Acalculus Cholecystitis Research Articles

Ascariasis presenting as hematemesis in a young boy

Most cases of round worm infestation are asymptomatic. Their migration to various unusual sites in the gastrointestinal tract leads to uncommon complications such as acute pancreatitis, biliary cholangitis, acalculus cholecystitis, and so on. Accumulation of worms inside intestinal lumen can lead to obstruction, intussuception, or volvulus. However, migration of the worm in the stomach and consequent hematemesis is a very rare complication. Acidic milieu of stomach and its strong peristalsis are considered to be the reason for this rarity. Mechanism of hematemesis is assumed to be erosion of the mucosa either by mechanical process or by the secretions of the worm. This young boy being presented here had vague abdominal complaints and later developed hematemesis along with vomiting out of three living round worms. He brought the worm to hospital and contributed in making prompt diagnosis. He was treated conservatively.

Incidence and management of acalculus cholecystitis in dengue fever - A retrospective study

Objectives: To investigate the frequency, clinical features, prognosis, clinical response of acute acalculous cholecystitis in dengue fevers. Materials and Methods: A study period from Jan 2010 to Dec 2012 in RLJH hospital, where patients diagnosed with dengue fever (DF), both clinically and with lab reports validating diagnosis with IgM antibody and IgG antibody positive for dengue antigen were included in the study. The incidence of acute acalculus cholecystitis among these patients was studied, acalculus cholecystitis diagnosed with clinical presentation and supported by USG abdomen. Fever, right upper quadrant (RUQ) pain and tenderness , positive murphy’s sign being the clinical findings and thickened gallbladder wall (defined as wall thickness > 3.5 mm), positive sonographic Murphy’s sign (defined as maximum tenderness of the sonographically localized gallbladder), pericholecystic fluid collection, and no stone(s) in the gallbladder being the USG findings. The patients satisfying the criteria were serially monitored for vitals – pulse rate and blood pressure with regular monitoring for development of any complication done. Treatment given with antibiotics, intravenous fluids, analgesics. Results: Total no of patients with confirmed dengue fever by antibody testing - 955. Among these, number of patients who developed the complication of acute acalculus cholecystitis were 68. The incidence observed was 7.12%. Mean period of stay for patients developing this complication at hospital was 7.1 days as against 3.4 days who had no complication. All of these patients recovered fully with conservative line of management with none requiring any surgical intervention. Conclusion: Acute acalculus cholecystitis is one of the common complications developing in patients with dengue fever. Conservative line of management with antibiotics, intravenous fluids, analgesics, regular monitoring is sufficient in managing this complication with no need for aggressive surgical intervention.

Cholecystostomy Offers No Survival Benefit in Patients with Acute Acalculus Cholecystitis and Severe Sepsis or Shock

Cholecystostomy Offers No Survival Benefit in Patients with Acute Acalculus Cholecystitis and Severe Sepsis or Shock

A nationwide examination of outcomes of percutaneous cholecystostomy compared with cholecystectomy for acute cholecystitis, 1998–2010

Improvements in percutaneous drainage techniques combined with the recognized advantages of avoiding surgery in critically ill patients have rendered cholecystostomy an attractive treatment option, particularly in those patients with acute acalculus cholecystitis. However, robust data to guide surgeons in choosing cholecystostomy versus cholecystectomy have been lacking. Retrospective analysis of the Nationwide Inpatient Sample (NIS) database from 1998-2010 was performed. Patients identified as having acute cholecystitis (calculus and acalculus) were identified by ICD-9 diagnosis codes and further classified as having undergone cholecystostomy or cholecystectomy. Patients with both procedures were included in the cholecystectomy group. Patients with neither procedure and those younger than age 18 years were excluded. Multivariate analyses examined mortality, length of stay, total charges, gallbladder/gastrointestinal complications, or any complication. Results were adjusted for age, race, gender, Charlson comorbidity index, and teaching-hospital status. Subset analyses were performed among patients who survived and patients who died. A total of 248,229 calculus and 58,518 acalculus acute cholecystitis patients were analyzed. On unadjusted analysis, mortality, length of stay, and total charges were higher, but complication rates were lower, in patients with a cholecystostomy. Adjusted analysis showed lower odds of complications [calculus: odds ratio (OR) 0.3, p < 0.001; acalculus: OR 0.4, p < 0.001] but higher odds of mortality, total charges, and LOS (calculus: mortality OR 5.2, p < 0.001, $29,113, p < 0.001, +5.1 days, p < 0.001; acalculus: mortality OR 3.7, p < 0.001; $43,771, p < 0.001, +6.2 days, p < 0.001) among patients who received cholecystostomy. Results were similar in subset analyses. Patients receiving cholecystostomy were more likely to be older and have more comorbidities. Among patients with calculus or acalculus cholecystitis, patients with cholecystostomy had decreased complication rates compared with patients with cholecystectomy. However, patients who received cholecystostomy had increased odds of death, longer length of stay, and higher total charges.

