Multiseptate gallbladder: A case report and literature review

Rationale:Multiseptate gallbladder (MSG) is a rare congenital gallbladder anomaly. Between 1963 and June 2021, only 56 cases were reported. There is currently no treatment guideline for pediatric or adult cases of MSG.Patient concerns:A 14-year-old woman visited our out-patient clinic in September 2020 for epigastric pain that last for 6 months. Honeycomb appearance of the gallbladder was noted under ultrasonography.Diagnosis:The patient was diagnosed with MSG. The diagnosis was confirmed through computed tomography and magnetic resonance cholangiopancreatography.Interventions:Cholecystectomy was performed.Outcomes:Epigastric pain showed limited improvement after the surgery. Since she was diagnosed with gastritis at the same time, a proton-pump inhibitor was prescribed. Epigastric pain was eventually resolved.Lessons:MSG cases can undergo cholecystectomy and show good recovery without complications. However, concomitant treatment may be required to resolve in the presence of other symptoms such as epigastric pain.     

The honeycomb gallbladder: a new category of acquired pseudo-multiseptate gallbladder

We report two cases of honeycomb gallbladder as a new category of acquired pseudo-multiseptate gallbladder associated with chronic cholecystitis with stones. The two patients were elderly women without any abdominal symptoms or abnormality of laboratory data. On the imaging examinations, a hyperechoic collection with acoustic shadowing on the inferior surface of the liver was typically observed on ultrasonography, with multiloculated gallbladder being observed on computed tomography. Macroscopic findings of the cut plane of the gallbladder showed a characteristic appearance, with thin pseudo-septations arising from the wall and bridging the lumen from side to side, with a honeycomb appearance, including small stones. Microscopic findings suggest that these septational structures could have developed over a chronic inflammatory course after acute obstruction of the cystic duct. Cholecystectomy should be the choice of treatment for honeycomb gallbladder from the viewpoint of clinical management.     

Colonic diverticular perforation by a migrated biliary stent: A case report with literature review

Rationale:Plastic endobiliary stents, after endoscopic retrograde cholangiopancreatography, can get spontaneously dislocated from the common bile duct and migrate intothe distal bowel. Most migrated biliary stents are removed with the passing of stool. However, migrated biliary stents can cause bowel perforation, albeit rarely, and surgical intervention may be required. Recently, we observed a colonic diverticular perforation caused by a migrated biliary stent, and we have reported this case with a review of the literature.Patients concerns:A 74-year-old man presented with severe right lower quadrant pain after biliary stent insertion 1month ago.Diagnoses:Abdominal computed tomography revealed perforation of the proximal ascending colon by the migrated biliary stent, combined with localized peritonitis.Interventions:Emergency diagnostic laparoscopic examination revealed penetration of the proximal ascending colon by the plastic biliary stent, and right hemicolectomy was performed.Outcomes:On pathological examination, colonic diverticular perforation by the biliary stent was confirmed. The patient was discharged without any additional complications.Lessons:Endoscopic retrograde cholangiopancreatography endoscopists must always be cautious of the possibility of stent migration in patients with biliary stents in situ. In cases of biliary stent dislocation from the common bile duct in asymptomatic patients, follow-up with serial, plain abdominal radiographs, and physical examination is needed until confirmation of spontaneous passage through stool. In symptomatic cases suggesting peritonitis, abdominal computed tomography scan confirmation is needed, and early intervention should be considered.     

Multiseptate gallbladder: Biliary manometry and scintigraphy

A 30-year-old man with multiseptate gallbladder, a very rare congenital anomaly, is presented. His presenting symptom was epigastric pain. A hypoplastic gallbladder with multiple septa was demonstrated by ultrasonography and endoscopic retrograde cholangiography. An injection of cerulein reproduced pain, and simultaneous biliary manometry and scintigraphy showed impairment of gallbladder filling and emptying. Laparoscopic cholecystectomy resulted in complete relief of the pain. Biliary manometry and scintigraphy are useful to determine the operative indication in a symptomatic patient with this entity.     

Endoscopic ultrasonography-guided gallbladder drainage: actual technical presentations and review of the literature (with videos)

Background/purpose

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has been developed as an alternative drainage method in patients with acute cholangitis. Here, we describe two successful EUS-GBD cases and review the literature on this topic.

Methods

EUS-GBD was conducted using a curved linear array echoendoscope and a 19-gauge needle.

Results

A 7-Fr double pigtail stent was successfully placed transgastrically in one patient and transduodenally in the other patient, without any serious early adverse events in either patient. No late complications or relapse of acute cholecystitis have been seen during the 3- to 6-month follow-up period.

