Gallbladder stones in patients with negative gallbladder x-rays.
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Alkaline Phosphatase↗
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[Surgical treatment of polypoid lesions of gallbladder].
INTRODUCTION: Polypoid lesions of the gallbladder can be divided into benign and malignant categories. Malignant polypoid lesions include carcinomas of the gallbladder, which is the fifth most common malignancy of the gastrointestinal tract and the most common malignancy of the biliary tract. Benign polypoid lesions of the gallbladder are divided into true tumors and pseudotumors. Pseudotumors account for most of polypoid lesions of the gallbladder, and include polyps, hyperplasia, and other miscellaneous lesions. Adenomas are the most common benign neoplasms of the gallbladder. Cholesterol polyps are the most common pseudotumors of the gallbladder. The polyps can be single or multiple, usually less than 10 mm in size. They have no predilection for any particular gallbladder site, and usually are attached to the gallbladder wall by a delicate, narrow pedicle. No malignant potential has been identified for this type of pseudotumor. Adenomas are the most common benign neoplasms of the gallbladder. They have no predilection site in the gallbladder, and may also be associated with gallstones or cholecystitis. The premalignant nature of adenomas remains controversial. Ultrasonography (US) has been demonstrated to be significantly better in detecting polypoid lesions of the gallbladder as compared with computed tomography and cholecystography. A mass fixed to the gallbladder wall of normal thickness, without shadowing, is seen in case of gallbladder polyp. Since gallbladder cancers usually present as polypoid lesions, differentiation between benign polypoid lesion and malignant lesion can be very difficult, even with high-resolution imaging techniques. PATIENTS AND METHODS: Retrospectively we have analyzed 38 patients with ultrasonographically detected gallbladder polyps during the period from January 1995 to December 2000, who were treated at surgical department of Health Centre in Uzice and at Surgical clinic of Clinical Centre in Nis. We have analyzed patients demographical data as well as their symptoms and radiographic findings. If the patient was operated, pathohistological findings were analyzed also. RESULTS: In our study 38 examined patients had mean age of 53.2 years (standard deviation of 12.8 years; range 26-80 years). The male-female ratio was 1:1. Overall 36 patients had symptoms that could be related to gallbladder diseases. Among these patients, 32 had pain in the upper-right quadrant of the abdomen that could be defined as biliar colic, and two had symptoms of acute cholecystitis. Among remaining four patients, two were examined because of the pain in the lower part of the abdomen. One patient had high temperature of unknown origin and the gallbladder polyp was detected accidentally during the ultrasonographic examination of the abdomen. Second patient had jaundice of unknown origin, with ultrasound showing no significant changes in biliary tract. Preoperative ultrasound findings were inconsistent. The size of the lesion was marked only in 18 out of 38 patients. Among 34 operated patients, just 11 of them had pathohistologically verified polipoid lesion. Pathohistological analyzes of extirpated gallbladders showed one normal gallbladder, seven cholesterol polyps, one polipoid cholecystitis, and two real gallbladder neoplasms. One patient had gallbladder adenoma while the other had adenocarcinoma. Malignancy rate was 2.94% (one in 34). All patients with neoplastic polyps had solitary lesion larger than 1 cm in diameter, while the patients with non-neoplastic lesions had multiple lesions smaller than 1 cm in diameter. All operated patients, with the exception of one, had pathologically verified abnormal gallbladders. This results showed the presence of chronic cholecystitis even in the absence of the polyps. DISCUSSION: Generally, no treatment is required in young patients with very small gallbladder polyps who are completely free from any symptoms. A patient with dyseptic symptoms but no painful episodes consistent with biliary colic should be managed conservatively. Cholecystectomy is also indicated in patients with large gallbladder polyps size over 10 mm, irrespective of symptomatology. In patients with gallbladder polypoid lesions smaller than 10 mm, cholecystectomy is indicated only if complicating factors are present, e.g., age over 50 years and coexistence of gallstones. If the gallbladder polyp is smaller than 10 mm and complicating factors are absent, the "watch-and-wait" strategy seems to be recommendable. CONCLUSION: Although gallbladder polyps are rare, they represent a significant health problem because they may be a precursor to gallbladder cancer. On the basis of the available data, and the results that we have gained in our study we suggest that gallbladder should be extirpated in cases when: 1. symptomatic lesions are present regardless of size; 2. polyps larger than 10 mm are present because they represent a risk for gallbladder cancer; 3. polyps are showing rapid increase in size. Polyps less than 10 mm that are incidentally identified and not removed should be assessed by ultrasonography at least every six months. This is especially critical for sessile polyps, in which the possibility of a small cancerous polyp is greater than in pedunculated polyps. Also, asymptomatic lesions less than 10 mm in diameter should be removed if patient is older than 50 years or if he has concomitant gallbladder calculosis.
