Significance of wall thickness in symptomatic gallbladder disease.

One hundred cases of patients who underwent urgent cholecystectomy after presenting with symptoms of acute or subacute gallbladder disease were retrospectively reviewed. Sixty patients had pathologically proved acute cholecystitis, and 40 had chronic cholecystitis alone. One patient had an incidental gallbladder carcinoma, and four had global gangrene of the gallbladder. Focal ischemia, transmural hemorrhage, or focal necrosis (indicating more severe disease) was present in 19 patients. Fifty-four percent of patients had thin-walled gallbladders. Among patients with more severe acute disease, 56% had thin walls. Conversely, 24% of thin-walled gallbladders and 22% of thick-walled gallbladders had evidence of focal necrosis or gangrene. We conclude that gallbladder wall thickness, although demonstrable on preoperative ultrasound examination in all patients, does not correlate directly with severity of disease or pathologic findings.     

Carcinoma in the porcelain gallbladder: a relationship revisited

BACKGROUND: Gallbladder cancer is the most common biliary tract malignancy. Calcification of the gallbladder wall is reported to be associated with gallbladder cancer. In the literature, the incidence is quoted to be between 12% and 61%. This study aims to clarify the risk of cancer in a calcified gallbladder. METHODS: The charts and pathology reports at the Massachusetts General Hospital were reviewed, and patients with either gallbladder cancer or a calcified gallbladder were included in the study. The Fisher exact test was used to test for the association between cancer and gallbladder wall calcifications. RESULTS: From 1962 to 1999, there were approximately 25,900 gallbladder specimens analyzed at the Massachusetts General Hospital. There were 150 patients with gallbladder cancer and 44 patients with calcified gallbladders. Two types of calcified gallbladders were noted: those with complete intramural calcification (n = 17) and those with selective mucosal calcification (n = 27). The incidence of cancer arising in a gallbladder with selective mucosal wall calcification was approximately 7%. There was a significant association between gallbladder cancer and selective mucosal calcification with an odds ratio of 13.89 (P =.01). There were no patients with diffuse intramural calcification and cancer. CONCLUSIONS: A calcified gallbladder is associated with an increased risk of gallbladder cancer, but at a much lower rate than previously estimated. The incidence of cancer depends on the pattern of calcification; selective mucosal calcification poses a significant risk of cancer whereas diffuse intramural calcification does not.     

Dye-staining stereomicroscopic examinations for fine mucosal structures of the gallbladder

BACKGROUND: In order to diagnose an unsuspected gallbladder carcinoma and to examine whether a differential diagnosis could be made between cancer and noncancerous lesions during surgery, we evaluated the findings of fine structures of various types of gallbladder mucosa. METHODS: We used stereomicroscopy with a dye-contrast technique under water and measured the maximum blood vessel diameters of the gallbladder mucosa: normal gallbladder, chronic cholecystitis, and carcinoma. RESULTS: All normal gallbladders showed fine-reticular-type findings. In chronic cholecystitis, 5.8% of the specimens (n = 69) had fine reticular type, 87.0% had rough reticular type, and 7.2% had atrophic type. All the cases of adenomyomatosis (n = 16) showed rough reticular type. In eight specimens of pancreaticobiliary maljunction, 75% of them showed high reticular type, and the other 25% showed papillary type. The two adenoma specimens showed fine granular type. In five gallbladder carcinomas, the lattice-like pattern completely disappeared and showed rough granular type. The average of maximum vessel diameters in the gallbladder mucosa were 41.0 microm in normal gallbladders, 99.1 microm in patients with chronic cholecystitis, and 614.8 microm in patients with a carcinoma. There were significant differences among them (p < 0.05). CONCLUSION: This study showed that differential diagnosis between cancer and noncancerous lesion is possible by dye-staining mucosal pattern and measurement of maximum vessel diameters by stereoscopic examination.     

Porcelain gallbladder in a child: a case report and review

Calcification of the gallbladder wall (porcelain gallbladder; PGB) is a rare form of gallbladder disease not previously described in a child. A 10-year-old girl is presented with PGB that was discovered incidentally during intravenous urography. Computed tomography localized the calcification to the gallbladder wall. Cholecystectomy was performed due to the associated increased incidence of biliary tract carcinoma reported in adult patients. The etiology, diagnosis, and management of PGB and its significance in a pediatric patient are discussed.     

