Cholecystitis and cholelithiasis

Cholelithiasis and cholecystitis, with their complications, remain major health problems in the United States. At this time, cholecystectomy is the treatment of choice for all patients with symptomatic gallstones and those with acute cholecystitis, except those who are too ill to undergo surgery. Present therapeutic options may be summarized as follows: Asymptomatic patients and those with flatulence and dyspepsia who have gallstones should be observed. Those who have symptoms of biliary pain, gallstone-induced pancreatitis, or common duct stones should have corrective surgery. Those who refuse surgery or who aren't surgical candidates might be treated with dissolution therapy. Dissolution of gallstones with chemical agents and extracorporeal shock-wave lithotripsy show some promise. We need a better understanding of the etiology and formation of gallstones to address the disease from a preventive standpoint and reduce the incidence of cholelithiasis and cholecystitis, and their complications.     

Staphylococcal acalculous cholecystitis in a child

Acute acalculous cholecystitis is inflammation of the gallbladder in the absence of gallstones. It usually occurs in critically ill patients and is rare in the pediatric age group. We describe a 12-year-old boy who presented with fever, jaundice, and abdominal pain and was found to have acute acalculous cholecystitis, sacroiliitis, and pelvic osteomyelitis associated with bacteremia as a result of Staphylococcus aureus. Antibiotic therapy without surgical intervention was effective. A high index of suspicion is required to make an early diagnosis and institute appropriate treatment for children with this condition. Although cholecystectomy has been considered the standard therapy, medical treatment alone can be successful.     

腹腔镜在治疗急性结石嵌顿性胆囊炎中的应用

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）治疗急性结石嵌顿性胆囊炎的可行性。方法：总结分析2007年10月至2009年6月36例急性结石嵌顿性胆囊炎行腹腔镜胆囊切除术的经验体会,包括手术适应证及手术技巧等。结果：35例（97.2%）成功完成腹腔镜胆囊切除术,1例（2.8%）中转开腹,无胆管、肠管损伤,无术后出血及围手术期（术后30天）死亡等并发症,均获治愈。术后随访4月～23月无手术并发症。结论：在术者熟练的操作技巧,合理选择中转开腹时机的前提下,急性结石嵌顿性胆囊炎行腹腔镜胆囊切除术安全、可行。     

Acute cholecystitis in the emergency department

Acute cholecystitis is a frequent consideration in patients presenting to the emergency department with the challenging complaint of upper abdominal pain. It is estimated that 20% of American adults have gallstones, and of these a large percentage (about one-third) will at some point develop acute cholecystitis. The epidemiology and associated risk factors of acute cholecystitis are briefly reviewed along with the pathogenesis and clinical presentation of the disease. Finally, an approach to the diagnosis in the emergency department and suggested management is discussed including a comparison of the strengths and weaknesses of ultrasonography and hepatobilary scintigraphy.     

胆囊癌合并胆囊结石的超声研究

目的 探讨易合并胆囊癌的高危胆囊结石声像图特征，为胆囊结石患者选择预防性胆囊切除提供影像学依据。方法 分析37例胆囊癌合并胆囊结石术前超声检查的声像图特点。结果 26例（71％）同时合并慢性胆囊炎。29例（78％）为单发结石且结石大小超过1cm。扫查时27例（73％）结石不移动。胆固醇性和混合性结石共33例（89％）。结论 单发、体积较大且移动性差的胆固醇性或混合性结石更倾向于合并胆囊癌，当超声检查发现上述特点，尤其是同时存在慢性胆囊炎时，提示有较强的预防性胆囊切除指征。     

Laparoscopic cholecystectomy in cardiac transplant patients - lower threshold for surgery?

Summary

Laparoscopic cholecystectomy is accepted by the surgical community as an advance in the definitive treatment of gallstones. In this paper we describe five patients post-cardiac transplantation, in whom laparoscopic cholecystectomy was undertaken. One patient, who had two previous laparo-tomies, required conversion to an open cholecystectomy. In each case the gallstones were symptomatic and were a major cause of morbidity. The average hospital stay was 4 days in uncomplicated cases, but was prolonged in one patient who required stabilization of cyclosporin levels (7 days) and in one patient due to a sub-hepatic collection (17 days). This was successfully treated by percutaneous ultrasound guided drainage. The technical problems of laparoscopic cholecystectomy are no different in transplant patients but it may have the advantage of being less immunotraumatic and allow earlier mobilization. Laparoscopic cholecystectomy is an advance in the treatment of gallstones and because of the risks of acute cholecystitis in cardiac transplant patients, should lower the threshold to definitive surgery.     

