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The authors analyze the experience with the association of the gall-bladder disease and sickle cell anemia in ten cases. The incidence of this association in these cases was higher, about 80% (eight patients). Because of the increased frequency of cholecystitis and cholelithiasis in this disease, cholecystography (oral or endovenous) is indicated in every patient with sickle cell anemia or another hereditary (Hemolytic jaundice).
Initially a simple anatomical curiosity discovered at operation or autopsy, agenesis of the ball bladder has now, and despite its rarity, become of the greatest interest from a pathogenic, physiopathological and diagnostic standpoint. Embryogenesis explains that this a developmental abnormality affecting the hepatic diverticulum which is probably of genetic origin, hence its frequent association with other malformations and the hereditary nature of the condition. The usual finding of a syndrome of blockage of the sphincter of Oddi with dilatation of the common bile duct raises the problem of synergism between the sphincter of Oddi and the gall bladder. The discovery of lithiasis of the hepatic and common bile ducts in agenesis of the gall bladder leads to discussion of the reality of organ lithiasis or the role of the distended wall of the common duct. Cholecystography and echotomography would appear to be the two techniques of investigation to be recommended preoperatively in order to increase support for the presumptive diagnosis once disorders affecting neighbouring structures have been eliminated. The definite diagnosis is made peroperatively by manual exploration, peroperative cholangiography or even coeliac arteriography during the operation. The indication for surgery is based upon clinical symptomatology. This does not treat the agenesis but the associated lesions which are its complications, in particular: lithiasis the common duct, sphincter of Oddi block syndrome and dilatation of the common duct.
For nearly 60 years, since it was introduced by Graham and Cole (1924), oral cholecystography (OCG) has been used as the imaging technique of choice in investigation of gallbladder disorders. Recently, the future of OCG has come into doubt, principally as a result of ultrasonography, with the advent of high-resolution real-time scanning. Stones are seen as echoes within the lumen of the gallbladder and are associated with an acoustic shadow, findings which are highly specific. On this basis, to evaluate the accuracy of ultrasonography in detecting cholelithiasis, the A. have performed by real-time cholecystosonography 60 patients with not diagnostic OCG in a group of 546 patients affected by gallbladder diseases. Our results have confirmed that sonography revealed 4 normal gallbladders, 51 gallstones and 1 primary gallbladder cancer, with 5 cases of false positive. The true false negative rate has been difficult to determine, as surgery is usually not performed after a negative study. The accuracy of cholecystosonography for gallstone diagnosis was found to be 88,1% for all three Crade's categories.
The Marche SIRMN group tried to set up standard of some common radiological examinations (cholecystography, single and double contrast examination of the upper gastro-intestinal tract, and single and double contrast enema). Scientific and professional reasons led to this work. Twenty-five radiologists from thirteen centers in the Marche region cooperated on it. Some differences between the plan and the real performance of the standard radiological examinations as well as between technical and methodological performance came out. Eventually preliminary and partial data about the cost of the procedures and the final diagnostic result were obtained.
Abdominal complaints require careful diagnostic investigations even if they are thought to be functional. In about 40% of patients seen in a gastroenterologist's office in a big city no organic causes of gastrointestinal complaints can be found. In about 36% false nutrition (for instance overeating, furfurism), gastrointestinal infectious disease, abuse of laxatives or food allergies are underlying factors. Microscopic examination of the stool should be done right from the beginning in mediterranean people in order to rule our parasitic disease. Early gastroscopy may be rational however sometimes not feasible; cholecystography may explain in some cases symptoms thought to be gastrointestinal.
The rating of sonography compared with contrast roentgenography is examined for the biliary system. A high quota of accuracy equivalent or superior to contrast radiography is achieved by sonography, as demonstrated by a comparison or oral cholecystography with sonography (accuracy 69% to 95.5%), IV cholangiocholecystography (accuracy 86.5% to 88.9%) and ERCP (accuracy 69.9% to 67.3%).
Medical treatment of gallstones as an alternative to cholecystectomy has been established in recent years. Considering certain conditions--i.e. radiolucent cholesterol gallstones, functioning gallbladder, stone size, patients' cooperation--it is possible in up to 70% to dissolve gallstones completely or partially, using a therapeutic regimen of chenodeoxycholic or ursodeoxycholic acid at a dosage of 10 mg or 15 mg/kg body weight respectively. Side effects as diarrhoea or slight increase of serum transaminase levels are harmless and occur only with chenodeoxycholic acid. Therapeutic success may be controlled either by ultrasound or by cholecystography. Recurrence rate after dissolution is about 20%. Stones of the common bile duct can be treated easily by endoscopic papillotomy (EPT). In many cases the stone has to be removed with a basket; however, it may pass spontaneously. Certain indications for this procedure are obligatory. In the first place there is the patient over 50 years of age with the gallbladder already removed.
