Cholelithiasis and Cholecystitis in Childhood

Six cases of cholecystitis and cholelithiasis confirmed by x-ray examination and surgical operation were observed in a ten-year period. Due to the wide variability in signs and symptoms in children, cholecystitis and cholelithiasis can be diagnosed only with a high degree of clinical suspicion and roentgenological examination. Gallbladder disease is uncommon in childhood but should be considered in children with vague abdominal pains or bouts of unexplained jaundice. If a normal appendix is found at laparotomy in the “acute abdomen,” the surgeon would be wise to palpate other specific organs within the abdomen, including the liver and gallbladder.The treatment of choice is cholecystectomy. The prognosis for recovery is excellent if there is no complicating systemic disease.     

Acute emphysematous cholecystitis

Acute emphysematous cholecystitis is an uncommon condition caused by gas-forming organisms and characterized by the presence of gas in the wall and lumen of the gallbladder. Its incidence is higher among male diabetics. AEC in an elderly North American diabetic man with Indian ancestry is reported with a brief review of the world literature. The diagnosis was made preoperatively with the aid of plain radiographic films of the abdomen. A gangrenous distended gallbladder was removed at operation. Clostridium perfringens was cultured from the gallbladder contents and wall. If AEC is suspected, intensive antimicrobial therapy and fluid and electrolyte replacement should be given prior to early surgical intervention.     

Feasibility of breast conservation after neoadjuvant taxene based chemotherapy in locally advanced breast cancer: a Prospective Phase I trial

Background

Acute cholecystitis can be the result of retention of bile in the gallbladder with possible secondary infection and ischaemia. The aim of the present study was to investigate whether internal drainage of the gallbladder could protect against the development of acute cholecystitis in a pig model.

Materials and methods

Twenty pigs were randomized to either internal drainage (drained) or not (undrained). Day 0 acute cholecystitis was induced by ligation of the cystic artery and duct together with inoculation of bacteria. Four days later the pigs were killed and the gallbladders were removed and histologically scored for the presence of cholecystitis. Bile and blood samples were collected for bacterial culturing and biochemical analyses.

Results

The histological examination demonstrated statistical significant differences in acute cholecystitis development between groups, the degree of inflammation being highest in undrained pigs. There were no differences in bacterial cultures between the two groups.

Conclusion

Internal drainage of the gallbladder protected against the development of acute cholecystitis in the present pig model. These findings support the theory that gallstone impaction of the cystic duct plays a crucial role as a pathogenetic mechanism in the development of acute cholecystitis and suggest that internal drainage may be a way to prevent and treat acute cholecystitis.     

Extramedullary plasmacytoma imitating neoplasm of the gallbladder fossa after cholecystectomy

Extramedullary plasmacytomas are plasma cell tumors that arise outside of the bone marrow. They account for approximately 3% of plasma cell neoplasms and are most frequently located in the head and neck region. Five months after undergoing cholecystectomy, a 69-year-old patient presented with the pain under the right costal margin and a 12 kg weight loss. Computed tomography of the abdomen demonstrated irregular, vascular mass in the gallbladder fossa that dents towards the duodenum and the pylorus and lowers caudally to the hepatic flexure. His laboratory tests indicated normocytic anemia and showed elevated sedimentation rate. During operative procedure, a tumorous mass in the gallbladder fossa was found, inseparable of the peritoneum of the hepatoduodenal ligament and the IVb liver segment. Histopathological examination and immunohistochemical staining determined the diagnosis of the plasmacytoma. Total resection of the tumor was achieved and after 24-month follow-up patient showed no signs of local recurrence or dissemination of the disease.     

妊娠合并急腹症的超声诊断-附686例临床病例分析

目的:评价超声在诊断妊娠合并急腹症中的临床应用价值。方法:回顾分析686例妊娠合并急腹症患者的临床资料,总结妊娠合并急腹症超声图像特征。结果:超声诊断符合率为:异位妊娠87.2%(184/211),急性阑尾炎84.2%(32/39),卵巢囊肿蒂扭转90.0%(27/30),急性胰腺炎66.7%(6/9),不全流产及难免流产、子宫肌瘤扭转、子宫肌瘤红色变性、胎盘早剥、泌尿系结石、急性胆囊炎和胆结石、急性胃肠炎、急性肠梗阻的诊断率为100%(43/43)。结论:超声可以作为妊娠合并急腹症首选的检查手段,为临床早期诊断及治疗提供可靠依据。     

