[Chronorehabilitation of the patients suffering from chronic cholecystitis with concomitant gallbladder dysfunction and opisthorchiasis]

The importance of the development of the effective rehabilitative measures for the patients suffering from chronic cholecystitis with concomitant gallbladder dysfunction and opisthorchiasis is beyond question. The adequate methods for the rehabilitation of the patients after an intensive de-worming remain to be developed. It is known that de-worming is not infrequently followed by the immediate amplification of the manifestations of the stagnation of bile in the gallbladder that become even more pronounced than before the de-worming procedure. With the purpose of improving the effectiveness of the spa and health resort-based rehabilitation and prevention of the complications, it is recommended to make use of the modern therapeutic physical factors to be prescribed taking into consideration the characteristics of the biological rhythms in the functional activity of the biliary system in the individual patients. The most effective rehabilitation methods for the treatment of the pathology in question include the application of the therapeutic physical factors known to produce the beneficial effect on the functional state of the biliary system and exert the normalizing influence on the structure of the biological rhythms of the functional activity of various organs and systems. We used a range of approaches for the treatment of 123 patients with chronic cholecystitis and concomitant gallbladder dysfunction plus opisthorchiasis including extremely high-frequency electromagnetic irradiation (EHF therapy) in the combination with the oral intake of the choleretic herbal remedies followed by the transverse galvanization of the epigastric region with due regard for the phase of the rhythm of the functional activity of the gallbladder. The results of such treatment gave evidence of the positive dynamics of all the studied indicators of the functional activity of the biliary system and the organism as a whole which suggests the highest therapeutic effect (87.9%) of the proposed treatment that was maintained during 6 to 12 months.

HEPATOBILIARY ASCARIASIS COMPLICATED BY PANCREATITIS

Ascaris lumbricoides is the commonest organism causing soil-transmitted helminth infection. It is particularly common in poor sanitary conditions. Nevertheless, involvement of the gallbladder by Ascaris is a rare entity. A lady presented to us with long-standing history of vague abdominal symptoms suggesting dyspepsia. Ultrasound showed a tube like structure invading the biliary channels. Serum amylase was elevated and the patient was managed conservatively, as for acute pancreatitis. She improved clinically, but subsequent imaging with magnetic resonance cholangiopancreatography revealed worm in the gallbladder. Laparoscopic cholecystectomy was done and Ascaris lumbricoides was removed. Ascaris infestation is an important differential diagnosis of patients with upper abdominal symptoms and screening with stool examination and ultrasound is warranted in high-risk population.

Eosinophilic cholecystitis along with pericarditis caused by Ascaris lumbricoides: A case report

Although the etiology of eosinophilic cholecystitis is still obscure, the postulated causes include allergies, parasites, hypereosinophilic syndrome, and eosinophilic gastroenteritis. It is sometimes accompanied by several complications, but a simultaneous onset with pericarditis is very rares. A 28-year-old woman complained of acute right hypocondrial pain and dyspnea associated with systemic eruption. Several imaging modalities revealed acute cholecystitis and pericarditis with massive pericardial effusion. A marked peripheral blood eosinophilia was observed, and the eruption was diagnosed as urticaria. Her serum had a high titer of antibody against Ascaris lumbricoides. Treatment with albendazole drastically improved all clinical manifestations along with normalization of the imaging features and eosinophilia. We report herein a rare case of simultaneous onset of acute cholecystitis and pericarditis associated with a marked eosinophilia caused by parasitic infection.

Presentation and endoscopic management of biliary ascariasis

Ascaris lumbricoides is a common parasite and the most serious and dramatic presentation is hepatobiliary and pancreatic ascariasis (HPA). Therefore, this study was planned prospectively to elucidate the clinical presentation of HPA and evaluate the efficacy and safety of endoscopic intervention. In this study we documented 77 consecutive patients with HPA from January 2000 to November 2005. All the patients had endoscopically proven HPA. A total of 77 patients were included in the study. The age ranged from 6 to 80 years, with the third decade most commonly (28.6%) affected. Females were 6 times more likely to be affected than males. The commonest presentation was biliary colic (97.4%); other presentations were acute cholangitis (15.6%), obstructive jaundice (9.1%), acute pancreatitis (6.5%), choledocholithiasis (6.5%), acute cholecystitis (6.5%) and liver abscess (2.6%). In this report 51 (66.2%) had living, 10 (13%) had dead and 16 (20.8%) had both living and dead worms. Choledocholithiasis was associated only with dead worms. From one to 23 worms were found in the biliary tree. In 94.8% of cases we had to remove the worm by wide papillotomy followed by basket extraction. We did not experience any major complications during or following the procedures. Three patients had recurrent HPA during the course of follow-up (1 to 12 months). The majority of patients with HPA presented with biliary colic. This should be kept in mind in the management of an acute abdomen, especially in tropical countries. Endoscopic extraction is a safe and effective procedure for the treatment of HPA.

