Cystic artery bleeding due to blunt gallbladder injury: computed tomography findings and treatment with transcatheter arterial embolization

Blunt gallbladder injury is rare, and bleeding from the cystic artery due to blunt trauma is even rarer. We report herein a case of extraluminal bleeding of the gallbladder in a patient following blunt abdominal trauma. Contrast-enhanced computed tomography revealed pericholecystic fluid and extravasation of contrast material in the subcapsular liver space adjacent to the gallbladder. Abdominal digital subtraction angiography revealed pseudoaneurysm originating from a branch of the cystic artery. Successful treatment was achieved using selective transcatheter embolization, and cholecystectomy was not required.     

Percutaneous chemical gallbladder sclerosis after laser-induced cystic duct obliteration: results in an experimental model.

OBJECTIVE. Chemical gallbladder sclerosis has been attempted as a way to defunctionalize the gallbladder in patients who have undergone nonsurgical removal of gallstones and who are unable to undergo surgical/laparoscopic cholecystectomy. The purpose of this investigation was threefold: to study an animal model for chemical sclerosis of the gallbladder with 95% ethanol and 3% sodium tetradecyl sulfate, to attempt chemical sclerosis immediately after percutaneous cystic duct obliteration by laser thermocoagulation, and to assess histopathologic changes in the gallbladder after sclerosis. MATERIALS AND METHODS. Percutaneous cholecystostomy and laser thermocoagulation of the cystic duct was performed in 13 pigs. Eight pigs underwent immediate gallbladder sclerosis with 95% ethanol and 3% sodium tetradecyl sulfate while two pigs received 95% ethanol only. The remaining three pigs served as controls. The cholecystostomy catheter was removed immediately after the procedure. All animals were sacrificed 6 weeks after laser thermocoagulation. Multiple sections through the gallbladder, which included the adjacent liver, the cystic duct, and the common bile duct, were obtained for histologic examination. RESULTS. At autopsy, the gallbladder in all 10 animals who underwent gallbladder sclerosis was reduced in size compared with controls. In all treated animals, the gallbladder mucosa was denuded; however, in nine of 10 cases reepithelialization had occurred. Complete sclerosis without reepithelialization was achieved in one pig who received both ethanol and sodium tetradecyl sulfate. In the two animals who received ethanol only, the depth of wall necrosis around the gallbladder lumen was less than in those pigs who received both ethanol and sodium tetradecyl sulfate. No pigs showed signs of hepatic necrosis or injury to the common bile duct. CONCLUSION. Cystic duct laser thermocoagulation allows immediate gallbladder sclerotherapy without injury to the common bile duct. Sclerosis with ethanol and sodium tetradecyl sulfate results in denudation of the gallbladder mucosa. However, a single therapeutic session with immediate removal of the cholecystostomy catheter was inadequate for gallbladder ablation in this model because of reepithelialization.     

Cystic renal disease in tuberous sclerosis

The clinical and radiologic findings of tuberous sclerosis in three family members, which manifested as renal insufficiency due to extensive renal cystic disease, are described. The family was thought to have polycystic kidney disease until coexisting tiny angiomyolipomas were found among the cysts (by computed tomography in two patients and at autopsy in one). The radiologic and pathologic factors that establish the diagnosis of renal cystic disease associated with the tuberous sclerosis complex are reviewed.     

Ablation of the cystic duct and gallbladder: clinical observations

The cystic duct and gallbladder were ablated in eight patients with acute gallbladder disease who had been treated with minicholecystostomy instead of cholecystectomy because of multiple risk factors. First, endoluminal transcatheter radio-frequency electrocoagulation of the cystic duct was performed under fluoroscopic control, which resulted in complete occlusion in all eight patients. Next, the mucosa of the isolated gallbladder was sclerosed with 95% ethanol and 3% sodium tetradecyl sulfate in one to four sessions; no analgesics were required. The gallbladder volumes of all patients, estimated by means of ultrasound, were 1.5-22 cm3 (average, less than 10 cm3) after a mean follow-up period of 5 months. One patient died of a cerebrovascular accident 15 months after sclerotherapy. In all surviving patients, the gallbladder fistulas are dry and obliterated. These early clinical data indicate that electrocoagulation permits reliable, safe obliteration of the human cystic duct. The authors believe that sclerotherapy of the isolated gallbladder is feasible without toxic effects but that their treatment needs adjustment to achieve complete ablation of the gallbladder mucosa in a shorter period and in all patients.     