Ultrasound examinations of 140 patients with a clinical suspicion of gallstones were compared with radiographic, surgical and pathologic findings to determine the accuracy of cholecystosonography. Ultrasound was 95% accurate for gallbladder disease, with a 5% false negative rate. Oral cholecystography was 96% accurate. The abnormal ultrasound examinations were divided into three groups, as described by Crade. Group 1 -- shadowing echoes within the gallbladder which move with gravity -- was 100% accurate for gallstones. Group 2 -- non-visualization of the gallbladder with acoustic shadowing -- was 94% accurate for gallstones. Group 3 -- non-shadowing echoes within the gallbladder -- was only 59% accurate for gallstones, but 96% accurate for gallbladder disease. We recommend cholecystosonography as the initial study in the investigation of gallbladder disease.
The accuracy, sensitivity, and specificity of ultrasound versus oral cholecystography (OCG) in the preoperative diagnosis of gallstones was studied in 144 patients undergoing cholecystectomy. The 89 per cent accuracy of ultrasound was similar to the 92 per cent achieved with OCG. However, ultrasound was found to have a lower false-positive rate and a greater sensitivity with far fewer indeterminate studies than OCG. A high rate of nonvisualization diminished the usefulness of OCG as a first-line test. Because of a greater sensitivity less tendency for false-positive results, and a moninvasive nature, ultrasound should be the initial diagnostic study of choice in patients with suspected gallstones.
On the basis of oral cholecystography (OCG), we selected gallstone patients for nontoperative intervention. Their gallbladder function was considered as normal when gallbladder contracted over 50%-75% after a fat meal at 1 hour. We collected 99 gallstone patients and 19 normal controls; gallbladder function was normal in 77 patients and poor in 22. After a fat meal gallbladder volumes were calculated by B ultrasonography. The results showed that both fasting and residual volume in patients with so-called normal contraction were significantly greater than that in the controls (P < 0.001), though the contraction rate was not different. The combination of gallbladder contraction rate measurement and residual volume calculation by ultrasonography was superior over traditional OCG.
Subtotal gastrectomy with bilateral truncal vagotomy is a good operation for peptic ulcer disease. Recurrence rates are low, and diarrhea and dumping are usually tolerable. The development of gallstones following this procedure, however, has become more problematic in that further opeation becomes a real necessity. In two groups of patients having undergone a standardized subtotal gastrectomy, with and without truncal vagotomy, only 6 per cent of the patients with resection alone had biliary calculi develop. This is consistent with the incidence of gallstone formation in the normal population. However, in the group undergoing resection with bilateral vagotomy, 21 per cent had gallstones develop which were detected by ultrasonography or oral cholecystography and confirmed at operation. This suggests that cholelithiasis following truncal vagotomy is a long term complication which must be recognized and, unless otherwise indicated, requires an additional surgical procedure. Only when results of long term follow-up studies verify the therapeutic effectiveness of such operations as highly selective or parietal cell vagotomy without drainage will a more physiologically sound operation be within our grasp.
OBJECTIVES: The appearance of gallstone opacification during oral bile acid administration indicates that stones are no longer susceptible to dissolution and represents, therefore, a definitive treatment failure. Ursodeoxycholic acid (UDCA) has been imputed to facilitate gallstone opacification; however, data regarding the comparative occurrence of gallstone opacification during UDCA and chenodeoxycholic acid (CDCA) administration are not yet available. Our objectives were to evaluate the frequency of acquired opacification in gallstone patients taking UDCA and in gallstone patients taking CDCA, to verify whether or not gallstone opacification is a peculiar side effect of UDCA treatment and, further, to evaluate gallstone opacification in gallstone patients receiving tauro-UDCA (TUDCA) to verify whether the administration of the more soluble tauroconjugate might prevent the deposition of calcium salts on the stone surface. METHODS: 106 gallstone patients on UDCA, 125 gallstone patients on CDCA, and 31 gallstone patients on TUDCA were evaluated. Before treatment, all patients had radiolucent gallstones as assessed by oral cholecystography; further cholecystographic evaluations were performed every 6 months during treatment. RESULTS: The frequency of gallstone opacification was 13.2% (14/106) in UDCA patients, 8.8% (11/125) in the CDCA patients, and 12.9% (4/31) in the TUDCA patients. The differences were not statistically significant (p = NS). Sex, stone size, dose of bile acid, and duration of treatment were not significantly related to an increased frequency of gallstone calcification in any of the treatment groups. The frequency of gallstone opacification appeared to be higher in older patients. CONCLUSIONS: 1) UDCA rich bile is not a major predisposing factor for acquired gallstone opacification; 2) the administration of TUDCA does not prevent gallstone opacification; 3) opacification could be related to the natural history of gallstone disease.