Adult↗
Ultrasonography in the assessment of gallbladder motor activity.
Ultrasonography is an accurate and useful method for studying gallbladder volume variations and thus indirectly gallbladder emptying and refilling in humans. It has been shown that gallbladder main motor function is the result of a bellows-like mechanism with outflow and inflow of bile occurring during continuously alternating phases of gallbladder emptying and filling, that in turn lead to bile recycling within the gallbladder. Therefore, bile flux through the gallbladder cannot be properly expressed by time and rate of gallbladder emptying and gallbladder ejection fraction. In an attempt to analyse the gallbladder volume-hepatic bile flux relationship, simultaneous assessment of the gallbladder volume variations at ultrasonography and of the labelled bile in the gallbladder at cholescintigraphy during continuous infusion of an hydroxy iminodiacetic acid compound has been carried out. By applying a mathematical model to the analysis of gallbladder volume ultrasonography measurements, it is possible to measure the flux of bile through the gallbladder. By validating ultrasonography assessment of gallbladder volume variations with quantitative cholescintigraphy, it has been shown that the single non-invasive ultrasonography technique with serial frequent measurements of the gallbladder volume enables separate estimation of the flux of bile through the gallbladder in humans and in physiological conditions. In the postprandial state, hepatic bile was mainly: (1) stored in the gallbladder in a first phase; (2) emptied from the gallbladder in a second phase; and (3) stored in the gallbladder in a third phase. The amount of bile flowing bidirectionally through the cystic duct was about fivefold greater than that estimated with the usually employed variables, such as gallbladder ejection fraction or emptying and refilling delta volume. The mathematical analysis of minute-by-minute ultrasonography measurements of gallbladder volume variations yields both physiological and pathological insights. In healthy volunteers, it has been shown that: (1) caloric content of meals affects the total amount of bile recycled by the gallbladder; and (2) fat content of meals affects the modality of gallbladder emptying and refilling but does not affect the total amount of bile recycled by the gallbladder. In gallstone patients, a decreased turnover of bile has been shown which may contribute to cholesterol crystal precipitation and stone growth. In conclusion, unlike conventional variables used to assess gallbladder motor function such as gallbladder ejection fraction and rate of gallbladder emptying, mathematical analysis of frequent ultrasonography measurements of gallbladder volume variations enables non-invasive estimation of bile flow through the gallbladder in normal and abnormal physiological conditions.
Bile↗
Gallbladder contractility: variation in normal subjects.
Gallbladder contractility can be quantified radiologically, but it is not known whether the degree of contraction exhibited by a person's gallbladder varies from day to day. Thirty healthy volunteers were studied with sonography on three separate occasions to determine the variation of individual gallbladder contractility. Using the ellipsoid method, we measured gallbladder volume after an overnight fast (fasting gallbladder volume) and between 45 and 60 min after a standard fatty meal (residual gallbladder volume). Percentage gallbladder contraction was calculated by dividing the difference between the fasting and residual gallbladder volumes by the fasting gallbladder volume and multiplying by 100. The 90 studies in 30 subjects exhibited a wide range of values: fasting gallbladder volume from 1.9 to 45.5 ml, residual gallbladder volume from 0.1 to 21.0 ml, and percentage gallbladder contraction from -10% to 99%. Within each subject, fasting gallbladder volume measurements varied from 1.5 to 26.2 ml (mean +/- two standard deviations, 10.3 +/- 5.1 ml) and residual gallbladder volume from 0.3 to 15.4 ml (5.1 +/- 3.8 ml). Percentage gallbladder contraction varied from 6% to 87% (28% +/- 18%). In 60% of the subjects, percentage gallbladder contraction values varied by more than 20%, and in 20% of the subjects it varied by more than 40%. These data show that a wide variation exists within a normal person in the degree of gallbladder contraction exhibited from one day to another, and a single test for gallbladder contraction can be misleading.
Adult↗
Gallbladder disorders and type 2 diabetes mellitus--a clinic-based study.