Laparoscopic cholecystectomy for porcelain gallbladder

The porcelain gallbladder is uncommon type of chronically inflamed gallbladder wall considered to be associated with a high frequency of adenocarcinoma and subsequently not suitable for a laparoscopic approach. In 12,000 patients chosen for a laparoscopic cholecystectomy 4 porcelain gallbladders were diagnosed. In 2 cases the laparoscopic approach was successful. One conversion was due to an unconfirmed suspicion of gallbladder cancer and the other one to a fistula between the gallbladder and the common bile duct. Patients with a preoperative diagnosis of porcelain gallbladder must not be excluded from the laparoscopic approach yet a low threshold for conversion must be maintained in those with a cancer suspicion.     

Calcified ballbladder (porcelain gallbladder)

Calcification of the gallbladder wall, otherwise known as porcelain gallbladder, is a relatively rare disease and is frequently asymptomatic. Symptoms suggestive of biliary disease are often absent in patients with this manifestation. Since the condition is uncommon, it is important to recognize the clinical as well as the roentgenographic characteristics of the disease because of the high frequency (22%) of adenocarcinoma in the porcelain gallbladder. To our knowledge, no pathognomic sign of symptoms of the disease have been reported so far. Of five cases of porcelain gallbladder reported, carcinoma of the gallbladder was discovered in one patient. This disease seems to appear mostly in the sixth decade of life and is more prevalent in women. Diagnosis is made in most cases by a simple flat plate of the abdomen, and workup should include other roentgenographic examinations to exclude calcification of other viscera or the thoracic wall. Surgery should not be delayed even if the patient is asymptomatic since the occurence of carcinoma in porcelain gallbladder is remarkably high.     

The porcelain gallbladder-laparoscopic approach

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.     

Mechanisms of impaired gallbladder contractile response in chronic acalculous cholecystitis

The mechanisms involved in the impaired gallbladder contractile response in chronic acalculous cholecystitis are unknown. To determine the mechanisms that may lead to impaired gallbladder emptying in chronic acalculous cholecystitis, gallbladder specimens removed during hepatic resection (controls) and after cholecystectomy for chronic acalculous cholecystitis were attached to force transducers and placed in tissue baths with oxygenated Krebs solution. Electrical field stimulation (EFS) (1 to 10 Hz, 0.1 msec, 70 V) or the contractile agonists, CCK-8 (10^-9 to 10^-5) or K⁺ (80 mmol/L), were placed separately in the tissue baths and changes in tension were determined. Patients with chronic acalculous cholecystitis had a mean gallbladder ejection fraction of 12% ± 4%. Pathologic examination of all gallbladders removed for chronic acalculous cholecystitis revealed chronic cholecystitis. Spontaneous contractile activity was present in gallbladder strips in 83% of control specimens but only 29% of gallbladder strips from patients with chronic acalculous cholecystitis (P < 0.05 vs. controls). CCK-8 contractions were decreased by 54% and EFS-stimulated contractions were decreased by 50% in the presence of chronic acalculous cholecystitis (P < 0.05 vs. controls). K⁺-induced contractions were similar between control and chronic acalculous cholecystitis gallbladder strips. The impaired gallbladder emptying in chronic acalculous cholecystitis appears to be due to diminished spontaneous contractile activity and decreased contractile responsiveness to both CCK and EFS. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation). Supported by the Veterans Administration Research Service and National Institutes of Health training grant HLO 7485-19.     

Prevalence and risk factors for gallbladder neoplasia in patients with primary sclerosing cholangitis: evidence for a metaplasia-dysplasia-carcinoma sequence

