Chronic acalculous gallbladder disease: multiimaging evaluation with clinical-pathologic correlation

Despite the recent advances in hepatobiliary imaging, the diagnosis of chronic acalculous gallbladder disease remains difficult. A retrospective study was undertaken to assess the value of a multiimaging approach in detecting chronic acalculous gallbladder disease and in predicting which patients would obtain symptomatic relief after cholecystectomy. Of 199 patients with chronic cholecystitis, 26 (13%) had no gallstones. Of these 26, only 17 (65%) had symptoms related to chronic cholecystitis; in the remainder, the histologic diagnosis was made incidentally. After cholecystectomy, 13 (76%) of the 17 symptomatic patients obtained long-term symptomatic relief, while in four, the symptoms recurred. Among patients with histologic changes of chronic cholecystitis, biliary scintigraphy was the most sensitive technique (sensitivity, 89%). The sensitivity of sonography and oral cholecystography was 61.5% and 66%, respectively. However, for identifying symptomatic patients who may obtain long-term symptomatic relief after cholecystectomy, the accuracy of sonography, oral cholecystography, and biliary scintigraphy was 82%, 86%, and 38%, respectively. When two tests were in agreement the accuracy was 88%. For chronic acalculous cholecystitis, more than one study must be performed in order to make the correct diagnosis and to predict good results from cholecystectomy.     

Pericholecystic hepatic activity in cholescintigraphy

Gallbladder nonvisualization in cholescintigraphy has been shown to be a reliable finding in acute cholecystitis. In some cholescintigrams, we have observed faintly increased pericholecystic hepatic activity in conjunction with gallbladder nonvisualization. To determine the frequency and significance of the pericholecystic hepatic activity finding, we evaluated 334 consecutive adult patients who had cholescintigrams with technetium-99m diisopropylphenylcarboamoyl iminodiacetic acid. Pericholecystic hepatic activity was seen in 21% of the abnormal scans demonstrating gallbladder nonvisualization but in none of the other scans. Thirteen of these patients underwent surgery; 11 (85%) were found to have acute cholecystitis, and two (15%) had chronic cholecystitis. Four patients (31%) had acute gangrenous cholecystitis, and five (39%) had cholecystitis complicated by gallbladder perforation. The pericholecystic hepatic activity sign is not specific for gangrenous cholecystitis or gallbladder perforation but does reliably indicate inflammatory gallbladder disease and is associated with a relatively high incidence of cholecystitis complicated by perforation.     

Carcinoma of the gallbladder: a risk associated with gallbladder-preserving treatments for cholelithiasis

Five cases of carcinoma of the gallbladder associated with nonsurgical treatment of cholelithiasis are presented in view of the recent interest in gallbladder-preserving procedures. Three patients developed gallbladder cancer that was diagnosed 4, 11, and 72 years, respectively, after cholecystostomy. One other patient had gallbladder carcinoma diagnosed 7 months after extracorporeal shock wave lithotripsy for common bile duct stones. The tumor was probably present but not identified at the time of lithotripsy. The last patient had undiagnosed gallbladder malignancy at the time of cholecystostomy for treatment of acute calculous cholecystitis. Gallbladder carcinoma has been reported in 1% of patients undergoing cholecystectomy, and the risk of carcinoma developing in patients with asymptomatic cholelithiasis has been estimated at less than 1%. These figures should not diminish the role of gallbladder-preserving treatments in elderly and selected high-risk patients for whom cholecystectomy may be hazardous. However, such patients must undergo a thorough imaging assessment both before and after treatment to ensure that a gallbladder carcinoma is not overlooked.     

Technetium-99m-pyridoxylideneglutamate: a new hepatobiliary radiopharmaceutical. II. Clinical aspects.

