[Gallbladder injury, injury of the gallbladder, traumatic rupture of the gallbladder].
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Diagnosis, Differential↗
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Effect of extracorporeal shock-wave lithotripsy on gallbladder emptying in patients with solitary and multiple gallbladder stones.
In a prospective study, we investigated the effect of extracorporeal shock-wave lithotripsy (ESWL) on gallbladder contractility and on fasting and residual gallbladder volume in patients with solitary and multiple gallbladder stones with stone densities < 100 Hounsfield units (HU) and adequate gallbladder function. Twenty-five patients (seven males and 18 females, mean age 48.5 +/- 11.7 years) treated with ESWL were assigned to either group I, consisting of 13 patients with solitary stones < 20 mm diameter, or group II, including patients with two to three stones and maximum stone diameter of 30 mm. ESWL was performed with the MPL 9000 lithotripter. Gallbladder ejection fraction was determined using the method of Dodds after a 12-hr fast and following application of a standard stimulative meal. Gallbladder volume was measured by ultrasound over 90 min at 10-min intervals before ESWL, then at 1, 30, 120, and 210 days after ESWL. At 24 hr after ESWL, residual gallbladder volume increased in group I from 7.4 ml to 13.9 ml (P = 0.0567) and in group II from 6.5 ml to 20.2 ml (P = 0.0076). Thereafter, residual volumes returned to pre-ESWL levels. In group II, post-ESWL fasting volumes were significantly increased over initial values at all time intervals. Correspondingly, only at 24 hr after ESWL, ejection fractions decreased from 73.1% to 64.9% in group I and from 76.5% to 62.7% in group II. No statistically significant differences in gallbladder contractility between the two groups were observed at any point of the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Preserved extrinsic neural connection between gallbladder and residual stomach is essential to prevent dysmotility of gallbladder after distal gastrectomy.
Many reports have been made on gallbladder dysfunction after gastric surgery. We reported that the gallbladder contractions were abolished after antrectomy. Our hypothesis is that preservation of the neural connection along gastric vessels maintains normal gallbladder function during fasting after antrectomy. Six dogs underwent antrectomy with preservation of the extrinsic nerves and six other dogs underwent conventional antrectomy with dissection of the extrinsic nerves and vessels. Laparotomy alone was performed on another six control dogs. Motor activities of the gallbladder and upper gastrointestinal tract were recorded by strain gauges in conscious dogs. Motilin and CCK-OP were used for pharmacological interventions. In conventional antrectomy, the amplitudes of the cyclic motor activity of the gallbladder and the stomach during fasting were significantly reduced, while this activity was maintained in dogs when extrinsic nerves were preserved. The coordination of the motor activity among the gallbladder, stomach and the duodenum was not impaired in the dogs when extrinsic nerves were preserved. The contractions of the gallbladder induced by exogenous motilin were reduced significantly in conventional antrectomy. Therefore, the preserved neural connection along the gastric vessels maintains normal gallbladder function in the fasting state even after distal gastrectomy.
Animals↗
Prolonged postprandial abdominal pain following Kawasaki syndrome with acute gallbladder hydrops: association with impaired gallbladder emptying.
Acute hydrops of the gallbladder is a well-recognized complication of Kawasaki syndrome. We report a case of a child with this syndrome whose gallbladder hydrops slowly resolved after intravenous gamma-globulin therapy. However, he continued to experience postprandial right upper quadrant abdominal pain. Hepatobiliary scintigraphy revealed normal filling of the gallbladder but marked impairment of meal-stimulated gallbladder emptying. Endoscopy with biopsy of the esophagus, stomach, and duodenum was normal, ruling out peptic complications of his aspirin therapy. This child's discomfort improved slowly over several months, finally ending approximately 6 months after the onset of his illness. A repeat gallbladder emptying study done ultrasonographically at that time revealed near-normal meal-stimulated gallbladder emptying. We conclude that poor emptying of the gallbladder may be associated with prolonged abdominal pain in Kawasaki syndrome. Meal-stimulated gallbladder emptying can be assessed by a simple ultrasonographic technique and should be considered in any patient with Kawasaki syndrome and abdominal pain.