Primary sclerosing cholangitis (PSC) carries an increased risk (10% to 20%) of hepatobiliary malignancy, especially cholangiocarcinoma (CC). Dysplasia, adenomas, and carcinomas of the gallbladder have been described in PSC but are less common than bile duct carcinomas. However, the prevalence and risk factors for gallbladder neoplasia among patients with PSC undergoing orthotopic liver transplantation (OLT) have not been well studied. We evaluated 72 gallbladders from 100 consecutive liver explants for PSC, including 66 cholecystectomies performed at the time of OLT and 6 performed before OLT. All specimens were totally embedded for histologic examination. We evaluated the following histologic features: presence of diffuse lymphoplasmacytic chronic cholecystitis, pyloric metaplasia, intestinal metaplasia, dysplasia (low-grade or high-grade), and adenocarcinoma. Gallbladder dysplasia and adenocarcinoma were correlated with several clinicopathologic parameters using Fisher exact test and t test, including: (1) sex, (2) age, (3) PSC duration, (4) inflammatory bowel disease (IBD) at time of OLT, and (5) concomitant bile duct dysplasia or carcinoma. Lymphoplasmacytic chronic cholecystitis was present in 35 (49%), pyloric metaplasia in 69 (96%), intestinal metaplasia in 36 (50%), dysplasia in 27 (37%; low-grade in 12 and high-grade in 15), and adenocarcinoma in 10 (14%; 2 with lamina propria invasion and 8 with invasion into muscularis or adventitia). Gallbladder carcinoma was associated with intrahepatic bile duct dysplasia (P=0.001), CC (P=0.023), and IBD (P=0.03). Gallbladder dysplasia was associated with hilar/intrahepatic bile duct dysplasia (P=0.0006), CC (P=0.028), IBD (P=0.0014), and older age at OLT (P=0.007). Neither gallbladder carcinoma nor dysplasia had a significant association with sex or PSC duration. These results indicate that complete histologic evaluation of gallbladders in patients undergoing transplantation for PSC yields high frequencies of inflammatory, metaplastic, and neoplastic changes. The strong correlation between gallbladder dysplasia/adenocarcinoma and bile duct dysplasia/CC supports the concept of a neoplastic "field effect" along the intrahepatic and extrahepatic biliary tract in PSC.     

Significance of preoperative ultrasound measurement of gallbladder wall thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.     

Infection after laparoscopic cholecystectomy: effect of infected bile and infected gallbladder wall.

OBJECTIVE: To assess the incidence of infected bile and gallbladder wall infection at the time of laparoscopic cholecystectomy, and find out if they influenced the rate of postoperative infective complications. DESIGN: Prospective study. SETTING: District hospital, Kuwait. SUBJECTS: All 279 patients who had their gallbladders removed laparoscopically for gallbladder disease between September 1995 and August 1998. INTERVENTIONS: Samples of bile and gallbladder wall were taken from all patients and cultured separately for aerobic and anaerobic bacteria. Patients with complicated gallbladder disease (n = 80) were given preoperative therapeutic antibiotics for five days (cephalosporin plus metronidazole), and other high-risk patients (n = 138) were given prophylactic ceftriaxone either 1 g x 3 starting at induction of anaesthesia (n = 42), or a single dose at induction (n = 96). MAIN OUTCOME MEASURES: Incidence of infected cultures, and infective morbidity. RESULTS: 26 specimens of bile (9%) and 56 specimens of gallbladder wall (20%) were infected. Two patients in whom neither specimen had shown any growth developed minor infections at the umbilical port. No patient in whom either specimen was infected developed an infective complication. CONCLUSIONS: The overall rate of infective complications was negligible, and did not correlate with the presence of bacteria in the bile or gallbladder wall. This is probably a reflection of our aggressive antibiotic regimen in the management of high-risk patients.     

Porcelain gallbladder: a clinical case and a review of the literature

Porcelain bladder is defined as calcification of the gallbladder wall. It is a rare condition and is seen in 0.06% to 0.8% of cholecystectomies. It origin is still unknown.We report two cases of patients with a porcelain gallbladder. One case is a 60 year-old male patient who was seen due to having biliary symptoms. The diagnosis was made by ultrasound and computed tomography, and he was surgically intervened by performing a partial cholecystectomy. The histopathology reported a gallbladder wall with sclerohyalinosis and dystrophic calcification foci. The other case is a 98 year-old female patient, whose form of presentation was incidental given that she suffered from symptoms of an intestinal obstruction. A cholecystectomy was performed with a good post-surgical outcome.A series published in between 1950 and 1960 show that the porcelain bladder can be frequently observed in patients with cancer of the gallbladder, although this relationship is currently being rejected. The reason why these cases are being presented is because of their low incidence and the controversy over what treatment to use, due to its association with gallbladder cancer.     