Conclusions

EUS-GBD holds high potential as an alternative gallbladder decompression procedure. However, because current experience is limited, multicenter trials for the accurate evaluation of this procedure appear to be necessary in the near future.     

Carcinosarcoma of the gallbladder: A case report and review of the literature

A rare case of a huge carcinosarcoma of the gallbladder is presented. Despite a tumor thrombus in the portal vein, this tumor was resected successfully by extended right hepatic lobectomy with right caudate lobectomy and gastroduodenectomy. However, hepatic metastases developed rapidly, and the patient died only 3 months after surgery. Macroscopically, a whitish tumor filled the body and neck of the gallbladder and involved the right lobe and left medial segment of the liver, stomach, and duodenum. Microscopically, the neoplasm consisted of both carcinomatous and sarcomatous components. The former contained adenocarcinoma and squamous cell carcinoma, which were observed in the wall of the gallbladder. The latter comprised the bulk of the mass and contained malignant cartilage and osteoid. Immunohistochemically, the sarcomatous cells reacted to antibodies for epithelial membrane antigen and cytokeratin, but were negative for vimentin antibody, Although stromal differentiation into osteoid and cartilage was noted, the sarcomatous component was felt to be derived from mesenchymal metaplasia of the carcinomatous cells. Only 14 cases of carcinosarcoma of the gallbladder have been reported in the English language literature since 1967.     

Primary spindle cell sarcoma of gallbladder: An unusual case report and a literature review

Introduction:Primary spindle cell sarcoma of the gallbladder is a rare condition.Patient concerns:A 67-year-old woman was admitted to a local hospital with a chief complaint of abdominal pain in the right upper quadrant for the past 2 months.Diagnosis and intervention:Surgical resection was performed following the diagnosis of primary gallbladder sarcoma with local hepatic metastasis. Histological examination confirmed a diagnosis of primary spindle cell sarcoma and hepatic metastasis with simultaneous cholecystolithiasis.Outcomes:Adjuvant chemoradiation therapy was not performed because the patient refused treatment. Three months after the surgery, a relapsed lesion was diagnosed. The patient underwent transcatheter arterial chemoembolization.Conclusions:The disease should be differentially diagnosed from gallbladder carcinoma or carcinosarcoma with hepatic metastasis. An aggressive surgical approach should be based on a balance between the risk of surgery and the outcome.     

胆囊囊肿合并潴留性肝囊肿1例报告并文献复习

临床中胆囊囊肿很罕见,大部分为后天性囊肿,极少数为先天性。患者可表现为消化不良、腹痛、黄疸,也可无明显症状。而胆囊囊肿合并潴留性肝囊肿国内外期刊尚无报道。现将北京医院收治的1例胆囊囊肿合并潴留性肝囊肿患者报告如下,并进行回顾性文献复习。     

Xanthogranulomatous cholecystitis: report of a case and literature review on clinical differentiating factors from gallbladder carcinoma

Xanthogranulomatous cholecystitis (XGC) is a rare, benign, destructive inflammatory disease of the gallbladder that is assumed to be a variant of chronic cholecystitis. We herein present a rare case of XGC, which simulates gallbladder carcinoma with extensive involvement of the liver, omentum and the biliary trees. At surgery, total cholecystectomy with partial hepatectomy of the gallbladder bed and excision of adjacent xanthogranulomatous tissue was performed, but bilio‐enteric anastomosis for biliary decompression, which was the procedure preoperatively planned, was impossible to indicate because the common bile duct could not be clearly exposed by its infiltration showing mass formation. Therefore, retrograde transhepatic biliary drainage was eventually indicated for subsequent endoscopic therapy using stent placement to deal with the biliary structure caused by XGC. The patient has been leading a normal life after stent placement in the biliary tract for 6 months duration without any symptoms suggesting biliary stricture. In conclusion, XGC can simulate gallbladder cancer in its clinical presentation, radiological findings and even gross operative features. It is important to make preoperative ultrasound‐guided fine‐needle aspiration cytological diagnosis or intraoperative pathological diagnosis in order to avoid misdiagnosis and unnecessary therapy. Cholecystectomy, excision of adjacent xanthogranulomatous tissue, which often includes partial hepatic resection, are still the best management of XGC.     