AIMS OF THE STUDY: To study the prevalence of gallbladder disorders in type 2 diabetic patients and their correlation with patient factors like age, sex, weight, duration of diabetes and autonomic neuropathy. METHODOLOGY: Fifty type 2 diabetic patients and 30 healthy controls underwent realtime ultrasonography to study the prevalence of gallbladder disorders. The fasting gallbladder volume and contraction 60 minutes after a fatty meal of the diabetic subjects were compared with 30 age and sex matched healthy volunteers. The age, sex, weight, duration of diabetes, autonomic neuropathy, control of diabetes were correlated to the prevalence of gallbladder disorders in diabetic patients. RESULTS: 32% of the diabetic patients had ultrasonographic evidence of gallstones, as compared to 6.7% in healthy subjects. 73.7% of the diabetic patients with gallbladder disorders were females. Mean fasting gallbladder volume was significantly increased in diabetic patients (26.2 cm3) as compared to non-diabetic healthy subjects (15.8 cm3). Further mean fasting gallbladder volume of diabetic patients with gallbladder disorder (28.1 cm3) was found to be significantly larger than that of those patients without gallbladder disorder (24.6 cm3). Mean percentage of contractions of gallbladder 60 min after fatty meal was reduced in diabetic patients (53.1%) and it was observed to be further reduced in the patients with gallbladder disorder (41.8%). Mean fasting gallbladder volume was larger in diabetic subjects with autonomic neuropathy, than those without. However, difference in mean percentage contraction of gallbladder 60 min after fatty meal was not statistically significant. Mean duration of diabetes was significantly longer in diabetic patients with gallbladder disorder. CONCLUSIONS: We conclude that type 2 diabetic patients have increased prevalence of gallbladder disorder which can only partially be explained by autonomic neuropathy leading, to increased fasting volume. Factors like decreased cholecystokinin or decreased sensitivity of the smooth muscle of gallbladder to normal level of cholecystokinin need to be studied.
Diabetes Mellitus, Type 2↗
Gallbladder mucosal blood flow increases during early cholesterol gallstone formation.
Gallbladder absorption increases during early cholesterol gallstone formation and is influenced by the intraluminal presence of lithogenic bile. The effect of lithogenic bile on gallbladder mucosal blood flow is unknown. The current study tested the hypothesis that the presence of lithogenic gallbladder and hepatic bile enhances gallbladder mucosal blood flow in cholesterol-fed (0.4%) prairie dogs, as determined by hydrogen gas clearance. Gallbladder mucosal blood flow in control animals was 35.57 +/- 3.9 mL.min-1.100 g-1. In contrast, basal gallbladder mucosal blood flow in cholesterol-fed animals was significantly (P less than 0.01) increased to 64.94 +/- 8.7 mL.min-1.100 g-1. In crossover studies, the addition of lithogenic gallbladder bile to control animals (n = 6) resulted in a significant (P less than 0.025) 26% increase in gallbladder mucosal blood flow, whereas the addition of nonlithogenic gallbladder bile into gallbladders of cholesterol-fed prairie dogs resulted in a significant (P less than 0.025) 58% decrease in gallbladder mucosal blood flow. Similarly, hepatic bile crossover studies showed that the addition of lithogenic hepatic bile to control gallbladders significantly increased (P less than 0.025) gallbladder blood flow by 30%, whereas instillation of nonlithogenic hepatic bile in gallbladders of cholesterol-fed animals significantly (P less than 0.025) decreased gallbladder mucosal blood flow by 29%. These results suggest that alterations in gallbladder mucosal blood flow, influenced by the presence and absence of lithogenic bile, may play a role in cholesterol gallstone formation.
Animals↗
Contraction pattern of opossum gallbladder during fasting and after feeding.
Our major aims in this study were to determine in unanesthetized opossums the gallbladder volume, pressure, and tone during fasting as well as after feeding, model the kinetics of changes in gallbladder volume, and correlate gallbladder contractility with concurrent spike burst activity in the upper gastrointestinal tract and sphincter of Oddi (SO). In 10 animals, we implanted electrodes on the gastric antrum, duodenum, SO, and jejunum. An indwelling catheter monitored gallbladder pressure and volume. In two animals, a force transducer sutured to the gallbladder wall monitored gallbladder tone. In each animal, fasting migrating myoelectric complexes (MMCs) were recorded in the stomach and small bowel. Cyclic changes in SO spike bursts occurred in synchrony with the MMCs. During fasting, gallbladder pressure, tone, and volume showed cyclic variations. During the second half of the duodenal MMC cycle, the gallbladder exhibited phasic as well as tonic contractions associated with net gallbladder emptying, whereas during the first half of the cycle the gallbladder relaxed and refilled. Minimal gallbladder volume during the MMC cycle averaged 4.8 +/- 0.7 (SE) ml compared with a maximal volume of 7.0 +/- 0.9 ml. Decreases in gallbladder volume occurred as an exponential function, whereas increases in gallbladder were linear. After feeding, the gallbladder underwent a sustained tonic contraction, without superimposed phasic contractions. Decreases in gallbladder volume occurred exponentially to a residual volume of 2.0 +/- 0.5 ml. Net postprandial gallbladder emptying was maximal by 40 min; then the volume remained unchanged for 2-3 h.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Association of cyclin D1, p16 and retinoblastoma protein expressions with prognosis and metastasis of gallbladder carcinoma.