Limited abdominal MRI in the evaluation of acute right upper quadrant pain

Background: We investigated whether limited abdominal magnetic resonance imaging (MRI) is as effective as transabdominal ultrasound (US) in evaluating patients presenting with acute right upper quadrant pain.Methods: Twenty-four patients underwent evaluation with a limited abdominal MRI using single-shot fast spin-echo sequences and a right upper quadrant US within 24 h. Two MRI and two US readers independently evaluated the images for gallstones, gallbladder wall thickness, pericholecystic fluid, acute cholecystitis, visualization of the common bile duct, and requests for further imaging. US and MRI findings were compared. Surgical pathology was the gold standard.Results: MRI and US demonstrated no statistically significant difference in the diagnosis of gallbladder wall thickening, the presence of gallstones or pericholecystic fluid, or the diagnosis of acute cholecystitis (p > 0.05). The sensitivity of both for acute cholecystitis was 50%, with specificities of 89% and 86% for US and MRI, respectively. US readers more frequently requested additional tests and displayed more variability in whether they could adequately see the common bile duct.Conclusion: Limited MRI is equivalent to US in diagnosing gallstones, gallbladder wall thickening, pericholecystic fluid, and acute cholecystitis in patients presenting with symptoms of acute right upper quadrant pain. Especially in sonographically challenging patients, limited MRI may provide a faster, easier method of diagnosis.     

Intramural gallstones mimicking typical lithiasic cholecystitis

Gallstone disease is common in the western population. Intramural gallstones are rare, with only a few cases reported in the literature. We present a 30-year-old female patient with typical symptoms of cholecystitis. The patient underwent laparoscopic cholecystectomy one month later. Dark greenish intramural gallstones were identified right after the resection of the gallbladder, and the pathologic examination revealed adenomyomatosis of the gallbladder. To our knowledge, this is the first report of intramural gallstones presenting with cholecystitis. The presence of intramural gallstones is not easily detected during ultrasound examination, and does not affect the natural course or treatment of gallstone disease.     

Gallstones--surgical aspects

Between 10% to 15% of the adult population develop gallstones. Therefore, cholecystectomy is among the most common operations in general surgery. The diagnosis of cholelithiasis depends on the patient's history, clinical findings, laboratory tests and ultrasound examination. Once diagnosis of symptomatic gallbladder disease has been confirmed, laparoscopic cholecystectomy is the treatment of choice. Its advantages in comparison with open surgery are decreased morbidity, costs and hospital stay. Open cholecystectomy is still the treatment of choice for complicated gallstone disease (i.e. cancer, Mirizzi's syndrome, severe inflammation) and in high-risk patients. In case of acute cholecystitis, early laparoscopic cholecystectomy is a safe procedure and is associated with the same benefits as for symptomatic disease.     

Timing of Cholecystectomy in Acute Cholecystitis

Background

Cholecystitis is an inflammation of the gallbladder that most commonly occurs as a result of obstruction of the cystic duct by gallstones. The current standard of treatment for acute cholecystitis is cholecystectomy.

Hepatobiliary imaging

A patient's clinical presentation should prompt an imaging evaluation that is cost effective for accurate diagnosis and leads to appropriate treatment of gallbladder inflammatory disease. In the setting of recurrent biliary colic, chronic cholecystitis is the main diagnostic consideration. Imaging hallmarks include gallstones and gallbladder wall thickening for which ultrasonography is uniquely suited. When a patient appears more toxic with right upper quadrant pain, one would more strongly consider acute cholecystitis. Because the morbidity and mortality of acute cholecystitis are reduced with early cholecystectomy, it is incumbent upon the clinician to make the diagnosis promptly and accurately. Hepatobiliary imaging with an IDA derivative has proven superior sensitivity, specificity, and accuracy for this condition. The examination has validity because it detects cystic duct obstruction, the primary pathophysiologic event responsible for most acute calculous and acalculous disease. Utilizing morphine augmentation when delayed filling is present has reduced the total examination time to less than 2 hours. Use of ancillary findings including gallbladder hyperemia and the "hot rim" sign help predict complicated cholecystitis, enabling more urgent intervention. The bulk of data presented in this review supports hepatobiliary imaging as the modality of first choice in the evaluation of acute cholecystitis. In the intensive care setting, where acalculous disease and atypical presentations are common, hepatobiliary imaging also plays a major role. We recommend liberal use of Sincalide pretreatment, morphine augmentation, and delayed images to promote gallbladder filling. If the gallbladder is nonvisualizing despite these maneuvers, sonography is often added as an aid to detect secondary signs of acute cholecystitis and help confirm the diagnosis with greater certainty prior to high-risk surgery.     