Acute cholecystitis caused by Clonorchis sinensis

We are reporting a case of a 43-year-old Chinese male from Hong Kong, who came to see a doctor complaining of acute onset of severe upper abdominal pain. A diagnosis of acute cholecystitis was made and an emergency cholecystectomy was carried out. On opening the common bile duct, lancet-shaped worms were seen emerging from it. About 45 adult worms were collected and sent to the Department of Parasitology University of Malaya for identification. The worms were identified as Clonorchis sinensis. After the operation the patient was treated with praziquantel and he had an uneventful recovery.

Cholecystitis in otters (Lutra lutra ) and mink (Mustela vison ) caused by the fluke Pseudamphistomum truncatum

Between 1988 and 2004, postmortem examinations were carried out on 445 otters found dead, mostly as a result of road traffic accidents, in southern and south-west England. Thickened, shrunken gall bladders were observed in 10 cases, the first in 2000 and the others between February 2002 and August 2004. A digenean fluke, Pseudamphistomum truncatum, was found in the gall bladders of three cases and also in three of seven American mink examined. Nine of the 10 otters and all the mink came from a localised area of Somerset, indicating that the fluke has become established in the local fish population. P. truncatum has not been recorded previously in Britain, and the results suggest that it has been introduced recently, possibly in imported fish.

Histological analysis of gallbladder diseases in relation to opisthorchiasis in endemic areas of Thailand

Chronic gallbladder disease frequently accompanies infection with the liver fluke, Opisthorchis viverrini, in Northeast Thailand. However, the pathology and pathogenesis of the gallbladder disease have not been described. Accordingly, gallbladder specimens from 187 consecutive patients who had undergone cholecystectomy at a referral hospital in an endemic area in Thailand were histologically characterized in relation to O. viverrini infection. The infection was assessed by the presence of parasite eggs in the bile and/or antibody response to the liver fluke. The average level of parasite-specific IgG was significantly higher in patients with Opisthorchis eggs in the bile than those without (P<0.001). The main histopathologic features of the gallbladder included inflammation, mucosal atrophy/or hyperplasia, goblet cell metaplasia, mucous gland hyperplasia, Rokitansky-Aschoff sinus formation, dysplasia and fibrosis. The fibrosis was strongly associated with elevated levels of Opisthorchis-specific antibody (P<0.001) but not with the presence of parasite eggs. Other pathologic features did not vary in frequency or severity with parasitological status. Our results show that severe fibrosis of the gallbladder is a more common histologic feature of cholecystitis among those with O. viverrini infection compared to those without infection. The close relationship between parasite-specific IgG and severe fibrosis suggests that specific immune response to the parasite play an important role in the pathogenesis of the fibrotic change.

[Gallbladder ascariasis with acute hepatitis. Conservative treatment]

We report two cases of gallbladder ascaridiasis associated with acute hepatitis, its clinical evolution with conservative treatment, making diagnosis by both laboratory and ultrasono-graphic studies. Case 1: was a male in his early forties who experienced symptoms of acute hepatitis and cholecystitis within a time lapse of 72 h of evolution. When laboratory tests and ultrasound (US) were done, an ascaris inside gallbladder was corroborated. There were also alterations compatible with acute non-viral hepatitis. Conservative treatment was done with observations within an 8-day period that hepatic examinations were normal as well as absence of helminthus inside gallbladder. Case 2: A 10-year-old female, who expelled worms 8 months previously had 11 days evidence of acute cholecystitis and hepatitis. An ultrasound of liver and biliary tract was done, with evidence of Ascaris lumbricoides inside gallbladder, with alterations in hepatic tests. This was medically treated, achieving expulsion of the Ascaris lumbricoides from inside the gallbladder and normalization of liver function tests. Gallbladder ascaridiasis management may be conservative. Patient general condition must be evaluated, as well or medical evolution and associated pathologies that may interfere in certain ways in surgery. Follow-up of these patients must be strict, with medical evaluation and laboratory controls.