AIM: To investigate the role of cyclin D1, p16 and retinoblastoma in cancerous process of gallbladder carcinomas and to assess the relation between cyclin D1, p16, Rb and the biological characteristics of gallbladder carcinoma. METHODS: Forty-one gallbladder carcinoma, 7 gallbladder adenoma and 14 chronic cholecystitis specimens were immunohistochemically and histopathologically investigated for the relation of cyclin D1, p16 and Rb with Nevin staging and pathologic grading. RESULTS: The expression rates of abnormal cyclin D1 in gallbladder carcinoma (68.3%) and gallbladder adenoma (57.1%) were significantly higher than those in chronic cholecystitis (7.1%) (P<0.05). No significant difference was found both among the pathological grades G(1), G(2) and G(3) and among Nevin stagings S(1)-S(2), S(3) and S(4)-S(5) of gallbladder carcinoma. The positive rates of p16 (48.8%) and Rb (58.5%) in gallbladder carcinoma were significantly lower compared to those in adenoma (100.0%) and cholecystitis (100.0%) (P<0.05). The positive rates of p16 and Rb in Nevin stagings S(1)-S(2) (80.0% and 90.0%) and S(3) (46.2% and 61.5%) gallbladder carcinomas were significantly higher than those in S(4)-S(5) (33.3% and 38.8%) (P<0.05), and those in pathologic grades G(1) (54.5% and 81.8%) and G(2) (50.0% and 62.5%) gallbladder carcinoma were significantly higher than those in G(3) (28.6% and 35.7%) (P<0.05). The protein expression of p16 and Rb had a negative-correlation in gallbladder carcinoma (r = -0.2993, P<0.05), and this negative-correlation was correlated with Nevin staging (P<0.05). Moreover, the protein expression of p16 and cyclin D1 had a negative-correlation in gallbladder carcinoma (r = -0.9417, P<0.05). CONCLUSION: Cyclin D1 may play a role in the early stage of gallbladder carcinoma. Mutation of p16 and Rb genes might be correlated with progression of gallbladder carcinoma. Analysis of p16 and Rb can estimate the prognosis of gallbladder carcinoma. Expression of p16 and Rb may be correlated with Nevin staging and pathologic grading in gallbladder carcinoma.
Adenoma↗
Mucin gene expression in gallbladder epithelium with black pigment stone ascertained by in situ hybridization.
Black pigment stones are usually found in patients with liver cirrhosis or hemolytic disease. Mucoglycoproteins are present in a significant amount in black pigment stones and contribute to the matrix of gallstones. Epithelium of stone-containing gallbladders contains much more mucin than those without stones. In this study, we try to determine by in situ hybridization the mucin gene expression in black stone-containing gallbladders and try to find the diversity of mucin gene expression in gallbladders containing black pigment stones and those without stones. In situ hybridization with DIG-tailed oligonucleotides was performed on sections of paraffin-embedded tissues of gallbladders with black pigment stones (n = 10) and those without stones (n = 6) to identify the expression of MUC1, MUC2, MUC3, MUC4, MUC5B and MUC6 in gallbladder epithelium. The findings showed that (1) mRNA expression of MUC1, MUC3, MUC5B and MUC6 were found in all gallbladders with black pigment stones, while they were expressed in 33.3%, 83.3%, 83.3% and 66.7% respectively in those without stones. They were expressed more strongly and extensively in gallbladders with stones when compared to those without stones. (2) MUC2 and MUC4 labeling were absent in gallbladders without stones, while they were present in 20% and 60% of gallbladders with black pigment stones, respectively. We conclude that MUC3, MUC5B and MUC6 were the main mucin gene expression in either gallbladder with or without stones. Altered mucin gene expression occurred in gallbladders with black pigment stones, such as the presence of MUC2 and MUC4 and increased expression of MUC1, MUC3, MUC5B and MUC6 in black stone-containing gallbladders. The higher incidence and stronger labeling intensity of mucin gene expression of MUC2, MUC3, MUC5B and MUC6 in black stone-containing gallbladder may reflect abundant mucin content in these gallbladders. Increased expression of MUC2 and MUC4 in black stone-containing gallbladder epithelium indicated that intestinal metaplasia and altered mucin genes could occur in diseased gallbladders.
