Right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy

A case of pseudoaneurysm of the right hepatic artery after laparoscopic cholecystectomy is reported. The patient presented with recurrent episodes of massive upper gastrointestinal bleeding. Diagnosed on selective angiography, the patient was treated with ligation of the right hepatic artery at laparotomy.

Duodenogastric reflux after choledochoduodenostomy

Duodenogastric reflux (DGR) has been implicated in several disease processes. The present study was carried out to document the incidence and evaluate the clinical significance of DGR after choledochoduodenostomy (CDD). A total of 13 patients who had undergone cholecystectomy with a standard side-to-side CDD for choledocholithiasis or chronic pancreatitis were studied by symptom evaluation, scintigraphy, endoscopy, and gastric mucosal histology at least 6 months after surgery. The scintigraphic findings were then compared with those of 10 patients who had undergone cholecystectomy alone. Only two patients (15%) had mild dyspeptic symptoms. The incidence of DGR after CDD was 69% compared to 20% in the cholecystectomy alone group (P < 0.05). In the majority of patients the DGR was only mild to moderate and the severity correlated well with the degree of endoscopic gastritis, but not with the clinical symptoms or histological findings. These results indicate that while CDD is associated with a high incidence of DGR, its occurrence does not produce significant clinical symptoms.

'Latent' portal hypertension in benign biliary obstruction

A prospective study was undertaken to evaluate the changes in portal venous pressure in patients with benign biliary obstruction (BBO) but without overt clinical, endoscopic or radiological evidence of portal hypertension. Portal venous pressure was measured at laparotomy in 20 patients (10 each with either benign biliary stricture or choledocholithiasis) before and after biliary decompression. Pressure was found to be on the high side in seven patients (> 25 cm of saline in three patients and > 30 cm of saline in four). The mean fall of pressure was 3.4 cm of saline after biliary decompression. No correlation could, however, be found between portal venous pressure and duration of biliary obstruction, serum bilirubin or bile duct pressure. Liver histology showed mild to moderate cholestatic changes but maintained portal architecture in all. Benign biliary obstruction may therefore, lead to elevation of portal pressure, even though the patient may not necessarily have any clinical, endoscopic or radiological manifestations of portal hypertension. The pathogenesis of this 'latent' portal hypertension is probably multifactorial. If biliary obstruction is left untreated the development of overt portal hypertension may become a possibility in the future.

Comparative evaluation of scintigraphy and upper gastrointestinal tract endoscopy for detection of duodenogastric reflux

Duodenogastric reflux, the reflux of duodenal bile into stomach, when suspected clinically requires an objective evaluation for proper management. In this study hepatobiliary scintigraphy in 91 patients of different clinical conditions was evaluated for presence of duodenogastric reflux. Upper gastrointestinal endoscopy was also performed in 44 of these patients. On scintigraphy duodenogastric reflux was present in 26 (29%) of 91 patients. Upper gastrointestinal endoscopy revealed presence of refluxed bile in the stomach in 12 (27%) of 44 patients. In the same groups of patients scintigraphy detected reflux in 18 (41%) of 44 patients. This shows that hepatobiliary scintigraphy is superior to upper gastrointestinal endoscopy in detection of duodenogastric reflux and also has the advantage of being non-invasive and physiological.

Gastric emptying in patients with gallstone disease with or without dyspepsia: effect of cholecystectomy

Dyspepsia is a common complaint in patients presenting with gallstone disease. Since the stomach appears to be its site of origin, the present study was undertaken to assess gastric emptying in patients with gallstone disease and to find out its correlation with dyspeptic symptoms before and after cholecystectomy. Gastric emptying (t1/2) was prospectively assessed in 43 patients with symptomatic gallstones (29 with and 14 without dyspepsia). These data were compared with that of 20 healthy volunteers (control group). Delayed gastric emptying (> 112 min: mean + 2 s.d. of the control group) was observed in 18 patients (42%; P < 0.002), 10 of whom presented with dyspepsia and eight without (NS). Re-evaluation in 18 of the 29 patients with dyspepsia, 3 months after cholecystectomy, revealed complete disappearance of symptoms in three, improvement in 11 and no change in four patients. After 6 months, two patients had reverted back to their pre-operative dyspeptic status; resulting in three patients completely cured, nine partially cured and six without any change in their dyspeptic status at this time. Gastric emptying was delayed in nine of the 18 patients before cholecystectomy. After cholecystectomy, normal emptying was observed in all but one patient (P < 0.005). Dyspeptic symptoms, however, completely disappeared in one patient, improved in five and remained unchanged in three. In the remaining nine patients, gastric emptying was normal both before and after cholecystectomy. Gallstone disease is associated with delayed gastric emptying but this delay was not the cause of dyspepsia in these patients. Cholecystectomy normalizes gastric emptying, a finding that has not been reported previously.(ABSTRACT TRUNCATED AT 250 WORDS)

Amebic liver abscess with intra-biliary rupture

The case of a large amebic liver abscess with an atypical presentation is reported. High output bile drainage persisted after ultrasound guided percutaneous catheter drainage because of a preexisting communication of the abscess with the right hepatic ductal system. The abscess was managed successfully by surgical evacuation and internal drainage into a defunctioned jejunal loop.