Posttraumatic acute cholecystitis on the rehabilitation service

Posttraumatic acute cholecystitis is a serious complication which can occur in multitrauma patients. Predisposing factors may include fasting, hypotension, transfusions, sepsis, and narcotics. Common signs and symptoms include right upper-quadrant pain or tenderness, nausea and vomiting, and fever. Symptoms began 26 days and 108 days posttrauma in the two patients studied while they were on the rehabilitation service. The recommended treatment is immediate cholecystectomy. Conservative management results in much higher mortality.     

Postoperative fistula of the abdominal wall after laparascopic cholecystectomy due to lost gallstones.

Abdominal fistula caused by cholesterol gallstones, which remained in the abdominal wall after laparascopic cholecystectomy: a laparascopic cholecystectomy was performed in a 60-years-old man who was diagnosed as acute necrosing cholecystitis due to cholecystolithiasis. After removal of the gallbladder using an Endocath some gallstones remained in the excision channel of the abdominal wall. Therefore, a fistula developed in the excision channel postoperatively. As the wound healing was disturbed an investigation of the abdominal wall was performed by ultrasound. In the former excision channel several small, oval, formations with high echogenicity and faint ultrasound shadows were detected, corresponding to additional gallstones. After excision of granulation tissue and removal of the cholesterol stones, complete healing of the fistula in the abdominal wall was achieved.     

Multiseptate gallbladder with acute acalculous cholecystitis

Multiseptate gallbladder is a rare congenital malformation of the gallbladder. In some cases, right upper quadrant pain, recurrent abdominal pain, and gallstones were present. We present the sonographic findings in a case of multiseptate gallbladder with acute cholecystitis, which (to our knowledge) has not been reported before. We hypothesize that bile sludge accumulated and subsequent cholecystitis developed as a result of bile stasis in our case because the classic predisposing factors that have been described were absent.     

Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis

A positive sonographic Murphy sign, the presence of maximal tenderness elicited over a sonographically localized gallbladder, has been reported to be a helpful adjunctive finding in patients with proven acute cholecystitis who are evaluated with ultrasonography. We evaluated 200 patients with right upper quadrant pain, thought to be acute cholecystitis. Results of ultrasound examinations and subsequent follow-up were tabulated. The sensitivity of the sonographic Murphy sign in acute cholecystitis was 86% with a specificity of 35%, positive predictive value of 43%, and negative predictive value of 82%. The sensitivity of the sonographic findings, including stones, gallbladder wall edema, and pericholecystic fluid collections, was 93%, a specificity of 53%. The combination of the Murphy sign accompanied by gallstones yielded a specificity of 77%. The large number of false positives, and only moderate improvement in specificity when accompanied by gallstones, makes this sign unreliable in separating acute from chronic cholecystitis. © 1995 John Wiley & Sons, Inc.     

Inflammatory pseudotumor of the liver in association with spilled gallstones 3 years after laparoscopic cholecystectomy: report of a case

We report on a case of a female patient diagnosed with inflammatory pseudotumor of the liver in association with spilled gallstones 3 years after laparoscopic cholecystectomy for calculous acute cholecystitis. She was asymptomatic, but CT revealed an intrahepatic mass and two other extrahepatic masses between the liver and the diaphragm. Furthermore, diffusion-weighted MRI and PET suggested all three lesions could be malignant tumors. As the preoperative diagnosis was intrahepatic cholangiocellular carcinoma with peritoneal disseminations, we performed a posterior segmentectomy of the liver combined with partial resection of the diaphragm. Histological examination showed the intrahepatic tumor was an inflammatory granuloma with abscess formations. There were bilirubin stones between the liver and the diaphragm. Therefore, the tumor was diagnosed as inflammatory pseudotumor of the liver in association with spilled gallstones. In conclusion, the liver tumor emerged after laparoscopic cholecystectomy and may involve inflammatory pseudotumor of the liver in association with spilled gallstones.     

腹腔镜胆囊切除术治疗老年急性结石性胆囊炎的体会

目的:评价腹腔镜胆囊切除术(Laparoscopic cholecystectomy,简称LC)治疗老年急性结石性胆囊炎的效果。方法:2006年～2008年对我院56例老年急性结石性胆囊炎患者行腹腔镜胆囊切除术,术后对其疗效进行评价。结果:对56例66岁～91岁、发病时间在48小时内的老年性急性结石性胆囊炎患者行腹腔镜胆囊切除术,术后随访3月以上,均恢复良好,未发生不良反应。结论:老年结石性胆囊炎急性发作,发病在48小时内如及时就诊,合理治疗合并症,老年人均可耐受LC,手术成功的关键在于术前准备充分,治疗合理、及时,术中操作仔细、认真,术后严密观察病情,积极对症治疗合并症、处理并发症,均可取得良好的效果。     

Port-site metastasis of unsuspected gallbladder carcinoma with ossification after laparoscopic cholecystectomy: A case report

