Spontaneous Disappearance of Limy Bile: Report of a Case with Review of the Literature

Spontaneous disappearance of limy bile is extremely rare, and only four cases have so far been reported. This is the account of the fifth case, a 42–year-old woman, who spontaneously lost a stone incarcerated in the neck of the gallbladder and all of the limy bile, after symptoms suggestive of a transient obstructive jaundice. Various investigations including ultrasound, computed tomography, and percutaneous transhepatic cholangiography suggested spontaneous passage of the stone through the cystic duct and the papilla of Vater, followed by limy bile. Apparently the patient's gallbladder had a contracting capacity. The literature on this subject is briefly reviewed.     

Review of five cases of limy bile--particularly on radiological, chemical and crystallographic studies--.

Incidence of "limy bile" is relatively rare and only 120 cases have been recorded in Japan so far. The present report is to add five more cases operated on at our clinic. On chemical analysis by atomic absorption spectrophotometry calcium carbonate was the major constituent of solid portion and ranged from 73.5 to 88.5%. On crystallographic analyses, the infrared spectra by means of KBr-disk method gave patterns of calcium carbonate in all cases, and the X-ray powder diffraction studies disclosed those of aragonite only in cases 2 and 4, and aragonite-calcite mixture in cases 1 and 3. The exact etiology of formation of limy bile in the gallbladder has not yet been understood completely.     

Double cancers of the gallbladder and bile duct associated with anomalous choledochopancreatic duct junction

A rare case of double cancers of the gallbladder and bile duct associated with anomalous choledo-chopancreatic duct junction (ACPDJ) is reported. The patient was a 61-year-old Japanese woman who with presented right upper quadrant abdominal pain. Liver function tests results were normal. Computed tomography showed a polypoid lesion in the gallbladder, and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated ACPDJ and irregular wall of the inferior bile duct. A diagnosis of double cancers of the gallbladder and bile duct was made and a pancreaticoduodenectomy and liver bed resection was performed. His topathological examination showed papillary adenocarcinoma of the gallbladder and mucosal adenocarcinoma of the bile duct. The patient is in good health 15 months after the operation and shows no signs of recurrence. A review of the literature is presented.     

Limy bile cast of gallbladder

Summary 1. A case of limy bile cast of the gallbladder has been presented.2. The necessity for a routine preliminary scout film prior to cholecystography has been emphasized.3. The radiographic visualization of the gallbladder prior to the administration of the dye is an important factor in the diagnosis of a limy bile gallbladder.     

Anomalous junction of the pancreaticobiliary duct accompanied by gallbladder cancer and obstructive jaundice in a patient with high serum and bile cytokine levels

We report a case of anomalous junction of the pan creaticobiliary duct (AJPBD) associated with gallbladder cancer and obstructive jaundice in a patient with high serum and bile cytokine levels. The patient was a 63-year-old woman who complained of right hypochondralgia. Ultrasound, computed tomography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangio-pancreatatography revealed dilation of the bile ducts, an elevated lesion of the gallbladder, and AJPBD. She underwent percutaneous transhepatic cholangio-drainage (PTCD) for obstructive jaundice. However, the total bilirubin concentration remained high 7 days after PTCD. Her serum interleukin 6 level was 57 359 pg/ml before PTCD, and gradually decreased to 10 pg/ml after PTCD. Bile interleukin 6 level was 10 pg/ml before PTCD, 8997 pg/ml 3 h after PTCD and gradually decreased there after. Serum and bile levels of tumor necrosis factor α and hepatocyte growth factor were high before and after PTCD. The patient underwent an extended cholecystectomy and resection of the extrahepatic bile duct. The resected specimen showed two elevated lesions of the gallbladder which, microscopically, revealed moderately differentiated tubular adenocarcinoma. These findings suggest that pre-existing inconspicuous inflammation of the biliary tract due to reflux of pancreatic juice is involved in elevation of serum and bile cytokines, and that cytokines may participate in gallbladder carcinogenesis associated with AJPBD. (Received July 24, 1997; accepted Jan. 23, 1998)     