超声引导下经皮经肝胆囊置管治疗老年化脓性胆囊炎伴胆囊积液的应用价值

目的：探讨超声引导下经皮经肝胆囊置管引流治疗化脓性胆囊炎伴胆囊积液的应用价值。方法：老年患者不能耐受手术或不愿手术治疗,胆囊颈部结石嵌顿引起的化脓性胆囊炎伴胆囊积液患者86例,在超声引导下,8F猪尾巴导管经皮经肝进行胆囊穿刺置管治疗。治疗后用超声进行随访观察,结合临床症状判断疗效。结果：在超声引导下,86例化脓性胆囊炎伴胆囊积液患者均成功进行胆囊穿刺置管引流冲洗治疗,患者症状明显改善,经治疗临床症状消失后出院,择期拔管。结论：超声引导下经皮经肝胆囊置管微创治疗是不能手术或不愿接受手术的化脓性胆囊炎伴胆囊积液患者的一种有效治疗方法。     

超声引导下经皮经肝胆囊置管治疗老年化脓性胆囊炎伴胆囊积液

目的:探讨超声引导下经皮经肝胆囊置管引流治疗化脓性胆囊炎伴胆囊积液的应用价值。方法:老年患者不能耐受手术或不愿手术治疗,胆囊颈部结石嵌顿引起的化脓性胆囊炎伴胆囊积液患者86例,在超声引导下,8F猪尾巴导管经皮经肝进行胆囊穿刺置管治疗。治疗后用超声进行随访观察,结合临床症状判断疗效。结果:在超声引导下,86例化脓性胆囊炎伴胆囊积液患者均成功进行胆囊穿刺置管引流冲洗治疗,患者症状明显改善,经治疗临床症状消失后出院,择期拔管。结论:超声引导下经皮经肝胆囊置管微创治疗是不能手术或不愿接受手术的化脓性胆囊炎伴胆囊积液患者的一种有效治疗方法。     

Ultrasonographic guidance in diagnostic and therapeutic interventions in diseases of the internal organs

A hundred fifty four invasive diagnostic and therapeutical interventions were made in patients with diseases of the abdomen and retroperitoneal space under ultrasonographic guidance. Various biopsies were performed in 139 patients; positive results were achieved in 120 (86.3%) cases. In 15 patients, diagnostic biopsies were combined with therapeutical interventions, such as aspiration of cysts in the liver (n = 3) and kidney (n = 2); drainage of abscesses in the abdomen (n = 5) and liver (n = 5). Fourteen patients with mechanical jaundice caused by extrahepatic bile duct tumors or pancreatic head cancer underwent percutaneous transhepatic cholecystocholangiography followed by external drainage. Percutaneous transhepatic drainage of the gallbladder was made in 1 patient with acute cholecystitis.     

妊娠合并急腹症的超声诊断-附686例临床病例分析

目的：评价超声在诊断妊娠合并急腹症中的临床应用价值。方法：回顾分析686例妊娠合并急腹症患者的临床资料,总结妊娠合并急腹症超声图像特征。结果：超声诊断符合率为：异位妊娠87.2%（184/211）,急性阑尾炎84.2%（32/39）,卵巢囊肿蒂扭转90.0%（27/30）,急性胰腺炎66.7%（6/9）,不全流产及难免流产、子宫肌瘤扭转、子宫肌瘤红色变性、胎盘早剥、泌尿系结石、急性胆囊炎和胆结石、急性胃肠炎、急性肠梗阻的诊断率为100%（43/43）。结论：超声可以作为妊娠合并急腹症首选的检查手段,为临床早期诊断及治疗提供可靠依据。     

Quantitative analysis of troponin I serum values in patients with acute cholecystitis

