude endoscopic intervention.

Increased incidence of acute calculous cholecystitis observed during COVID-19 social restrictions

Purpose

In response to the outbreak of COVID-19 in Ireland, the government implemented a nationwide stay-at-home order, with the closure of all non-essential businesses. During this period, there was a significant increase in supermarket expenditure. It has been shown that stress, anxiety and boredom are triggers for unhealthy eating habits. Fat consumption is a risk factor for both the development of gallstones and, additionally, the development of acute calculous cholecystitis. The aim of this study was to assess the incidence of acute calculous cholecystitis during the nationwide lockdown and compare it to the same period one year prior.

Methods

A retrospective review of all emergency abdominal imaging performed during the first 5 weeks of the lockdown was completed using the hospital PACS (picture archiving and communication system). All cases of acute calculous cholecystitis were identified and compared with the same period 1 year prior.

Results

Eighteen cases of acute calculous cholecystitis were identified from 24 March to 27 April 2020. Eleven cases were identified during the same period in 2019. This represented an increase of 63%. Non-COVID-19-related emergency presentations decreased during this period, and imaging of emergency presentations decreased by 24%. The rate of scans positive for acute cholecystitis more than doubled (p < 0.037).

Conclusion

A statistically significant increase in cases of acute calculous cholecystitis was observed during a nationwide lockdown during the COVID-19 pandemic. It is hypothesised that this is due to increased consumption of fatty foods during this period due to stress, anxiety and boredom.

Role of magnetic resonance imaging in Bouveret's syndrome: A case report with review of the literature

Bouveret's syndrome is a rare form of gallstone ileus occurring due to obstructing gallstone into the proximal duodenum through a cholecystoduodenal fistula. We report the case of a 72-year-old female presenting with abdominal pain secondary to a large gallstone in the region of the duodenal bulb, causing the upstream gastric obstruction. Here we discuss the clinical features, imaging technologies, and surgical management of Bouveret's syndrome.

Risk of Gallstone Formation in Aberrant Extrahepatic Biliary Tract Anatomy: A Review of Literature

The age-long mnemonic of '5Fs' (fat, female, fertile, forty, and fair) has traditionally been used in medical school instructions to describe the risk factors for gallstone disease. However, evidence suggests that aberrant extrahepatic biliary tract (EHBT) anatomy may contribute significantly to the risk of gallstone disease. This review explores the anatomy and embryological bases of EHBT variations as well as the prevalence of these variations. Also, we discuss the risk factors for gallstone formation in the relationship between gallstone disease and aberrant EHBT anatomy.

Peach pit impaction presenting as gallstone ileus

Small bowel obstruction (SBO) secondary to fruit pit impaction is rare. The presence of an ovoid, stony body in the bowel lumen on radiologic imaging in a patient presenting with signs and symptoms of SBO is likely to raise concern for gallstone ileus. We report the case of a 56-year-old man who presented with a 1-day history of intermittent left-sided abdominal pain and nausea associated with a single episode of vomiting. CT scan of the abdomen and pelvis revealed a 3.3 cm impacted stony mass in the terminal ileum resulting in high-grade partial SBO. The mass had a hypodense centre encased within a hyperdense, ridged outer layer. The diagnostic impression was gallstone ileus. The object was removed via enterotomy and was found to be a peach pit.