Relationship between cystic duct diameter and the presence of cholelithiasis

We sought to measure cystic duct diameter in patients without biliary calculi and in those with cholelithiasis or choledocholithiasis. Using endoscopic retrograde cholangiopancreatography (ERCP), we visualized the cystic duct in 168 patients referred to our unit. These patients were distributed into three groups based on findings at ERCP: Group I (N=57), no calculi in the gallbladder or common bile duct; group II (N=27), stones found in the gallbladder but absent from the common bile duct; and group III (N=34), stones present in the common bile duct with or without gallbladder stones. The diameter of the cystic duct was measured at its widest and narrowest dimensions. The largest diameter measured was greater in group III (7.72±2.29 mm) than in groups I (2.63±0.67 mm) and II (4.59±1.13 mm) (P<0.001). The same differences were found in measurement of the smallest diameter (5.00±0.99 mm, 3.10±0.62 mm, and 1.83±0.53 mm, for groups III, II, and I, respectively) (P<0.001). Maximal and minimal cystic duct diameter show a progressive increase at each level of disease. This increase in cystic duct size may facilitate the migration of gallstone fragments after lithotripsy and facilitate the instrumentation of the cystic duct during ERCP and laparoscopic cholecystectomy.     

Jaundice and enlargement of the gallbladder: A diagnostic problem

Summary Jaundice and a palpable gallbladder occurred in 2 patients in the absence of common bile duct occlusion. In both, the jaundice resulted from hepatic parenchymal disease. Obvious obstruction of the cystic duct by a gallstone accounted for the cholecystomegaly in one case; in the other, obstruction of the cystic duct was attributed to impingement by a metastasis.Courvoisier's Law pertains strictly to the differential diagnosis of common bile duct obstruction, and not to cases such as these. Other uncommon causes of icterus and enlargement of the gallbladder are enumerated.Herman Glantzberg, M.D., translated appropriate portions of the work of Courvoisier.     

Endoscopic diagnosis and treatment of Mirizzi's syndrome.

Mirizzi's syndrome is the name given to common bile duct obstruction secondary to a stone in the cystic duct. The cause of the biliary obstruction is often difficult to establish before operation. We report two cases of Mirizzi's syndrome, diagnosed endoscopically and treated without surgery. One of the patients was treated by drainage of both the common bile duct and the gallbladder associated with monooctanoin dissolution of the gallstone. The other was treated by common bile duct stenting.     

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.     

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.     

An alternative surgical approach to a difficult case of Mirizzi syndrome： A case report and review of the literature

INTRODUCTION Mirizzi syndrome (MS) is a rare complication of long- standing cholelithiasis, which results from impaction of a large calculus or multiple small stones in the cystic duct or in the neck of the gallbladder causing extrinsic narrowing of the c…     

Selective cannulation of the cystic duct at time of ERCP

Although the cystic duct can sometimes be cannulated at ERCP, no one has attempted a prospective study of how often this can be done, nor have the potential indications been evaluated. Accordingly, 50 consecutive patients with a variety of pancreaticobiliary conditions were studied prospectively. In 86% of the patients, free cannulation of the common bile duct was accomplished; in 74%, the cannula could be inserted selectively into the cystic duct. Such direct access to the gallbladder may lead to: 1) better gallbladder visualization at time of ERCP, 2) retrieval of pure gallbladder bile for culture and sensitivity on chemical analysis, and 3) gallstone dissolution or extraction.     

Mirizzi Syndrome without Cholecystolithiasis

BACKGROUND: Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis. CASE REPORT: A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice. CONCLUSION: In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.     

Mirizzi syndrome in an anomalous cystic duct： A case report

Mirizzi syndrome is a rare complication of gallstone disease, and results in partial obstruction of the common bile duct or a cholecystobiliary fistula. Moreover, congenital anatomical variants of the cystic duct are common, occurring in 18%-23% of cases, but Mirizzi syndrome underlying an anomalous cystic duct is an important clinical consideration. Here, we present an unusual case of type Ⅰ Mirizzi syndrome with an uncommon anomalous cystic duct, namely, a low lateral insertion of the cystic duct with a common sheath of cystic duct and common bile duct.     