Abdominal Pain↗
Evaluation of gallbladder function by quantitative radionuclide cholescintigraphy in patients with gallbladder sludge or stones.
Thirteen patients with gallbladder sludge, 14 patients with gallstones and 24 control cases with normal gallbladders were included in the study. Gallbladder function was represented as the filling fraction (FF) and the ejection fraction (EF) calculated using quantitative 99Tcm-DISIDA cholescintigraphy and compared in the groups. The results showed that (1) the patients with normal gallbladders had the highest FF and EF, (2) those with gallstones had the lowest FF, (3) the patients with gallbladder sludge had the lowest EF, and (4) the coefficient of variation (CV) of FF and EF of the normal controls were less than those for the patients with gallstones or sludge. There was only a statistically significant difference between the normal controls and the patients with gallstones for FF. However, no significant differences existed among the three groups for EF. In our preliminary results, we found that gallbladder sludge or stones may impair gallbladder function, especially FF, as evidenced by noninvasive and quantitative 99Tcm-DISIDA cholescintigraphy, and the higher CV value suggests that gallbladder function in patients with gallstones or sludge is more variable.
Aged↗
Increased acylCoA-cholesterol ester acyltransferase activity in gallbladder mucosa in patients with gallbladder cholesterolosis.
OBJECTIVE: Although cholesterolosis of the human gallbladder is a relatively common disease, its etiology has not been fully understood. The aim of this study was to determine this etiology. METHODS: The lipid composition of the gallbladder mucosa and gallbladder bile and the enzyme activities (acylCoA-cholesterol ester acyltransferase [ACAT] and cholesterol ester hydrolase [CEH]) of the gallbladder mucosa were measured in control subjects, patients with cholesterolosis, and patients with cholesterol gallstone disease. RESULTS: Levels of cholesterol ester in gallbladder mucosa in patients with cholesterolosis (n = 12) were higher than those in control subjects (n = 8). With regard to the lipid content in gallbladder bile, no differences were found in concentrations of cholesterol, phospholipids, and bile acids among control subjects (n = 11), patients with cholesterolosis (n = 13), and those with cholesterol gallstone disease (n = 15). In gallbladder mucosa, ACAT activity was significantly higher in patients with cholesterolosis (n = 10) than in control subjects (n = 8), whereas CEH activity did not differ between the two groups. As a result, the ACAT/CEH activity ratio was higher in patients with cholesterolosis than in control subjects. CONCLUSIONS: It would be suggested that cholesterol ester synthesis of gallbladder mucosa might play an etiological role in the development of cholesterolosis.
Bile↗
High risk of gallbladder carcinoma in elderly patients with segmental adenomyomatosis of the gallbladder.
The clinical significance of adenomyomatosis of the gallbladder remains unclear. This study aimed to clarify the relationship between segmental adenomyomatosis and gallbladder carcinoma, and to elucidate the histogenesis of gallbladder carcinoma associated with segmental adenomyomatosis. A total of 4,560 consecutive patients underwent cholecystectomy. The specimens were examined grossly and histologically. Adenomyomatosis of the gallbladder was divided into segmental, fundal, and diffuse types. Sixty noncancerous gallbladders with segmental adenomyomatosis were examined for epithelial metaplasia. The incidence of gallbladder carcinoma was higher in patients with segmental adenomyomatosis (22/334, 6.6%) than in those without (181/4226, 4.3%; P=0.049). This difference was more marked among patients equal to or older than 60 years of age (15/96,15.6% versus 147/2407, 6.1%, respectively; P<0.001). The other types of adenomyomatosis did not show any significant increases in the incidence of gallbladder carcinoma. In all 22 patients with both segmental adenomyomatosis and carcinoma, the tumors developed only in the fundal mucosa. Epithelial metaplasia was more marked in the fundal mucosa of segmental adenomyomatosis than in the neck mucosa (P=0.003). Segmental adenomyomatosis is a high-risk condition for gallbladder carcinoma, especially in elderly patients. Epithelial metaplasia appears to be related to increased carcinogenesis in the fundal mucosa of segmental adenomyomatosis.