Mirizzi's syndrome: identification and management strategy

Fourteen cases of Mirizzi's syndrome are presented here. Clinical presentation was pain (14), jaundice (14), fever (10) and peritonitis (1). A clinical diagnosis of choledocholithiasis was considered in all the patients. Pre-operative diagnosis of Mirizzi's syndrome was made in five patients on the basis of cholangiogram and the remaining cases were diagnosed at surgery. The stage (type) of Mirizzi's syndrome was based on the extent of erosion of the common bile duct. Four patients had type I, seven type II and three type III lesions. Associated choledocholithiasis was present in five and acute free perforation of the gall-bladder in one. The operative procedures performed were partial cholecystectomy for type I, partial cholecystectomy, choledochoplasty and T-tube choledochostomy for type II and bilioenteric anastomosis for type III lesions. Two patients had retained common bile duct stones. Mean follow up was 14 months (range 1-27 months). One patient with secondary biliary cirrhosis continues to have persistently elevated serum alkaline phosphatase levels without any demonstrable biliary obstruction. Diagnostic and operative strategies are discussed and a follow up protocol for such patients is suggested.

Prestomal ileitis

A case of prestomal ileitis resulting from incomplete ileostomy-stomal obstruction presented with intestinal perforation and massive bleeding perileostomy. The diagnosis and surgical implications of this unusual problem have been discussed.

Cholecystectomy and drainage: ultrasonographic and radioisotopic evaluation

Eighty patients undergoing cholecystectomy were either assigned deliberately (n = 30) or randomized (n = 50) to drainage (n = 38) or nondrainage (n = 42). Subhepatic collections were seen on ultrasonography (US) after 48 to 72 hours in 12 of 35 patients with drainage and 24 of 42 patients without drainage (p < 0.05). Only two patients with subhepatic collections were symptomatic, and none required treatment. Postoperative infective complications were seen in 13 of 38 patients with drainage and with a collection, and none of the 18 patients without drainage and without a collection had postoperative infective complications (p < 0.05). Cholecystectomy was then performed in 100 patients without using a drain. BULIDA radioisotope scans revealed a bile leak in only 4 of 34 patients studied. Subhepatic collections were seen on US after 48 to 72 hours in 42 patients. The collection resolved in 22 patients and was smaller in 6 on repeat US. None of the patients with collection was symptomatic, and none required treatment. Postoperative infective complications were seen in 7 of 42 patients with a collection and 5 of 58 patients without a collection (not significant). We conclude that (1) cholecystectomy with drainage is associated with more infective complications than when a drain is not used; (2) cholecystectomy without drainage is safe; and (3) asymptomatic nonbilious subhepatic collections are common after cholecystectomy without drainage but do not require treatment, resolving spontaneously.

Periampullary carcinoma in a young female with situs inversus

Periampullary carcinoma in a young female with situs inversus viscerum is reported. Endoscopy was difficult because of the altered anatomy.

Colonic lipoma, masquerading as malignant tumour

A case of symptomatic colonic lipoma, mimicking malignant tumour on colonoscopy, barium contrast studies and at laparotomy, is reported. The diagnosis was established on histopathology after left hemicolectomy.

Agenesis of the gallbladder--a case report

Agenesis of the gallbladder, which is an extremely rare anomaly, may present with biliary symptoms but is virtually impossible to diagnose by such conventional investigations as oral cholecystogram or ultrasonography. We report herein a case of a young man presenting with episodic epigastric pain on whom an ultrasonographic diagnosis of gallstones was made. A gallbladder was not visualized on oral cholecystogram, however, he was subsequently found to have agenesis of the gallbladder, the diagnosis of which was confirmed by intra-operative cholangiography and a postoperative N-2,6-dimethylphenylcarbamoyle methyl iminodiacetic acid scan (HIDA scan). His symptoms responded to antiulcer treatment with upper gastrointestinal endoscopic findings suggestive of oesophagitis and duodenitis.

Diverticular disease of colon; Indian variant

Diverticular disease of colon is a rare entity in our country; true incidence of which is not known. We present three cases of diverticular disease, two with lower gastro-intestinal (GI) hemorrhage and one with sigmoid colon perforation and peritonitis. All three patients underwent emergency surgical treatment. Two patients survived and one died. No further complications were noted on follow up.