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PubMed1990

The usefulness and limitations of ultrasonography for the diagnosis of adenomyomatosis of the gallbladder.

Ultrasonography has been popular for the diagnosis of gallbladder diseases since the mid-1970s. Although this technique has replaced oral cholecystography (OCG) for the diagnosis of cholecystolithiasis, it has not gained popularity in the diagnosis of adenomyomatosis of the gallbladder (AMMG). We examined 141 patients with clinically suspected gallbladder disease. Ultrasonography (previously done by a radiologist) had produced no positive findings. On ultrasonographic re-evaluation by the same radiologist, but in the presence of a surgeon from our study group, 64 cases of AMMG were detected. OCG revealed the diagnosis of AMMG in 13 other cases. In the study group there were no false-positive results. However, the false-negative rate of sonography in diagnosing AMMG was 16.9%. Thus, in our opinion ultrasonography is a worthwhile technique in diagnosing AMMG done by a surgeon.

Adult↗

PubMed1985

[Operative indications and surgical procedure in iodine-induced hyperthyroidism].

Clinical course, indications for surgical treatment, and results of treatment in 8 female patients with iodine induced thyrotoxicosis (IIT) are reported. The diagnosis of IIT could be established in all patients by a) clinical hyperthyroidism, b) increased T3 and T4 serum concentrations, and c) previous iodine contamination. Sources of iodine were radiographic contrast agents for urography (n = 4), oral cholecystography (n = 3), intravenous cholangiography (n = 1), phlebography (n = 1), and cranial computer tomography (n = 1). The onset of hyperthyroidism occurred 1-8 weeks after iodine exposure. Indications for surgical treatment of IIT were: 1. autonomous nodular goiter (n = 6), and 2. iodine exacerbation of preexisting thyrotoxicosis in patients with Graves' disease (n = 2). Corresponding to the different pathogenesis of autonomous and immunogenetic goiter the following surgical treatment is recommended: Enucleation of solitary autonomous adenomas or unilateral lobectomy in case of large adenomas, subtotal bilateral lobectomy in toxic multinodular goiter or, preferentially, unilateral lobectomy combined with subtotal resection of the contralateral thyroid lobe; "Near-total" thyroidectomy in Graves' immunopathy.

Adult↗

PubMed1987

Milk of calcium bile. Evidence that gallbladder stasis is a key factor.

Milk of calcium bile is a rare disorder in which the gallbladder lumen is filled with a semisolid radiopaque material composed primarily of calcium carbonate. The etiology is unknown, although gallbladder stasis is believed to be a prerequisite. We report a case of milk of calcium bile in which preexisting gallbladder stasis was retrospectively evaluated by reviewing plain abdominal films and by using iodide as a marker for retained contrast. This latter approach was validated by demonstrating that obstructed gallbladders do not physiologically sequester iodide and that following oral cholecystography functioning gallbladders do not retain significant iodide for prolonged periods. In the case described, we propose that gallbladder stasis was present as long as 2 1/2 years prior to the diagnosis of milk of calcium bile.

Adult↗

PubMed1986

Gallbladder dyskinesia in chronic acalculous cholecystitis.

To test the hypothesis that there is an early stage of cholesterol gallstone formation in man characterized by symptoms of chronic cholecystitis, poor gallbladder emptying, and biliary cholesterol crystals, we studied cholecystokinin-stimulated gallbladder emptying by DISIDA scintigraphy and examined bile for cholesterol crystals in symptomatic patients with normal oral cholecystography and gallbladder sonography. Of 36 patients studied, 16 had biliary cholesterol crystals; their mean 30-min gallbladder ejection fraction was 25.9 +/- 14.8%. Among the 20 patients without crystals, the mean ejection fraction was 60.3 +/- 23.3%. Fifteen patients, 11 with crystals and four without, had cholecystectomy because of persistent symptoms. All with crystals preoperatively and three without had chronic cholecystitis histologically. One patient without crystals had normal histology. We conclude that poor gallbladder contractility, well-established as an etiologic factor in animal models of cholesterol cholelithiasis, is now linked to acalculous cholecystitis, an early stage of human cholesterol cholelithiasis.