Adenomyoma↗
Endoscopic stenting of the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease awaiting orthotopic liver transplantation.
Cholecystectomy in patients with advanced cirrhosis is associated with excessive morbidity and mortality. Because open cholecystectomy in patients with Child's class C cirrhosis has a reported mortality rate as high as 83%, symptomatic gallbladder disease in patients awaiting orthotopic liver transplantation (OLT) poses a unique clinical problem. The goal of this study is to determine whether the treatment of symptomatic gallbladder disease with endoscopic stenting of the gallbladder effectively reduces biliary symptoms and complications or the need for cholecystectomy. Thirteen patients with symptomatic gallbladder disease with and without cholelithiasis and advanced cirrhosis who were candidates for OLT underwent placement of a biliary stent from the gallbladder to the duodenum at endoscopic retrograde cholangiography. In each patient, biliary symptoms and complications ceased after stent placement. Seven patients underwent successful OLT 1 to 24 months after the procedure. One patient subsequently became a noncandidate for OLT and died of diabetes complications 3 years after the procedure. Five others are awaiting OLT (6 to 28 months postprocedure). One patient had recurrent pericholecystic fluid collection requiring percutaneous drainage and antibiotic therapy 8 months after the procedure. No patient has had recurrent symptoms, and currently all patients are free of complications. None required surgical intervention of the gallbladder or biliary tree. We conclude that endoscopic stenting of the gallbladder is the preferred treatment for symptomatic gallbladder disease in patients with end-stage liver disease awaiting OLT. This approach is noninvasive, safe, and effective in preventing potential morbidity and mortality.
Adult↗
Control of gallbladder contractions by cholecystokinin through cholecystokinin-A receptors in the vagal pathway and gallbladder in the dog.
The mechanism of CCK action on gallbladder contractions in the physiological condition is unclear. Gallbladder contractions were monitored by means of chronically implanted force transducers in conscious dogs. Postprandial gallbladder contractions were partially inhibited by atropine and hexamethonium, and completely inhibited by devazepide. In vitro contractile response of canine gallbladder muscle strips to CCK-8 was also studied. CCK-8-induced muscle strip contraction was atropine and tetrodotoxin resistant, but was completely eliminated by devazepide. The existence of CCK receptors in the vagal nerve and gallbladder was examined by means of autoradiography. Forty-eight hours after ligation of the abdominal vagus, CCK-8 binding sites were found to accumulate in the subdiaphragmatic vagal nerve immediately proximal to the ligature, and similar binding sites were also found in the gallbladder smooth muscle layer. These binding sites were displaced by the addition of 10(-7) mol/1 unlabeled CCK-8 and devazepide, but L-365,260 had no effect. In conclusion, it is considerable that postprandial CCK-induced gallbladder contractions are controlled through CCK-A receptors both on the vagal nerve in stimulating endogenous release of acetylcholine and on the gallbladder directly to stimulate muscle contraction in the dog.
Animals↗
Carcinoma of the gallbladder: a risk associated with gallbladder-preserving treatments for cholelithiasis.
Five cases of carcinoma of the gallbladder associated with nonsurgical treatment of cholelithiasis are presented in view of the recent interest in gallbladder-preserving procedures. Three patients developed gallbladder cancer that was diagnosed 4, 11, and 72 years, respectively, after cholecystostomy. One other patient had gallbladder carcinoma diagnosed 7 months after extracorporeal shock wave lithotripsy for common bile duct stones. The tumor was probably present but not identified at the time of lithotripsy. The last patient had undiagnosed gallbladder malignancy at the time of cholecystostomy for treatment of acute calculous cholecystitis. Gallbladder carcinoma has been reported in 1% of patients undergoing cholecystectomy, and the risk of carcinoma developing in patients with asymptomatic cholelithiasis has been estimated at less than 1%. These figures should not diminish the role of gallbladder-preserving treatments in elderly and selected high-risk patients for whom cholecystectomy may be hazardous. However, such patients must undergo a thorough imaging assessment both before and after treatment to ensure that a gallbladder carcinoma is not overlooked.