Ascariasis-induced empyema of gallbladder: report of a case

A rare case of a 52-year-old woman with empyema of the gallbladder due to ascariasis causing an obstruction in the cystic duct is presented. She was admitted on September 20, 2000, and on September 23 an emergency cholecystectomy was performed. Ultrasonography is a highly sensitive and specific method for diagnosing gallbladder ascariasis, and a cholecystectomy is considered mandatory for the treatment of empyema of the gallbladder.

[Biochemical characteristics of hepatic functions in different clinical forms of chronic opisthorchiasis]

The main biochemical indices of hepatic functions (the activities of alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, alpha-amylase, choline esterase and the concentrations of total bilirubin, cholesterol, and glucose) were studied in the sera of 256 patients with chronic opisthorchiasis. It was found that with diseases manifested in different clinical forms (cholangitis, cholecystitis, cholangiocholecystitis, cholangiohepatitis, cholecystitis in combination with pancreatitis), most study indices are within the normal ranges, but significantly differ from the means in a group of apparently healthy individuals. The findings suggest that such clinical forms of opisthorchiais as cholangiocholecystitis and cholangiohepatitis are characterized by manifestations of cytolysis and cholestasis, as cholecystitis is manifested by cytolysis, as cholecystitis in combination with pancreatitis, by cholestasis, and as cholangitis, by cholestasis and hepatic cell insufficiency. It is possible that further studies will provide evidence for how to correct detected disorders during pathogenetic therapy.

[Parasitic gallbladder infection]

In two cases of cholecystectomy for gall bladder calculi, the histological diagnoses were inflammation, fibrosis, and numerous calcified parasite eggs in the wall of the gall bladder, compatible with eggs from the liver fluke, which can infect humans who eat raw or undercooked fresh water fish (sushi!).

Histologic proof of acalculous cholecystitis due to Cyclospora cayetanensis

It is suspected that Cyclospora cayetanensis can infect the biliary tract in persons with human immunodeficiency virus infection, but histologic proof has never been published. We report a case of acalculous cholecystitis in a person with acquired immunodeficiency syndrome who required cholecystectomy and demonstrated C. cayetanensis in the gallbladder epithelium.

Acalculous cholecystitis in a patient with visceral leishmaniasis

Acute acalculous cholecystitis (ACC) is unusual. We present a case of cholecystitis associated with visceral leishmaniasis (VL) in a man in Venezuela who presented high fever, anorexia and abdominal pain. Histopathological study of the gallbladder showed Leishmania spp. ACC in VL must be kept in mind in tropical countries.

An unusual presentation of acute cholecystitis: biliary ascariasis

A 37-year-old Malay lady from the state of Pahang was admitted to the surgical unit with colicky upper right quadrant abdominal pain radiating to the right shoulder and scapula region. This was accompanied by nausea and vomiting. She needed intramuscular analgesics for the pain. There was no past history of similar episodes. Clinically, she was not icteric, and examination of the abdomen revealed marked tenderness and guarding over the upper right quadrant with a positive Murphy's sign. Clinical diagnosis of acute cholecystitis was made, and she was commenced on intravenous antibiotics.

Sonographic diagnosis of Ascaris-induced cholecystitis and pancreatitis in a child

We describe the sonographic diagnosis of Ascaris-induced acute cholecystitis and pancreatitis in a 2-year-old girl. Abdominal sonography revealed a grossly distended gallbladder with a thick (0.5-cm) wall. The common bile duct was dilated to 0.6 cm without sludge or calculi. The pancreas was hypoechoic, with an enlarged, 3.3-cm pancreatic head. Sonography showed dilatation of the small- and large-bowel loops, with multiple roundworms in duodenal and colonic loops. Sonography has an important role not only in the diagnosis of this uncommon condition but also in the documentation of its unusual etiologic agent.

Localization of persistent Enterocytozoon bieneusi infection in normal rhesus macaques (Macaca mulatta) to the hepatobiliary tree

Enterocytozoon bieneusi is the most common microsporidian parasite recognized in human patients with AIDS. Recently, we identified a virtually identical organism causing a spontaneous infection associated with hepatobiliary and intestinal disease in simian immunodeficiency virus (SIV)-infected macaques. To examine the natural history of the infection, we examined captive rhesus macaques for E. bieneusi by PCR, in situ hybridization, and cytochemical techniques. PCR performed on fecal DNA detected enterocytozoon infection in 22 (16.7%) of 131 normal rhesus macaques (Macaca mulatta), compared to 18 (33.8%) of 53 rhesus macaques experimentally inoculated with SIV. In normal rhesus macaques, persistence of infection was demonstrated for up to 262 days and was usually not associated with clinical signs. In six of seven normal rhesus animals, E. bieneusi was detected by PCR in bile obtained through percutaneous cholecystocentesis but not by in situ hybridization performed on endoscopic biopsies of duodenum and proximal jejunum.