Embryological Basis and Clinical Correlation of the Rare Congenital Anomaly of the Human Gall Bladder: - “The Diverticulum” - A Morphological Study

Diverticulum of the human gall bladder is an important but distinct anatomical entity with significant clinical implications. It is one of the rarest congenital anomalies of the gall bladder being rarely discussed in literature. This article details the morphology of the diverticula found, along with the embryological basis and clinical significance of this important anatomical and clinical entity. To study the diverticula found, with respect to their morphology, and ascertain whether they were of congenital or acquired variety. Setting and Designs: The present study is a retrospective study carried on hundred cadavers during undergraduate dissection, in the Department of Anatomy, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, and Department of Anatomy, Subharti Medical College , Meerut during a four year period i.e. 2008-2012 after obtaining necessary permission from institutional ethical committee. Hundred gall bladder specimens collected from 10% formalin fixed cadavers were studied in detail with regard to their number, position, shapes dimensions and histology. Nine, congenital (true) diverticula were found in one hundred gall bladder specimens. The diverticula were of various shapes and dimensions. They formed pouches on the luminal surface of the gall bladder. Diagnosis of congenital diverticulum was confirmed by histology. In this cadaveric study, solitary diverticulum was found in nine (9%) specimens out of one hundred specimens. Association of diverticulum with non-specific prolonged ailments, acalculus cholecystitis, cholecystitis and cholelithiasis, recurrent cholangitis and carcinoma of gallbladder has been reported in literature. This important anatomical as well as clinical entity poses challenges for radiologists and laparoscopic surgeons during interventional procedures and also should be differentiated from other types of congenital anomalies and pathological states of gall bladder.

Postoperative abdominal complications after cardiopulmonary bypass

BackgroundTo summarize the diagnostic and therapeutic experiences on the patients who suffered abdominal complications after cardiovascular surgery with cardiopulmonary bypass(CPB).MethodsA total of 2349 consecutive patients submitted to cardiovascular surgery with CPB in our hospital from Jan 2004 to Dec 2010 were involved. The clinical data of any abdominal complication, including its incidence, characters, relative risks, diagnostic measures, medical or surgical management and mortality, was retrospectively analyzed.ResultsOf all the patients, 33(1.4%) developed abdominal complications postoperatively, including 11(33.3%) cases of paralytic ileus, 9(27.3%) of gastrointestinal haemorrhage, 2(6.1%) of gastroduodenal ulcer perforation, 2(6.1%) of acute calculus cholecystitis, 3(9.1%) of acute acalculus cholecystitis, 4(12.1%) of hepatic dysfunction and 2(6.1%) of ischemia bowel diseases. Of the 33 patients, 26 (78.8%) accepted medical treatment and 7 (21.2%) underwent subsequent surgical intervention. There were 5(15.2%) deaths in this series, which was significantly higher than the overall mortality (2.7%). Positive history of peptic ulcer, advanced ages, bad heart function, preoperative IABP support, prolonged CPB time, low cardiac output and prolonged mechanical ventilation are the risk factors of abdominal complications.ConclusionsAbdominal complications after cardiovascular surgery with CPB have a low incidence but a higher mortality. Early detection and prompt appropriate intervention are essential for the outcome of the patients.

