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PubMed1992

[Oral dissolvents and extracorporeal lithotripsy: respective role and modalities of application].

Oral dissolution therapy can be proposed to patients with symptomatic gallstones, with stones less than 15 mm diameter, in any number, without calcification, within a functioning gallbladder (i.e. opacified by oral cholecystography). In particular, it may be useful in patients aged over 70, or with a high operative risk, or who refuse surgery or general anesthesia. Extracorporeal shock wave lithotripsy (followed by oral dissolution therapy) is also indicated in symptomatic gallstones, without calcification or slightly calcified in a functioning gallbladder, when stone size is between 8-10 and 30 mm and stone number lower than 3. After successful dissolution, recurrence is observed with an incidence of 5 to 10% per year during the first five years. In case of symptomatic recurrence, retreatment is indicated.

Administration, Oral↗

PubMed1992

[Role of computerized tomography in the densitometric assessment of lithiasis of the gallbladder].

Radiolucent gallstones frequently contain significant calcium deposits. Their detection is important to select the patients to submit to medical gallstone dissolution. Since CT facilitates the identification of calcifications undetected at conventional radiologic procedures, 60 patients were studied with CT. All of them had US confirmation of cholelithiasis and in the whole of cases an X-ray examination of the right upper abdominal quadrant was performed (for the identification of radiopaque stones), together with oral cholecystography (to evaluate gallbladder function). CT attenuation values of the stones were measured and the patients subsequently divided into 2 groups; the threshold value was 50 HU: below it, the stones were considered hypo- or isodense (group I); above it, they were considered hyperdense (group II). Later on, 28 patients (14 from group I and 14 from group II) were selected for chemical dissolution with ursodeoxycholic acid over a 1-year period. US examinations were performed at 6 and 12 months. Seventy per cent of the patients in group I responded to treatment (50% with complete stone dissolution and 20% with partial dissolution), whereas no patient in group II had complete dissolution and only 30% had partial response.

Cholelithiasis↗

PubMed1992

[Hyperbilirubinemia].

A 22-year-old woman had icteric sclerae since childhood. Five years ago of Gilbert-Meulengracht's disease was diagnosed (hyperbilirubinemia, normal other liver laboratory parameters, no evidence of hemolysis). The patient was admitted for re-evaluation. Apart from jaundice of the sclerae no other clinical symptoms were found. Analysis of urine revealed bilirubin and an increased urobilinogen. Serum bilirubin was also elevated. The differentiation of the bilirubin gave evidence of an increase of the direct (conjugated) bilirubin portion. Additional investigations (total coproporphyrin in the urine, isomer I and isomer III coproporphyrin excretion and bromsulphalein test) suggested Rotor's syndrome. Further examinations (oral cholecystography, liver biopsy) were not added because of relative invasiveness, lack of clinical consequences and opposition of the patient. Nevertheless the diagnosis of a Rotor's syndrome is highly probable.

Adult↗

PubMed1992

Does computed tomography improve patients selection for extracorporeal shock wave lithotripsy (ESWL) of radiolucent gallbladder stones?

In 97 patients with radiolucent solitary gallbladder stones, the density of the calculi was evaluated by computed tomography (CT) prior to extracorporeal shock wave lithotripsy (ESWL). Sixty-three percent of the stones were isodense to bile (mean 48 +/- SD 11 HU), and 37% could be identified on CT-sections (maximal density 105 +/- 46 HU, mean density at the largest cross-section 53 +/- 31 HU). There was a slight trend toward better stone fragmentation and higher clearance rate in patients with isodense stones. However, the probability of complete fragment clearance was not significantly different in stones with a high or low CT-density. From these data we conclude that stone selection for ESWL and adjuvant bile acid therapy in patients with radiolucent solitary stones as assessed by oral cholecystography is only marginally improved by computed tomography.

Adult↗

PubMed1991

Prevalence of gallstone disease in patients with diabetes mellitus. A case-control study.

The prevalence of gallstone disease was analysed in 360 diabetic patients and in 359 control subjects. In 61 (17%) of the diabetic patients and 50 (14%) of the control subjects gallstone disease was verified by previous cholecystography, ultrasonography, or cholecystectomy. The remaining 608 with no history of gallstone disease were invited to have an ultrasound scan of the gallbladder; the prevalence of cholelithiasis was similar among diabetic patients (14.4% n = 28) and control subjects (12.5%, n = 26).

Aged↗

PubMedDate not supplied

[Gallstone ileus and cholecystoduodenal fistula. Case report].