Adult↗
Gallbladder motility and cholecystokinin secretion during continuous enteral nutrition.
OBJECTIVES: During total parenteral nutrition, gallbladder motility is impaired, resulting in sludge and stone formation. Little is known about gallbladder motility during prolonged enteral nutrition. METHODS: We studied gallbladder motility during continuous enteral nutrition (CEN) in nine hospitalized patients with active inflammatory bowel disease. The patients received a polymeric diet (2000 kcal/24 h) by CEN through a nasogastric tube for a prolonged period. Gallbladder volumes were obtained daily by ultrasonography, starting from day 0 (before CEN) and on 7 consecutive days during CEN. At days 0, 1, 4, and 7, the gallbladder response to i.v. cholecystokinin (CCK-33; 0.5 Ivy Dog unit/kg/h) was studied. Plasma CCK levels were determined at regular intervals by radioimmunoassay. RESULTS: No significant differences were observed on day 0 between patients and a group of nine healthy control subjects in fasting gallbladder volumes (19.4 +/- 2.3 and 19.6 +/- 2.4 cm3, respectively) and gallbladder contraction during CCK infusion (56 +/- 14% and 69 +/- 7%, respectively). During CEN, from day 1 to day 7, mean gallbladder volume remained significantly (p < 0.05) reduced compared with fasting gallbladder volume, and mean plasma CCK levels remained significantly (p < 0.05) increased compared with fasting levels. Although gallbladder volume was significantly reduced during CEN, the gallbladder contractile response to CCK was not affected; at days 1, 4, and 7, gallbladder contraction was 36-57%. CONCLUSIONS: During CEN, 1) gallbladder volume is significantly reduced and plasma CCK levels are significantly increased, 2) these effects are sustained over time (7 days), and 3) the gallbladder remains responsive to exogenous CCK. These results indicate that gallbladder contractility and gallbladder responsiveness to CCK are preserved during prolonged CEN in patients with inflammatory bowel disease.
Adult↗
Ultrasound evaluation of centenarians' gallbladder.
Background: Ultrasound (US) examination of gallbladder is considered to be reliable, both in morphological and functional evaluation. We used US to study the gallbladder of a series of centenarians in order to show the characteristics of this organ in these subjects. We then compared the data obtained with two control populations omposed of elderly and adult subjects, respectively. Methods: US examination was done after an overnight fast and after emptying the gallbladder at 15-min intervals for a period of 90 min. To induce emptying of the gallbladder, we chose a semisolid meal with a small caloric value (370 kcal). The following parameters were evaluated: fasting gallbladder volume (in milliliters) before administration of the meal (considered to be 100%); gallbladder emptying (according to the formula: fasting gallbladder volume minus post-meal gallbladder volume at 10-min intervals divided by fasting gallbladder volume: the result of this operation was multiplied by 100); gallbladder motor functions, such as ejection volume (ml), is considered as the difference between fasting gallbladder volume and residual volume; ejection fraction (%), considered as the difference between fasting gallbladder volume and residual volume, is expressed as percentage fasting volume; and ejection rate (%/min) is calculated by dividing ejection fraction by time requested to reach the residual volume. Results: We found a common bile duct diameter that was significantly higher in centenarians than in the elderly and adults. Gallbladder wall thickness was significantly higher in centenarians than in adults. We also found substantially significant differences between centenarians with and without gallstones and elderly and adult subjects in the following parameters: mean gallbladder volume (reduced), residual volume (reduced), ejection volume (reduced) and ejection rate (reduced). The differences were not significant for the ejection fraction, and they were slightly reduced in centenarians compared to the other groups. There was a negative correlation between age and axial length (transverse diameter), age and width and age and common bile duct (CBD) diameter in the elderly group only. Conclusions: The study of gallbladder function in elderly people and centenarians is important because this parameter is related to the quality of digestion and absorption of many alimentary substances as well as to the formation of cholesterol gallstones. We found that gallbladder functions in centenarians are almost normal with respect to the elderly and adults. Contractility was higher than in our elderly sample. This fact ensures a correct concentration of bile salts and a good intestinal transit rate. It may represent one of the factors allowing for good digestive function in these subjects, which contributes to their health status.