Biliary Excretion and Concentration of Cefazolin

The excretion of cefazolin into the human biliary tract in health and disease was investigated in 34 patients undergoing surgical procedures. The patients included: I. Four controls. IIA. Eleven patients with cholelithiasis and/or cholecystitis and a radiological visualized gallbladder. IIB. Nine patients with cholethiasis and cholecystitis and a radiologically nonvisualized gallbladder. III. Five patients with obstructive jaundice. IV. Five patients with a T-tube in the common bile duct. Two dose regimes: 1. A single dose of 500 mg and 2. four doses each of 500 mg. given every six hours, were used. Samples of serum, gallbladder bile, common duct bile and gallbladder tissue were assayed for antibiotic activity by the cylinder plate method with Bacillus subtilis. Following administration of four doses of the antibiotic, the mean level of the drug in the gallbladder bile, in controls was 127.0 mug/ml. In the group with cholelithiasis and cholecystitis and a gallbladder that is visualized, a similar high level was noted (mean = 132.2 mug/ml.). In the presence of a nonvisualized gallbladder or obstructive jaundice, the levels in bile were lower. Two hours following a single injection of the drug, the level in the common duct bile reaches a peak of 10 mug/ml and at eight hours falls to less than one mug/ml. In the absence of obstruction cefazolin reaches a significantly high level in bile and could be valuable in treatment of biliary infections.     

Adenomyoma of the common hepatic duct

BackgroundAdenomyoma occurs most commonly in the fundus of the gallbladder, seldom in other parts of the gallbladder and rarely in the extrahepatic biliary tree, where most lesions are localised to the common bile duct or papilla of Vater. Adenomyoma of the common hepatic duct is extremely rare. To the best of our knowledge, only three cases have been reported so far.Case outlineA 51-year-old woman was admitted with a three month history of attacks of right upper abdominal pain, nausea, vomiting and fever. Laboratory data, ultrasonography, ERCP and CT confirmed slight cholestasis and proximal bile duct dilatation due to a tumour within the common hepatic duct. Cholecystectomy was performed with excision of the suprapancreatic common bile duct including the convergence of the hepatic ducts plus lymphadenectomy and Roux-en-Y hepaticojejunostomy. Frozen section histology showed the benign nature of the lesion and a tumour-free resection line. Final histology showed adenomyoma. The patient has remained symptomfree for more than 30 months.DiscussionAlthough adenomyoma is a benign lesion and the surgical strategy has not been established, complete excision with frozen section is recommended to exclude small malignant foci and local recurrence as well as to avoid surgical over-treatment.     

Gallbladder agenesis with a stone in the cystic duct bud

An 84-year-old woman was admitted to the hospital because of pyloric stenosis caused by gastric cancer. Abdominal computed tomography and magnetic resonance imaging failed to demonstrate the gallbladder, but showed a gallstone in a ductlike structure parallel to the common bile duct. When laparotomy was performed, the gallbladder and the fossa were not observed, and a blind-end duct, similar to a cystic duct, was found beside the common bile duct. Incisional exploration of the common bile duct was done after distal gastrectomy; the gallstone was not found in the common bile duct, but in the duct parallel to it. By observing the duct beneath the common bile duct with a cholangioscope, we considered it to be a hypoplastic cystic duct. After the gallstone was removed, a T-tube was placed into the common bile duct. Agenesis of the gallbladder is a rare congenital anomaly and is often asymptomatic. As far as we know, this is the first report of gallbladder agenesis with a hypoplastic cystic duct impacted with a stone. Careful intraoperative examination using a cholangioscope is useful to confirm the structure of the common bile duct.     

Choledochoduodenal fistula at the anterior wall of the duodenal bulb: a rare complication of duodenal ulcer

A 38 year-old man was admitted to our hospital with the chief complaint of epigastralgia. His laboratory data revealed leukocytosis and increased serum amylase, and abdominal ultrasonography revealed diffuse swelling of the pancreas. Thus, he was diagnosed as having acute pancreatitis. Moreover, abdominal computed tomography showed pneumobilia in the gallbladder and the common bile duct. Gastroduodenal fiberscopy demonstrated peptic ulcer scars around a foramen with smooth margins at the anterior wall of the duodenal bulb. The bile juice flowed from the bottom of the foramen. Endoscopic retrograde cholangiopancreatography revealed the fistula between the common bile duct and the anterior wall of the duodenal bulb, but not the posterior wall. However, there was no pancreatico-biliary maljunction and no stones in the gallbladder or bile duct. This is a rare case of choledochoduodenal fistula at the anterior wall of the duodenal bulb caused by duodenal peptic ulcer disease.     

True left-sided gallbladder with variations of bile duct and cholecystic vein

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.     