BACKGROUNDUnsuspected gallbladder carcinoma (UGC) refers to cholecystectomy due to benign gallbladder disease, which is pathologically confirmed as gallbladder cancer during or after surgery. Port-site metastasis (PSM) of UGC following laparoscopic cholecystectomy is rare, especially after several years.CASE SUMMARYA 55-year-old man presenting with acute cholecystitis and gallstones was treated by laparoscopic cholecystectomy in July 2008. Histological analysis revealed unexpected papillary adenocarcinoma of the gallbladder with gallstones, which indicated that the tumor had spread to the muscular space (pT1b). Radical resection of gallbladder carcinoma was performed 10 d later. In January 2018, the patient was admitted to our hospital for a mass in the upper abdominal wall after surgery for gallbladder cancer 10 years ago. Laparoscopic exploration and complete resection of the abdominal wall tumor were successfully performed. Pathological diagnosis showed metastatic or invasive, moderately differentiated adenocarcinoma in fibrous tissue with massive ossification. Immuno-histochemistry and medical history were consistent with invasion or metastasis of gallbladder carcinoma. His general condition was well at follow-up of 31 mo. No recurrence was found by ultrasound and epigastric enhanced computed tomography.CONCLUSIONPSM of gallbladder cancer is often accompanied by peritoneal metastasis, which indicates poor prognosis. Once PSM occurs after surgery, laparoscopic exploration is recommended to rule out abdominal metastasis to avoid unnecessary surgery.     

急性结石性胆囊炎腹腔镜胆囊切除中转开腹影响因素分析

目的:探讨急性结石性胆囊炎行腹腔镜胆囊切除术过程中转开腹的影响因素。方法:回顾性分析3191例急性结石性胆囊炎行腹腔镜胆囊切除术患者的临床资料,按术中是否中转开腹胆囊切除术分为中转组和非中转组,通过多元回归模式对患者性别、年龄、BMI、既往病史(糖尿病病史、高血压病史及既往腹部外科手术史)、术前实验室检查(WBC、PCT、CRP及INR)、术前胆囊B超特征(胆囊结石数量、胆囊壁厚度)及手术时间等因素进行统计学分析。结果:资料数据经多元logistic回归分析显示,BMI、糖尿病病史、术前白细胞计数、PCT、CRP、结石数量、胆囊壁厚度是影响急性结石性胆囊炎患者行腹腔镜胆囊切除中转开腹的因素(P<0.05);BMI(OR=1.784;95%CI:1.621~1.973;P<0.001)、糖尿病病史(OR=21.79;95%CI:13.49~34.90;P<0.001)、WBC(OR=1.330;95%CI:1.254~1.410;P<0.001)、PCT(OR=1.839;95%CI:1.631~2.079;P=0.004)、CRP(OR=2.025;95%CI:1.019~4.031;P=0.004)升高及胆囊壁增厚(OR=1.680;95%CI:1.520~1.859;P<0.001)为中转开腹的独立危险因素,而结石数量(OR=0.422;95%CI:0.273~0.643;P=0.0005)为中转开腹的保护因素。结论:急性结石性胆囊炎患者实施腹腔镜胆囊切除术时,对BMI超标、术前有糖尿病病史、术前WBC、PCT及CRP较高或B超显示胆囊壁增厚、结石单发的患者,应考虑术中中转开腹手术可能。     

Endoscopic sphincterotomy: long-term results in 408 patients with complete follow-up

Endoscopic sphincterotomy was performed in 469 patients for the treatment of biliary calculi, with procedure-related morbidity of 6.3% and mortality of 0.4%. Long-term follow-up to 10.5 years (mean 3.7 years) was completed in all of 408 patients at least six months postsphincterotomy. Recurrent stones developed in 21 patients (5.8%) after a mean of 2.4 years (range 4 months to 7 years); in 6 after 3 years. Eight patients reformed stones more than twice at a mean interval of 1.8 years (range, 5 months to 3.5 years). In the 122 patients with gallbladders in situ, acute cholecystitis occurred in 5 of 31 with gallstones (16%), but in none of the 91 without gallstones. In the 237 patients who had undergone cholecystectomy, 4 late deaths occurred secondary to recurrent choledocholithiasis and cholangitis. In the 49 patients with primary intrahepatic stones, 3 late deaths occurred secondary to hepatic abscess. These results suggest that (a) endoscopic sphincterotomy is a very effective procedure in long-term follow-up, (b) cholangiography should be done at the appearance of slight abdominal symptoms even after 3 years, (c) patients who have ever reformed stones should undergo cholangiography yearly for at least 4 years, and (d) cholecystectomy is recommended for patients with gallbladders after sphincterotomy, only if gallstones are present.