Technetium-99m-pyridoxylideneglutamate (99mTc-PG) is a nontoxic radiopharmaceutical that was found to undergo rapid biliary excretion in normal humans. The biliary tree and gallbladder were seen within 10-15 min of injection and by 20 min marked accumulation of radioactivity was noted in the gallbladder and gastrointestinal tract. Of ten "control" volunteers, seven had normal 99mTc-PG-cholescintigrams. In the remaining three, the gallbladder was not visualized. Gallbladder disease was not excluded in these three subjects. Of 24 patients referred for investigation of right upper quadrant abdominal pain, 13 proved to have gallbladder disease. All seven patients with acute cholecystitis and one of four patients with chronic cholecystitis had nonvisualization of the gallbladder on the cholescintigram whereas five patients with chronic cholecystitis or cholesterolosis had normal cholescintigrams. Six of the eight patients with nonvisualization of the gallbladder on cholescintigram had contrast radiologic studies (oral cholecystogram or intravenous cholangiogram or both), and in all six, nonvisualization of the gallbladder was also reported on the contrast study. cholescintigraphy was found to be greatly inferior to contrast radiologic studies in the detection of gallbladder stones.Eleven patients had complete extrahepatic biliary obstruction and this diagnosis was correctly made in all 11 by the cholescintigram. Fourteen patients had incomplete extrahepatic biliary obstruction. The correct diagnosis was made on the cholescintigram in seven but in the remaining seven it was not possible to distinguish between incomplete extrahepatic biliary obstruction and hepatocellular disease. Malignant lesions (carcinomas of head of pancreas, gallbladder, common bile duct or ampulla of Vater) were the cause of obstruction in 10 of the 25 patients with complete or incomplete obstruction and the diagnosis of obstruction due to malignancy was correctly made in 8 of these 10 by means of a scintigraphic equivalent to Courvoisier's sing. Finally, 11 patients had hepatocellular disease and a nonspecific pattern consistent with either imcomplete biliary obstruction or hepatocellular disease was observed on the cholescintigram in all 11. The 99mTc-PG cholescintigram is suggested for a role complementary to that of contrast radiologic studies in the preoperative investigation of patients with possible surgical disease of the biliary tract. Contrast radiologic techniques are advocated as being more appropriate in the nonjaundiced patient with suspected gallbladder disease whereas the 99mTc-PG cholescintigram is advocated as being more appropriate in the patient with jaundice. The value of the 99mTc-PG cholescintigram lies in the confidence with which complete extrahepatic biliary obstruction can be diagnosed. The "scintigraphic Courvoisier's sign" seems a useful indicator of malignant obstruction.     

PIPIDA scintigraphy for cholecystitis: false positives in alcoholism and total parenteral nutrition

A review of gallbladder scintigraphy in patients with potentially compromised hepatobiliary function revealed two groups in whom cholecystitis might be mistakenly diagnosed. In 200 consecutive hospitalized patients studied with technetium-99m-PIPIDA for acute cholecystitis or cholestasis, there were 41 alcoholics and 17 patients on total parenteral nutrition. In 60% of the alcoholics and 92% of those on parenteral nutrition, absent or delayed visualization of the gallbladder occurred without physical or clinical evidence of cholecystitis. A cholecystagogue, sincalide, did not prevent the false-positive features which presumably are due to altered bile flow kinetics related to alcoholism and parenteral nutrition. Four patients on parenteral nutrition undergoing cholecystectomy for suspected cholecystitis had normal gallbladders filled with jellylike viscous thick bile. A positive (nonvisualized or delayed visualized) gallbladder PIPIDA scintigram in these two populations should not be interpreted as indicating a need for cholecystectomy.     

Radiological evaluation of the vertical banded gastroplasty for morbid obesity

Vertical banded gastroplasty (VBG) was performed in 70 morbidly obese patients between September 1988 and February 1991. All patients underwent a routine abdominal ultrasonographic (US) ctudy preoperatively, an upper gastrointestinal (GI) contrast study on the fifth day after VBG, and US and upper GI studies at 6, 12, 18 and 24 months postoperatively. The main abnormalities detected included staple-line distuption (22.85%), extragastric leak (2.85%), outlet obstruction (7.14%), gallstones (37.14%) and fatty liver (75.50 %). Asymptomatic cholelithiasis following VBG was detected by US in 25.8% of cases. Hepatic US follow-up showed the echographic pattern had returned to normal in 47.61% of cases. The 100% sensitivity and 100% specificity of gallstone detection at pre-VBG study in this series further confirms the role of US in the evaluation of cholithiasis, even in the morbidly abese. The 88.67% sensitivity and 100% specificity of fatty liver detection by US is similar to results from other studies. We suggest US and upper GI studies should be carried out routinely in morbidly obese patients not only for early detection of postsurgical complications but also to evaluate cholelithiasis and hepatic parenchyma following VBG. Correspondence to: J. D. Casas     