In vitro dissolution of cholesterol gallstones. A study of factors influencing rate and a comparison of solvents

Models of the common bile duct and gallbladder were constructed to study conditions that affect the rate of cholesterol gallstone dissolution by monooctanoin and other potential solvents. In the bile duct model, the rate of monooctanoin infusion was not an important factor in accelerating dissolution time. In contrast, the exclusion of bile from interfering with solvent-stone contact or the enhancement of solvent-stone contact by stirring significantly accelerated stone dissolution. The combination of both bile exclusion and stirring increased the dissolution rate of gallstones by monooctanoin 15-fold. When compared with two other ethers and with monooctanoin, methyl tert-butyl ether was found to be the most potent gallstone solvent. Methyl tert-butyl ether completely dissolved 219-mg cholesterol stones within 60 min. In the gallbladder model, in the absence of stirring both methyl tert-butyl ether and monooctanoin floated on bile, whereas the gallstones sank resulting in minimal stone-solvent contact. To increase the stone-solvent contact, we used a pump to create sufficient turbulence to mix the solvent with bile. Pump stirring of monooctanoin in the presence of bile achieved rates of stone dissolution approaching that of stirred monooctanoin without bile. Stirring of methyl tert-butyl ether and bile, however, did not achieve sufficient solvent-stone contact to appreciably accelerate dissolution in the presence of 50% bile. Stone-solvent contact was a critical factor in determining the rate of gallstone dissolution in both gallbladder and common bile duct models. Efforts to enhance contact include bile exclusion and intraluminal stirring--both of which are clinically applicable. Methyl tert-butyl ether is a potent new cholesterol gallstone solvent with excellent potential for use in humans. Even with this potent agent, however, rapid gallstone dissolution is likely to require removal of most of the bile from the dissolution medium.     

Surgical anatomy of innervation of the gallbladder in humans and Suncus murinus with special reference to morphological understanding of gallstone formation after gastrectomy

AIM： To clarify the innervation of human gallbladder,with special reference to morphological understanding of gallstone formation after gastrectomy.
METHODS： The liver, gallbladder and surrounding structures were immersed in a 10 mg/L solution of alizarin red S in ethanol to stain the peripheral nerves in cadavers （n = 10）. Innervation in the areas was completely dissected under a binocular microscope. Similarly,innervation in the same areas of 10 Suncus murinus （S. murinus） was examined employing whole mount immunohistochemistry.
RESULTS： Innervation of the gallbladder occurred predominantly through two routes. One was from the anterior hepatic plexus, the innervation occurred along the cystic arteries and duct. Invariably this route passed through the hepatoduodenal ligament. The other route was from the posterior hepatic plexus, the innervation occurred along the cystic duct ventrally. This route also passed through the hepatoduodenal ligament dorsally.Similar results were obtained in S. murinus.
CONCLUSION： The route from the anterior hepatic plexus via the cystic artery and/or duct is crucial for preserving gallbladder innervation. Lymph node dissection specifically in the hepatoduodenal ligament may affect the incidence of gallstones after gastrectomy.Furthermore, the route from the posterior hepatic plexus via the common bile duct and the cystic duct to the gallbladder should not be disregarded. Preservation of the plexus may attenuate the incidence of gallstone formation after gastrectomy.     

Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic)

Gallstones are common in Western countries and Japan. Most gallstones are found in the gallbladder, but they sometimes pass through the cystic duct into extrahepatic and/or intrahepatic bile ducts to become bile-duct stones, causing conditions known as choledocholithiasis and hepatolithiasis. Some 10-15% of gallstone patients concomitantly suffer from bile-duct stones. Bile-duct stones can also be formed in the absence of gallbladder stones, and such primary bile-duct stones are more common in East Asian countries than in the Western world. Thus pathogenesis of primary and secondary bile-duct stones is unlikely to be similar. Furthermore, the gallbladder stones are primarily cholesterol or black-pigment stones, whereas most bile-duct stones are brown-pigment stones (calcium bilirubin stones). Thus, epidemiology, pathogenesis and classification of biliary stones are very likely to differ according to stone location (intrahepatic and/or extrahepatic bile duct).     