Adult↗

PubMed1982

Gallstone dissolution rate during chenic acid therapy. Effect of bedtime administration plus low cholesterol diet.

We have studied the dissolution rate of radiolucent gallstones from validated measurements of gallstone area derived from standardized oral cholecystography in 48 patients receiving chenodeoxycholic (chenic) acid, 15 mg/kg/day. Patients were matched in pairs according to gallstone size and randomly allocated to one of two treatment groups. Group A was given chenic acid in three divided doses at mealtimes with an unrestricted diet (the conventional regimen), and group B was given bedtime chenic acid with a low cholesterol diet. In the 24 matched pairs, the mean reduction in gallstone area at 6 months on regimen A was 36% and on B 60%. Median reductions in area were 20% and 57%, respectively (P less than 0.02). Of these matched pairs, 20 were followed at 6 month intervals for 42 months. There was a significant correlation between percentage reduction in gallstone area at 6 months and length of treatment necessary for complete dissolution (P less than 0.001). Fifty percent achieved complete dissolution by 30 months on regimen A, and by 12 months on regimen B (NS). We conclude that gallstone dissolution rate during chenic acid treatment is approximately doubled by bedtime administration plus a low cholesterol diet, thus reducing the duration and cost of treatment.

Chenodeoxycholic Acid↗

PubMed1987

Bilio-pancreatic common channel in children. Clinical, biological and radiological findings in 12 children.

Twelve patients (11 girls and 1 boy) with dilated bile ducts and anomalous junction between the common bile duct and pancreatic duct are reported. All patients underwent preoperative opacification of the bile ducts either by transhepatic cholangiography or percutaneous cholecystography. Abdominal pain and jaundice were the main clinical symptoms. Reflux of pancreatic enzymes in the bile duct was proven by measuring amylase and lipase activity in the biliary system after IV injection of 1 IU/kg of cholecystokinin. All patients were operated upon. Bile ducts size returned to normal in all patients who are clinical well with a follow-up from 1 to 6 years.

Adolescent↗

PubMed1977

A case of carcinoma of the common bile duct, diagnosed at the non-icteric stage of the disease.

It is rather seldom to detect a cancer of the common bile duct at the non-icteric stage of the disease. This report presents a non-icteric case of carcinoma of the choledochus. A 70-year-old woman complained of r-hypochondralgia with occasional fever. Laboratory examination revealed an increased serum alkaline phosphatase activity without any elevation of serum bilirubin content. The oral cholecystography failed to visualize the gallbladder. By endoscopic retrograde cholangiopancreatography (ERCP), a bilateral filling defect was demonstrated at the common bile duct. Pancreatoduodenectomy was performed and the resected specimen showed a 1 X 2 cm tumor (adenocarcinoma) at the choledochus. She is now in good health over 13 months after operation.

Adenocarcinoma↗

PubMed1978

Iodine content of human tissues after administration of iodine containing drugs or contrast media.

Total iodine contents were determined in 209 bioptic or autoptic specimens of various extrathyroidal tissues. Fifty-two of the 80 subjects examined had no previous exposure to excessive iodine, 24 were tested after administration of x-ray contrast media and 4 after treatment with various iodine containing drugs. Unexposed subjects had tissue iodine contents (mean +/- SD) ranging from 0.85 +/- 0.17 microgram/100 g in the brain and 9.78 +/- 2.75 microgram/100 g in the liver of adults. A significantly lower iodine concentration was found in the liver of newborns (2.79 +/- 1.00 microgram, p less than 0.001). Most of the other tissues had iodine concentrations of 2-4 microgram/100 g. Subjects with previous exposure to iodine containing drugs or x-ray contrast media showed increased iodine contents of various degree in all examined tissues, including adipose tissue, bone, brain, kidney, liver, lung, skeletal muscle, skin and spleen. Accumulation of iodine in adipose tissue was still demonstrable more than two years after cholecystography.

Adipose Tissue↗

PubMed2005

Gallstone pancreatitis in children: atypical presentation and review.