Diagnosis of acute cholecystitis by cholescintigraphy: significance of pericholecystic hepatic uptake

Uptake of radionuclide by the liver next to the gallbladder in cholescintigraphy has been described as a useful secondary sign with a high positive predictive value for the diagnosis of acute cholecystitis. We retrospectively examined 780 consecutive cholescintigrams to (1) determine the positive predictive value at 1 hr of this sign for acute cholecystitis and (2) ascertain if the presence or absence of this finding could differentiate acute from gangrenous cholecystitis. Pericholecystic hepatic activity was present at 1 hr in 48 (34%) of 141 scans in which the gallbladder was not visualized, and cholecystectomy was performed within 6 days of scintigraphy. Forty-five of these patients had acute and three had chronic cholecystitis (94% positive predictive value for acute cholecystitis). In addition, 57% of patients with gangrenous cholecystitis exhibited pericholecystic hepatic activity, and the frequency of this finding was significantly higher (p less than .006) in gangrenous than in acute cholecystitis. In summary, pericholecystic hepatic uptake is a valuable secondary sign in the cholescintigraphic diagnosis of acute cholecystitis. The significance of the finding is (1) a high positive predictive value for acute disease at 1 hr and (2) a statistically significant increased frequency in patients with gangrenous cholecystitis.     

Contrast enhanced sonography of the gallbladder: A tool in the diagnosis of cholecystitis?

RATIONALE AND OBJECTIVES: To evaluate if contrast enhanced sonography (CES) can help to detect gallbladder inflammation and differentiate between acute and chronic cholecystitis. MATERIALS AND METHODS: Thirty-three patients with clinical suspicion of acute cholecystitis were examined with CES before cholecystectomy. Thirty patients with no history of gallbladder disease served as control. CES was performed using 2.5 mL SonoVue. A small mechanical index was chosen (0.1). The enhancement pattern of the gallbladder was ranked in a three-point scale: no enhancement, low enhancement and strong enhancement. 28/33 patients underwent surgery. Sonographic findings were compared to histological results. RESULTS: In 16/20 cases with histological proven acute cholecystitis, the gallbladder wall showed a strong enhancement. Low enhancement was found in four patients with acute and in six patients with chronic cholecystitis. The gallbladder wall of two patients with chronic inflammation and all patients (30/30) of the control group showed no enhancement. CONCLUSION: CES is a feasible tool for detecting gallbladder inflammation. Differentiating between acute and chronic cholecystitis seems to be possible.     

Acute cholecystitis: diagnostic accuracy of percutaneous aspiration of the gallbladder

Results of gallbladder bile aspiration and culture were correlated with presence or absence of acute cholecystitis in 36 patients to test the role of these procedures in hospitalized patients with sepsis. Diagnostic aspiration of the gallbladder was performed in 11 patients, and in the remaining patients a combination of percutaneous aspiration, percutaneous cholecystostomy, or cholecystectomy was used. Bile culture was not helpful in the prediction of acute cholecystitis, since results were not available for a minimum of 24-48 hours after aspiration. In addition, gram-stained smears and bile cultures suffered from low sensitivity (48% and 38%, respectively); consequently, a negative test does not allow the diagnosis of acute cholecystitis to be excluded. Bile aspiration of the gallbladder thus has a limited role in the diagnosis of this condition.     

More than just stones: a pictorial review of common and less common gallbladder pathologies

Although stone disease is by far the most commonly encountered pathology of the gallbladder, there are several other important disease processes affecting it. These include adenomyomatosis, cholesterolosis, polyps, porcelain gallbladder, acalculous cholecystitis, xanthogranulomatous cholecystitis, emphysematous cholecystitis, gallbladder cancer, and gallbladder hemorrhage. The purpose of this article was to review the different gallbladder pathologies encountered in everyday radiological practice and to describe their features in the standard imaging modalities.     