Acute cholecystitis and cholangitis caused by Echinococcus granulosus

We report for the first time in the recent North American literature, the case of a patient with rupture of a hepatic hydatid cyst into the gallbladder, with subsequent obstruction of the cystic duct by a daughter cyst acting as a ball-valve and causing acute acalculous cholecystitis.

[Fasciola hepatica--a unusual cause of acute cholecystitis with cholestatic jaundice]

A 29-year-old patient was admitted with acute abdomen in the 17th week of pregnancy. History revealed two episodes of colic in the right hypochondriac area during the previous six months, but no other abdominal complaints. Clinically the picture was that of acute cholecystitis. Laboratory findings included an elevated white cell count, a slight elevation of serum transaminases and a marked increase of serum alkaline phosphatase and bilirubin. Echographically there were dilated intra- and extrahepatic bile ducts containing two hyperechogenic elements without casting an acoustic shadow. A hydrops of the gallbladder with sludge and a thickening of the wall could also been seen. Because of pregnancy an ERCP could not be performed due to the need for X-ray, so we had to resort to open surgery. Under tocolytic and antibiotic shielding we carried out open cholecystectomy and choledochoscopic exploration of the common bile duct. Using a Fogarty balloon catheter we extracted two live, adult liver flukes and placed a T-tube in the duct. Because of positive fecal probes for fasciola eggs the T-tube had to be left in place until childbirth. Afterwards we performed a pre-cut-papillotomy by ERCP and took the T-tube out, having confirmed a clear duct on a T-tube-cholangiogram. With negative fecal probes and the eosinophilia on the white cell count returning to normal, we decided against the planned chemotherapy and assumed self-healing of the disease. The patient has been well since.(ABSTRACT TRUNCATED AT 250 WORDS)

Ascaris cholecystitis and cholangitis: an experience in Myanmar

Twenty-seven cases of ascaris cholecystitis and cholangitis were managed in a surgical unit of a general hospital in Yangon, Myanmar, from January 1989 to March 1990. Nineteen women and eight men with a mean age of 42 years were studied. Main clinical manifestations were right hypochondrial pain, fever, chills, rigors, nausea, vomiting and jaundice. Diagnosis was established by abdominal ultrasonograms in all cases. Laparotomy was performed in all cases because of failure to respond to initial conservative treatment. Live and dead ascarids were found in the gall bladder and biliary ductal system. Cholecystectomy, bile duct exploration, worm extraction and T-tube drainage were done in all cases. There were no deaths. Two patients developed minor wound sepsis. During the follow-up period ranging from 3 to 12 months, there was no recurrence of symptoms in all patients. All patients were given antihelminthics before discharge and three weeks later.

[Acalculous acute cholecystitis caused by Cryptosporidium in a patient with AIDS]

We report a patient with the acquired immunodeficiency syndrome who developed acute cholecystitis. Removal of the gallbladder revealed infection by Cryptosporidium spp. The clinical course after cholecystectomy was favourable. The pathogenesis and therapy of this complication in patients with AIDS is discussed.

Biliary ascariasis in fifteen patients

Ascarids in the biliary tract may cause cholecystitis, pancreatitis and obstruction of the common bile ducts. We retrospectively evaluated clinical features, radiographic findings and surgical treatment of 15 patients. Obstructive jaundice in eight patients (53.3%), acute cholecystitis in five patients (33.3%), and chronic calculous cholecystitis in two patients (13.3%) had been shown in our series. In four of the patients with obstructive jaundice signs of acute cholangitis were observed. Of 15 patients, two had hepatic abscess besides biliary ascariasis and one had hydatid cyst. In our series, all of the patients were operated on. Choledochotomy and primary closure were performed on six patients (40%), choledochoduodenostomy on six patients (40%), T-tube drainage on two patients (13.3%) and only cholecystectomy on one patient (6.6%). No mortality was determined in our patients.

[Acute, non-lithiasic, amebic cholecystitis]

The estimated percentage of non calculous cholecystitis is 2-14%. In most cases it is difficult to identify the cause and in very few cases it is possible to establish the etiology. Few cases are secondary to bacterial infections and the cause is very rarely a parasitic infection. We present a case of acute cholecystitis secondary to Entamoeba histolytica infection; the frequency, etiopathogenic mechanism and treatment are discussed.