Acute acalculus cholecystitis and hepatitis caused by Brucella melitensis

Acute cholecystitis is a very rare presentation of brucellosis. A case of acalculous cholecystitis caused by Brucella melitensis is reported with a review of previously reported cases.

Severity of acute hepatitis and its outcome in patients with dengue fever in a tertiary care hospital Karachi, Pakistan (South Asia)

BackgroundLiver injury due to dengue viral infection is not uncommon. Acute liver injury is a severe complicating factor in dengue, predisposing to life-threatening hemorrhage, Disseminated Intravascular Coagulation (DIC) and encephalopathy. Therefore we sought to determine the frequency of hepatitis in dengue infection and to compare the outcome (length of stay, in hospital mortality, complications) between patients of Dengue who have mild/moderate (ALT 23-300 IU/L) v/s severe acute hepatitis (ALT > 300 IU/L).MethodsA Cohort study of inpatients with dengue viral infection done at Aga Khan University Hospital Karachi. All patients (≥ 14 yrs age) admitted with diagnosis of Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS) were included. Chi square test was used to compare categorical variables and fischer exact test where applicable. Survival analysis (Cox regression and log rank) for primary outcome was done. Student t test was used to compare continuous variables. A p value of less than or equal to 0.05 was taken as significant.ResultsSix hundred and ninety nine patients were enrolled, including 87% (605) patients with DF and 13% (94) patients with DHF or DSS. Liver functions tests showed median ALT of 88.50 IU/L; IQR 43.25-188 IU/L, median AST of 174 IU/L; IQR 87-371.5 IU/L and median T.Bil of 0.8 mg/dl; IQR 0.6-1.3 mg/dl. Seventy one percent (496) had mild to moderate hepatitis and 15% (103) had severe hepatitis. Mean length of stay (LOS) in patients with mild/moderate hepatitis was 3.63 days v.s 4.3 days in those with severe hepatitis (P value 0.002). Overall mortality was 33.3% (n = 6) in mild/moderate hepatitis vs 66.7% (n = 12) in severe hepatitis group (p value < 0.001). Cox regression analysis also showed significantly higher mortality in severe hepatitis group (H.R (4.91; 95% CI 1.74-13.87 and P value 0.003) and in DHF/DSS (5.43; CI 1.86-15.84 and P value 0.002). There was a significant difference for the complications like Bleeding (P value < 0.001), Acute Renal failure (ARF) (P value 0.002), Acalculus cholecystitis (P value 0.04) and encephalopathy (P value 0.02) in mild/moderate and Severe hepatitis groups respectively.ConclusionSevere hepatitis (SGPT>300IU) in Dengue is associated with prolonged LOS, mortality, bleeding and RF.

Granulomatous Hepatitis and Acalculus Cholecystitis in an adolescent male with newly diagnosed Crohnʼs Disease: A Case Report