Xanthogranulomatous cholecystitis: clinical, sonographic, and CT findings in 26 patients

OBJECTIVE: The purpose of our study was to evaluate the sonographic and CT features of xanthogranulomatous cholecystitis, correlating the pathologic and surgical findings. MATERIALS AND METHODS: Xanthogranulomatous cholecystitis was pathologically diagnosed in 26 patients from January 1996 to August 1998. The patients were 15 women and 11 men with a mean age of 63 years. All patients had preoperative sonography and nine also underwent CT In five patients, sonography was performed on the surgical specimen. Clinical indications for imaging included cholecystitis (14 patients), biliary colic (six patients), stone-induced pancreatitis (three patients), tumor (two patients), and gallstone ileus (one patient). RESULTS: The most characteristic sonographic finding, confirmed by sonographic study of the surgical specimens, was the presence of hypoechoic nodules or bands in the gallbladder wall, which were seen in 35% of the patients. Cholelithiasis and a thickened gallbladder wall were frequent findings. The most characteristic (specific) CT finding was a hypodense band in the gallbladder wall, seen in 33% of the patients. Two of twelve patients who underwent laparoscopic cholecystectomy required conversion to open surgery. CONCLUSION: Although the preoperative imaging diagnosis of xanthoganulomatous cholecystitis is difficult, the presence of hypoechoic nodules or bands in the gallbladder wall on sonography or of a hypodense band around the gallbladder on CT, is highly suggestive of this disease.     

The role of morphine-augmented cholescintigraphy and real-time ultrasound in detecting gallbladder disease

OBJECTIVE: Rapid diagnosis of acute cholecystitis is essential to minimize morbidity and mortality. The purpose of this study was to assess the diagnostic utility of cholescintigraphy using morphine augmentation compared with ultrasound, in acute and chronic gallbladder disease. METHODS: Cholescintigrams were performed on 103 patients suspected of having acute cholecystitis. In 79 patients (Group A) morphine sulfate was administered to reduce the scintigraphic imaging time if the gallbladder was not visualized during the first hour. In 24 control patients (Group B) no morphine was administered. All patients were evaluated clinically and 93 patients had concurrent ultrasound examination. RESULTS: The clinical presentation was nonspecific. The ultrasound findings were sensitive in detecting gallbladder disease (100%), but had low specificity (24%). Only findings of sediments and pericholecystic fluid were specific for cystic duct obstruction. Morphine augmentation reduced the imaging time by 126 min in patients with chronic cholecystitis. CONCLUSION: Real-time ultrasound has low specificity for gallbladder disease. In the presence of an abnormal ultrasound, it is essential to perform a hepatobiliary scan, either to exclude gallbladder disease or distinguish acute from chronic cholecystitis. Low-dose morphine administration is a safe and useful adjunct to standard cholescintigraphy by substantially reducing the time required to obtain a diagnostic study.     

Chronic biliary-type pain in the absence of gallstones: the value of cholecystokinin cholescintigraphy.

Radiologic criteria for the diagnosis of gallbladder disease largely rest on the detection of calculi. Surgeons are reluctant to do a cholecystectomy in patients with symptoms of gallbladder disease if the results of sonography or cholecystography are normal. Consequently these patients are often left with no satisfactory treatment. Such patients may have chronic acalculous cholecystitis, partial obstruction of the cystic duct, or gallbladder dyskinesia. Increasing evidence indicates that at least some of these patients have decreased gallbladder emptying in response to a stimulus such as a test meal or cholecystokinin. Impaired emptying shown by cholecystokinin cholescintigraphy may be useful for predicting which patients with typical biliary-type pain but no evidence of calculi will be cured by cholecystectomy.     

Gallbladder bile in cholecystitis: in vitro MR evaluation

Fifty-three samples of gallbladder bile were obtained at the time of cholecystectomy from patients with the clinical diagnosis of acute or chronic cholecystitis. Five bile samples from patients with clinically normal gallbladders also were obtained. Proton magnetic resonance (MR) relaxation times, protein content, and water content were determined for the bile samples, and the data were grouped according to pathologic diagnosis, which disclosed 11 cases of acute cholecystitis, 41 cases of chronic cholecystitis, and six normal gallbladders. There was no significant difference in the mean T1 and T2 values between the groups with acute and chronic cholecystitis. Patients with chronic cholecystitis were found to have more concentrated bile than those with acute cholecystitis. Protein content varied widely within both groups of patients. We conclude that T1 and T2 relaxation times do not reliably differentiate acute from chronic cholecystitis.     

