Chronic Gallbladder Disease Research Articles

When cholecystectomy?

The crux of the matter is to avoid being forced into cholecystectomy when the patient is acutely ill and has an increased risk of operative mortality. The rationale for performing surgery on an elective basis in patients with chronic gallbladder disease and for early medical management in most patiens with acute disease is discussed, along with the specifics of diagnosis and special considerations in the handling of problem cases.

Chronic Cholecystitis and Intramural Diverticulosis of the Gall Bladder

Summary 1.A case of intramural diverticula of the gall bladder (Rokitansky-Aschoff sinuses), as demonstrated radiographically, is presented with pathological verification. 2.In the face of adequate concentrating power of the gall bladder and an otherwise indeterminate examination, the radiographic demonstration of such intramural herniations is considered strong evidence in support of chronic gallbladder disease.

Biliary system inflammation and cholecystitis: A study of 200 liver biopsies done at cholecystectomy

Two hundred cases of liver biopsy were studied in patients with proved acute or chronic gallbladder disease, 97.5 per cent with stones. Thirty-two per cent of these patients demonstrated changes consistent with a diagnosis of biliary tree inflammation or what is termed as “cholangitis.” It is believed that acute or chronic cholecystitis with or without stones is only one facet of a generalized process. An ascending type of inflammation as a means of etiology is presumed but not proved. There was a significantly large percentage of patients showing fatty change which was quite variable in extent, amounting to 29 per cent of the total cases. Fatty metamorphosis seemed to be independent of any other process. Attempt was made to correlate an impaired convalescence of the patient with the status of the liver but this was difficult and not conclusive. A discussion of the method of taking the biopsy has been made. Artefacts are an extremely common occurrence in the specimens, but are usually easily recognized. Pathologic descriptions are included and represented by the photomicrographs. We believe that due to the lack of a control group this problem warrants further study.

Technique of common duct exploration.

IN THE SURGICAL therapy of chronic gall bladder disease with stones, the indications for common duct exploration are specific and clear cut. On this surgical service, the common duct is opened and explored at the time of cholecystectomy under the following circumstances: (1) concomitant obstructive jaundice at the time of operation; (2) one or more episodes of jaundice in the past history of the patient; (3) finding of a dilated common duct at the time of cholecystectomy; (4) presence of a dilated cystic duct with small calculi in the gall bladder, and (5) finding of enlargement of the head of the pancreas due to chronic pancreatitis. In the conduct of the operation under the circumstances enumerated above, the diseased gall bladder with its contained calculi is removed, with careful individual ligation of the cystic vessels and duct under direct vision. It has been found important to excise the entire cystic

Roentgen visualization of the Rokitansky-Aschoff sinuses as an additional sign of chronic gallbladder disease.

The radiological visualization of the Rokitansky-Aschoff sinuses is considered by many as of only academic interest. The case to be reported here, however, illustrates the clinical accuracy of their demonstration as evidence of chronic gallbladder disease. In the normal healthy gallbladder one rarely sees what are considered to be the Rokitansky-Aschoff sinuses. This term can be applied only to the deep outpouchings of mucosa extending into or through the muscular coat and into the perimuscular layers, leading to separation of the interstices and delicate walls of the muscle bundles. Normally the gallbladder muscle bundles are resistant to such outpouchings. In the presence of inflammation, however, these contractile structures become weakened. With obstruction and chronic over-distention, the mucosa can readily herniate through the intermuscular septa and extend into the perimuscular tissues, even reaching the serosa. Pathologically the gallbladder in which Rokitansky sinuses are found is usually thickened as a result of chronic inflammatory changes, with the usual inflammatory infiltration of the connective tissues and associated proliferation of fibroblasts and edema. These changes are rarely detected on the roentgenogram because of the reduced contractibility of the gallbladder and its inability to concentrate the usual opaque media. The pathologist has long used the microscopic and gross detection of Rokitansky-Aschoff sinuses as a basis for diagnosis of chronic gallbladder disease, even in the absence of other changes. As early as the seventeenth century pathologists demonstrated gland-like, branched mucosal outpouchings in the gallbladder walls. It was not until 1861, however, that von Rokitansky (10) adequately described these hernia-like outpouchings, not as true glands, but as herniations of the mucosa extending into the deeper layers of the walls and at times containing small concretions. Halpert (6) later differentiated these sinuses from the true Luschka ducts, which are actually accessory bile ducts joining the liver through the cystic bed. Aschoff (3) later showed that the mucosa of the gallbladder lacks a muscularis mucosae and that the underlying tunica muscularis is somewhat thinly spread and of irregular structure. Through this muscular network penetrate the blood vessels. These potential intermuscular spaces are often separated by increased intracystic tension with associated herniation of the mucosa. This latter observation is of interest in that in all cases of roentgenologically demonstrated Rokitansky-Aschoff sinuses reported there has been present an associated stricture of the proximal portion of the gallbladder. Robertson and Ferguson (9) of the Mayo Clinic found some herniation of the mucosa in 50 per cent of gallbladders of persons over the age of thirty.