Crohn's Disease (CD) is often characterized by the presence of inflammatory granulomas in the intestines as well as tissues such as the liver and gallbladder. We report a case of granulomatous hepatitis and clinical cholecystitis as the initial presentation of CD in an adolescent male. Sixteen-year-old adolescent male presented to Harbor-UCLA Medical Center Emergency Department complaining of a weeklong history of worsening abdominal pain, vomiting, and fever. Further history revealed intermittent diarrhea and a fifteen-pound weight loss over the course of a year. On exam, the abdomen was tender, especially over the right hypochondrium, with noticeable rebound but no overt peritoneal signs. Blood tests showed elevated AST and ALT twice above normal range, a total bilirubin of 2.7 mg/dL that was primarily direct, and an elevated C-reactive protein. Stool was positive for blood and pus, but CBC and electrolytes were normal. A liver ultrasound was significant for gallbladder sludge and splenomegaly. Patient was given fluid and intravenous antibiotics and was admitted for further evaluation. Surgery was consulted and ordered an abdominal scan that revealed an abnormal liver with a heterogeneous texture, pericholecystic fluid, splenomegaly, and a diffusely thickened terminal ileum with surrounding lymphadenopathy. Cholescintigraphy was notable for delayed clearance of the blood pool and a severely impaired gallbladder ejection fraction of eight percent. The patient underwent upper and lower endoscopy with the latter demonstrating severe inflammation of the cecum and deep, lineal ulceration of the terminal ileum (Figure 1). Histology confirmed the diagnosis of CD, noting chronic inflammation and nonceating granulomas. Surprisingly, liver biopsy was positive for multiple, giant noncaseating granulomas with parenchymal inflammation (Figures 2 and 3). Copper stain was negative. Cholecystectomy was considered but deferred due to the patient's clinical improvement on antibiotics, steroids, and enteral nutritional (EN). The patient has maintained clinical remission with enteric budesonide, partial EN, and 6-mercaptopurine. Fissuring ulcer in cecum (black arrow). Granulomatous hepatitis. Note giant cell (black arrow) within granuloma (blue arrow). The clinical presentation of right upper quadrant pain associated with vomiting, fever, and cholestasis is consistent with gallbladder dysfunction. Acalculus cholecystitis has been described in long-standing CD; granulomas are found within the livers of about 8% of patients with CD.i,ii,iii,iv This is the first reported finding of such entities at the initial presentation of CD. We suspect that granulomatous inflammation of the gallbladder in our patient was responsible for its dysfunction. Repeat cholescintigraphy, liver biopsy, and colonoscopy will shed further light on this interesting and complicated case.

Pancreatitis and Cholecystitis from Gastrostomy Tube

Purpose: For prolonged enteral feeding, gastrostomy tubes (GT) are prefered over nasogastric tubes. Most of GT complications are minor but some can lead to significant morbidity and even mortality if not recognized early. We report a case of pancreatitis and cholecystitis secondary to migrated GT. Methods: A 77 year old hispanic male with history of cerebrovascular accident had a GT inserted about 4 years ago. His GT was replaced with a balloon GT endoscopically about 8 months ago due to leakage around the tube. His GT was attended by a visiting nurse. He was admitted to our hospital with complaint of moderate to severe non-radiating epigastric pain associated with vomiting and leaking around the GT. Nasogastric tube was inserted and about 300 cc of greenish colored fluid was obtained. His vital signs were stable and he was afebrile. Physical exam revealed marked tenderness in the epigastrium and the GT was found to be migrated more than 10 cm into the stomach. His abnormal laboratory results were white blood cell count 17.3 × 106/L, amylase 3249 IU/L, lipase 3007 IU/L, aspartate transaminase 214 IU/L, alanine transaminase 140 IU/L, and alkaline phosphatase 165 IU/L. He had normal triglyceride and bilirubin levels. Ultrasound of the abdomen revealed distended gall bladder with thickened wall and edema consistent with acalculus cholecystitis. Computed tomography of the abdomen confirmed the ultrasound findings. It also revealed peripancreatic inflammatory changes extending into anterior pararenal spaces and paracolic gutters. GT was seen in the second portion of the duodenum with its balloon significantly distended with air and fluid. The gastric antrum, pylorus and third and fourth portion of the duodenal wall were noted to be edematous and thickened. The GT balloon was deflated and the tube was repositioned. The patient's symptoms and laboratory values significantly improved the next day and became normal over the course of 3 days. There was no more leakage around GT. Results: The patient tolerated his feeding and was discharged uneventfully. Conclusion: Endoscopic enteral access for enteral nutrition in patients who are unable to maintain oral intake is an important tool in the armamentarium of the gastroenterologist. Even though GT is relatively safe, sometimes it can lead to severe life threatening complications such as pancreatitis and cholecystitis if GT is not handled well. Proper care of GT by trained persons is extremely important in order to prevent GT related severe complications. This reported case clearly proved that fact.