Percutaneous cholecystostomy for patients with acute cholecystitis and an increased surgical risk

Purpose To evaluated percutaneous cholecystostomy in patients with acute cholecystitis and an increased surgical risk. Methods Thirty-three patients with acute cholecystitis (calculous,n=22; acalculous,n=11) underwent percutaneous cholecystostomy by means of a transhepatic (n=21) or transperitoneal (n=12) access route. Clinical and laboratory parameters were retrospectively studied to determine the benefit from cholecystostomy. Results All procedures were technically successful. Twenty-two (67%) patients improved clinically within 48 hr; showing a significant decreased in body temperature (n=13), normalization of the white blood cell count (n=3), or both (n=6). There were 6 (18%) minor/moderate complications (transhepatic access,n=3; transperitoneal access,n=3). Further treatment for patients with calculous cholecystitis was cholecystectomy (n=9) and percutaneous and endoscopic stone removal (n=8). Further treatment for patients with acalculous cholecystitis was cholecystectomy (n=2) and gallbladder ablation (n=2). There were 4 deaths (12%) either in hospital or within 30 days of drainage; none of the deaths was procedure-related. Conclusion Percutaneous cholecystostomy is a safe and effective procedure for patients with acute cholecystitis. For most patients with acalculous cholecystitis percutaneous cholecystostomy may be considered a definitive therapy. In calculous disease this treatment is often only temporizing and a definitive surgical, endoscopic, or radiologic treatment becomes necessary.     

Comparison of CT and MRI findings in the differentiation of acute from chronic cholecystitis

We compared individual computed tomography (CT) and MRI findings in differentiating acute from chronic cholecystitis. Thirty-seven patients undergoing both studies before cholecystectomy were included. Two radiologists (R1/R2) independently assessed all cases. For detecting acute cholecystitis, MRI showed better sensitivity (R1) using gallbladder wall thickening, accuracy (R1) and sensitivity (R1) using gallstones, sensitivity (R1 and R2) and accuracy (R2) using gallbladder wall hyperemia, accuracy (R1 and R2) using gallbladder wall defect, and accuracy (R2) using adjacent liver hyperemia (P=.004–.063). MRI also showed better specificity (R2) using pericholecystic fat stranding (P=.016). Overall, several findings showed better sensitivity and/or accuracy for acute cholecystitis on MRI than CT.     

意外胆囊癌129例临床病理分析

 目的 探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC)中意外胆囊癌(incidental gallbladder carcinoma, IGC)的临床病理特征。方法 收集我院2001-07至2012-04收治的40 512例腹腔镜胆囊切除术并发意外胆囊癌129例并进行临床病理回顾性分析。结果 意外胆囊癌多发于老年和女性患者。大体形态表现为胆囊壁不规则增厚,黏膜粗糙,多伴有胆囊结石、慢性胆囊炎及胆囊息肉。好发部位为胆囊体部,病理类型主要为腺癌,以中度分化及低度分化为主。病程较长,大多处于临床中晚期,多数患者预后较差。结论 重视患有胆囊结石、慢性胆囊炎及胆囊息肉等老年女性患者腹腔镜胆囊切除术术前检查,对早期诊断及有效预防意外胆囊癌的发生具有非常重要的意义。     

Percutaneous cholecystolithotomy: preliminary experience and technical considerations

Surgical cholecystectomy is associated with a high morbidity and mortality in elderly patients with acute calculous cholecystitis and underlying cardiac or pulmonary disease. Currently there are few alternatives for treating these patients. The authors have used percutaneous cholecystolithotomy in 11 such high-risk patients for definitive treatment of gallbladder calculi. In all 11 patients all stones were successfully removed from the gallbladder and cystic duct. The entire procedure--from initial tube placement to final tube removal--lasted 17-40 days (mean, 21 days). There were two complications: one minor--local wound infection--and one major--bile peritonitis with eventual death. Percutaneous cholecystolithotomy is an effective alternative therapy for acute calculous cholecystitis in elderly, debilitated patients.     