Radiographic aspects in transcatheter contact dissolution of calcified gallbladder concrements

The present study on 10 patients reports upon an attempt to perform percutaneous contact dissolution of partially calcified gallbladder concrements. These gallstones, which exhibited structural calcifications on CT scans, required time-consuming complex dissolution procedures with transcatheter administration of methyl tert-butyl ether (MTBE) and ethylene diamine tetraacetic acid (EDTA). Insertion of the catheter system (5 F) was performed via a percutaneous transhepatic route. Catheter placement was maintained for a maximum of 4 days. Complete lysis was achieved in seven of the ten cases. In six patients, significant regional or disseminated chemically induced cholecystitis and pericholecystitis could be observed on CT examination. However, on follow-up CT examinations, these changes proved to be completely reversible. It has been demonstrated that tolerance of the gallbladder wall and adjacent tissue layer against the lytic media employed is rather limited and that meticulous controlling of the morphological reaction can be helpful in minimizing complications.     

Indications, procedures and choice of embolization material in transcatheter vascular occlusion

If it is planned to effect transcatheteral occlusion of vessels, it must be examined whether the relevant vessel should be occluded permanently or temporarily and whether the occlusion should be located centrally in the vascular trunk or in a major twig, or peripherally in the region of the capillaries, arterioles and small vessels. Temporary occlusion with fibrospum is usually sufficient for treating a haemorrhage. Ethibloc or Bucrylate can be employed to shut off an organ and to achieve partial organ necrosis. Arteriovenous connections with a large vascular lumen can be occluded by means of metal particles. Peripherally occluding substances should not be used for embolisations in the gastrointestinal range because of the risk of local necrosis and possible dangerous infection resulting therefrom. To the present day hardly any indications have been found for the use of absolute alcohol. Bucrylate has the drawback, compared against Ethibloc, that the catheter may adhere to the vascular wall. Vessels with a low flow rate should be occluded either by means of balloon catheter or a coaxial catheter system because of the risk of reflux.     

Transcatheter sclerosis of the gallbladder in rabbits. A preliminary study

Catheter sclerosis of 56 rabbit gallbladders was attempted at laparotomy. The proximal cystic duct was occluded with a hemoclip and transcatheter administration of six different sclerosing agents and a saline control was performed. Eight animals were used for each agent, three being sacrificed after two weeks and the remainder after six weeks. Hot contrast and sotradecol were comparable with saline in their lack of effect on gallbladder mucosa. Alcohol alone, tetracycline, methylcyanoacrylate and alcohol plus trifluoroacetic acid were successful at two weeks in denuding the gallbladder epithelium and promoting fibrosis of the gallbladder wall. After six weeks, evidence of mucosal regeneration was present with all agents, and the epithelium appeared to have grown back from the occluded cystic duct. Late regeneration has not been previously reported and its significance when considering the application of the technique to the human gallbladder is discussed.     