Aged↗
Relationship between gallbladder histopathology and ability to concentrate biliary lipids and bilirubin. A study on gallstone patients with functioning gallbladder.
Biliary lipids and bilirubin were measured in hepatic and gallbladder bile obtained at routine cholecystectomy in 35 gallstone patients. The gallbladders had opacified at cholecystography and the cystic ducts were patent at operation. The histologic changes in the gallbladder wall were evaluated by an independent pathologist. Increasing abnormality of the gallbladder wall was shown to be associated with reduced gallbladder contents/hepatic bile ratio of biliary lipids and of bilirubin. The concentrating function of the human gallbladder thus appears to be impaired in proportion to the severity of histologic lesions in its wall. Taken together with earlier findings in vitro, this relationship suggests impaired absorption of electrolytes and water by the gallbladder mucosa, or diffusion of biliary constituents from the lumen of the inflamed gallbladder.
Bile↗
Endoscopic ultrasonography for demonstrating loss of multiple-layer pattern of the thickened gallbladder wall in the preoperative diagnosis of gallbladder cancer.
The purpose of this study was to elucidate the roles of endoscopic ultrasonography (EUS), conventional US, CT, and MRI in differential diagnosis of gallbladder wall thickening. We scrutinized images for the presence of the multiple-layer patterns of the thickened gallbladder walls during preoperative images (EUS, n = 22; US, n = 23; CT, n = 20; MRI, n = 15) and retrospectively correlated them with surgical results in 25 patients. The pathological diagnoses included 7 gallbladder cancers, 9 cases of chronic cholecystitis, 5 cases of xanthogranulomatous cholecystitis, and 4 cases of adenomyomatosis. Multiple-layer patterns of gallbladder wall were observed in patients with inflammatory and benign diseases by US, EUS, CT, and MRI. This pattern was demonstrated by EUS more efficiently compared with other means of imaging. All subjects with loss of multiple layers were finally diagnosed by use of EUS as having gallbladder cancer at surgery. Loss of multiple-layer patterns of the gallbladder wall demonstrated by EUS was the most specific finding in diagnosing gallbladder cancer.
Adenomyoma↗
Preoperative diagnosis and management of thick-walled gallbladder based on bile cytology obtained by endoscopic transpapillary gallbladder drainage tube.
BACKGROUND: It is often difficult to distinguish gallbladder cancers (GBC) from benign gallbladder diseases, which show thickened walls. OBJECTIVES: To evaluate the efficacy of bile cytology using endoscopic transpapillary gallbladder drainage (ETGD) and CT. DESIGN: Retrospective study. SETTING: Division of Gastroenterology, Tokyo Medical University, Tokyo, Japan. PATIENTS AND INTERVENTIONS: Eighty-five patients with gallbladder diseases, consisting of 27 GBC and 58 benign gallbladder diseases, were reviewed. A pigtail-type nasobilliary drainage tube was left indwelling in the gallbladder, and through this drainage tube washing cytology was performed with an ETGD tube. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of CT and cytology. Complications and outcome were also evaluated. RESULTS: CT and cytology with the ETGD tube had 81% and 81% sensitivity, 91% and 83% specificity, and 88% and 82% accuracy, respectively (P > .05). Looking only at the 71 successful ETGD cases, CT and ETGD cytology had 82% and 100% sensitivity, 92% and 98% specificity, and 89% and 99% accuracy, respectively (P = .036 and .025, respectively). Four patients with GBC in whom CT showed benign findings underwent open cholecystectomy because ETGD cytology revealed malignant findings. In contrast, 4 patients with benign diseases in whom CT suggested malignant finding underwent LC because the findings of ETGD cytology suggested benign disease. CONCLUSIONS: Cytology using an ETGD tube is very useful in the diagnosis and management of gallbladder diseases.