&lt;i&gt;Oerskovia turbata&lt;/i&gt; and&lt;i&gt; Myroides&lt;/i&gt; species: Rare isolates from a case of acalculus cholecystitis

Here we report a case of acalculus cholecystitis, which presented with features of obstructive jaundice of one-week duration. The patient underwent cholecystectomy and bile grew a mixed culture of Oerskovia turbata and Myroides spp. Being a rare isolate, characteristic features of the former are described in this report. The patient recovered without any complication.

Prevalence of biliary ascariasis and its relation to biliary lithiasis.

Hepatobiliary ultrasound was carried out on 2224 consecutive patients at the Center for Nuclear Medicine and Ultrasound and at one private diagnostic center in Mymensingh for ultrasound examination of different systems. The purpose of this study was to investigate the prevalence of biliary ascariasis and its association with other biliary diseases, specially biliary lithiasis. Data regarding the presence of stone, worm or other diseases were recorded accordingly in this prospective study. There were 952 male and 1272 female patients with an age range of 5-90 years. Biliary diseases were detected in 305 patients (13.71%), of whom 97 were male (10.19%) and 208 were female (16.35%). The most common biliary disease in both sexes was cholelithiasis (11.87%), which was found in 84 male patients (8.82%) and in 180 female patients (14.15%). Other diseases found were choledocholithiasis in 14 patients (3 males, 11 females), gall bladder mass in 9 patients (3 males, 6 females), common bile duct mass in 7 patients (4 male, 3 female) and biliary ascariasis in 10 patients (3 male, 7 female). Overall prevalence of biliary ascariasis was 0.45% (0.31% in male patients and 0.55% in female patients), and age range of patients with the condition was 6-50 years. No case of biliary ascariasis was associated with cholelithiasis or choledocholithiasis. Acute cholecystitis was associated with 8 cases (80%) of biliary ascariasis. Common sonographic findings in patients with biliary ascariasis were a single long, linear or curved echogenic structure within the bile duct, without acoustic shadowing. Other findings were gall bladder distention with sludge inside, an edematous wall and mildly dilated biliary tree. Prevalence of biliary ascariasis in the study was 0.45%, with incidence being higher in female subjects (0.55%). No correlation was found between biliary ascariasis and biliary lithiasis. Most of the cases of biliary ascariasis were associated with acute cholecystitis. We concluded that a careful search for biliary ascariasis should be considered for patients with acute acalculus cholecystitis, especially in areas in which ascariasis is endemic, such as Bangladesh.

Computed Tomographic Imaging of Acute and Complicated Cholecystitis

Acute cholecystitis is the fourth most common cause of hospital admission among patients presenting with an acute abdomen. Imaging plays a key role in the evaluation of patients with acute cholecystitis, because no single clinical finding or laboratory test carries sufficient weight to establish or exclude the diagnosis.1 The vast majority of cases of acute cholecystitis are due to obstruction of the cystic duct by a gallstone. Acalculus cholecystitis, which accounts for approximately 5% to 10% of the cases, is a complication seen in the setting of major trauma and prolonged critical illness.2

Percutaneous Needle Decompression during Laparoscopic Gastric Surgery: A Simple Alternative to Nasogastric Decompression

Laparoscopic gastric surgeries are routinely performed with use of a nasogastric tube to decompress the upper gastrointestinal tract. A distended upper gastrointestinal tract can complicate successful laparoscopic gastric surgery as the distention compromises not only the visual field but also the laparoscopic manipulation of the stomach. Since nasogastric intubation is not without risks, we have attempted laparoscopic-assisted gastric cancer surgeries without nasogastric tubes. In this article we describe a simple method of aspirating gastric contents using a 9 cm long 19-gauge needle inserted percutaneously during laparoscopic-assisted gastrectomy. First, a 9 cm long 19-gauge disposable needle was introduced through the abdominal wall. This needle was then introduced to the stomach through the anterior wall and the stomach gases and fluids were aspirated by connecting the needle to suction. Thus, a collapsed upper gastrointestinal tract was easily obtained. We performed this procedure instead of nasogastric decompression on twenty-two patients with gastric cancer who underwent laparoscopic-assisted distal subtotal gastrectomy with lymph node dissection. The results were good with only one patient experiencing wound infection (4.5%) and one patient with postoperative acalculus cholecystitis (4.5%). There were no patients with either intraabdominal infection or anastomotic leakage and none of the patients needed postoperative nasogastric decompression, except the patient who experienced acaculus cholecystitis. Percutaneous needle aspiration is a very simple and efficient technique with little risk of postoperative complications. It can be used as an alternative to nasogastric tube decompression of the gastrointestinal tract for laparoscopic-assisted gastrectomy.