OBJECTIVE: We report on a patient with gallstone ileus and cholecystoduodenal fistula at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI (IMSS) Mexico City, Mexico. CLINICAL CASE: A 54-year-old male patient was admitted to the hospital with a diagnosis of acute cholecystitis. He had undergone an appendectomy at 34 years of age. There was no history of biliary disease. He was afebrile, with moderate abdominal distention and right upper quadrant pain, Murphy (+). His white blood cell count was 8,900/mm(3) with 40% bands. His liver function tests, amylase and lipase, were all within normal limits. Ultrasound revealed edema and thickening of the gallbladder wall with calculi. He underwent exploratory surgery, which provided the following findings: sclerotrophic gallbladder with intense surrounding inflammation. We therefore decided to perform a cholecystostomy. Two days postoperatively the patient presented abdominal distention and vomiting as well as the presence of intestinal material through the cholecystostomy catheter. Plain abdominal film showed the bowel to be dilated and an aberrantly located gallstone. Cholecystography was performed and showed a cholecystoduodenal fistula. Computed tomography was carried out and disclosed the bowel to be slightly dilated and with an intraluminal gallstone. A laparotomy with enterolithotomy was performed. Sized of the gallstone found was approximately 3 cm. Presently the patient is asymptomatic.

Biliary Fistula↗

PubMed1991

[Informative value of various methods of diagnosing chronic calculous cholecystitis].

Resulting from comparative study of informative value of the radionuclide scanning, oral cholecystography, intravenous cholegraphy, ultrasound investigation (USI) performed in 316 patients with chronic calculous cholecystitis, it was established that the most effective method of diagnosis was USI: pre- and postoperative diagnosis coincided in 93.4% of cases.

Cholecystitis↗

PubMed1991

Cystic duct occlusion by microwave tissue coagulator in rabbits.

In this preliminary study a flexible bipolar microwave electrode, 1.8 mm in diameter, was designed to occlude the cystic duct in 18 rabbits. Thermal model tests were performed to evaluate the effect of the antenna and to master the coagulating condition. Through surgical cholecystostomy, the antenna was inserted into the proximal cystic duct for various coagulation treatments. Cholecystography showed that the cystic duct was occluded minutes to hours after coagulation. Histologically, the microwave technique induced a chronic inflammation and fibrosis which eventually obliterated the coagulated cystic duct permanently. In group A (30 mA for 20 s) the cystic duct epithelium regeneration occurred and surrounding liver damage was limited, while in groups B (50 mA for 10 s) and C (70 mA for 6 s) no epithelium regeneration was observed and injury to the liver was mild to moderate. It was found that microwaves generated at 50 mA for 10 s to occlude the rabbit's cystic duct are effective and less injurious.

Animals↗

PubMed1991

[Polypoid lesions of the gallbladder. Clinical and pathological correlations].

Fourty patients (21 males, 19 females; mean age 43.95 +/- 11.58 years) had polypoid lesions of the gallbladder, which were confirmed surgically and pathologically. The incidence of the disease was 15.8% in patients undergoing cholecystectomy and 1.4% in patients having ultrasonography. In the 40 patients, 23 (57.5%) had cholesterol polyps, 5 (12.5%) inflammatory polyps, 4 (10%) adenocarcinomas, 3 (7.5%) xanthomatous polyps, 2 (5%) papillary adenomas, 1 mixed polyp, 1 neurofibroma, and 1 adenomatoid proliferative polyp. The mean age of patients with nontumorous polyp was 41.27 +/- 10.16 years. In these patients, 78.8% had polyps less than 5 mm in diameter, and 69.7% had multiple lesions. However, the mean age of patients with tumorous polyp was 56.71 +/- 9.79 years and 71.4% of the patients had polyps more than 5 mm in diameter and 85.7% single lesions. 72.5% of the patients had clinical symptoms. Polyps were detected ultrasonographically, but one third of them were overlooked by either cholecystography or CT. Nomenclature, pathological classification and management of the lesions are discussed.

Adolescent↗

PubMed1991

[Clinicopathological and immunohistochemical studies of xanthogranulomatous cholecystitis--possible pathogenetic role of cell mediated immunity].