The diagnosis and staging of acute cholecystitis, upon a lot of diagnostic methods and some scoring systems, is still a great clinical problem. The aim of the study was to investigate if serum Troponin I is elevated in patients with acute cholecystitis. Following informed consent, 65 patients with clinical and laboratory signs of acute cholecystitis were enrolled. All patients had measured serum Troponin I level and an abdominal ultrasound was done before definitive treatment was performed. Increased serum Troponin I level was found in most patients with severe form of acute cholecystitis (p < 0.00001). It reached sensitivity of 94.5% and specificity of 57.1% of this test. In multiple regression analysis Troponin I significantly correlated (p < 0.05) with the serum aspartate aminotransferase (r = 0.27), gamma-glutamyl transferase (r = 0.25) and gallbladder wall (> 6 mm) thickness (r = 0.58). Our study confirms that in most patients with severe and acute cholecystitis, serum Troponin I is increased. Troponin I level is in a lower range than it would be in patients with cardiac muscle damage or necrosis. Measuring serum Troponin I is a fast, reliable and widely performed test that could, with other routinely measured parameters, help in early diagnosis of the severe form of acute cholecystitis.     

Cytologic diagnosis of suppurative cholecystitis due to Candida albicans and actinomyces. A report of 2 cases

BACKGROUND: Cholecystitis is a common inflammatory disease of the gallbladder. Actinomycosis and candidiasis of the gallbladder are uncommon causes of acute cholecystitis. There has been no previous report on the cytologic diagnosis of actinomycosis and candidiasis from aspirated gallbladder bile intraoperatively. CASES: Purulent bile was intraoperatively aspirated from the gallbladder of 71-year-old Indian and a 30-year-old Australian woman. The specimens were sent for cytologic examination. The first case revealed sulphur granules characteristic of Actinomyces spp. The second case showed budding spores and pseudohyphae of Candida spp. Pure colonies of Candida albicans grew from the bile culture. CONCLUSION: Actinomycosis and candidiasis rarely cause acute suppurative cholecystitis. Initial diagnosis can be made by cytologic examination of the aspirated purulent bile intraoperatively.     

Neutrophils injure gallbladder interstitial Cajal-like cells in a guinea pig model of acute cholecystitis

Acute cholecystitis is a common disease with gallbladder dysmotility. Disease pathogenesis involves immune cell infiltration as well as changes in gallbladder interstitial Cajal-like cells (ICLCs). However, it remains unclear if or how the immune cells affect ICLC morphology, density, distribution, and function in gallbladder tissue during acute cholecystitis. In this study, we explored the acute cholecystitis-related alterations in gallbladder ICLCs in a guinea pig model, focusing on the effects of neighboring neutrophils. Adult guinea pigs were randomly divided into four groups (control, 24 hr common bile duct ligation [CBDL], 48-hr CBDL, and antipolymorphonuclear neutrophil [PMN] treated) and analyzed using methylene blue staining and immunofluorescence. Gallbladder contractility was also monitored. To culture gallbladder ICLCs, collagenase digestion was performed on tissue from 10- to 15-day-old guinea pigs. Neutrophils isolated from the peripheral blood of experimental animals 48-hr postsurgery were also cocultured with the gallbladder ICLCs. Intracellular calcium was detected with Fluo-4 AM dye. Our results showed that gallbladder ICLC density significantly declined during acute cholecystitis and was accompanied by shortening of the cellular processes and damage to their network-like structure. However, pretreatment with anti-PMN partially prevented these changes. Gallbladder contraction was also significantly decreased during acute cholecystitis, and this appeared to be mediated by the neutrophils. Moreover, ICLCs cocultured with neutrophils also had shortened and reduced processes and impaired network-like structure formation. Intracellular calcium transient was less sensitive to contraction agonists and inhibitors when cocultured with neutrophils. Taken together, neutrophils greatly affect gallbladder ICLCs and dysmotility during acute cholecystitis.     

Effect of preoperative feeding on gallbladder size and peristaltic of the small bowel following spinal anesthesia for the hip surgery