Adult↗
Effect of indomethacin and misoprostol on fasted gallbladder volume and meal-induced gallbladder contractility in humans.
Impaired gallbladder contractility is a prerequisite for gallstone formation in animal models. Prostaglandins are important mediators of gallstone formation and may affect gallbladder contractility in animals. The aim of this study was to evaluate the effect of indomethacin, an inhibitor of prostaglandin synthesis, and misoprostol, a synthetic prostaglandin, on gallbladder contractility in man. Seven male volunteers (18-33 years old, mean age 23 years) were studied under blinded conditions after an overnight fast, during control periods and following ingestion of indomethacin 125 mg (75 mg at 10 PM, 50 mg at 6:30 AM) or misoprostol 800 micrograms (400 micrograms at 10 PM, 400 micrograms at 6:30 AM) orally. Gallbladder residual volume was determined by real-time ultrasonography before and 10, 20, 30, 40, and 50 min after ingestion of a standard liquid fatty meal stimulus. Fasting gallbladder volume (milliliters) was similar in all three periods [control 20.8 (1.6); indomethacin 20.8 (2.9); misoprostol 18.3 (1.6)]. The fatty meal stimulus caused prompt contraction, resulting in minimum residual volume of 7.5 (1.4) ml in the control period. Pretreatment with misoprostol or indomethacin did not affect the minimum volume obtained compared with control period [misoprostol: 5.8 (1.4) ml; indomethacin 5.9 (1.3) ml)]. Thus administration of indomethacin and misoprostol had no effect on fasting gallbladder volume or gallbladder contractility in humans as assessed by ultrasonography.
Adolescent↗
Gene mutations of K-ras in gallbladder mucosae and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct.
OBJECTIVE: In this study, we examined the mutational spectrum of K-ras in cases of gallbladder and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct (AJPBD). METHODS: We examined 35 gallbladders with AJPBD (20 with hyperplasia, 15 with carcinoma) and 38 gallbladders without AJPBD (four normal gallbladders, four with hyperplasia, six with adenoma, 24 with carcinoma). Polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) and direct sequencing were performed to detect mutations in codon 12 or 13 of K-ras. RESULTS: In the cases with AJPBD, the prevalences of K-ras mutation were 15% (3/20) in hyperplasia, 60% (6/10) in stage I carcinoma, and 100% (5/5) in stage II-IV carcinoma. In the cases without AJPBD, the prevalences of K-ras mutation were 0% (0/4) in normal gallbladder, 0% (0/4) in hyperplasia, 17% (1/6) in adenoma, 7% (1/16) in stage I carcinoma, and 38% (3/8) in stage II-IV carcinoma. Prevalences of K-ras mutation in hyperplasia and carcinoma with AJPBD were greater than those without AJPBD (p < 0.05). The point mutation of GGT to GAT in codon 12 was frequently observed in the cases with AJPBD. CONCLUSION: These results suggest that the specific K-ras mutation in codon 12 (GGT to GAT) may contribute to the early stage of carcinogenesis in the gallbladder with AJPBD.
Adenoma↗
Blood flow in healthy gallbladder walls on color and power Doppler sonography: effect of wall thickness and gallbladder volume.