UNLABELLED: Pancreatitis in children is less common than in adults and is mostly related to trauma, infection and anatomical anomalies. Gallstone pancreatitis is an even rarer entity in infants and children. We present an unusual case of gallstone pancreatitis in a 17- month-old girl who presented with jaundice of 1 month duration. The laboratory studies showed conjugated hyperbilirubinaemia with associated acute pancreatitis and pseudo-hyponatraemia secondary to the markedly elevated lipid profile. Further evaluations revealed obstruction at the Ampulla of Vater with no evidence of a choledochal cyst and no mass lesion seen in the pancreas. The patient initially underwent urgent decompressive cholecystostomy with intraoperative cholecystography. When the biochemical parameters improved, the patient underwent formal cholecystectomy with common bile duct exploration, extraction of multiple impacted stones in the ampullary region and Fogarty balloon sphincterotomy. The post-operative course was uneventful. CONCLUSION: Acute gallstone pancreatitis in children may present as jaundice or abdominal pain. Recognition, early diagnosis and surgical intervention are the mainstay for a good outcome.

Acute Disease↗

PubMed2004

Is drip infusion cholecystocholangiography (DIC) an acceptable modality at cholecystectomy for cholecystolithiasis, considering the frequency of bile duct maljunction and intraoperative bile duct injury?

BACKGROUND/PURPOSE: Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis. METHODS: Preoperative diagnostic accuracy of BDM was analyzed in relation to operative bile duct injury using 469 patients with benign biliary diseases who was diagnosed with DIC and endoscopic retrograde cholecystography and underwent cholecystectomy. BDM was classified according to Hisatsugu criteria. RESULTS: Out of 469 consecutive patients who underwent a cholecystectomy for biliary stones between January 1, 1995, and September 30, 1998, at Ohta Nishinouchi General Hospital, 21 (4.48%) had a cystic duct maljunction (CDM) and 12 (2.56%) had an aberrant bile duct (ABD). The most common variants were types C and D for CDM, and types II and III for ABD, according to Hisatsugu's classification. Fourteen patients (42.4%) were diagnosed before the surgery; 13 of them received preoperative endoscopic retrograde cholangiography (ERC), and the remaining patient underwent preoperative drip infusion cholecystocholangiography (DIC). Nineteen patients could not be correctly diagnosed based on their preoperative examinations, but were diagnosed during surgery. Operative bile duct injury occurred in 1 patient (0.2%) whose maljunction could not be diagnosed before the operation. CONCLUSIONS: Taking into account the medical cost and invasiveness, and the frequency of BDM and related bile duct injuries, we conclude that DIC is an acceptable preoperative diagnostic modality to employ at cholecystectomy for cholecystolithiasis. Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis.

Bile Ducts, Extrahepatic↗

PubMed1975

Bacteriology of the gallbladder bile in normal subjects.

A bacteriologic analysis of the gallbladder bile in eighty patients who underwent operation was performed in a prospective study. In all twenty patients with a normal gallbladder as assessed by oral cholecystography and intraoperative palpation, cultured were negative. Among patients with chronic cholecystitis only 30 per cent had positive bile cultures and this rose to 47 per cent among patients with acute cholecystitis.

Adult↗

PubMed1980

Long-term results of selective vagotomy plus pyloroplasty. 12 to 17 year follow-up.

Among an initial series of 103 patients with selective vagotomy plus pyloroplasty for duodenal ulcer, 9 patients died of causes unrelated to ulcer and 7 were lost to follow-up without signs or symptoms of ulcer 8 to 15 years after operation; the remaining 87 patients were followed up for 12 to 17 years. Insulin testing revealed only one inadequate vagotomy in a patient who had a recurrence in the short term. Insulin tests were negative in 61 and negative or adequate in 6 other patients. Complete vagotomy reduced basal secretion effectively in the great majority of patients but not in a small minority. Three patients had antral hyperfunction with persistent hypersecretion despite complete vagotomy as indicated by two negative insulin tests in each patient. Inexplicably, only one of these patients had a stomal ulcer recurrence. Long-term follow-up revealed the development of gastric ulcer in one patient wit stasis from a pyloroplasty stenosed by angulation from adhesions. Three other patients, one with ulcer and two with hemorrhagic gastritis, developed gastric ulceration in the long term despite low acid output and negative insulin tests. Biliary reflux was demonstrated in two of these three patients and was probably the cause of gastric ulcer in the third. Pre- and postoperative cholecystograms in 66 patients showed the formation of gallstones in 4 patients after vagotomy. Another patient who did not undergo cholecystography developed acute cholecystitis from stone. This rate of gallstone formation was the normal expected rate and was not increased as in some series of total vagotomy. Dumping with and without associated diarrhea was the most frequent and troublesome sequela. Postvagotomy diarrhea did not occur. To prevent dumping, and also to decrease acid secretion more effectively, pyloroplasty was abandoned in favor of Maki's pyloruspreserving antrectomy to complement selective vagotomy in 1968.