Sonography of the gallbladder: significance of striated (layered) thickening of the gallbladder wall

Sonographic identification of thickening of the gallbladder wall that consists of multiple striations (alternate hypoechoic and hyperechoic layers) has been considered strong evidence of the presence of acute cholecystitis. We studied 27 patients in whom sonograms showed striated thickening of the gallbladder wall to determine the diagnostic significance of this finding. Striations were classified as focal or diffuse. Sonograms were correlated with pathologic findings in 16 patients and with clinical diagnoses and laboratory findings in 11. Patients were categorized as having cholecystitis with or without gangrene or edema of the gallbladder wall unrelated to gallbladder disease. Striated thickening of the gallbladder wall was due to cholecystitis in 10 patients, and all 10 had gangrenous changes at surgery or at pathologic examination. Striations were focal in eight of these patients and diffuse in two. Striated thickening of the gallbladder wall was due to edema of the wall unrelated to gallbladder disease in 17 patients. Causes included congestive heart failure (n = 4), renal failure (n = 5), liver disease (hepatic failure [n = 1], hepatitis [n = 6]), ascites (n = 2), hypoalbuminemia (n = 3), pancreatitis (n = 1), blockage of the lymphatic/venous drainage of the gallbladder (n = 2), and prominent Rokitansky-Aschoff sinuses (n = 1). More than one abnormality was present in five patients. Striations were focal in 11 of these patients and diffuse in six. The sonographic finding of striated gallbladder wall thickening is no more specific for cholecystitis than the observation of gallbladder wall thickening by itself, and it may occur in a variety of diseases. However, in the clinical setting of acute cholecystitis, the presence of striations suggests gangrenous changes in the gallbladder. The extent of the striations (focal or diffuse) is not useful in predicting the cause of the striated gallbladder wall thickening.     

Acute cholecystitis: MR findings and differentiation from chronic cholecystitis

PURPOSE: To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging for differentiation between acute and chronic cholecystitis, with histopathologic analysis as the reference standard. MATERIALS AND METHODS: Institutional review board approval with waived informed consent was obtained for this HIPAA-compliant study. Four reviewers blinded to the cholecystitis type but aware that cholecystitis was present retrospectively evaluated MR images for predetermined findings in 32 patients (15 male, 17 female; mean age +/- standard deviation, 55 years +/- 20) with histopathologically proved acute or chronic cholecystitis. The final MR diagnoses and MR findings in both groups were compared with each other and with the histopathologic diagnoses to determine the sensitivity and specificity of MR imaging. Chi(2) tests were used to detect differences in MR findings between the acute and chronic cholecystitis groups. RESULTS: MR imaging sensitivity and specificity for detection of acute cholecystitis were 95% (18 of 19 patients) and 69% (nine of 13 patients), respectively. The sensitivities of increased gallbladder wall enhancement and increased transient pericholecystic hepatic enhancement were 74% (14 of 19 patients) and 62% (10 of 16 patients), respectively. Both findings had 92% (12 of 13 patients) specificity. Sensitivities of increased wall thickness, pericholecystic fluid, and adjacent fat signal intensity changes were 100% (19 of 19 patients), 95% (18 of 19 patients), and 95% (18 of 19 patients), respectively; specificities were 54% (seven of 13 patients), 38% (five of 13 patients), and 54% (seven of 13 patients), respectively. Pericholecystic abscess, intraluminal membranes, and wall irregularity or defect each had 100% (13 of 13 patients) specificity; sensitivities were 11% (two of 19 patients), 26% (five of 19 patients), and 21% (four of 19 patients), respectively. Increased gallbladder wall enhancement (P<.001) and increased transient pericholecystic hepatic enhancement (P=.003) were the most significantly different between acute and chronic cholecystitis. CONCLUSION: Increased gallbladder wall enhancement and increased transient pericholecystic hepatic enhancement had the highest combination of sensitivity and specificity for the diagnosis and differentiation of acute and chronic cholecystitis.