Advanced gallbladder cancer accompanied with cancer-associated dermatomyositis: A case report and literature review

Rationale:Muscle weakness due to cancer-associated dermatomyositis (CADM) can be misdiagnosed as cancer cachexia and disuse atrophy.Patient concerns:A 75-year-old female was admitted to our institute with muscle weakness, dysphagia, and suspected gallbladder cancer. Computed tomography and cytopathological examinations of the liver biopsy and fine-needle aspiration from swollen lymph nodes using endoscopic ultrasonography revealed cancer in the gallbladder body and metastasis to the lymph nodes around the abdominal aorta. We avoided the administration of anticancer drugs due to her poor general condition.Diagnosis:Subsequently, we diagnosed her with muscle weakness and dysphagia as a result of CADM using species from muscle and skin biopsy.Interventions and Outcomes:Prednisolone therapy and anticancer agents partially improved the patient symptoms.Lessons:CADM is reported to be associated with a high incidence of dysphagia, which may aid in the diagnosis of this disease.     

Breast carcinoma with metastasis to the gallbladder:an unusual case report with a short review of literature

Gallbladder metastases are very rare and usually arise from malignant melanoma, renal cell carcinoma and cervical carcinoma. Breast carcinoma tnetastatic to the gallbladder is extremely rare and only 4 cases have been reported in the English literature. We hereby report a 54-year-old lady who was diagnosed as having breast carcinoma and underwent modified radical mastectomy. One month after the operation, she developed acute abdomenal pain and underwent cholecystectomy after clinical investigation. Histopathological examination revealed metastasis to the gallbladder. Being considered a patient with tnetastatic breast carcinoma she was subjected to taxane and anthracycline-based palliative chemotherapy. Later she had CNS involvement and died of the progressive disease soon after few months.     

Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method

Background—Magneticresonance cholangiography (MRC) is a new technique for non-invasiveimaging of the biliary tract.
Aim—To assess theresults of MRC in patients with suspected bile duct stones as comparedwith those obtained with reference imaging methods.
Patients/Methods—70patients (34 men and 36 women, mean (SD) age 71 (15.5) years; median75) with suspected bile duct stones were included (cholangitis, 33;pancreatitis, three; suspected post-cholecystectomycholedocholithiasis, nine; cholestasis, six; stones suspected onultrasound or computed tomography scan, 19). MR cholangiograms with twodimensional turbo spin echo sequences were acquired. Endoscopicretrograde cholangiography with or without sphincterotomy (n = 63),endosonography (n = 5), or intraoperative cho- langiography (n = 2)were the reference imaging techniques used for the study and wereperformed within 12 hours of MRC. Radiologists were blinded to theresults of endoscopic retrograde cholangiography and previous investigations.
Results—49patients (70%) had bile duct stones on reference imaging (common bileduct, 44, six of which impacted in the papilla; intrahepatic, four;cystic duct stump, one). Stone size ranged from 1 to 20 mm (mean 6.1, median 5.5). Twenty seven patients (55%) had bile duct stones smallerthan 6 mm. MRC diagnostic accuracy for bile duct lithiasis was:sensitivity, 57.1%; specificity, 100%; positive predictive value,100%; negative predictive value, 50%.
Conclusions—Stonessmaller than 6 mm are still often missed by MRC when standard equipmentis used. The general introduction of new technical improvements isneeded before this method can be considered reliable for the diagnosisof bile duct stones.

Keywords:bile duct calculi; endoscopic retrogradecholangiography; magnetic resonance cholangiography

     

Gallbladder lymphangioma: a case report and review of the literature

Lymphangiomas are benign neoplasms usually occurring in childhood and located in the head and neck. Intraabdominal lymphangiomas account for less than 5% of cases. The involvement of the gallbladder is rare. We report a case of a 29-year-old woman who presented with right upper quadrant pain that had persisted for 6 months. Imaging with ultrasound and magnetic resonance imaging (MRI) revealed a multiseptated lesion surrounding the gallbladder. The patient underwent an exploratory laporatomy, and the mass was resected en bloc with the gallbladder. Histological evaluation of the cystic mass revealed findings consistent with lymphangioma. The prognosis is generally good after complete surgical excision, as was the case for our patient.     

Diagnostic yield of endoscopic retrograde cholangiography and of EUS-guided fine needle aspiration sampling in gallbladder carcinomas

Background

Obtaining histological evidence of gallbladder carcinoma (GBC) is difficult due to its extraductal nature, and pathological confirmation remains challenging. We compared the diagnostic value and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with endoscopic retrograde cholangiography (ERC) in patients with suspected GBC.

Patients

Eighty-three patients with GBC were evaluated. Prior to definitive management, pathological evidence of GBC was obtained through either ERC cytopathologic sampling (n?=?33), EUS-FNA (n?=?24) or both (n?=?26).