Perforation of the gallbladder

In a fifteen-year period forty-four cases of perforation of the gallbladder were encountered among 2,807 operations for acute and chronic cholecystitis. These cases are classified as follows: Type i (acute, free perforation), five cases; Type ii (subacute perforation with pericholecystic abscess), twenty-five cases; Type iii (chronic perforation with cholecystoenteric fistula), fourteen cases. The mortality rate was 40 per cent for Type i, 4 per cent for Type ii and zero for Type in. Type i or acute, free perforation of the gallbladder is a rare occurrence carrying a high mortality. It is more common in male patients who may have no previous history of gallbladder disease. Physical signs, fever and leukocytosis may be deceptively mild but should be sufficient to justify a diagnosis of an acute abdomen and a decision to operate without delay. Aspiration of the peritoneal cavity, cholecystostomy and drainage is the procedure of choice. In the absence of severe associated disease early operation limited to this simple, essential procedure should result in a reasonably good prognosis. Type ii or localized perforation with the formation of a pericholecystic abscess is the most common sequence in perforation of the gallbladder. Most of the patients are in the sixth decade and most of them give a history of chronic cholecystitis. The immediate clinical picture may be that of acute, subacute or chronic cholecystitis, depending on the time of perforation and the nature of the abscess. A history of chills and fever is suggestive and a mass is palpable in the right upper quadrant in about half of the cases. Cultures of the abscess are usually positive, with the colon bacillus the most common organism. The usual operative procedure is drainage of the abscess and cholecystostomy, but cholecystectomy is often feasible. Convalescence is surprisingly smooth and the mortality is low. Type iii or chronic perforation of the gallbladder with formation of a cholecystoenteric fistula is an uncommon end stage of chronic gallbladder disease. Most of the patients are in the seventh decade and females predominate. About one-third of the patients are admitted with intestinal obstruction due to a gallstone lodged in the terminal ileum. Slowly developing, incomplete obstruction is characteristic. Recovery is rapid after simple ileotomy and removal of the stone. In the other two-thirds of the patients the fistula is found at operation for chronic cholecystic disease which is usually of many years' duration. Jaundice, chills and fever are common symptoms. Stones are frequently found in the common duct. The duodenum and the colon are the most frequent sites of fistula formation. The results have been excellent after cholecystectomy, closure of the fistula and choledochostomy if indicated. The incidence and mortality of perforation of the gallbladder can be reduced somewhat by a general policy of early operation for acute cholecystitis and perhaps even more by the practice of elective cholecystectomy for all patients presenting the history and findings of chronic cholecystitis. If cholecystostomy is done during an acute episode, it should be followed with cholecystectomy a few months later.

Melancholia; clinical study of 50 selected cases.

Since 1940, when one of us (T. T. S.) startedto treat various forms of mental illness with the newly discovered shock technics, an unusual situation has been found in many cases of melancholia. In a large number of cases of mental depression this commonly occurring predicament was not recognized. Instead, these patients were treated for such conditions as diabetes mellitus, hypertension, menopausal syndrome, arteriosclerosis, neuritis, fatigue, cachexia, thyroid disease, chronic gallbladder disease, senility, chronic gastric and peptic ulcer, brucellosis or anemia. Although some of these patients did have high blood pressure, sugar in the urine or signs of the menopause, the diagnosis of melancholia was not made until late in the disease. The elapsed time from the onset of the symptoms to the time of accurate recognition of the disease was three to thirty-six months. This failure of accurate classification was found only occasionally in cases of the cyclic form

The Clinical Diagnosis of Chronic Gall-Bladder Disease

The Clinical Diagnosis of Chronic Gall-Bladder Disease

THE CONCEPT OF LIVER DEATHS

In 1922 following a rather prolonged period of clinical observation it became evident that there were certain types of mortality that followed operations on the external biliary system. 1 There were three types of death that followed gallbladder surgery. Later these findings were more formally presented as follows: Group 1.— Liver deaths associated with hyperpyrexia and coma. Death ensues in eighteen to thirty-six hours. The first group is composed of patients who have had a comparatively simple gallbladder operation. The patients were usually obese and gave a history of chronic gallbladder disease. Preoperative study did not reveal any contraindication to surgical intervention. Following cholecystectomy the recovery from the anesthesia was slow; in fact, the patient never did emerge fully from the anesthesia. In four to six hours after the return to the ward the patient was in a semicomatose state that passed rapidly into stupor and coma, with a rapidly