OBJECTIVE: The purpose of this study was to determine the effect of gallbladder contraction on the conspicuity of flow in the normal gallbladder wall. SUBJECTS AND METHODS: Ten healthy adult volunteers without clinical evidence of gallbladder disease participated in the study. After patients fasted overnight, the gallbladder was scanned using gray-scale, color Doppler, and power Doppler sonography. The subjects were then given a standard meal consisting of 478 ml of a carbohydrate-rich dietary supplement, and the imaging sequence was repeated 20 and 45 min thereafter. Mural flow was graded using a four-step grading scheme. Gallbladder volume, wall thickness, and visibility of mural flow at all three time points were statistically compared. RESULTS: Enhanced mural flow was seen after meal consumption in all but one volunteer. Overall, mural flow was significantly greater 45 min after eating than at baseline or 20 min on color Doppler sonography (p = .004) and power Doppler sonography (p = .008). CONCLUSION: Flow in the gallbladder wall is a normal finding that is seen more easily when the gallbladder is contracted. This fact must be kept in mind when sonography is used with patients in whom acute cholecystitis is suspected, particularly if they do not fast before sonography.
Adult↗
A hepatocellular carcinoma with lymph node metastasis and invasion into the gallbladder: preoperative difficulty ruling out a gallbladder carcinoma.
We present a case of resected hepatocellular carcinoma (HCC) which invaded the gallbladder with a metastasis to a lymph node. It was extremely difficult to make a differential diagnosis between HCC and gallbladder cancer preoperatively. A 68-year old man was admitted to hospital with complaint of a fever. Ultrasonography (US) and CT scan showed a mass, growing invasively from the gallbladder bed of the liver (S4) to the lumen of the gallbladder. A selective arteriography showed the mass stained by the cholecystic artery, internal branch of the left hepatic artery, and frontal branch of the right hepatic artery. Endoscopic retrograde cholangiopancreatography (ERCP) showed the non-visualized gallbladder, a constriction of the common hepatic duct with suspicion of metastatic lymph nodes in the hepatoduodenal ligament. The tumor markers were: alpha-fet-protein 13175 ng/ml, PIVKA-II 26200 mAU/ml and CA19-9 0.0 U/ml. Both HBs antigen and HCV antibody were negative. We performed cholecystectomy with en-block resection of the anterior and middle inferior segment of the liver, the common bile duct and a part of the transverse colon, with dissection of the lymph nodes. The tumor, 8 cm in diameter, was brown colored without a capsule, growing diffusely in the liver, to the inside of the gallbladder and the transverse colon. Histopathological inspection of the specimen revealed moderately differentiated hepatocellular carcinoma with a metastatic lymph node along the common hepatic artery. TNM classification was IVB phase [T3,N0,M1 (LYM,OTH)]. There are only 3 previous cases of HCC reported with invasion into the gallbladder. At most 2.2% of the resected cases of HCC had metastatic lymph nodes at resection, while it was as high as 20-50% of the autopsy cases. Operation on such an invasive HCC case should consider lymph node metastasis.
Aged↗
Detection of perfusion areas of the gallbladder vein on computed tomography during arterial portography (CTAP)--the background for dual S4a.S5 hepatic subsegmentectomy in advanced gallbladder carcinoma.
BACKGROUND/AIMS: It has been speculated that the veins of the gallbladder join the intrahepatic portal veins supplying the Couinaud's S4a-S5. This has been the theoretical ground for the resection of these 2 hepatic subsegments in advanced gallbladder carcinoma. However, no consensus has been reached on this concept. METHODOLOGY: The current study describes the non-neoplastic perfusion defects in connection with the gallbladder bed in 100 consecutive hepatic CTAP (computed tomographies during arterial portography). The suitability of S4a and S5 subsegmentectomies of the liver for advanced gallbladder carcinoma was also investigated by examining CTAP images of the branches of the portal vein involved in the perfusion defect. RESULTS: Two types of gallbladder venous perfusion were observed: 1) sphenoid distribution from the gallbladder bed into the P4a (37%), P5 (52%) and P6 (3%), and 2) perfusion into the P4 (9%) or directly into the middle hepatic vein (9%) after communicating with the hepatic hilum at the dorsal side of S4. CONCLUSIONS: These results support liver resection at S4a and S5 as the surgical approach for cases of advanced gallbladder carcinoma.
Gallbladder↗