Journal Article↗
Carcinoma in the porcelain gallbladder: a relationship revisited.
BACKGROUND: Gallbladder cancer is the most common biliary tract malignancy. Calcification of the gallbladder wall is reported to be associated with gallbladder cancer. In the literature, the incidence is quoted to be between 12% and 61%. This study aims to clarify the risk of cancer in a calcified gallbladder. METHODS: The charts and pathology reports at the Massachusetts General Hospital were reviewed, and patients with either gallbladder cancer or a calcified gallbladder were included in the study. The Fisher exact test was used to test for the association between cancer and gallbladder wall calcifications. RESULTS: From 1962 to 1999, there were approximately 25,900 gallbladder specimens analyzed at the Massachusetts General Hospital. There were 150 patients with gallbladder cancer and 44 patients with calcified gallbladders. Two types of calcified gallbladders were noted: those with complete intramural calcification (n = 17) and those with selective mucosal calcification (n = 27). The incidence of cancer arising in a gallbladder with selective mucosal wall calcification was approximately 7%. There was a significant association between gallbladder cancer and selective mucosal calcification with an odds ratio of 13.89 (P =.01). There were no patients with diffuse intramural calcification and cancer. CONCLUSIONS: A calcified gallbladder is associated with an increased risk of gallbladder cancer, but at a much lower rate than previously estimated. The incidence of cancer depends on the pattern of calcification; selective mucosal calcification poses a significant risk of cancer whereas diffuse intramural calcification does not.
Adult↗
Endoscopic sonographic evaluation of the thickened gallbladder wall in patients with acute hepatitis.
PURPOSE: Thickening of the gallbladder wall is often observed during abdominal sonographic examination in patients with acute hepatitis. However, there is rarely an opportunity for a histopathologic analysis of these structural changes. Endoscopic sonography (EUS) can accurately delineate the structure of the gallbladder wall and therefore may be useful for visualizing changes in the gallbladder wall in patients with acute hepatitis. Hence, we prospectively studied the ability of EUS to detect specific structural changes in the gallbladder wall in patients with acute hepatitis and examined the effect of high elevation of serum liver enzyme levels on the gallbladder wall. METHODS: A study group of patients diagnosed with acute hepatitis who had gallbladder wall thickening and a control group of patients without acute hepatitis or gallbladder disease underwent EUS between May 1, 1999, and June 1, 2002. EUS was used to measure the thickness of the gallbladder wall and to visualize each of its layers. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels of the patients with acute hepatitis were measured at the time of the EUS examination. Statistically significant differences were determined using an independent t test and the chi-squared test. A p value of less than 0.05 was considered statistically significant. RESULTS: The acute hepatitis group comprised 28 men and 24 women with a mean age of 40.8 years. The control group comprised 25 men and 25 women with a mean age of 45.1 years. The mean gallbladder wall thickness +/- standard deviation in the acute hepatitis group (6.3 +/- 2.6 mm) was significantly greater than that in the control group (1.6 +/- 0.4 mm; p < 0.01). The mean thickness of the gallbladder wall for patients in whom both the AST and the ALT levels were 500 U/l or higher (7.0 +/- 2.6 mm) was significantly greater than that for patients with levels below 500 U/l (5.4 +/- 2.3 mm; p < 0.05). In the acute hepatitis group, EUS showed thickened, well-defined muscular and serosal layers of the gallbladder wall in 24 of the patients and a diffusely thickened gallbladder wall, in which each layer was ill defined, in the other 28 patients. The mean thickness of the gallbladder wall for patients with the pattern of ill-defined layers was significantly greater than that for the patients with the pattern of well-defined layers (p < 0.05). The pattern of ill-defined layers was more common among patients in whom the serum AST and ALT levels were at least 500 U/l than among patients with levels below 500 U/l (p < 0.05). CONCLUSIONS: We propose that gallbladder wall thickening in patients with acute hepatitis is associated with prominent changes in the muscular and serosal layers. Patients with highly elevated serum liver enzyme levels are more likely to have gallbladder wall thickening and disruption of planes between the muscular and serosal layers than are patients with normal liver enzyme levels.
Acute Disease↗
Characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver, sphincter, and gallbladder in patients with sphincter of Oddi spasm.