Diagnostic Approach to the Patient with Jaundice following Trauma

Jaundice in trauma patients may reflect serious underlying pathology. The aim of this review was to determine the appropriate diagnostic approach to the patient with jaundice following trauma. A MEDLINE search was performed to retrieve publications which outlined the causes of jaundice in trauma patients. The main causes of jaundice in trauma patients were found to be bilirubin overload caused by breakdown of transfused- and extravasated blood and hepatic dysfunction caused by sepsis, infections, initial shock and systemic hypotension. Bile duct injury or drug induced liver injury are rare. Liver function tests are often uninformative but commonly show a cholestatic pattern. Ultrasound, CT or ERCP are the diagnostic imaging methods most widely used. Abdominal ultrasound and CT may reveal specific organ injuries, bile duct dilatation, intraabdominal fluid collections, hematomas or acalculus cholecystitis. ERCP is often diagnostic and permits a therapeutic intervention when a bile duct injury is present. The primary aim of the diagnostic approach should be to identify all cases of bile duct injury or obstruction. Sepsis and infections should be actively looked for. The number of blood transfusions must be calculated. Ultrasound, CT or ERCP are the diagnostic imaging methods most widely used.

Gall bladder ascariasis

Around 1.5 billion people around the worldharbour Ascaris lumbricoides (round worm) intheir digestive tracts. From the intestines, wormscan invade the biliary tree causing cholangitis, thepancreatic duct causing pancreatitis, and thegallbladder causing acalculus cholecystitis or evenliver abscesses. Gallbladder ascariasis, althoughlesscommonthanbileductascariasis,isquiteoftenseen in endemic areas. Isolated gallbladder ascar-iasis accounts for approximately 4% of all hepato-biliary ascariasis.

Laparoscopic management and clinical outcome of emphysematous cholecystitis.

As opposed to acute, chronic, and acalculus cholecystitis, emphysematous cholecystitis (EC) is associated with significant morbidity and mortality. Only a few studies have specifically reviewed the operative management and clinical outcome of EC. This study documents the operative management and clinical outcome of EC at the Cleveland Clinic Foundation. Between January 1996 and June 1999, 18 consecutive patients underwent cholecystectomy for emphysematous cholecystitis at our institution. All charts were reviewed retrospectively, and patients undergoing concurrent procedures were excluded. Mean values +/- standard deviation (SD) of the mean were calculated for patient demographics, preoperative white blood cell count (WBC), bilirubin, alkaline phosphatase, and length of hospital stay. Operative procedure (laparoscopic, converted, or open), preoperative imaging studies, operative time, ICU stay, morbidity, and mortality were reviewed. Patients presented with a mean age of 53.4 years (range, 18-80) and a male/female ratio of 3.5 (14/4). There were no differences between groups in terms of patient demographics. Mean WBC on admission was 14.2 K/mL (range, 5.4-19.7). Mean alkaline phosphatase and total bilirubin were 115 U/L (range, 45-428) and 1.4 mg/dl (range, 0.5-3.4), respectively. Thirteen patients (72%) were completed laparoscopically, two patients (11%) were converted to an open procedure, and three patients (17%) had open surgery. Overall mean length of hospital stay was 5 days (range, 1-18). Two patients from the open group ultimately died 1 year later due to progression of preexisting illness. One of these patients had congestive heart failure and chronic renal failure; the other had metastatic malignant melanoma. None of the patients died in the immediate perioperative period. There were five complications (27.8%). Two patients presented with bleeding secondary to heparin and coumadin therapy. One developed sepsis, and another developed leakage from the cystic duct stump, necessitating an endoscopic retrograde cholangiopancreatogram (ERCP) with stent decompression. The fifth complication, ileus, required readmission 3 days postoperatively, but the patient responded to conservative management. Complications were evenly distributed between the three groups. There were two complications in the laparoscopic group, two in the open group, and one in the conversion group. All other patients were alive at the time of this publication. Using current techniques, patients with EC can be managed successfully utilizing laparoscopy. Morbidity and mortality appear to be slightly higher than published reports for acute, chronic, and acalculus cholecystitis. Conversion rates are comparable to patients with acute and chronic cholecystitis who undergo laparoscopic cholecystectomy. Based on these data, laparoscopic cholecystectomy should be considered the first-line treatment for patients with known or suspected EC.