Tape ligature of cystic duct and fundus-down approach for safety laparoscopic cholecystectomy: outcome of 500 patients

It is important to identify the structure of Calot's triangle at the time of cystic duct isolation to decrease intraoperative bile duct injury. Isolation of the cystic duct is the first dangerous technique in laparoscopic cholecystectomy. In conventional open cholecystectomy, the fundus-down approach (retrograde) is a more common procedure than the approach in the reverse direction. Similarly, the fundus-down approach is safe and has benefits of reducing common bile duct injury. We report the easy and safe contrivance for laparoscopic cholecystectomy with taping of the cystic duct followed by resection of the gallbladder with the fundus-down approach, performed for 500 patients. The identified cystic duct was ligatured temporarily with Teflon tape. Then, fundus of the gallbladder was isolated with the fundus-down approach except for Calot's triangle. The tape was used for pulling down the cystic duct and Calot's triangle was easily visible. The cystic duct was cut off only after the confirmation of no bile duct injury. Thanks to this tape procedure, there was no bile duct injury in our 500 cases. We recommend this tape ligature of the cystic duct with the fundus-down approach to decrease the incidence of common bile duct injury.     

Anomalous pancreaticobiliary ductal junction without bile duct dilatation in gallbladder cancer

BACKGROUND/AIMS: Anomalous pancreaticobiliary junction is a rare anomaly but is a risk factor for primary carcinoma of the gallbladder. To define the relationship between anomalous pancreaticobiliary junction, especially if it is not associated with common bile duct dilatation, and gallbladder carcinoma, we retrospectively reviewed data of 126 patients with gallbladder carcinoma. METHODOLOGY: All these patients had undergone direct cholangiography either by endoscopic retrograde cholangiopancreaticography or percutaneous transhepatic cholangiography. RESULTS: Among 126 patients with gallbladder cancer, 23 patients (18.3%) exhibited anomalous pancreaticobiliary junction. Patients with anomalous pancreaticobiliary junction were younger (mean age: 54 +/- 9.1 years) than patients without anomalous pancreaticobiliary junction (mean age: 65 +/- 9.7 years). The incidence of gallstones in patients with anomalous pancreaticobiliary junction (17%) was significantly lower than in those without this anomaly (64%) (P < 0.01). Among the 23 patients with anomalous pancreaticobiliary junction, 12 patients (52%) had no bile duct dilatation and, 11 patients (48%) had bile duct dilatation in the form of fusiform or cylindrical dilatation. However, no cases with severe cystic dilatation were found. Patients of anomalous pancreaticobiliary junction without common bile duct dilatation had more advanced disease and poor prognosis than those with common bile duct dilatation. CONCLUSIONS: The present study revealed that gallbladder cancer in the patients of anomalous pancreaticobiliary junction without common bile duct dilatation was diagnosed at advanced stage and the prognosis was very poor. Therefore, if a minor abnormality is detected in the wall of acalculous gallbladder on ultrasonography, direct cholangiography should be done to exclude this anomaly.     

Mirizzi syndrome: evaluation by MR imaging

We report three cases of Mirizzi syndrome diagnosed by MR imaging. MR cholangiography revealed dilation of the intrahepatic bile ducts, narrowing of the common hepatic duct, the level of obstruction, and the location of gallstone in the cystic duct. MR showed thickening of the gallbladder wall and the pattern of wall enhancement. MR evaluation with MR cholangiography sequences proved to be useful in these patients with Mirizzi syndrome.     

Gallbladder motility and lithogenicity of bile in patients with choledocholithiasis after endoscopic sphincterotomy

Background/Aims: Ablation of the sphincter of Oddi has been shown to inhibit gallstone formation in the prairie dog model, probably by allevaiting gallbladder bile stasis. The effect of endoscopic sphincterotomy (ES) on gallbladder emptying and lithogenicity of bile has not been studied adequately in humans. We, therefore, studied the changes in gallbladder emptying and lithogenicity of bile following ES in patients with choledocholithiasis and gallbladder in situ.Methods: Thirteen patients with choledocholithiasis with intact gallbladder underwent ES and common bile duct clearance. Eight patients had concomitant gallstones. Gallbladder emptying was studied by real time ultrasonography after stimulation by ceruletid infusion. Fasting gallbladder bile was collected during endoscopic retrograde cholangiography by placing a 7F or 8F catheter in the common bile duct and after ceruletid stimulation of gallbladder for bile microscopy and cholesterol nucleation time determination. Gallbladder emptying, nucleation time and bile microscopy were performed before ES and again between 4 and 8 weeks after ES after cholangiographic confirmation of clearance of common bile duct stones.Results: Fasting and residual gallbladder volumes decreased and ejection fraction increased significantly following ES, suggesting decreased stasis and improved emptying of gallbladder. Nucleation time was prolonged and cholesterol crystal index in bile decreased after ES, suggesting decreased lithogenicity. The decrease in gallbladder volumes and increase in ejection fraction after ES were observed in both groups of patients, with or without concomitant gallstones.Conclusions: ES decreases the stasis of gallbladder bile, improves gallbladder emptying and decreases the lithogenicity of bile in patients with gallstone disease as reflected by prolongation in nucleation time. ES may find a role as an adjunct to oral bile acid therapy and extracorporeal shock wave lithotripsy in addition to a prophylactic role of preventing gallstone formation in high risk groups.     

