Insufficient cholecystectomy diagnosed by endoscopic ultrasonography

Recurrent attacks of upper right quadrant pain after cholecystectomy are not infrequent. In most of these cases, the cause of the pain remains undiagnosed. Insufficient cholecystectomy has been described as a rare cause of post-cholecystectomy pain, although the true incidence is unknown. It is difficult to diagnose a residual gallbladder or a large cystic duct with residual stones, due to the size of the remaining structures. This report presents three patients who had experienced a long period of agonizing biliary-type pain after cholecystectomy. Abdominal ultrasound examinations, and magnetic resonance cholangiopancreatography (MRCP) in one patient, were normal. Endoscopic ultrasonography (EUS) demonstrated the presence of a small cystic structure with echogenic foci compatible with a residual gallbladder containing small gallstones. Two of the three diagnoses were confirmed by repeat surgery. EUS thus appears to be a valuable method for diagnosing insufficient cholecystectomy, and should be considered in patients with persistent pain attacks after cholecystectomy.     

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.     

Chronic acalculous gallbladder disease: a clinical variant

A review of 228 cholecystectomies done over a two-year period revealed 15 cases (6.6%) in which gallstones were absent. These 15 patients were all characterized by colicky abdominal pain in the right upper quadrant, with a mean duration of eight months. Ultrasonographic examination was falsely positive for gallstones in one third (5/15) of the patients, and further diagnostic evaluation in the remaining two thirds (10/15) failed to define a clear-cut surgical problem. All 15 patients ultimately had operation on the basis of symptoms. Every patient reported resolution of preoperative symptoms at short-term follow-up (four to eight weeks). Seven patients available for long-term follow-up (ten to 27 months) reported complete symptomatic resolution. The postoperative outcome failed to correlate reliably with gallbladder histology, bile cultures, and results of diagnostic testing. There was no mortality, and morbidity was limited to three patients. This series confirms previous reports of a small set of relatively young, healthy patients having chronic disabling symptoms of gallbladder disease in the absence of gallstones. Our results suggest that the most reliable factor predicting a successful outcome of cholecystectomy in these patients was the presence of severe biliary colic.     

Carcinoid tumor mistaken for persistent neurogenic bowel symptoms in a patient with paraplegia: a case report.

Neurogenic bowel in spinal cord injury (SCI) can present with constipation and diarrhea as ongoing problems. Usually, these manifestations are adequately controlled with modification in the bowel program. When these symptoms persist, other causes should be considered. This case report describes a jejunal carcinoid tumor with colonic extension that was diagnosed in a paraplegic patient with persistent constipation and diarrhea. A 39-year-old man sustained a T1 paraplegia with neurogenic bowel and bladder dysfunction from a gunshot wound. His bowels were initially managed adequately with digital disimpaction. Over the next 8 years, he had intermittent constipation that was managed with the addition of various suppositories. He then developed progressively worsening constipation, and other gastrointestinal (GI) symptoms. Although his symptoms initially resolved with medical management, the constipation worsened. Upper endoscopy revealed a submucosal bulge in the duodenal bulb. A month later, gallstones were found on renal ultrasound performed to evaluate recurrent urinary tract infections. He underwent cholecystectomy, but his GI symptoms persisted over the next several months. Repeat upper endoscopy subsequently revealed an ulcerated tumor at the duodenojejunal flexure. An upper-GI scan with small bowel follow through showed a proximal jejunal mass. The patient underwent laparotomy with resection of the mass. Final pathologic diagnosis was malignant carcinoid tumor. This case shows the importance of entertaining other clinical entities in patients with SCI when constipation and diarrhea persist despite adequate management.     

Paraganglioma of the bile duct

We report the case of a 28-year-old woman with a 3-month history of right upper quadrant abdominal pain. Medical history and physical examination were unremarkable. Abdominal ultrasonography showed a dilated gallbladder, suggestive of gallstones, without bile duct dilatation. Serum chemistry values were normal. Laparoscopic cholecystectomy was planned, and a mass encircling the common bile duct was found. The procedure was converted to an open operation, and cholecystectomy, mass excision, and hepaticojejunostomy were done. The specimen was interpreted as paraganglioma of the bile duct. There were no manifestations of catecholamine hypersecretion or signs of biliary obstruction. Six years later, the patient is asymptomatic without signs of recurrence. This is the third report of paraganglioma of the hepatic ducts. We describe the clinical and pathologic findings and therapeutic approach in this unusual case and review the literature.     

