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The frequency of the (TA)7/(TA)7 promoter genotype of UDP-glucuronosyltransferase gene (UGT1A1) was significantly higher (p<0.05) in a group of 30 children with cholelithiasis than in a control group of 40 healthy children, indicating that this genotype might be an underlying factor for gallstone initiation in otherwise healthy children.
Cholelithiasis is a rare pathology in children and with a different etiology, composition and clinic than adult. Cholecystectomy is the standardized treatment. The cholecystectomy is an alternative treatment in childhood. We studied 30 patients, aged between 8 months and 13 years, 15 of them with cholecystectomy and 15 with removal of pigment gallstones. The patients were followed up for 3 months-11 years. Recurrent stone formation was noted in one patient. 14 of the patients were non-symptomatic with normal ecography controls.
The prevalence and the pathogenesis of gallstones in patients with chronic pancreatitis have never been studied prospectively. The aim of this study was to evaluate prospectively the prevalence of gallstones with ultrasonography and to look for markers of pigment or cholesterol stone formation in gallbladder bile. Ultrasonography was performed in 39 patients and detected gallstones in 7 patients and sludge in 3. Common bile duct and intrahepatic bile duct dilatation were observed in 16 and 13 patients, respectively. Liver biopsies were obtained in 31 patients and cirrhosis was found in 4. There were calcium bilirubinate granules in 7 of the 27 bile samples examined. Cholesterol crystals were not found in any case. The nucleation time (median: 21 days) was higher in patients with chronic pancreatitis than in patients with cholesterol stones (median: 2 days) (P < 0.001) but was not different from nucleation time in patients either free of stones (median: 21 days) or with pigment stones (median: 21 days). The cholesterol saturation index was similar in patients with chronic pancreatitis and in controls. The 2 patients with chronic pancreatitis who underwent cholecystectomy had pigment stones. Calcium bilirubinate granules were more frequent in patients with intrahepatic bile ducts dilatation (P < 0.02). In conclusion, this study demonstrates a high prevalence of cholelithiasis in chronic pancreatitis patients. Pigment stone formation could be favored by cholestasis.
Three patients with cholelithiasis were found to possess a duplicate gallbladder. A 48-year-old woman continued to have symptoms one year after cholecystectomy, a 69-year-old woman had symptoms even though her gallbladder had been removed 40 years before, and in a 29-year-old woman a second gallbladder was found during cholecystectomy. In all three patients, the second gallbladder was removed as well, after which they recovered. The differential diagnosis of persistent symptoms following cholecystectomy should also consider the possible presence of an accessory gallbladder.
Tuberculosis of the gallbladder is rare, even in our country known for being an endemic area. The positive diagnosis depends on suspicion of tuberculosis, peroperative findings and histological examination. From a review of the literature, the physiopathology of this infection is discussed, emphasizing the role of lithiasis in the development of tuberculous lesions. The authors report a case of gallbladder tuberculosis in a female patient who presented with a clinical picture of chronic cholelithiasis. The diagnosis of gallbladder tuberculosis was reached only after surgery and proven by histopathology. In our case, the presence of stones associated with non specific inflammatory alterations and possibly low resistance against tubercle bacillus, is believed to have been of importance for the development of the tuberculous infection.
A 13-year-old Thoroughbred mare, retired from race, was admitted to Equine Hospital, Korea Racing Association with signs of colic. One and a half months following the previous treatment (second time) and 11 days following her previous discharge (third time), the mare repeatedly exhibited signs of colic and finally along with icteric eyes. Routine medical treatment with intravenous fluids, analgesics resulted in resolution of signs of colic in the first and second admission. The condition of the mare did not improve in the third admission despite over one month supportive treatment and she was subject to euthanasia at the request of the owner on the thirtyeighth day of hospitalization (95 days from her first admission). The clinical signs (fever, icterus, mild intermittent colic) in conjunction with clinical laboratory findings (leukocytosis, elevations of serum total bilirubin, direct bilirubin, alkaline phosphatase, aspartate aminotransferase, gamma glutamyl transferase, creatine phosphokinase, lactic dehydrogenase and blood fibrinogen indicative of obstructive biliary disease) in this mare suggested possible chlolelithiasis. However, liver enzymes and bilirubin estimations are often not part of routine screening in emergency colic cases. At necropsy, multiple dark brown choleliths of various sizes obstructing hepatopancreatic ampulla were found in the hepatic duct. The choleliths were found as large as 3-5 cm in diameter, faceted to each other, dark brown in color and showed soap consistency. Histopathologic findings revealed: biliary fibrosis, plugging of the bile canaliculi with bile pigments, cholangiohepatitis and pigmentation of the hepatic lymph node with bile pigment laden macrophages. Although definitive diagnosis of cholelithiasis might be challenging, clinicians should consider this condition in the differential diagnosis of recurrent colic.