The main aim of our study was to determine the influence of preoperative feeding with clear carbohydrate rich drink (PreOp 200 mL) on peristaltic of the small intestine and gallbladder size early after the orthopedic surgery in spinal anesthesia. Clinical study includes 120 patients with fracture of femoral neck or pertrochanteric fracture. All patients were randomized in two groups, sixty patients, PreOp group, consumed carbohydrate drink two hours before surgery. Other 60 patients, Control group, represent patients who fasted overnight. After surgery, patients were submitted to ultrasound examination for measurement of the small bowel motions and gallbladder size. Four quadrants (up-right, up-left, down-right and down-left) of the abdomen were examined, each one in duration of 30 seconds. The results show that the length of the gallbladder is considerably different across the two groups; 5.866 cm in the PreOp group and 7.178 cm in the Control group (p = 0.00). The width, however, differed somewhat less (PreOp group 2.437 cm, Control group 2.735 cm) and the statistically significant difference can be observed at 7% level (p = 0.073). We found no statistically significant relationship between PreOp and Control group variables of each abdominal quadrant (lowest p > 0.087). Accordingly, the means of the variables were found statistically significantly different between groups (p > 0.05). In conclusion our study showed that the preoperative feeding of the patients undergoing orthopedic surgery in spinal anesthesia shortens the length but not the width of the gallbladder when compared with overnight fasting patients and also clearly enhance motility of the small bowel in all four quadrant of the abdomen.     

Perforation of the gallbladder: analysis of 19 cases.

Perforation of the gallbladder occurred in 19 (3.8%) of 496 patients with acute cholecystitis treated at one hospital in an 8-year period. The average age of the 19 patients was 69 years and the female:male ratio was 3:2. Most had a history suggestive of gallbladder disease and most had coexisting cardiac, pulmonary, renal, nutritional or metabolic disease. The duration of the present illness was short, perforation occurring within 72 hours of the onset of symptoms in half the patients; the diagnosis was not suspected preoperatively in any. In the elderly patient with acute cholecystitis who has a long history of gallbladder disease, cholecystectomy should be performed early, before gangrene and perforation of the gallbladder can occur.     

Rectal examination in patients with pain in the right lower quadrant of the abdomen.

OBJECTIVE--To determine whether rectal examination provides any diagnostic information in patients admitted to hospital with pain in the right lower quadrant of the abdomen. DESIGN--Casualty officer or surgical registrar recorded symptoms and signs on admission on detailed forms. Final diagnosis was noted on discharge from hospital. SETTING--District general hospital. PATIENTS--1204 Consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen as their major complaint; 1028 had a rectal examination on admission. MAIN OUTCOME MEASURES--Odds ratio for each symptom and sign related to final diagnosis. Results of multiple logistic regression analysis for acute appendicitis. RESULTS--Right sided rectal tenderness, present in 309 of those examined, was more common in patients with acute appendicitis (odds ratio 1.34, p less than 0.05). This odds ratio was considerably less than that for other clinical signs--namely, tenderness in the right lower quadrant (odds ratio 5.09), rebound tenderness (3.34), guarding (3.07), and muscular rigidity in the abdomen (5.03). In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance. Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis. No other unexpected diagnoses were established, and no useful additional diagnostic information was obtained by routine rectal examination. CONCLUSION--If patients presenting with pain in the right lower quadrant of the abdomen are tested for rebound tenderness then rectal examination does not give any further diagnostic information.     

Dedifferentiated liposarcoma of the gallbladder: first reported case

Background

Liposarcoma of the gallbladder is an extremely rare sarcoma, with only five cases reported in the literature according to our knowledge.

Case presentation

A 71-year-old woman was referred to the Surgical Oncology Division of Napoleão Laureano Hospital (João Pessoa, PB, Brazil) due to a solid mass at the right side of the abdomen and fever, with no signs of jaundice. Abdominal ultrasonography and computed tomography (CT) evidenced an extensive gallbladder lobular formation adhered to the inferior border of the right hepatic lobe and cholelithiasis. The CT report suggested gallbladder liposarcoma. A cholecystectomy associated with resection of segments IV-B and V of the liver were performed. Intraoperative frozen sections were compatible with gallbladder sarcoma. Anatomopathological examination and immunohistochemistry confirmed dedifferentiated liposarcoma with foci of heterologous leiomyosarcomatous differentiation and undifferentiated fusocellular areas of high histological grade.

Conclusion

This is the first case of dedifferentiated liposarcoma of the gallbladder to be reported.