Calcification of the Gallbladder: Roentgenographic and Pathologic Study

Calcification of the gallbladder is sometimes an incidental necropsy finding in older patients. Its occurrence has been reported by Robb (1) and others (2–10). The condition in itself seldom produces clinical symptoms, but its close relationship to chronic gallbladder disease and the problems involved in differential diagnosis are of utmost importance. Three proved cases of calcified gallbladder will be presented, and 3 cases in which this diagnosis was suggested by the roentgenograms but was not surgically verified. Case Reports Case 1: T. D., a 40-year-old colored woman, was admitted to the Cook County Hospital Nov. 19, 1938. She had been well until two years before admission, when she began to experience dull right upper quadrant pain, which radiated around the right side of the abdomen to the back, just beneath the right scapula. She complained, also, of belching and bloating, and a sense of fullness in the epigastrium following the ingestion of a moderately heavy meal of fatty or fried foods. There h...

Non-calculous chronic gall-bladder disease

The data for this study were derived from 346 uncomplicated cases of non-calculous chronic cholecystitis. The physiology of the gall-bladder in its modern conception and the principles of cholecystography have been reviewed. Surgery of the gall-bladder began as early as 1618, when Fabricius Hildanus removed gallstones from a living patient. In 1909, Moynihan called attention to the type of gall-bladder disease now known as the strawberry gall-bladder. Stanton, in 1911, made a study of the results in stoneless gall-bladder disease. Cholecystectomy has been accepted as the operation of choice in this type of gall-bladder disease. The question as to when the gall-bladder should be removed is unsettled. Latest classification of pathology in this disease has been discussed.

Bile salt therapy in gall bladder disease

(1) 3 groups of patients with gall bladder disease are described. (2) The use of a low fat diet and large amounts of bile salts is advocated in the treatment of these cases. (3) In the group (13 cases) with the type of postcholecystectomy syndrome not due to organic obstruction, relief was obtained in most of the cases with this form of therapy. (4) In two other groups, i.e., those with stones and normally functioning gall bladders (14 cases) and those with chronic gall bladder disease in whom the gall bladder failed to visualize (11 cases) considerable relief from symptoms was also obtained. (5) In the cases in whom gastric hyperacidity was present atropin and alkalies were helpful adjuvants in the therapy. (6) In view of these results, the use of this mode of therapy in a larger group of cases seems advisable.

Common Germs Blamed for Chronic Gall Bladder Disease

Common Germs Blamed for Chronic Gall Bladder Disease

The Cause of Chronic Gall Bladder Disease

The Cause of Chronic Gall Bladder Disease

The Cause of Chronic Gall Bladder Disease

The Cause of Chronic Gall Bladder Disease

Oral cholecystography in the diagnosis of chronic gall-bladder-disease

1.1. The diagnosis of chronic gall bladder disease is discussed with reference to the symptomatology, differential diagnosis, laboratory diagnosis, and roentgenologic diagnosis.2.2. Thirty operated cases are analyzed according to symptomatology.3.3. The rationale, technic, and interpretation of cholecystograms are discussed.4.4. The findings in 216 consecutive examinations of the gall bladder are tabulated.5.5. Comparison of the roentgenologic and operative diagnosis in 30 operated cases is presented.6.6. Comment is made upon the relative position of cholecystography in the diagnostic scheme in chronic gall bladder disease.

On the effect of ether anesthesia on liver function. К. Voshamer (Klin. Woch., 1928, No. 10)

К. Boshamer deduces from his studies that every ether anesthesia gives a small damage to the liver, which is made very noticeable if the organ has been previously diseased, even if it is latent. Such latent damage to the liver occurs in chronic gallbladder disease, alcoholism, chronic pancreatitis, cancer and chronic diseases. In such cases the named anesthesia should be especially avoided.

The medical aspects of chronic gall-bladder disease

1. 1. The diagnosis of chronic gall-bladder disease is based on the history, the roent-genographic findings and some laboratory findings. 2. 2. The treatment is essentially medical, and consists of dietetic stimulation of biliary drainage and removal of focal infections. 3. 3. Surgical treatment is to be confined to the complications of the gall-bladder disease. 4. 4. Postoperative treatment is important.

CHRONIC GALLBLADDER DISEASE IN THE YOUNG ADULT

The basis for this paper is a series of fifty-seven cases of chronic gallbladder disease in young adults, operated on in the early stages of the disease, with no mortality. All of these patients have improved, and most of them have lost their symptoms. We have been particularly interested in the early manifestations of chronic cholecystitis. We have come to feel that, before our study of the series from which these cases were selected and before our study of the pathologic findings in these cases, we commonly missed the diagnosis of a surgical condition of the gallbladder until the patient was in the late stages of gallbladder disease. We find that, as our cases have multiplied, we have been making the diagnosis of chronic cholecystitis earlier, and with increasing confidence. These fifty-seven cases were selected after a restudy of a larger series of obscure cases presenting persistent abdominal symptoms, all