Is Biliary Lithogenesis Affected by Length and Implantation of Cystic Duct? (Study of 270 Patients with Endoscopic Retrograde Cholangiopancreatography)

The gallbladder seems to play an important rolein lithogenesis. Moreover, the morphology and theimplantation of the cystic duct may also influence thisprocess. Our purpose was to evaluate if the length and the implantation of the cystic duct mayaffect the formation of gallstones. Between April 1992and March 1994, 270 patients who underwent endoscopicretrograde cholangiopancreatography were included in the study, and the radiological length ofthe cystic duct was carefully recorded. Patients weredivided into two groups: I, absence of lithiasis: 113patients (65 men, 48 women); and II, gallbladder lithiasis or lithiasis in the common bile ductwith or without gallbladder lithiasis: 157 patients (73men, 84 women). A statistically significant differencewas observed among the two groups regarding the insertion of the cystic duct: implantationon the left side of the common bile duct represented arisk factor of lithiasis. The length of the cystic ductwas not directly implicated. Hypokinesis of the gallbladder is currently recognized asbeing a major factor in the initial steps oflithogenesis, but the implantation of the cystic ductcan play an important role by increasing cystic ductresistance and causing a reduced washout effect of thegallbladder contents, including cholesterolcrystals.     

An extrahepatic bile duct metastasis from a gallbladder cancer mimicking Mirizzi's syndrome

We report a case of an extrahepatic bile duct metastasis from a gallbladder cancer that mimicked Mirizzi's syndrome on cholangiography. A 67-yr-old woman was admitted to our hospital with a diagnosis of acute calculous cholecystitis. As obstructive jaundice developed after the admission, percutaneous transhepatic biliary drainage was performed to ameliorate the jaundice and to evaluate the biliary system. Tube cholangiography revealed bile duct obstruction at the hepatic hilus, and extrinsic compression of the lateral aspect of the common hepatic duct, with nonvisualization of the gallbladder. No impacted cystic duct stone was visualized on CT or ultrasonography. Laparotomy revealed a gallbladder tumor as well as an extrahepatic bile duct tumor. We diagnosed that the latter was a metastasis from the gallbladder cancer, based on the histopathological features. This case is unique in that the extrahepatic bile duct metastasis obstructed both the common hepatic duct and the cystic duct, giving the appearance of Mirizzi's syndrome on cholangiography. Metastatic bile duct tumors that mimic Mirizzi's syndrome have not been previously reported. The presence of this condition should be suspected in patients with the cholangiographic features of Mirizzi's syndrome, when the CT or ultrasonographic findings fail to demonstrate an impacted cystic duct stone.     

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.     

胆囊结石与急性胰腺炎的关系

目的 探讨胆囊结石患者发生急性胰腺炎（AP）的影响因素.方法 选取武汉大学人民医院消化内科收治的诊断为胆囊结石的患者118例,通过影像学检查,测量胆囊大小、胆囊结石大小及数量,判断是否伴有胆总管结石.根据有无并发AP进行分组,比较各相关因素对AP发生率的影响.结果 118例胆囊结石患者中并发AP 61例.74例的胆囊大小正常,其中49例（66.2％）发生AP;44例胆囊增大或缩小,其中12例（27.3％）发生AP.31例为单发结石,其中11例（35.5％）发生AP;87例为多发结石,其中50例（57.5％）发生AP.发生AP的11例单发结石患者,其中8例（72.7％）结石≥10mm;50例多发结石患者中41例（82.0％）结石＜10 mm.19例伴有胆总管结石,其中17例（89.5％）发生AP;99例无胆总管结石,其中44例（44.4％）发生AP.各因素的两组间差异均有统计学意义（Х^2=16.758,P=0.000;Х^2 =4.425,P=0.029;Х^2=13.434,P=0.001;Х^2 =12.994,P=0.000）.结论 急性胆源性胰腺炎的发生与胆囊结石相关,胆囊是否正常、胆囊结石大小及数量、是否伴有胆总管结石均是影响AP发生的相关因素.