Fifty six cases of cholelithiasis in patients aged two months to 15 years (mean age 7.65 years) concerning to 11 hospitals are reviewed. The study protocol followed was the same in all medical records, although own criterions were considered on management performed in each center. From the cases, it follows: 1. Male/female rate is 1/1.5. 2. Symptomatology in infancy is relatively poor and pain localization is not orientative. 3. It was an incidentally finding in 41 per 100 of the cases. 4. Ultrasonography is the best examination procedure rendering diagnosis in the 51 cases it was underwent. 5. Hematologic study was abnormal in six of 46 cases. 6. Medical treatment was not performed in any hospital. 7. Existence of "lithogenic families" seems to be demonstrated. 8. The presence of four patients with Down syndrome in this series must be pointed out. 9. Among total 56 cases, 21 underwent surgical treatment, 29 were conservatively treated, two have died and four patients had spontaneous stone resolution. 10. In the face of these, we propose: A) Surgical treatment in symptomatic cases, porcelain gallbladder and nonfunctionating gallbladder. B) Expectant management and sonographic monitoring in asymptomatic cases. C) Carefully evaluation in patients with predisposing factors and patients with recurrent abdominal pain.
BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholelithiasis. About 8-15 per cent of patients with symptomatic gallstones may bear associated common bile duct (CBD) stones, The management of choledocholithiasis in the laparoscopic era remain debatable. Although pre-operative endoscopic cholangiopancreatography (ERCP) is available and highly accurate in the detection of CBD stones, its routine use is controversial because of its inherent disadvantages. OBJECTIVE: The aim of this retrospective study was to generate an effective predictive model for bile duct stones detection by pre-operative ERCP. METHOD: Twelve pre-operative clinical, biochemical and sonographic variables from 206 consecutive patients who underwent pre-operative ERCP with LC for gallstones with/without CBD stones from October 1998 to December 2000 were retrospectively analysed RESULTS: 143 of the 206 patients with gallstones were found to have CBD stones. The mean age was 61 (20-93) yr old, and 55.9 per cent were female. Multivariate analysis showed a high predictive value for the presence of CBD stones in patients aged > or = 55 yr old (Odd radio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.05), jaundice (OR 2.7, 95% CI 1.7-4.8), elevated alkaline phosphatase (OR 1.002, 95% CI 1.000-1.005), CBD dilatation on ultrasound (OR 3.8, 95% CI 1.8-8) and CBD stone on ultrasound. CONCLUSION: The important clinical presentations and investigating could allow more appropriate use of pre-operative ERCP in patients who have symptomatic gallstones with a suspected CBD stone prior to cholecystectomy.
AIM: To evaluate the occurrence of cholelithiasis (CL) diagnosed by routine autopsy and to compare these data with the results of ultrasonographic examination of the general population. MATERIAL AND METHODS: Autopsy protocols (n = 1124) from a large general hospital were analysed, and a representative sample of Novosibirsk population (1678 examinees aged 25-64 years) was examined by ultrasonography. RESULTS: Prevalence of CL increased with age and was five-fold higher in females than in males. Both methods showed good concordance. The age-adjusted CL prevalence rates in 25-64 year-old groups was 1.94% in males and 9.53% in females in autopsy series, and 2.16% and 11.16%, respectively, in ultrasonographic study. CONCLUSION: Routine autopsy may serve as a reliable tool in evaluating prevalence of CL among the population provided the values are gender- and age-standardized.
Organ anomalies and organ system transposition may cause diagnostic and therapeutic difficulties. We report a patient with situs inversus totalis and symptomatic cholelithiasis successfully treated via laparoscopic cholecystectomy. We present a laparoscopic and MR cholangiographic pictures of our patient with gallbladder agenesis.