Evaluation of prostacyclin production by human gallbladder

The prostanoids have been demonstrated to be involved in gallbladder physiology and disease. In previous reports, prostaglandin E (PGE) compounds were found to be increased in inflamed human gallbladders. Prostaglandin synthetase inhibition decreased PGE formation by human gallbladders; however, the relief of symptoms of cholecystitis did not correlate well with the decrease in PGE formation. This suggested that other prostanoids may be involved in cholecystitis. The purpose of this study was to evaluate the production of the proinflammatory arachidonic acid metabolite prostacyclin by gallbladders from patients with calculous cholecystitis. The formation of PGE and 6-ketoprostaglandin F1 alpha (6-keto-PGF1 alpha), the stable metabolite of prostacyclin, in normal human gallbladder mucosal cells and muscle tissue was compared with that produced by diseased mucosal cells and muscle tissue. Normal human gallbladders produced small amounts of 6-keto-PGF1 alpha, and no differences in formation rates were evident when muscle tissue was compared with mucosal cells. Diseased gallbladders produced significantly greater amounts of 6-keto-PGF1 alpha than did normal gallbladders, and diseased gallbladder muscle produced approximately four times greater amounts of 6-keto-PGF1 alpha than did diseased gallbladder mucosa. Prostacyclin formation is increased in diseased human gallbladders and may be an important mediator of the inflammatory changes of cholecystitis.     

Laparoscopic cholecystectomy and gallbladder cancer

Background: This study was designed to assess the treatment of patients in whom gallbladder cancer was diagnosed in the course of histological examination of their gallbladders, which were removed during laparoscopic cholecystectomy. Methods: Six (0.29%) cancers were found among 2,017 patients who underwent laparoscopic cholecystectomy. Four of these cancers (0.22%) were in 1,831 gallbladders with normal walls, two (1.0%) were in 186 with thicker walls, and two (1.8%) were in 109 patients in whom conversion was necessary because of extensive inflammation and thickening of gallbladder wall. Results: In two cases, the cancer did not cross the muscular layer. In one of them, no further treatment was undertaken. In the second case, liver resection and lymphadenectomy was performed. In the other four cases, dissemination was diagnosed during laparotomy, precluding radical treatment. Conclusions: Thickened and infiltrated gallbladder walls in patients without preoperative symptoms of cholecystitis should raise a suspicion of cancer. The surgeon should be prepared to perform a conversion, an intraoperative histological examination, and an appropriate radical operation, if necessary. Received: 16 June 1998/Accepted: 17 November 1998     

Porcelain gallbladder complicated with pancreas divisum

We report a rare case of porcelain gallbladder associated with pancreas divisum (PD). A 60-year-old woman suffered from discomfort in the back of the right side. An abdominal radiograph revealed a calcified spherical mass in the right upper quadrant. Ultrasonography revealed a scattered echo with a posterior acoustic shadow in the gallbladder wall. A plain computed tomography (CT) scan showed flecks of intramural calcification in the wall of the gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) showed separate openings for the Santorini and Wirsung ducts. The patient underwent cholecystectomy after porcelain gallbladder and pancreas divisum had been diagnosed. The porcelain gallbladder resulted from a stone impacted in the neck of the gallbladder. Patients with PD should be followed carefully, because gallstones often accompany PD, and porcelain gallbladder may result, as in this patient.     

黄色肉芽肿性胆囊炎误诊为胆囊癌十例分析

目的 分析黄色肉芽肿性胆囊炎（xanthogranulomatous cholecystitis,XGC）误诊为胆囊癌的原因.方法 分析我院1996-2005年间确诊为黄色肉芽肿性胆囊炎的33例的临床资料,其中10例在术前和术中误诊为胆囊癌.结果 10例患者中B超和CT均诊断为胆囊癌5例,慢性胆囊炎1例;B超诊断为胆囊癌而CT诊断为慢性胆囊炎2例;B超诊断为慢性胆囊炎而CT诊断为胆囊癌2例;术中均见有胆囊壁增厚,胆囊与肝、大网膜等周围组织粘连.3例行胆囊切除＋肝部分切除术,6例行胆囊切除＋肝部分切除术＋肝十二指肠韧带清扫术,1例行部分胆囊切除＋胆囊空肠吻合＋横结肠部分切除.术后病理为黄色肉芽肿性胆囊炎.结论 黄色肉芽肿性胆囊炎影像学表现和肉眼所见易误诊为胆囊癌.确诊需依赖病理检查.术中冰冻组织学检查有助于明确病变性质.     