Clinicopathological and immunohistochemical studies were performed on 22 cases of xanthogranulomatous cholecystitis (XGC). Incidence of XGC was 3.6% of surgically resected gallbladder diseases. All cases of XGC were associated with cholelithiasis in which cholesterol gallstones were 6 times as many as pigment ones. XGC was frequently accompanied by incarceration of gallstones. In cholecystography, two-thirds of gallbladders were not visualized. Histologically, the granulomatous lesion of XGC consisted of accumulations of foam cells, lymphocytes, variable numbers of giant cells, granulocytes and fibroblastic cells. Although there had been no established theory in relation to the origin of foam cells, it is considered that foam cells were derived from monocyte/macrophages because they reacted variably with lysozyme, alpha 1-antichymotrypsin and alpha 1-antitrypsin, and almost invariably with OKM 1 and EBM 11 antibodies. Interspersed among macrophage foam cells, many T lymphocytes were identified. In terms of T cell subsets, CD 8 positive lymphocytes outnumbered CD 4 positive lymphocytes. Electron microscopy demonstrated intimate apposition of T lymphocytes to macrophages or macrophage foam cells. HLA-DR was expressed by most macrophages, macrophage foam cells and T lymphocytes. In conclusion, the results suggest that the features of XGC are those of granulomatous inflammation characterized by accumulation of macrophages, macrophage derived foam cells and activated T cells. It is suggested that delayed type hypersensitivity reaction of cell mediated immunity is operative in the pathogenesis of XGC.

Cholecystitis↗

PubMed1991

[Image diagnostics for carcinoma of the biliary tract].

Although it is clear that US is the procedure which should be selected as a method of the first choice to detect carcinoma of the biliary tract, a rational selection and combination of diagnostic procedures are essential for further evaluation on the nature or extension of tumor and its resectability. The next procedure which should be selected after US, in our opinion, is ERCP which can be followed by ERBD, if necessary, because it is useful to know the site and extension of tumor. However, the cases who have the lesion at the upper portion of the biliary tract or which is considered to be unresectable should be converted to percutaneous transhepatic approaches (PTC, PTBD, PTCS) at this stage as a method of next choice with diagnostic and subsequent therapeutic purposes. On the other hand, EUS is also an important first line diagnostic procedure to delineate the lesion at the lower portion of the biliary tract which can be used in parallel with ERCP. In this paper, usefulness of EUS was strongly advocated, because the information concerning the extension and resectability of tumor are also provided with it as it is obtained with CT, MRT and angiography. Cytology of bile, cholecystography, percutaneous transhepatic cholangioscopy and biopsy under endoscopic control carried out after percutaneous transhepatic drainage of the gallbladder are the procedures used for the diagnosis of gallbladder carcinoma, but they should be only indicated in the cases, in which early carcinoma is strongly suspected, because it cannot provide us any information necessary to make therapeutic plan in the cases with advanced carcinoma.

Biliary Tract Neoplasms↗

PubMed1990

Reliability of ultrasonography in diagnosis of biliary lithiasis.

Preoperative B-mode ultrasonograms of the biliary system in 302 patients with cholelithiasis confirmed operatively between March 1981 and December 1986 were analyzed retrospectively in contrast to the operative findings. The results showed that during 1985-1986 the sensitivity of ultrasonography (US) to detect stones in gallbladder (GB), extrahepatic bile duct (EHD) and intrahepatic bile duct (IHD) was 98.4%, 68.2% and 82.4% respectively, each was much higher than its counterpart during the periods 1981-1982 and 1983-1984 (P less than 0.01). The specificity of US in detecting GB, EHD and IHD stones was all over 90% during the latter two years. The observations made in the present study suggest that the accuracy of US has risen so significantly that it should be used as the first modality in diagnosing cholelithiasis, particularly cholecystolithiasis. It, however, should be supplemented with such tests as oral cholecystography, intravenous cholangiography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP) to establish a correct diagnosis when its interpretation is equivocal.

Bile Duct Diseases↗

PubMed1990

[Choledochal cyst].

The persistence of recurrent abdominal pains in a 6 year-old girl without medical history lead to an ultrasonography being performed that showed a liquid formation, assigned to a dilated biliary duct. An oral cholecystography showed that this formation corresponded to a voluminous choledochal cyst. Surgical treatment consisted of a cyst excision with an hepatico-jejunostomy as biliary drainage.

Child↗

PubMedDate not supplied

Hepatobiliary imaging: imaging modalities.