The major objectives of this project were to establish the pattern of basal hepatic bile flow and the effects of intravenous administration of cholecystokinin on the liver, sphincter of Oddi, and gallbladder, and to identify reliable parameters for the diagnosis of sphincter of Oddi spasm (SOS). Eight women with clinically suspected sphincter of Oddi spasm (SOS group), ten control subjects (control group), and ten patients who had recently received an opioid (opioid group) were selected for quantitative cholescintigraphy with cholecystokinin. Each patient was studied with 111-185 MBq (3-5 mCi) technetium-99m mebrofenin after 6-8 h of fasting. Hepatic phase images were obtained for 60 min, followed by gallbladder phase images for 30 min. During the gallbladder phase, 10 ng/kg octapeptide of cholecystokinin (CCK-8) was infused over 3 min through an infusion pump. Hepatic extraction fraction, excretion half-time, basal hepatic bile flow into the gallbladder, gallbladder ejection fraction, and post-CCK-8 paradoxical filling (>30% of basal counts) were identified. Seven of the patients with SOS were treated with antispasmodics (calcium channel blockers), and one underwent endoscopic sphincterotomy. Mean (+/-SD) hepatic bile entry into the gallbladder (versus GI tract) was widely variable: it was lower in SOS patients (32%+/-31%) than in controls (61%+/-36%) and the opioid group (61%+/-25%), but the difference was not statistically significant. Hepatic extraction fraction, excretion half-time, and pattern of bile flow through both intrahepatic and extrahepatic ducts were normal in all three groups. Gallbladder mean ejection fraction was 9%+/-4% in the opioid group; this was significantly lower (P<0.0001) than the values in the control group (54%+/-18%) and the SOS group (48%+/-29%). Almost all of the bile emptied from the gallbladder refluxed into intrahepatic ducts; it reentered the gallbladder after cessation of CCK-8 infusion (paradoxical gallbladder filling) in all eight patients with SOS, but in none of the patients in the other two groups. Mean paradoxical filling was 204% (+/-193%) in the SOS group and less than 5% (P<0.05) in both the control and the opioid group. After treatment, six of the SOS patients had complete pain relief and one, partial pain relief. The basal tonus of the sphincter is variable in patients with SOS, and allows relatively more of the hepatic bile to enter the GI tract than the gallbladder. Due to simultaneous contraction of the sphincter and gallbladder in response to CCK-8, most of the bile emptied from the gallbladder refluxes into intrahepatic ducts, and reenters the gallbladder immediately after cessation of hormone infusion. The characteristic features of gallbladder filling, emptying, and paradoxical refilling with cholecystokinin provide objective parameters for noninvasive diagnosis of SOS by quantitative cholescintigraphy.
Adult↗
[Effect of gastrectomy on gallbladder motility: an experimental study].
Gallstone formation is frequently seen following gastric surgery. Since dysmotility and bile stasis of the gallbladder is considered as an important factor in the pathogenesis of gallstone formation, altered gallbladder motility due to gastric surgery may have a role in the development of post-gastrectomy gallstone formation. To test this hypothesis, the effect of distal partial gastrectomy on gallbladder motility were studied. Gastroduodenal and gallbladder contractions were recorded by chronically implanted strain gauge transducers under conscious state. Gallbladder volume changes were monitored using chronically indwelling gallbladder catheter. Fasted and fed motility were studied in control (n = 5) and gastrectomized (n = 3) dogs. Plasma concentration of putative hormone CCK was measured. Effect of CCK-OP and motilin on gallbladder emptying were also studied. In fasted state, gallbladder volume was periodically decreased synchronous with phase 3 of interdigestive migrating contractions (IMC) in the gastroduodenum in both group of dogs. The correlation between gastric and gallbladder contractions was preserved even following distal partial gastrectomy, though the frequency of phasic contractions during phase 3 of IMC was decreased in the gastrectomized dogs. Postprandial gallbladder emptying tend to decreased in the gastrectomized dogs, while there were no difference in the postprandial plasma CCK concentrations and CCK-OP induced gallbladder emptying between groups. Digestive period was shortened in the gastrectomized dogs, which resulted in early gallbladder refilling and prolonged interdigestive period. Decreased frequency of gallbladder phasic contractions during IMC and prolonged interdigestive period could cause bile stasis in the gallbladder, which may, in part, explain post-gastrectomy gallbladder formation.
Animals↗
Sonographic findings in perforation of the gallbladder.