Management of gallstones

Many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones (e.g., steady, nonparoxysmal pain lasting four to six hours located in the upper abdomen) or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones. Medical management strategies are mostly palliative and are not widely supported. Patients with longer-lasting biliary pain, in combination with abdominal tenderness, fever, and/or leukocytosis, require an ultrasound evaluation to help establish a diagnosis of acute cholecystitis. Once a patient is diagnosed, having cholecystectomy early in the course of the disease can significantly reduce the hospital stay.     

Common bile duct distensibility after cholecystectomy

To assess the possibility of common bile duct distensibility after cholecystectomy, we made a retrospective study of patients who had ultrasonography and endoscopic retrograde cholangiopancreatography (ERCP). The study comprised 52 patients without extrahepatic biliary obstruction; 19 had had cholecystectomy, 18 of whom complained of biliary colic similar to that they had had originally. The other 33 patients had intact, well visualized gallbladders; 15 of these patients had pain in the right upper quadrant or epigastrium, but none had chronic pancreatitis. The average diameter of the common bile duct at its widest point by ultrasonography was 4.8 mm (range, 4.0 to 9.0 mm) in the 33 patients with intact gallbladders, and 5.7 mm (range, 4.0 to 8.0 mm) in the 19 patients who had had cholecystectomy. The diameter by ERCP was 4.4 mm (range, 2.9 to 6.3 mm) in the patients with intact gallbladders, and 11.17 mm (range, 6.9 to 14.7 mm) in the patients who had had cholecystectomy. In each patient who had had cholecystectomy the diameter as measured by ERCP was larger than it appeared by ultrasonography. The results suggest that the common bile duct is distensible, and that this distensibility may be related to the postcholecystectomy syndrome.     

Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury.

The objectives of this study were to define where fluid accumulation is shown on screening ultrasonography after blunt abdominal trauma and to determine how fluid accumulation patterns are associated with the site of injury. From 1994 to 1998, 2,693 screening examinations for blunt abdominal trauma were performed, in which 7 regions were examined for fluid. On the basis of a preliminary analysis of patients with solitary injuries, all 194 patients with sonographically detected fluid were grouped by fluid accumulation pattern. Fluid patterns were compared with sites of injury. The patterns differed between hepatic and splenic injuries. Fluid in the left upper quadrant, in both upper quadrants, or diffusely distributed suggested splenic injury, whereas fluid in the right upper quadrant or the right upper quadrant and lower recesses suggested hepatic injury (P < .0001). Fluid accumulation was random after enteric injury. Patients with extraperitoneal injury had no fluid or had fluid focally at the injury site. The ability to predict the injury site on the basis of fluid patterns should expedite treatment of hemodynamically unstable patients with blunt abdominal trauma.     

Prevalence of and risk factors for gallstones in female population of Novosibirsk

AIM: To investigate the prevalence of gallstones and associated factors in female population of Novosibirsk (Western Siberia). MATERIALS AND METHODS: A representative sample of 870 women aged 25-64 years was drawn from general population according to WHO "MONICA" protocol. The subjects were screened for the presence of gallstones by gallbladder ultrasonography, completed a questionnaire relating to food and alcohol consumption, smoking, gastrointestinal symptoms and obstetric history. They also underwent physical examination and blood chemistry tests. Age-adjusted prevalence of cholelithiasis was 9.5%. Increasing age, obesity, diabetes mellitus, consumption of animal fat, pregnancies and opisthorchiasis positively correlated with gallstones in univariate analysis. Serum lipids, family history of gallstones, consumption of alcohol and tobacco were not predictors of gallstones. Only association with age and obesity was significant in multivariate analysis. Among subjects with cholelithiasis 52.1% were not aware of having gallstones. Subjects with gallstones more frequently suffered from biliary colics and non-specific dyspeptic symptoms. However, their predictive value was poor. Cholecystectomized patients revealed more often upper abdominal pain and dyspeptic symptoms. CONCLUSION: Prevalence and risk factors for gallstones in female population of Novosibirsk are similar to those reported in Western European countries. Cholecystectomy is not recommended in patients with symptomless disease.     