A 33-year-old woman with symptomatic cholelithiasis underwent laparoscopic cholecystectomy. Preoperative evaluation did not suggest the presence of choledocholithiasis, but intraoperative cholangiography showed a totally obstructing stone in the distal common bile duct. Laparoscopically directed, transperitoneal choledochoscopy was performed by passing a 9.4 F flexible ureteroscope through the cystic duct into the distal common bile duct. A single calculus was visualized and removed with a basket. The patient was discharged the next day, returned to full activity within 1 week, and has done well in the subsequent postoperative interval. The management of incidentally discovered common bile duct stones during performance of laparoscopic cholecystectomy is discussed.
An increased incidence of cholelithiasis has been widely reported after gastric surgery. In the early phase of patient selection, previous gastric surgery has been considered a relative contraindication to laparoscopic cholecystectomy. Between 1999-2003, in our clinic, laparoscopic cholecystectomy was attempted on 3145 patients. Of these patients, 37 patients had gallstone, which occurred several years (mean 17.9 years) after gastric surgery for peptic ulcer (34 cases), gastric cancer (1 case) and hiatal hernia (2 cases). Surgical procedures that had been performed included Billroth I gastrectomy (14 cases), Billroth II gastrectomy (15 cases), truncal vagotomy and piloroplasty (6 cases), and Nissen (2 cases). On this group there were 19 chronic cholecystites, 17 acute cholecystites and one cholesterolosis with gallbladder polyps. One patient was diagnosed with gallstone in common bile duct, successfully removed preoperatively after endoscopic sphincterotomy. The laparoscopic approach was possible in 26 cases. The technical difficulty after Cuschieri was level III--26 patients and level IV--11 patients (reconversion). The mean operative time was 75 minutes. The postoperative evolution of the patients was good in 36 cases. One case had a biliary fistula. The mean postoperative hospital stay was 3.6 days for laparoscopic cholecystectomy and 9 days after conversion. The postoperative adhesions determine the main technical difficulty, but it proved to be a relative contraindication for laparoscopic cholecystectomy for gallstones after gastric surgery. Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe laparoscopic cholecystectomy in these patients.
The Interventional Radiologist plays an important part in the team with Surgeons and Gastroenterologists for the treatment of stone disease in the Gallbladder and Bile ducts. He must be familiar with the natural history, the clinical picture, the treatment variety, and the technical details of radiologic intervention under fluoroscopic control in order to assume his proper place in the therapy of cholelithiasis. This is especially true for the patient with a high surgical risk factor.
Classical performance of bile duct exploration is always strictly connected with the problem of an incised bile duct closure. In majority of surgical centers an external T-tube drainage was carried out in last century. But is an external drainage the best method to be used? The aim of the paper was to establish criteria for including (or excluding) patients to groups undergoing primary suture of bile duct. The comparison of the patients in whom bile duct exploration was followed by primary suture with the group in which T-tube was left in bile duct lumen was performed. Recently in our Department a classical method has been used to operate on 65 patients with cholelithiasis. In 42 patients a preoperatively planned bile duct exploration has been performed. In 14 patients a T-tube was left after the exploration, in 24 patients bile duct was closed with a primary suture. In other 18 patients with residual and recurrent bile duct stones T-tube was left in bile duct only in two patients. Based on literature analysis, our observations, and surgical experience criteria for including and excluding patients for primary suture of bile duct have been established. Groups of patients with and without T-tube were compared, considering complications and economic aspects of hospitalization. Our opinion is that whenever in specialized surgical centers detailed criteria are established and followed precisely, primary bile duct closure is a simple and safe procedure, responsible for few complications. The cost of hospitalization in the case of primary suture is half as much as the price of the hospitalization in the case of T-tube.
Cholelithiasis is one of the clinically common and frequently encountered diseases. In this paper, the Chinese Meteria Medica and prescriptions utilized to treat cholelithasis were discussed in four aspects. In addition, we discussed the clinical effect and mechanism of actions of these drugs in order to provide some reference for future drug development in this area.