Bile Reflux↗

PubMed1981

Gallstones after vagotomy.

A control group of 53 patients with selective vagotomy plus pyloroplasty was studied with pre- and postoperative cholecystography. At the fourth to seventh years the size and motility of the gallbladders were the same. Gallstones developed in two patients. A series of 91 patients with total vagotomy plus pyloroplasty was studied by similar methods. In 46 patients the gallbladders were grossly dilated and in 30 of the 46 the gallbladders were noncontractile. Gallstones developed in nine of the 46 patients. In the other 45 patients hypotonic dysfunction of the gallbladder was insignificant, and stones developed in only 1 of them. Explanation of these variable results is thwarted by unknown variations in the degree of both hypotonic dysfunction of the gallbladder and lithogenic change in the bile of patients with complete hepatic and complete celiac vagotomy after total vagotomy, and also by the unknown occurrence of incomplete hepatic and incomplete celiac vagotomy in series of allegedly complete total vagotomy. It is concluded that total vagotomy increases the incidence of gallstones, and that this increase occurs primarily in patients with significant hypotonia of the gallbladder. Selective vagotomy prevents these sequelae.

Cholelithiasis↗

PubMed1981

Evaluation of biliary disease by scintigraphy.

The value of biliary scintigraphy was studied in 180 patients with suspected biliary tract disease. Scintigraphy was performed after intravenous injection of technetium-99m labelled (1) N-substituted iminodiacetic acid derivative (HIDA) in 91 patients, and (2) butyl derivative of iminodiacetic acid (BIDA) in 89 patients. Most of the patients were investigated additionally by conventional techniques such as cholecystography, cholangiography and ultrasonography. It is concluded that biliary scintigraphy is a simple and safe technique for visualization of the biliary tract. It is particularly useful in the evaluation of acute cholecystitis, in patients with iodine sensitivity requiring imaging of biliary tract, and in the differentiation of obstructive from nonobstructive jaundice. Its value in kinetic disturbances of the gallbladder and in quantitative evaluation of hepatobiliary function needs further study.

Adolescent↗

PubMed1989

Efficacy and safety of a combination of chenodeoxycholic acid and ursodeoxycholic acid for gallstone dissolution: a comparison with ursodeoxycholic acid alone.

Chenodeoxycholic acid (CDC) and ursodeoxycholic acid (UDC) have distinct physicochemical and metabolic properties which, being complementary, should favor more rapid removal of cholesterol from gallstones when both bile acids are administered together. To see if the combination is more effective and well tolerated, we have compared 5 mg/kg of CDC plus 5 mg/kg of UDC with a 10-mg/kg dose of UDC alone in 120 patients with radiolucent, sonographically confirmed gallstones and characteristics favoring complete dissolution. Ursodeoxycholic acid was chosen as the reference because it dissolves stones faster and is better tolerated than CDC. To minimize the influence of stone size, the major determinant of dissolution, patients were divided, on admission, into two groups according to the maximum stone diameter: 50 had stones less than or equal to 5 mm, 70 had stones greater than 5 mm but less than 15 mm. The effects of treatment on stone dissolution evaluated by cholecystography and ultrasonography at 6, 12, and 24 mo, were analyzed by the actuarial life-table method. In the group with smaller stones, significantly more patients had obtained complete dissolution after treatment with the combination (52%) than after treatment with UDC alone (24%) at 6 mo. After longer periods, results were still better with the combination, although the differences from UDC alone became smaller. In the patients with larger stones, rates of complete and partial dissolutions were higher after treatment with the combination (51% vs. 24% with UDC) at 6 mo and again the differences had become smaller after longer treatment. Although not statistically significant, stone calcification occurred more often with UDC (7 cases) than with the combination (1 case). We conclude that CDC plus UDC is preferable to UDC alone because it dissolves stones more quickly, with a lower incidence of stone calcification, and may result in reduced cost of treatment.