Primary sclerosing cholangitis in which differential diagnosis from gallbladder carcinoma was difficult

We report a case of localized primary sclerosing cholangitis (PSC) which was difficult to distinguish from gallbladder carcinoma. A 75-year-old woman with elevated serum bilirubin was hospitalized and underwent endoscopic nasobiliary drainage (ENBD). There was no history of diseases such as gallbladder stone, pancreatitis, or ulcerative colitis. Cholangiography through the ENBD tube showed localized stenosis of the common bile duct; the gallbladder could not be seen. Angiography showed no encasement of the hepatic artery. Ultrasonography showed a tumor in the cystic duct, and the tumor had invaded the gallbladder and common bile duct. We diagnosed gallbladder carcinoma on radioimaging, and performed an S4aS5 subsegmentectomy of the liver and resection of the extrahepatic biliary tree. Pathologically, no malignant cells were detected, and fibrosis around bile ducts and infiltration of inflammatory cells into hepatic tissue were found. It is well known that PSC is sometimes difficult to differentially diagnose from cholangiocarcinoma. Our case is of high interest because ultrasonography showed findings suggestive of gallbladder carcinoma. It is therefore necessary to keep the possibility of PSC in mind for the diagnosis and treatment of such localized biliary stenosis.     

Presence or absence of inhibitors of crystal growth in bile. 1. Effect of bile on the formation of calcium phosphate, a constituent of gallstones.

When calcium and phosphate ions were mixed so that their final concentration was 4 mmol/1 and the pH was kept at 7-0, an amorphous precipitate immediately formed and this changed into crystalline material with an apatite-like structure after a period of time. The formation of either or both types of precipitate could be slowed down or prevented by adding to the crystallising medium trace amounts of pyrophosphate or citrate which are known inhibitors of the formation of calcium phosphate, or large quantities of sodium chloride which increased the ionic strength of the solution and hence the solubility of calcium phosphate, Both common duct and gallbladder bile from patients with gallstones composed of cholesterol and/or calcium carbonate had a very pronounced inhibitory action on the formation of these precipitates. Only very small amounts of bile were necessary to produce these effects, which therefore were not due to an increase in ionic strength. Ultrafiltration of bile showed that material with a molecular weight greater than 10 000 was mainly responsible for this activity. Because the inhibitor was present in both common duct and gallbladder bile, the liver is the likely source of origin. The possible identity of this material is examined. The powerful inhibitory effect of bile on the crystallisation of calcium phosphate is probably a contributory factor to the rare occurrence of the calcium phosphates, apatite and whitlockite, in gallstones.     

Excretion of metroindazole in human bile. Investigations of hepatic bile, common duct bile, and gallbladder bile

Excretion of metronidazole (MNZ) in the normal and in the diseased biliary tract was investigated in 58 patients after oral or intravenous administration of MNZ. After oral administration MNZ appeared rapidly in hepatic bile, and throughout the period of absorption and elimination almost identical concentrations of MNZ were found in serum and hepatic bile. After intravenous administration no significant differences were found between concentrations of MNZ in common duct bile and serum in the non-obstructed common duct; in common duct obstruction, concentrations of MNZ in common duct bile were 56--99 per cent of corresponding concentrations in serum. MNZ was concentrated in normal gallbladders. In patients with gallbladder stones and preserved function of the gallbladder and in patients with no function of the gallbladder but a patent cystic duct, no significant differences were found between concentrations of MNZ in gallbladder bile, common duct bile, and serum. In most gallbladders with the cystic duct blocked by a stone, no MNZ was found in gallbladder bile.     

Trypsin level in gallbladder bile and ductitis and width of the cystic duct

BACKGROUND/AIMS: The change from laparotomy to laparoscopy for cholecystectomy has raised the question of how to manage concomitant bile duct stones. The present-day interest--and controversy--has focused on a transcystic approach reported to be feasible in 66-96% of cases, but without explaining the necessary prerequisite: the widening of the cystic duct. The cystic duct, wide mainly in patients with bile duct stones, has been reported to be highly variable: from strictured to very wide. The present study aims at comparing the trypsin level in the gallbladder bile and the cystic duct morphology and width in patients with and without bile duct stones. METHODOLOGY: A prospective series of 63 gallstone patients, 30 with and 33 without bile duct stones (controls), underwent cholecystectomy and bile duct clearance. The study includes the trypsin level in the gallbladder bile, the width and morphology of the cystic duct, and the size of the gallstones. RESULTS: The patients with bile duct stones had, in contrast to the controls, higher trypsin levels in the gallbladder bile (P < 0.001) and wider cystic ducts (P < 0.001) with more pronounced signs of chronic ductitis. CONCLUSIONS: The obtained results strongly suggest that the increased trypsin level, a sign of reflux of pancreatic juice, caused changes in the cystic duct that facilitate gallstone migration, which also ought to render a transcystic stone extraction feasible.     