     

Plasma procalcitonin in patients with ileus. Relations to other inflammatory parameters

Plasma procalcitonin (PCT) is a highly specific marker for the diagnosis of bacterial infections and sepsis. PCT levels are usually low in viral infections, chronic inflammation or postsurgical states. The purpose of this study was to characterize PCT plasma levels in patients with various types of ileus at preoperative stage, where the other inducing factors suchas a surgical stress are excluded. The prospective study was performed on 54 patients admitted to in-patient surgical department with a proven diagnosis of ileus. Patients were divided to three groups--obstructive, vascular and paralytic ileus. Plasma levels of PCT (Kryptor analysis), TNFalpha, IL-1beta, IL-6, cortisol (ELISA) and CRP (Kryptor ultrasensitive analysis) were estimated before any invasive procedure was realized. We demonstrated significant elevation of PCT in both obstructive ileus in adhesions and vascular ileus compared with healthy subjects (p 0.01). PCT levels were not elevated in paralytic ileus. The regression coefficient was the highest for PCT and CRP (r=0.78, p 0.01), for TNFalpha and IL-8 (r=0.76, p 0.01) in vascular ileus. There was no significant correlation between PCT and other inflammatory parameters. The different types of ileus induce an elevation of plasma PCT levels and PCT shows itself as an acute phase reactant. The highest PCT concentrations were presented in patients with vascular ileus, whereas paralytic ileus revealed similar cytokine and PCT pattern as in healthy subjects. Plasma PCT estimation extended to a measurement of CRP and IL-6 may become a useful complementary examination for diagnostics of acute abdomen in patients.     

Cholecystokinin (CCK) down regulates PGE2 and PGI2 release in inflamed Guinea pig gallbladder smooth muscle cell cultures

This study examines the hypothesis that cholecystitis down-regulates Guinea pig gallbladder (GPGB) smooth muscle cholecystokinin (CCK)-stimulated prostaglandin (PG) release. Guinea pig gallbladder from Control and 48 h bile duct ligated (BDL) animals were placed in cell culture and grown to confluence. The cultures underwent Western Blot analysis for smooth muscle cell content of COX-1, COX-2, Prostacyclin Synthase (PS), or were incubated with CCK at 10(-8)M or 10(-6)M with and without indomethacin for 1h and analyzed for release of 6-keto-PGF1alpha, PGE2 and TxB2 by EIA. BDL increased Guinea pig gallbladder cell culture basal PGE2 and PGI2 release which was in part due to increased COX-2 content. CCK incubation down-regulated BDL Guinea pig gallbladder cell culture release of 6-keto-PGF1alpha and PGE2 and down-regulated COX-2 content but did not alter the Control group. The decrease in CCK-mediated BDL cell Guinea pig gallbladder release may be an endogenous mechanism to limit physiologic derangements induced by increased endogenous gallbladder PG synthesis during early acute cholecystitis.     

Nonvisualization of the gallbladder by 99mTc-HIDA cholescintigraphy as evidence of cholecystitis.

Cholescintigraphy with N-substituted iminodiacetic acid (HIDA) labelled with technetium-99m is a new noninvasive technique for evaluation of the hepatobiliary system. The significance of nonvisualization of the gallbladder by this method in comparison with standard radiologic examinations was studied. In 43 healthy subjects the gallbladder was visualized by the two methods. By contrast, all 27 patients in whom the gallbladder was not visualized by cholescintigraphy had cholecystitis. When visualization failed to occur, a repeat cholescintigraphic study after an injection of cholecystokinin demonstrated the status of the cystic duct. Visualization excludes cystic duct obstruction and acute cholecystitis, whereas persistent nonvisualization indicates cystic duct obstruction.     

Caja1间质细胞与慢性假性结肠肠梗阻关系的研究进展

Cajal间质细胞（interstitial cells of cajal,ICC）主要分布在胃肠道平滑肌细胞与神经纤维之间,是一类特殊的间质细胞,它是胃肠运动的起搏细胞,具有产生、传导慢波,调节胃肠道平滑肌运动的功能。而慢性假性肠梗阻是由于胃肠神经抑制,毒素刺激或肠壁平滑肌本身病变,导致的肠壁肌肉运动功能减弱,临床上具有肠梗阻的症状和体征,但无肠内外机械性肠梗阻因素存在,故又称动力性肠梗阻。按病程有急性和慢性之分,麻痹性肠梗阻和痉挛性肠梗阻属于急性假性肠梗阻,深入研究Caja1间质细胞,对进一步认识胃肠运动的生理及胃肠动力疾病的发生机制有重要意义。