Results

Among the 83 patients, 59 (71.0%) with biliary obstruction were sampled using ERC with 47.4% (28/59) sensitivity. In 19 of the remaining 31 cases, EUS-FNA sampling had 100% diagnostic sensitivity. Likewise, 50 (60.2%) of the 83 patients with suspected GBC underwent EUS-FNA of regional lymph nodes or the gallbladder (GB) mass itself with 94.8% sensitivity. The overall diagnostic sensitivity rates of ERC and EUS-FNA were 47.4 and 96%, respectively (P?<?0.001). Post-procedural complications were seen in 6.7% of the ERC group (4/59, all were mild pancreatitis), and in none of the EUS-FNA group (P?=?0.10).

Conclusions

Gallbladder carcinoma sampling using ERC and EUS-FNA should be incorporated into the diagnostic workup of GB lesions as complementary tools, and EUS-FNA should be applied in the setting of failed or not indicated ERC.     

全内脏反位胆总管结石行经内镜逆行胰胆管造影取石治疗1例报告并文献复习

1病例资料 患者男性,35岁,因＂左上腹部持续性疼痛2 d＂于2012年9月19日入本院。疼痛开始为阵发性绞痛,入院前1天成持续性疼痛,伴有恶心、呕吐。查体：巩膜黄染,左上腹部压痛（＋＋）,反跳痛（＋）,墨菲征（-）,血清脂肪酶907 U/L。入院前上腹部CT示：急性胰腺炎,右位心,内脏反位。     

Right hepatic artery syndrome: report of three cases and literature review

Anatomical variations of the hepatic artery have been described as responsible for the onset of jaundice or stone formation. We present three cases of intrahepatic stones secondary to a compression of the proximal common bile duct (CBD) by the right hepatic artery (RHA). Three consecutive patients (males, mean age 65 years) with symptoms of cholangitis and intra-hepatic stones admitted between October 2017 and June 2018 with a final diagnosis of CBD compression from the RHA. The three patients underwent ERCP and biliary sphincterotomy with extraction of intra-hepatic stones; after stone removal cholangiograhy showed CBD compression just below the main hepatic confluence which was confirmed to be secondary to RHA compression on subsequent MRI. The patients remained asymptomatic after 12 months mean follow-up. Compression of the CBD by the RHA might be responsible for intra-hepatic stone formation. Endoscopic treatment is feasible and effective on short-term follow-up.     

Impact of the operator's experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: A prospective comparison using endoscopic retrograde cholangiography as the gold standard

Objective. Transabdominal ultrasound (US) is the most frequently used imaging method for the diagnosis of choledocholithiasis. The aim of this prospective study was to evaluate the diagnostic accuracy of high-resolution US in the diagnosis of common bile duct stones depending on the operator's experience and in comparison with endoscopic retrograde cholangiography (ERC) as the gold standard. Material and methods. From April 2003 through November 2004, 126 patients referred because of clinically and biochemically suspected common bile duct stones were included in the study. Two patients were excluded because they refused to undergo ERC. Consequently, the study comprised 124 patients (86 F, 38 M, mean age 63.2 years, range 21–91 years). High-resolution US was performed (2–5 MHz sector scanner; Siemens Elegra, Erlangen, Germany) by operators who were unaware of the results of other imaging procedures. The definitive diagnosis was established by means of ERC. Results. Thirty-five out of 124 patients were investigated by experienced examiners. Twenty-seven of 35 patients (77%) were found to have stones at ERC. Bile duct stones were correctly found by US in 22 out of 27 patients (sensitivity 82%, 95% CI: 63–92). Of the 8 patients without stones at ERC, one false-positive diagnosis was made with US (specificity 88%, 95% CI: 53–98). Correct diagnoses were made in 29 out of 35 (accuracy 83%, 95% CI: 67–92) patients investigated by experienced examiners. Eighty-nine out of 124 patients were investigated by less-experienced examiners. Fifty-four of 89 patients (61%) were found to have stones at ERC. Choledocholithiasis was found correctly in only 25 out of 54 patients (sensitivity 46%, 95% CI: 34–59). Of the 35 patients without stones at ERC, three false-positive diagnoses were made with US (specificity 91%, 95% CI: 78–97). In conclusion, correct diagnoses were observed in 57 of 89 patients (accuracy 64%, 95% CI: 54–73) investigated by less-experienced examiners (p<0.05 in comparison with the results of experienced examiners). Conclusions. High-resolution US carried out by experienced examiners has a high diagnostic accuracy in the diagnosis of choledocholithiasis. Therefore, good training and continued experience are prerequisites for successful sonographic detection of bile duct stones using US. Under these conditions, further expensive and invasive methods such as ERC, magnetic resonance cholangiopancreatography and endoscopic ultrasonography may not be necessary in cases with a clear sonographic diagnosis.