Pancreatitis-associated fluid collections involving the spleen: Sonographic and computed tomographic appearance

The clinical and radiographic features of 2 patients with dissecting pancreatitis-associated fluid collections involving the spleen are described. A typical appearance of left upper quadrant fluid collection lateral to the splenic pulp was observed by ultrasonography (US) or computed body tomography (CBT). Although these findings are nonspecific, a left upper quadrant fluid collection may be characterized definitively by US/CBT-guided needle aspiration.     

ED ultrasound in hepatobiliary disease

To evaluate the diagnostic accuracy of gallbladder ultrasound performed by emergency physicians (EPUS) in patients with right upper quadrant (RUQ) and epigastric (EPI) pain, adults>18 years of age with RUQ or EPI pain were prospectively evaluated by physical examination, laboratory data, and EPUS followed by a blinded radiology department ultrasound (RADUS). Diagnostic categories included: "normal gallbladder"; "uncomplicated symptomatic cholelithiasis" (uncomplicated SCL; stones present but symptoms and signs relieved and no abnormal blood-work); or "complicated symptomatic cholelithiasis" (CSCL; stones and positive symptoms and signs including abnormal blood-work). Final Emergency Department patient assessments based on the RADUS were compared to the EPUS. Over 2-years, 127 patients were enrolled. The sensitivity of the EPUS for detecting stones was 94% (positive predictive value 99%; specificity 96%; negative predictive value 73%). In conclusion, the EPUS is a highly sensitive and reliable indicator of the presence of gallstones.     

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.     

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.     

胆囊结石行胆囊切除术的远期疗效观察

目的：评估胆囊结石行胆囊切除术的远期疗效。方法：回顾性分析本院1980年1月－1989年12月间540例单纯胆囊切除术的资料，并作随访。男148例，女392例，平均年龄50．2岁，其中60岁以上者128例（19．8）。结果：在527例术前有症状者中，术后症状完全消失者448例（85．0％），明显改善者72例（13．7％），仍有隐痛不适、饱胀者7例（1．3％）。术后2－17年发现胆道结石13例（2．4％），肝外胆管炎性狭窄1例。结直肠癌12例（2．2％）。切口疝8例（1．5％）。结论：从远期疗效看，胆囊切除术仍然是目前治疗胆囊结石的有效方法。胆囊切除术后大肠癌的发生率似有增加，应引起重视。     

Choledochal cyst complicating pregnancy: Antepartum diagnosis with MRI

Choledochal cyst presenting during pregnancy is a rare condition, associated with potentially life-threatening complications for both the mother and developing fetus. Clinical symptoms are nonspecific, and radiographic evaluation is complicated by the presence of the gravid uterus. The authors describe a 34-year-old pregnant female presenting in the third trimester with obstructive jaundice and a right upper quadrant mass. Multiplanar and multisequence imaging with MR established the antepartum diagnosis of choledochal cyst, avoiding the use of ionizing radiation during pregnancy.     

Efficacy of plain abdominal radiography in patients with biliary tract disease

A retrospective review was performed to determine the usefulness of plain abdominal radiographs in patients presenting to the emergency department with gallbladder disease. Patients with the clinical diagnosis of biliary tract disease were divided into two groups: those with confirmed biliary tract disease and those who did not have gall bladder disease. There were no major radiologic findings (pneumoperitoneum, pneumobilia, or bowel obstruction) in any patient with biliary tract disease. No significant difference was noted in the incidence of minor radiologic findings (right upper quadrant calcification, mild ileus and right basilar atelectasis) in patients with biliary colic and acute cholecystitis. Additionally, there was no significant difference in minor findings between patients with biliary tract and nonbiliary tract disease. Plain abdominal radiographic findings were found to be nonspecific in patients with gallbladder disease and not useful in differentiating between patients with biliary colic and acute cholecystitis. Our results also suggest that plain abdominal radiographic findings are not useful in differentiating between patients with and without biliary tract disease, although the selection of patients without biliary tract disease may have biased this finding.     