ISCHAEMIC CHOLECYSTITIS AND INFARCTION OF THE GALLBLADDER

The clinicopathological features of forty three patients with gallbladder disease are presented where ischaemia appeared to be the primary aetiological factor. Histopathological changes of severe ischaemia (ischaemic cholecystitis) were present in 16 patients and of infarction of the gallbladder in the remaining 27 patients. All patients with ischaemic cholecystitis and 19 of the patients with infarction of the gallbladder had a thick walled gallbladder due to a serosal reaction, and these 35 gallbladders all contained calculi. The remaining eight patients with infarction of the gallbladder had a thin walled gallbladder without serosal reaction. Only two of these patients had gallbladders that contained calculi. The pathogenesis of thick walled ischaemic cholecystitis or infarction appeared to be related to intramural vascular Insufficiency which accompanies calculus disease of the gallbladder. Thin walled infarction of the gallbladder appeared to develop as a result of extramural arterial insufficiency due to arterial disease, thrombosis or trauma. The clinical course of thick walled ischaemic gallbladder disease was not significantly different from severe acute cholecystitis with calculi. However, 75% of the patients with thin walled infarcted gallbladders were severely ill from their associated illness or trauma, and nearly all died.     

Detection of occult gallbladder disease by duodenal drainage

Examination of gallbladder bile in the sediment of duodenal drainage obtained after magnesium sulfate stimulation was used to evaluate the presence or absence of gallbladder disease in thirty-four patients with symptoms suggestive of cholecystitis and normal or equivocal oral cholecystography. Ten patients had positive tests and nine of these had cholecystectomy. All nine had pathologically confirmed cholecystitis and seven of nine had cholelithiasis. Three patients with negative test results had laparotomy and normal gallbladders. The remaining twenty-one patients with negative tests have been followed up to three years, and none have returned with evidence of biliary tract disease. The results of this study suggest that duodenal drainage (Meltzer-Lyon test) is a valuable adjunctive diagnostic study in patients with gallbladder disease symptoms in whom normal or equivocal oral cholecystograms are obtained.     

Lysolecithin-mediated inflammatory reaction in rabbit gallbladder. Permeability increase and enzyme liberation.

Aseptic inflammation in the gallbladder wall was studied in vitro using rabbit gallbladders. Wall permeability changes, measured as changes in the transmural passage of radioactively labelled hippuran and biligraphin as well as enzyme (acid phosphatase) release from wall to lumen were registered as parameters permitting quantitative assessment of an inflammatory process. Lysolecithin, a surface-active substance of possible significance in the pathogenesis of acute cholecystitis was chosen as inflammation-inducing agent. When 6-20 mg/ml lysolecithin was instilled into the gallbladders, dose-dependent increases in permeability and enzyme release occurred. No effects as compared with controls were seen when 2 mg/ml was instilled. Lysolecithin-treated gallbladders showed morphological signs of inflammation as opposed to untreated. The data reported are consistent with earlier observations that lysolecithin may cause inflammatory lesions to the gallbladder wall. The experimental model used may prove useful in examining the effects of aggressive and protective agents upon the gallbladder mucous membrane.     

Role of cyclooxygenase-2 for fluid secretion by the inflamed gallbladder mucosa

Inflammatory fluid secretion by the gallbladder mucosa in experimental cholecystitis is induced by activation of cyclooxygenase, which leads to an increase in prostaglandin formation. Cyclooxygenase exists as a constitutive (cyclooxygenase-1) and an inducible (cyclooxygenase-2) isoform. The aim of this study was to demonstrate the role of cyclooxygenase-2 in inflammatory fluid secretion of the feline gallbladder. Experiments were performed 10 weeks after a surgical procedure in which chronic cholecystitis was induced in cats by ligation of the cystic duct and implantation of a gallstone in the gallbladder. Gallbladder fluid transport was continuously monitored via a perfusion system. In inflamed gallbladders the continuous fluid secretion was reversed to absorption by intravenous injection of the selective cyclooxygenase-2 blocker, NS 398 (P < 0.001). Increased levels of the inducible cyclooxygenase-2 were shown by immunoblotting in inflamed gallbladders. Selective pharmacologic blockade of cyclooxygenase-2 reduced the prostaglandin Ez release to the inflamed gallbladder lumen (P < 0.01). These data suggest that cyclooxygenase-2 is involved in the inflammatory response during chronic cholecystitis. Selective cyclooxygenase-2 blockers may offer an alternative to traditional nonsteroidal anti-inflammatory drugs with fewer side effects in patients with cholecystitis who are awaiting operation. Supported by the Swedish Medical Research Council (grants 04984,04341,10375, and 11611) and the Swedish Medical Society. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.