The heterogeneity of serum low-density lipoproteins (LDL) was studied in patients with cholelithiasis (CL) and gallbladder cholesterolosis (GBC). Native gradient (3-12%) polyacrylamide gel electrophoresis was used, followed by densitometric scanning and analysis; a correlation analysis of the levels of cholesterol levels, the body-mass index (BMI), and age was made. Various heterogeneity of LDL was revealed in CL and GBC. In the group of patients with GBC, the subfraction spectrum of LDL was characterized by a predominance of minor dense particles of LDL (Rf = 0.171 +/- 0.003), which significantly differed from that in the patients with CL (Rf = 0.146 +/- 0.004) and the controls (Rf = 0.144 +/- 0.013, p < 0.05). The increased levels of total cholesterol were associated with the changes in the subfraction spectrum of LDL with a moderate correlation (r = 0.596 and r = 0.343, respectively). However, a correlation was found between the variability of LDL, BMI, and age (r = 0.533 and r = 0.363, respectively) whereas in GBC it was absent (r = 0.148 and r = 0.117). The findings suggest that the minor dense subfractions of LDL are a risk factor for GBC irrespective of age and body mass. The modified minor particles of LDL more rapidly penetrate than other LDL fractions into the gallbladder tissue, where the gallbladder wall is intensively captured by macrophages, and participate in the formation of foamy cells. In CL, the increase in total cholesterol levels is not followed by so marked changes in the structure of LDL. The much lower proportion of minor dense particles that are components of LDL is a cause of the low entry of apolipoproteins into the gallbladder wall in CL as compared with GBC.
In a period of 5 years 790 patients underwent operation in the surgical clinic for cholelithiasis. Relaparotomy had to be conducted on 23 (2.9%) patients because intraabdominal complications occurred: escape of bile from the gallbladder bed and choledochus in its drainage, and development of peritonitis in 13 patients, pancreatitis in 2 patients, abdominal abscesses in 5, bleeding into the free abdominal cavity and the gastrointestinal tract in 3 patients. The diagnosis of complications is difficult. The developing symptoms are masked by infusion and antibiotic therapy, injection of narcotics, intestinal paresis. A complex approach is conducive to the establishment of the diagnosis: one doctor in charge, intensive surveillance of the patient, study of the results of laboratory and clinical methods of examination in dynamics. The indications for operation should be considered from the very onset in some cases. Nine (39.1%) patients died after relaparotomy.
AIM: To study heterogenic forms of LDLP and LP(a) in blood serum of patients with cholelithiasis (CL) and gallbladder cholesterosis (GBC). MATERIAL AND METHODS: Native gradient (3-12%) electrophoresis in polyacrylamide gel, rocket immunoelectrophoresis with antibodies to apo(a) were made in 20 patients with CL and 20 with GBC, 13 controls without gastrointestinal disease. Correlation of retardation factor (Rf) of LDLP and LP(a) with blood lipids, cholesterol (C) and triglycerides (TG) levels, body mass index (BMI) and age was studied. CL and GBC risk factors were analysed basing on a retrospective assessment in random representative samples of patients (100 CL and 100 GBC patients). RESULTS: There was a shift of the main peak in LDLP spectrum in the direction of smaller particles in GBC (Rf = 0.171 +/- 0.003) which was significant in comparison with CL group (Rf = 0.146 +/- 0.004, p < 0.001) and control (Rf = 0.114 +/- 0.013, p < 0.05). The analysis of LDLP Rf distribution in patients with different C levels has shown that LDLP small particles can occur in a normal C level: 75% in GBC and 50% in CL groups. Prevalence of small dense LDLP was recorded in both groups (87.5% cases) in hypercholesterolemia. Compared to control, LP(a) concentration was significantly elevated both in GBC (23.7 +/- 4.9 mg/dl) and CL (15.7 +/- 4.4 mg/dl) patients (control--7.5 +/- 1.4 mg/dl, p < 0.01), p > 0.5 in comparison between the groups. The correlation analysis found no correlations between LP9(a), other lipids, BMI and age in both study groups while Rf of LDLP correlated with C and TG levels (r = 0.596 and r = 0.226, respectively, p < 0.05), age and BMI (r = 0. 533 and r = 0.363, respectively, p < 0.05) in CL and did not correlate in GBC. CONCLUSION: A C level in CL changes with age and BMI while in GBC high LDLP C level was caused by other factors. No correlation of LP(a), LDLP Rf with age, body mass and blood lipids indicates that the above factors are independent in development of GBC.