肝内外胆管及胆囊扩张程度和低位梗阻性黄疸病变的相关性

目的探讨肝内、外胆管及胆囊扩张程度、形式对低位梗阻性黄疸的诊断价值。方法回顾性分析105例低位阻塞性黄疸患者的CT和内窥镜逆行胰胆管造影（ERCP）的影像资料，将胆系扩张分为下列7种类型：Ⅰ型为肝内、外胆管及胆囊均重度扩张；Ⅱ型为肝外胆管、胆囊重度扩张伴肝内胆管轻度扩张；Ⅲ型为肝内、外胆管重度扩张伴胆囊不扩张或轻、中度扩张；Ⅳ型为肝外胆管重度扩张伴肝内胆管和胆囊不扩张或轻、中度扩张；Ⅴ型为肝内胆管重度扩张伴肝外胆管及胆囊不扩张或轻、中度扩张；Ⅵ型胆囊重度扩张伴肝内、外胆管不扩张或轻、中度扩张；Ⅶ型为肝内、外胆管及胆囊均不扩张或轻、中度扩张。结合手术和病理结果，分析各类型胆系扩展和其低位阻塞性黄疸病变的相关性。结果105例低位阻塞性黄疸中33例为肿瘤性病变，72例为非肿瘤性病变。肿瘤性病变中．Ⅰ型16例，Ⅱ型10例，Ⅲ型4例，Ⅳ型1例，Ⅶ型2例。非肿瘤性病变中，Ⅰ型4例，Ⅱ型4例，Ⅲ型9例，Ⅳ型33例，Ⅴ型2例，Ⅵ型11例，Ⅶ型9例。Ⅰ、Ⅱ型扩张和Ⅲ～Ⅶ型扩张在肿瘤和非肿瘤病变中差异有统计学意义（χ^2=47．33，P〈0．01）。结论低位阻塞性黄疸病变性质和肝内、外胆管及胆囊扩张程度密切相关：（1）Ⅰ型和Ⅱ型扩张提示绝大多数为肿瘤性病变，少数为嵌顿性结石。（2）Ⅲ～Ⅶ型扩张常为胆管、胆囊结石及炎症。     

Chemical sclerosis of the gallbladder. An experimental study in pigs of the effect of absolute ethanol and polidocanol on gallbladder epithelium

Chemical ablation of the gallbladder with absolute ethanol and polidocanol 3% was attempted in 23 and 10 pigs, respectively, after open transhepatic cholecystostomy. Absolute ethanol caused complete necrosis of the gallbladder epithelium in 10 pigs and partial necrosis with focally present gallbladder epithelium in 9. An intact epithelium was observed in 4 pigs but it was not possible to determine whether this epithelium was the original one, not affected by the ethanol, or regenerated after previous damage. Gallbladders with hemorrhage and hydrops were frequently encountered. Gallbladders treated with polidocanol all had an intact epithelium.     

经导管肝动脉化疗栓塞术后胆管损伤的临床意义

目的 观察经导管肝动脉化疗栓塞术（TACE）治疗肝脏恶性肿瘤后继发胆管损伤的发生率、影响因素和临床过程.方法 对1240例患者做TACE 2 680次,术前影像学检查均无明确胆系异常表现,18例于术后3周～3个月出现胆管损伤并发症.采用回顾性调查,观察TACE术后胆管损伤的发生率、临床表现、转归以及影响因素.结果肝转移性肿瘤TACE后胆管损伤的发生率为8.8%（13/148）,肝细胞性肝癌（HCC）组为0.5%（5/1092）.胆管损伤的影像学表现有局灶性胆管扩张4例、多发性肝内胆管扩张8例、囊性病灶或胆汁瘤6例.3例多灶胆管损伤表现为轻度黄疸,2例对保守治疗反应良好,1例于出现黄疸后2周死于肝功能衰竭.4例胆汁瘤合并感染,3例采取经皮穿刺置管引流和抗生素治疗,其中2例死于感染囊腔破入腹腔、继发化脓性腹膜炎,1例治愈;1例仅用抗生素治愈.与胆管损有关的病死率为16.7%（3/18）.其余11例无相关症状.统计学分析显示：无肝硬变背景的肝转移瘤患者TACE术后胆管损伤发生率明显高于有肝硬变的HCC患者（P〈0.01）;其他高危因素有肿瘤为少血供型（P〈0.01）和用铂类制剂与碘油乳化后做超选择性栓塞（P〈0.01）.结论 认识TACE后继发胆管损伤的影像学表现可避免误诊,特别是肿瘤复发.对存在胆管损伤高危因素患者,适当减少碘油乳化的化疗剂（特别是铂类）剂量,有可能降低胆系缺血损伤并发症.