Imaging modalities are a major part of the diagnosis and follow-up to therapy of hepatobiliary disease. Changes of the liver, spleen, gallbladder and pancreas can be assessed by a variety of highly technical and evolving methods. The purpose of this paper is to review briefly some diseases of the hepatobiliary tree and pancreas and how they may be diagnosed through imaging modalities. Hepatic diseases may include those that affect the parenchyma, biliary tree, or gallbladder. The spleen is often altered in size secondary to liver disease. Pancreatic diseases present particular difficulties in diagnosis as they relate to clinical chemistry tests, tumor markers or imaging. Imaging modalities for hepatobiliary disease include x-ray studies with or without contrast, and with or without computerized tomographic enhancements. Some of the x-ray procedures are done in association with percutaneous or endoscopic retrograde approaches. Ultrasound is an excellent technique for evaluation of cholelithiasis and gives useful information for hepatic and splenic size. Radionuclide studies can be either anatomically or physiologically based. Magnetic resonance imaging is evolving as a very useful, specific and sensitive method of evaluating the liver, gallbladder, spleen and pancreas. There is a diverse armamentarium of imaging modalities available for the evaluation of hepatobiliary disease. Ultrasound is the first choice for cholelithiasis. Endoscopic retrograde cholecystography (ERCP) is a definitive method for evaluating the biliary tree. Radionuclide studies with the iminodiacetic acid (IDA) derivatives are very useful for functional disorders of the gallbladder. Computer assisted tomography and magnetic resonance imaging (MRI) provide optimal anatomic resolution for tumors, abscesses, and other metastatic lesions involving the liver and spleen.

Biliary Tract Diseases↗

PubMed1990

[Value of ultrasonography for the diagnosis of cholelithiasis in light of surgical verification].

Up to the age of ultrasonography the cholelithiasis diagnostics has been based on the radiologic examination that is on the peroral cholecystography introduced by Graham and Cole in 1924 as well as on the intravenous cholangiography performed for first time by Langecker and Harwat in 1952. During last years the cholelithiasis diagnostics is more and more frequently based on the ultrasonographic examination. The purpose of this study was in evaluation of ultrasonography in detection of cholelithiasis. The diversity of ultrasonographic images according to the cholelithiasis type and the accompanying alterations in the wall and surrounding area of the gallbladder has been taken into account. The USG diagnostic value and that of routine radiologic methods in diagnosis of cholelithiasis has been additionally compared.

Cholelithiasis↗

PubMed1990

[Ultrasonic diagnosis of polypoid formations of the gallbladder].

Altogether 4000 patients were examined using an ultrasonograph Toshiba SAL 38AS working in the real time mode. 1.08% of the patients were diagnosed to have small polypoid formations of the gallbladder which, in many cases, could not be recognized at oral cholecystography. Routine repeated sonography of the gallbladder demonstrated that in 94.9% of cases, small polypoid formations did not increase in size for 12 to 18 months. Four patients subjected to cholecystectomy manifested polypous cholesterosis of the gallbladder.

Adolescent↗

PubMed1990

Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy?

Patients with chronic right upper quadrant pain who do not have gallstones on ultrasound or cholecystography are often referred for surgery for presumed acalculous chronic cholecystitis. We followed 26 patients who had cholecystokinin (CCK) cholescintigraphy for evaluation of chronic right upper quadrant pain without demonstrable gallstones on ultrasound who underwent cholecystectomy so that it could be determined whether there was any relation between a low ejection fraction (EF), morphological features of chronic cholecystitis, and clinical outcome. Eighteen patients (69%) were considered therapeutic successes, whereas eight (31%) were failures after an average 2-yr follow-up. Both patient groups had significantly reduced EF: the successful group at 0.39 and the failures at 0.25. Thus, a low EF did not predict clinical outcome, since the failure group had an even lower EF than the success group. Seven gallbladders demonstrated chronic acalculous cholecystitis; the average EF of this group was 0.35. The remaining 19 gallbladders were normal, yet also had an EF of 0.35. Thus, decreased EF does not predict the histologic features of chronic cholecystitis without gallstones. The diagnostic value of cholescintigraphy in patients with acalculous right upper quadrant pain is low, probably because this entity represents a variety of processes, including inflammation, gallbladder dysmotility, and the irritable bowel syndrome.

Abdominal Pain↗

PubMed1989

[Asymptomatic cholelithiasis. When is a cholecystectomy justified?].

Since the introduction of routine abdominal echography, silent gallstone has become a major medical concern. The management of a patient with silent gallstone, is very controversed, and routine cholecystectomy is not always beneficial. Aged and high operative risk patients, should be treated conservatively. Literature review can identify subgroups of patients in whom cholecystectomy is justified: patients with micro or macro-lithiasis, patients in whom oral cholecystography reveals multiple floating stones, dyskinectic, not opacified or calcified gallbladder, and patients receiving general anesthesia for other reasons than gallbladder disease.

Cholecystectomy↗