Bile↗

PubMed1985

Socioeconomic status and the prevalence of clinical gallbladder disease.

The prevalence of clinical gallbladder disease was determined in a cross-sectional survey of Mexican Americans and non-Hispanic whites. The study population was randomly selected from three urban neighborhoods representing different socioeconomic strata. Gallbladder disease was defined as a history of cholecystectomy, or of stones on cholecystography. Mexican American women had an age-standardized prevalence of 16.9%, vs 8.7% for non-Hispanic whites (p less than 0.0001). Prevalences in men were 4.2 and 3.4%, respectively. The ethnic differences in women persisted after stratification by age, parity, and body mass index. Gallbladder disease prevalence was inversely related to four measures of socioeconomic status. After controlling for age, obesity, parity, and ethnicity, the prevalence in women was inversely related to levels of education, income, occupational status, and neighborhood. These socioeconomic differences, if not the result of detection bias, suggest that environmental factors may play a role in gallstone pathogenesis. Identification of such factors may lead to the development of preventive strategies.

Adult↗

PubMed1992

Management of recurrent gallstones.

The risk of gallstone recurrence following non-surgical treatment has been overestimated in the past for two reasons: (1) diagnosis of primary gallstone dissolution was based on oral cholecystography; and (2) gallstone recurrence was expressed as a cumulative recurrence rate. Results based on better methodologies for diagnosis of gallstones (ultrasonography) and for calculation of results (life-table analysis) have indicated that gallstones recur in about 50% of patients, and that the risk of recurrence is confined mainly to the first 5 years after dissolution. Pretreatment gallstone characteristics, but not patient characteristics, are important risk factors for gallstone recurrence. Multiple stones are more likely to recur than solitary stones, a phenomenon attributable to the presence of a potent pronucleating factor in the bile of patients with multiple stones. This observation, and the finding that NSAID administration may reduce gallstone recurrence via inhibition of mucin secretion, suggests that the nucleation defect might be a key factor in the pathogenesis of recurrent gallstones. Prophylaxis with low-dose CDCA or UDCA has proven ineffective for preventing gallstone recurrence, although it may reduce it. Since the majority of recurrent gallstones are small when first seen because of regular ultrasonographic follow-up, multiple, radiolucent and in functioning gallbladders, they are amenable to bile acid retreatment, and intermittent bile acid therapy is probably a viable strategy for long-term management of cholesterol cholelithiasis.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1993

Cholecystectomy and colorectal cancer in China.

Colorectal cancer is a major public health problem in China: 79,800 new cases are estimated to occur each year, which ranks it among the five most common tumours in China. Although the association between cholecystectomy and colorectal cancer has been studied elsewhere, few studies have been conducted in the Chinese population, characterized by a lower fat intake, and low colorectal cancer incidence. We conducted this hospital-based case-control study to explore this association. The study included a total of 503 incident cases with pathologically diagnosed colorectal cancer in Drum Tower Hospital at Nanjing in China from 1965 to 1986, and 2188 healthy controls who had annual routine physical examinations at the same hospital. Diagnosis of cholelithiasis was confirmed by ultrasonography or X-ray cholecystography, and the information on cholecystectomy was obtained by checking medical charts for both cases and controls. The prevalence of cholelithiases was 5.8% for cases and 6.1% for controls (P > 0.05). Eight cases (1.6%) and 18 controls (0.8%) had a history of previous cholecystectomy. The period between cases' cholecystectomy and diagnosis of colorectal cancer ranged from 2.5 to 23 years, and the mean interval was 8.9 years. The crude odds ratio for patients having previous cholecystectomy is 1.95 (95% CI: 0.84-4.51) compared with controls. The odds ratio for female patients with previous cholecystectomy was 2.79 (95% CI: 1.03-7.59). When subsites were analysed, a significant association between right colon cancer and cholecystectomy was noted: the odds ratio was 6.2 (95% CI: 2.24-16.9), and that for females was even higher 8.61 (95% CI: 2.44-3.04) with statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

Case-Control Studies↗