The sonographic findings in 13 patients with proven gallbladder perforation are described. Two patients were scanned immediately before and after gallbladder perforation. The sonographic findings before gallbladder perforation were gallbladder distension (one case) and gallbladder wall edema (one case). Pericholecystic collections develop after gallbladder perforation. These collections have a varied sonographic appearance ranging from anechoic to complex collections, and their internal characteristics seem to depend on the duration of the pericholecystic process. The residual gallbladder lumen or calculi can be identified within or peripheral to the pericholecystic process. The most acceptable mechanism for perforation of the gallbladder is: (1) impaction of a calculus in the cystic duct; (2) gallbladder distension due to secretion into its lumen by mucous glands located in the walls of the gallbladder; (3) vascular impairment of the gallbladder due to distension of the viscus; and (4) ischemia, necrosis, and perforation of the gallbladder wall. Gallbladder perforation is a significant complication of acute cholecystitis associated with morbidity and mortality. Detection of this complication of acute cholecystitis by clinical means is difficult since the patient's symptoms are similar to those of uncomplicated acute cholecystitis. The inherent resolution of sonography offers an excellent display of the gallbladder and surrounding tissues allowing detection of pericholecystic collection secondary to gallbladder perforation.
Abscess↗
Relative risk factors analysis of 3,922 cases of gallbladder cancer.
OBJECTIVE: To make clear the relationship between gallstones and gallbladder cancer, the relationship between the size of gallstones and gallbladder cancer, the course of gallbladder cancer, and the relationship among adenoma and carcinoma of gallbladder and ascariasis in the biliary tract. METHODS: A total of 3,922 cases of gallbladder cancer from 28 provinces in china from 1986 to 1998 were reviewed, according to a standard protocol called "the clinical epidemiological list of gallbladder cancer". RESULTS: Gallbladder cancer accounted for 0.4% - 3.8% of bile tract disease in the same period, averaging 1.53%. Gallbladder cancer accounted for 0.1% - 1.1% of abdominal surgery in the same period. Gallstones were found in 46.7% of the cases of gallbladder cancer, the related risk (RR) of gallbladder cancer with gallstones was 13.7. The average course with gallstones was 10 - 15 years. The gallstone in gallbladder was 3 cm or above in diameter. The ratio of the progression from adenoma to carcinoma of gallbladder was 1.5%. Only 4 cases of ascariasis was reported. CONCLUSIONS: Gallbladder cancer and gallstones are closely associated. Patients with gallstone of 3 cm or above in diameter and a course of 10 - 15 years are usually at an increased risk for cancer. We found the adenoma and carcinoma of gallbladder are closely related, and there is no relationship between gallbladder cancer and ascariasis in our group.
Ascariasis↗
Nonalcoholic Fatty gallbladder disease: the influence of diet in lean and obese mice.
The obesity epidemic has contributed to an increased prevalence of gallstones and a higher percentage of chronic acalculous cholecystitis. Obesity is associated with Type II diabetes and hyperlipidemia in murine models. In addition, we have previously demonstrated that serum glucose, insulin, cholesterol, and triglycerides correlated with gallbladder contractility in murine models. However, the relative role of insulin resistance and gallbladder fat infiltration in this phenomenon remain unclear. Therefore, we tested the hypothesis that gallbladder wall lipids are related to obesity and diet and are inversely correlated with gallbladder contractility. One hundred lean control (C7BL/6J) and 36 obese leptin-deficient (Lep(ob)) 8-week-old female mice were fed either a chow diet or a 1.0% cholesterol, 15% butterfat (high-lipid) diet for four weeks. Pooled gallbladders were then analyzed for free fatty acids (FFA), phospholipids (PL), total cholesterol (TC), and triglycerides (TG). Cholesterol/phospholipid ratios were then calculated. The Lep(ob) mice fed a chow diet had significantly higher (P < 0.01) gallbladder lipids than the three other groups. The lean mice that were fed a high-lipid diet had increased (P < 0.05) gallbladder TC compared to the lean mice on a chow diet. In addition, the cholesterol/phospholipid ratio was significantly increased (P < 0.01) in the lean mice fed a high-lipid diet compared to the other three groups. Finally, the high-lipid diet decreased gallbladder FFA (P < 0.01), PL (P = 0.08), and TC (P < 0.05) in Lep(ob) mice. These data suggest that (1) obese mice have increased gallbladder lipids; (2) a high-cholesterol, high-fat diet increases gallbladder lipids and the cholesterol/phospholipid ratio in lean mice; but (3) decreases gallbladder fatty acids, phospholipids, and cholesterol in obese mice. Prior studies have documented similarly decreased gallbladder response to neurotransmitters in obese mice on a chow diet, as well as lean and obese mice on a high-lipid diet. Therefore, we conclude that leptin-deficient obesity and/or a high-fat diet causes nonalcoholic fatty gallbladder disease, which is manifested by diminished gallbladder contractility.
Adipose Tissue↗