Carcinoma of the gallbladder from an anomalous connection between the bile duct and the pancreatic duct

Anomalous connection between the common bile duct and the pancreatic duct has recently been reported to be associated with cancerous changes of the biliary tract. A 52-year-old Chinese man had a fungating tumor in the gallbladder, and a long common channel between the bile duct and the pancreatic duct. The association of these two rare disease entities especially in a Chinese man may imply a close relationship between pancreatobiliary anomalous connection and the gallbladder cancer. It is thus prudent to monitor patients with such an anomalous connection closely by serial ultrasonic examination. More aggressively, prophylactic cholecystectomy and reconstruction of the biliary tract may be indicated.     

Small Cell Carcinoma of the Gallbladder Arising in a Patient with Pancreaticobiliary Maljunction without Bile Duct Dilatation

We report a 36–year-old female patient with small cell carcinoma of the gallbladder with liver metastasis, that was associated with pancreaticobiliary maljunction (PBM) without bile duct dilatation. On admission, a gallbladder mass and multiple liver tumors were detected by US, CT and ERCP. Moreover, ERCP clearly demonstrated an abnormally long common channel between the pancreatic and bile ducts, indicating PBMwithout choledochal dilatation. US-guided biopsy of the tumor histopathologically confirmed small cell carcinoma. The serum neuron-specific enolase (NSE) level was very high. Transarterial chemo-embolization followed by systemic chemotherapy resulted in marked tumor reduction, but this was followed by rapid exacerbation. The patient died of the tumor 145 days after admission. The proposed mechanism of the car-cinogenesis of this rare gallbladder malignancy under the preexisting condition of PBM was discussed. (Dig Endosc 1999, 11: 246–249)     

Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.     

Synchronous carcinoma of the gallbladder in a patient with intrahepatic bile duct carcinoma

An 83-year-old woman, diagnosed as having cholelithiasis, was admitted to the Department of Surgery, Nippon Medical School, with right hypochondrial pain. Ultrasonography and computed tomography revealed a mass in the gallbladder fundus and a hypovascular tumor in the anterior segment of the liver. Magnetic resonance imaging showed stenosis of the intrahepatic bile duct and dilatation of its proximal portion. She was diagnosed as having intrahepatic bile duct carcinoma combined with gallbladder carcinoma. At laparotomy, there was evidence of multiple peritoneal metastases and intraoperative histological examination of the gallbladder tumor revealed adenocarcinoma. Accordingly, only cholecystectomy and needle biopsy of the liver tumor was performed. Histological examination of the gallbladder revealed papillary adenocarcinoma invading the muscularis propria with medullary growth or intermediate stroma. There was no microvessel invasion, no perineural invasion and no lymph node involvement. On the other hand, the liver tumor was a cholangiocarcinoma with a well-differentiated tubular pattern. Therefore, this was a rare case of synchronous carcinoma of the gallbladder associated with intrahepatic bile duct carcinoma.     

Patients with uncomplicated cholelithiasis acidify bile normally

Reports have suggested that patients with gallstones have gallbladder bile that is less acidic and more saturated with calcium carbonate than patients without gallstones. This failure to acidify bile may play a role in the formation of gallstones. We, therefore, compared gallbladder bile pH, ionized calcium, and calcium carbonate saturation index from patients undergoing either incidental gallbladder removal (controls, n = 23) or elective cholecystectomy for gallstones (n = 55). Gallstones were classified as either cholesterol (n = 39) or black pigment (n = 16) stones. No difference in gallbladder bile pH was noted among the controls, cholesterol stone, and pigment stone patients. In addition, no difference in ionized calcium concentration or CCSI was noted among the three groups. The pH in additional patients (n = 49) with acute cholecystitis, common bile duct obstruction, biliary tract infection, and cystic duct obstruction was significantly more acidic. We conclude that neither a defect in bile acidification nor increased saturation of calcium carbonate explains why human cholesterol or pigment gallstones form.