The interrater variation of ED abdominal examination findings in patients with acute abdominal pain

OBJECTIVE: The physical examination of the abdomen is crucial to emergency department (ED) management of patients with abdominal pain. We sought to determine the interrater variation between attending and resident physicians in detecting abdominal exam findings. METHODS: Research enrollers surveyed attending and resident physicians on abdominal exam findings in the ED in patients with abdominal pain. Strength of agreement was calculated using the kappa statistic. RESULTS: A convenience sample of 122 surveys was completed. Calculated kappa results are in parentheses. There was almost perfect agreement on the presence of masses and substantial agreement on the need for imaging studies. There was moderate agreement on guarding, distension, tenderness, and need for laboratory tests and surgical consultation. For 88 (72%) patients with tenderness, substantial agreement was calculated for epigastric tenderness, moderate agreement on right upper quadrant, supraumbilical, suprapubic, left lower quadrant, right lower quadrant tenderness, and fair agreement on left upper quadrant tenderness. Sixty-one (50%) patients received pain medicine in the ED. Among those, there was fair agreement on a presence of a surgical abdomen. Upper level resident physicians noted a higher level of agreement with the attending physician for tenderness than junior resident physicians. CONCLUSIONS: There was moderate agreement between resident and attending physicians for most of the findings in patients with abdominal pain. Recognition that selected findings are more variable than others should encourage careful confirmation of resident physicians' assessments in teaching settings.     

An unusual presentation of inflammatory bowel disease

A 32 year-old male presented to his general practitioner for a routine health check. Microscopic haematuria was noted in an otherwise asymptomatic and fit patient. Subsequent investigation was normal apart from abnormal liver function tests for which no cause was found. A cholecystectomy was performed for gallstones which were detected by ultrasound after the patient complained of upper right quadrant pain. Wedge biopsy of the liver at operation was suggestive of cholangitis. A barium enema was performed which revealed ulceration of the transverse colon suggestive of Crohn's disease. The association of cholangitis and inflammatory bowel disease is discussed.     

Endoscopic sonography in the diagnosis of gallbladder wall lesions in patients with gallstones

PURPOSE: The purpose of this study was to evaluate the diagnostic accuracy of endoscopic sonography (EUS) in the detection of gallbladder wall lesions in patients with and without gallstones. METHODS: We retrospectively reviewed the medical records, sonograms, and sonographic reports of 62 patients who underwent cholecystectomy for gallbladder wall lesions evaluated by EUS. We assessed the accuracy of EUS in diagnosing gallbladder wall lesions in the presence or absence of gallstones and on the basis of the size and number of stones and the size of the gallbladder wall lesions. We also evaluated the effect of acoustic shadowing. The EUS results were compared with the histopathologic results. RESULTS: EUS correctly diagnosed the gallbladder wall lesions in 17 (71%) of 24 patients with gallstones and in 34 (89%) of 38 patients without gallstones. The diagnostic accuracy of EUS was 86% in patients with gallbladder wall lesions smaller than 20 mm and 79% in patients with gallbladder wall lesions 20 mm or larger. The diagnostic accuracy was 75% in patients with gallstones smaller than 5 mm and 67% in patients with stones 5 mm or larger. The accuracy was 67% in patients with 1-5 stones and 83% in patients with 6 or more stones. None of these differences was statistically significant. Acoustic shadowing did not affect the diagnostic accuracy of EUS. CONCLUSIONS: The diagnostic accuracy of EUS for gallbladder wall lesions is not affected by the presence of gallstones. However, better diagnostic criteria must be established based on larger studies, and technical refinements of the equipment are needed to increase the accuracy of EUS in the diagnosis of gallbladder wall lesions.