The purpose of our study is to show results obtained after a cholecystectomy on 25 patients in order to present a suggestive clinic of bile origin and a positive result for determination of microcrystals in the bile probe even in the case of negative radiologic diagnoses (echography, cholecystography). Out of 25 patients operated on the following results were obtained: microscopic cholelithiasis in 12, granular cholelithiasis in 3, acute cholecystitis in 2, cholesterolosis in 2 and without pathologic findings in 6 patients after an observation period of 24 months following the operation it was demonstrated that almost all the patients (96%) had no symptoms. On the other hand, the above mentioned results are compared to the findings obtained during an observation period of a group of 34 patients with positive probe results with the same clinic characteristics and not having been operated on refusing the operation suggested.
The preoperative diagnosis of less than ss depth gallbladder cancer is difficult. Its preoperative diagnosis rate was low (27.5%), and even lower with the presence of concomitant gallstone. In the latter case, the diagnosis rate was particularly low when the stones diameter was greater than 1 cm. Gallstones are frequently associated with macromorphologically invasive type of gallbladder cancer and this may be the reason for the lower diagnostic rate. We compared preoperative diagnosis rate of ultrasonography (US), computed tomography (CT) and drip infusion cholecystography (DIC) for each invasion depth. In US, the preoperative diagnosis rate for m depth invasion was 6/16 (37.5%), pm depth was 1/13 (7.7%), and ss depth was 14/41 (34.1%). In CT, its rate for m depth was 3/11 (27.3%), pm depth was 1/10 (10.0%), and ss depth was 11/37 (29.7%). In DIC, its rate for m depth was 3/11 (27.3%), pm depth was 1/10 (10.0%), and ss was depth 1/23 (4.3%). None of the currently used imaging techniques were very accurate in diagnosing gallbladder cancer. Thus, during preoperative work up, if one discovers a gallbladder full of stones, stones of greater than 1 cm in diameter, thickened gallbladder wall, or a non visualized gallbladder with DIC, gallbladder cancer must be highly suspected.
Rotor's syndrome is a rare hereditary non hemolytic hyperbilirubinemia. The authors report a new case of a 22-year-old man, with chronic asymptomatic fluctuating jaundice. Liver function tests such as alkaline phosphatase, gammaglutamyl transferase and aminotransferase were normal, the same applying to globulin levels. The diagnosis was confirmed by a typical bromsulphalein clearance test, oral cholecystography, and increased total urinary coproporphyrin as well as coproporphyrin isomer I.
Two cases of congenital absence (agenesis) of the gallbladder seen at one hospital over a 5-year period are presented. One patient presented with ascending cholangitis due to choledocholithiasis, while the other presented with right upper quadrant abdominal pain and equivocal findings on ultrasound and oral cholecystography. Although diagnosis was made at laparotomy in both cases, it is likely that the arrival of laparoscopic cholecystectomy will avoid laparotomy in the future. The place of laparoscopy in establishing the presence of this anomaly is discussed.
Duplication of the gallbladder is a rare congenital anomaly, which must be depicted by sonography, although false positive and negative diagnosis could still be made. Usually abdominal sonography allows duplication diagnosis as reported in our case and a cholecystography may be performed to determine the type of the anomaly. When a surgical procedure needs to be performed, especially in case of coelioscopic technique, surgeon needs to know the exact anatomic type of the anomaly and the number of gallbladders he will find.
Ultrasonography (US) is the method of choice for evaluation of gallbladder stones with an accuracy of 96%. Number, size and calcification can be assessed by virtue of US reflection and attenuation. If more than five stones are present, the accuracy decreases. To determine the calcium content of stones more precisely, computed tomography can be used. This allows an assessment of the success rate of lithotripsy and chemolysis. Oral cholecystography is an alternative method of similar accuracy as US. It provides additional information about the patency of the cystic duct. In the presence of ductal stones, the accuracy of US decreases to 30%, mainly because of overlying bowel gas. Since 8 to 16% of all cases of cholecystolithiasis are accompanied by choledocholithiasis and since this entails a change in treatment, intravenous cholecystocholangiography with an accuracy of more than 90% is the method of choice in this case. Additionally, it provides knowledge on the biliary anatomy preoperatively. It does not, however, replace US, because opacification of the gallbladder is limited with this method. If intravenous cholecystocholangiography fails in case of impaired liver function, transcholecystic cholangiography or, in cases of dilated ducts, percutaneous transhepatic cholangiography can be used. Plain film radiography is not a suitable technique, since only 10 to 15% of all gallstones calcify.