Schistosomal cholecystitis: report of six cases

Six cases of schistosomal cholecystitis are reported; five also had calculi. Histopathological studies revealed extensive fibrocalcific reaction of the walls and around the cystic ducts. We hypothesise that this fibrosis produced strictures of the cystic duct and stagnation of bile, predisposing to cholelithiasis. Surgeons practising in endemic areas should be aware of this rare complication of chronic schistosomiasis.

Acute cholecystitis and Fasciola sp. infection in Thailand: report of two cases

Two cases of fascioliasis gigantica from Northeast Thailand presenting with cholecystitis and gall stones were reported. Both cases complained of abdominal pain. On laparotomy the worms were found. In one case five worms were recovered during bile duct exploration and bile drainage; eggs were also revealed in the bile. In the other case of ectopic fascioliasis one young adult worm was found in a nodule which adhered to liver and diaphragm. The parasites were identified as Fasciola gigantica.

Experimental cholecystitis in goats caused by mature Fasciola gigantica

Mature Fasciola gigantica obtained from naturally infected cattle were surgically transferred into the gallbladders of six fluke-free goats. Two of the goats died at two and 19 weeks and the remaining four were slaughtered at 12, 48, 48 and 80 weeks after the transfer. Nine of 20 transferred F gigantica were recovered from the gallbladder and common hepatic duct of the experimental goats. The walls of gallbladders and bile ducts were thickened by epithelial proliferation, fibrosis and mononuclear cell infiltration. Large numbers of globule leucocytes were present in the epithelium of gallbladders and common hepatic ducts as well as in minute intrahepatic bile ducts. Very few mast cells were observed in these locations. Globule leucocytes in two goats were positive for argentaffin reaction with Gomori hexamine silver stain. The proliferative cholecystitis in experimental goats was similar to adenomatous cholecystitis in cattle naturally infected with fascioliasis. Globule leucocytes had no obvious deleterious effects on the parasites.

Cytomegalovirus- and Cryptosporidium-associated acalculous gangrenous cholecystitis

A well-documented case of cytomegalovirus- and Cryptosporidium-associated cholecystitis is described in a 19-year-old heterosexual Haitian man who had the acquired immune deficiency syndrome and acute acalculous gangrenous cholecystitis associated with these pathogens. This case adds to the spectrum of the manifestations of the profoundly immunocompromised state.

[Choledochal obstruction due to Fasciola hepatica (author's transl)]

A 45-year-old woman was admitted in July, 1976 with an acute cholecystitis without jaundice. She had suffered from hepatic colic without fever, jaundice, diarrhea or allergic episodes for the past 8 years. The physical examination only revealed an elective pain on the cystic point. Laboratory data were unremarkable, except for a 12 percent eosinophils. The cholecystogram showed a cholelithiasis. The lithiasis was confirmed during the surgical operation and a fasciolasis was diagnosed after one and 10-12 parasites had been found into the cystic and common bile duct, respectively. A cholecistectomy and choledochoduodenostomy were performed. The patient was treated with 60 mg dehydroemetine during 10 days and 500 mg chloroquine during the other next 10 days. Eggs of Fasciola hepatica were found in the stool culture. The follow-up examinations 3 months and a year after surgery were completely normal. The national literature on this topic is reviewed and the clinical manifestations and therapy of this disease are commented on.

[Cholangiocholecystitis, an acute attack with acarids in B bile]

The present paper reports on an acute febrile attack in a patient suffering from chronic non-lithiasis cholecystitis. Acarids and acarid eggs in various stages of development were found in bile B following duodenal intubation in the course of the attack. The administration of magnesium sulphate was followed by abundant biliary vomiting. Fever fell within 6 days and marked clinical improvement was obtained.

Adenomatous cholecystitis in cattle with chronic fascioliasis

Gall bladders from 80 mature cattle infested with liver flukes were shrunken; their walls were thickened; and mucosa was raised into rugose folds, nodules and papillary projections. All contained thick bile and mature liver flukes, predominantly Fasciola gigantica and to a lesser extent Fasciola hepatica. There was an adenomatous proliferation of the lining epithelium as well as of submucosal glands forming numerous tubuloalveolar structures and cysts lined with a uniform layer of columnar epithelium. Fibrous stroma was more than normal, and there was a mild to heavy infiltration by inflammatory cells. Some bladders had many enterochromaffin cells in the epithelium lining the glandular structures. Mitotic figures were rare, and there was no evidence of malignancy. The condition is inflammatory and hyperplastic and is believed to be common in cattle infested with liver fluke. The clinical effects of this condition have not been studied.