Prophylactic Cholecystectomy Is Not Indicated following Renal Transplantation

Background: The appropriate management of gallstones in patients undergoing renal transplantation is controversial. Screening for gallstones and subsequent prophylactic cholecystectomy has been recommended by some authors for kidney transplant candidates. Our program does not practice routine pretransplant screening for gallstones, and we reviewed our data to determine the outcome of our management approach. Methods: We reviewed the records of the 1,364 currently followed patients who have undergone kidney transplant at our institution since 1985 in order to evaluate the morbidity and mortality of biliary disease in the post-transplant period. We attempted to contact all patients by telephone or mail survey for the presence of biliary tract disease or operations. Results: Six hundred and sixty-two patients were fully evaluated. Fifty-two (7.85%) required cholecystectomy for stone disease. Seven patients underwent incidental cholecystectomy during other operations, 2 patients developed acalculus cholecystitis, and 14 patients with asymptomatic cholelithiasis are being followed up. Surgical indications included 38 biliary colic, 9 acute cholcystitis, 3 gallstone pancreatitis, and 2 patients who were asymptomatic. Fifty-two patients underwent 30 laparoscopic cholecystectomies, 20 open cholecystectomies, and 2 conversions. Surgery occurred from 7 days to 9.6 years following transplantation. Overall, the median hospital stay (no postoperative stay) was 4 days (range 1 to 57). Patients undergoing laparoscopy had a median stay of 2 days compared with 7 days for those undergoing an open procedure. Complications were seen in 6 patients (11.5%) with no morbidity and no graft loss. The 1-, 2-, and 5-year graft survival was 98%, 96%, and 85%, respectively, in patients undergoing cholecystectomy. Conclusions: Transplant patients are not at an increased risk for developing biliary tract disease compared with nontransplant patients. Gallstone disease does not have a negative impact on graft survival. Treatment of gallstones has a low risk and does not represent an increased risk of complications in patients following renal transplantation.

Laparoscopic cholecystectomy in the treatment of acalculus cholecystitis in patients after thermal injury.

Acalculus cholecystitis accounts for 2% to 14% of all cases of acute cholecystitis and is seen with increasing frequency in patients after major trauma and burns. In these already compromised patients, acute acalculus cholecystitis can be difficult to diagnose and more difficult to treat. We present our experience with laparoscopic cholecystectomy in seven patients with this often lethal combination treated over the last 5 years. All the patients who underwent surgery survived and had minimal morbidity from their operations. We discuss the etiology and diagnosis and review the literature of the treatment of acalculus cholecystitis in patients after thermal injury.

Cholecystosonographic evaluation of the prevalence of gallbladder diseases a university hospital experience

Ninety-five healthy volunteers and 515 patients with problems other than those of the biliary tract were examined using real-time, gray-scale, B-mode ultrasonography. Eighty-two patients (13.44%) were found to have asymptomatic gallbladder disease: 68 (11.14%) had cholelithiasis, 5 (0.81%) had acalculus cholecystitis, and 2 (0.32%) had polyps. Three cases of carcinoma of the gallbladder were also detected, suggesting that ultrasound examination of the highrisk population in an endemic area should not be confined to the disease concerned but that the gallbladder of such patients should also be screened to pick up asymptomatic gallbladder disease. Hence ultrasound can be used as a screening modality for the early detection of carcinoma of the gallbladder.