Diagnosis Of Chronic Cholecystitis Research Articles

Prevalence of Empyema or Mucocele or Other Histological Diagnoses in Patients Undergoing Cholecystectomy With Diagnosis of Chronic Cholecystitis.

BackgroundChronic cholecystitis is inflammation of the gall bladder usually caused by stones. The aim was to find out the prevalence of mucocele and empyema in chronic cholecystitis using cholecystectomy findings and histopathological reports.MethodologyThis was a cross-sectional observational study conducted in Surgical Ward 1, Jinnah Postgraduate Medical Center, Karachi from December 2019 to December 2021 for two years. Patients above 12 years of age diagnosed with chronic cholecystitis with cholelithiasis on clinical examination and investigations were included. Patients who were diagnosed with acute cholecystitis, mucocele, or empyema on clinical examination and ultrasonography were excluded from the study. Laparoscopic cholecystectomy was done and operative findings were noted. Gall bladder specimens were examined for mucocele and empyema and were sent for histopathology. Results were recorded and analyzed.ResultsThere were 241 patients diagnosed with chronic cholecystitis with cholelithiasis on clinical examination and investigations. On examination, tenderness in the right hypochondrium was absent in all patients. Chronic cholecystitis was proved on histopathology in 231 patients (95.85%). Other findings diagnosed on peroperative findings and histopathology reports were strawberry gall bladder (2.41%), empyema (0.83%), mucocele (0.41%), and polyp (0.41%). Two hundred eight patients were female (86.31%), 33 were male(13.69%). The male to female ratio was 1:6.43. The average age was 31 years.ConclusionInflammation and fibrosis of the gallbladder around Calot’s triangle increase the chances of vascular and common bile duct injury. In such cases, cholecystectomy can become difficult. It was concluded that empyema, mucocele, and strawberry gall bladder could be found in chronic cholecystitis, and cholecystectomy becomes difficult in such cases.

Experience of using galvanopalpation in the diagnosis of chronic cholecystitis

The principle of galvanopalpation was first proposed by Kagane and further developed by Albrecht. E. T. Zalkindson, M. N. Tumanovsky and others.

On the diagnosis of chronic cholecystitis and the clinical significance of some methods for the study of bile

The problems of liver and biliary tract pathology occupy a prominent place among the problems attracting special attention of clinicians.

Estrogen-induced gallstone pancreatitis in a transgender female.

The case of a transgender female who developed gallstone pancreatitis in the context of estrogen use for gender-affirming hormone therapy is reported. A 24-year-old Caucasian transgender female presented to the emergency department for abdominal pain and vomiting after referral from urgent care for suspected pancreatitis. Her home medications included estradiol, medroxyprogesterone, and spironolactone for gender-affirming hormone therapy and omeprazole for reflux. The patient reported minimal alcohol intake, presented with mildly elevated triglyceride levels, and did not have a family history of pancreatitis or gallstone disease. She underwent a laparoscopic cholecystectomy on hospital day 4 and was given a postoperative diagnosis of chronic cholecystitis, cholelithiasis, and pancreatitis. Given her history and the present illness, the use of estrogen therapy is a likely risk factor for the development of gallstone pancreatitis. Estrogen is a cornerstone of gender-affirming hormone therapy used by transgender women; however, in addition to its role in gender identity confirmation, estrogen can result in drug-induced pancreatitis.

PECULIARITIES OF CHOLELITHIASIS CLINICAL COURSE IN PATIENTS WITH TYPE 2 DIABETES

Diabetes mellitus (DM) is characterized by multi-organ and systematic damage. In 70% of cases diabetes is accompanied by digestive system diseases. Rather often diabetes is associated with a wide range of diseases of the hepatobiliary system, which are able to impede its progress and worsen the prognosis. Diabetes is also considered as a factor that triggers the development of gallstone disease (GSD).The purpose – to analyze the peculiarities of the pathology of the gall bladder in patients with type 2 diabetes.Material and methods. A comprehensive survey of 170 patients with type 2 diabetes (113 women and 57 men, average age constituted 60,8±0,9 years) was carried out. Verification of diagnosis of diabetes was based on the determination of carbohydrate balance and level of glycated hemoglobin. The diagnosis of chronic cholecystitis was verified on the basis of clinical data, characteristic changes of the gallbladder wall according sonography (wall thickness greater than 3 mm, compression and deformation of the wall). The diagnosis of cholelithiasis was made at the presence of concrements in the lumen of the gall bladder according to ultrasound.Results and conclusions. Reliable predominance was ascertained among patients with comorbidity females. It has been found out that GSS has minimal non-specific clinical course more often in patients with GSD type 2 diabetes. The characteristic laboratory changes of blood biochemical parameters were not found. Reliably method of diagnosis of pathological changes in the gall bladder (concrements) is ultrasound investigation. However, it is impossible to diagnose the earliest changes in the gallbladder, using this method.

The utility of apparent diffusion coefficient in diagnosis of acute cholecystitis

Background: Acute cholecystitis (AC) is a very common gastrointestinal pathology. Patient's history, physical examination, and laboratory investigations are usually not sufficient for accurate diagnosis. Moreover, imaging findings can overlap with that of many other gallbladder pathology especially chronic cholecystitis (CC). Therefore, there is a reasonable necessity for new diagnostic tools for AC. Objective: This study aimed to evaluate the efficiency of the apparent diffusion coefficient (ADC) as a diagnostic tool for AC and differentiating it from CC. Materials and Methods: During the period from April 2017 to March 2018, a total of 62 patients with suspected cholecystitis were enrolled in this prospective cross-sectional study. Patients were subjected to diffusion-weighted imaging, from which the ADC values were calculated. All patients were then undergone laparoscopic or open cholecystectomy, and the diagnosis of AC or CC was proven through histopathological examination. Receiver operating characteristic analysis was used to find out the area under the curve (AUC), sensitivity, and specificity of ADC in the diagnosis of AC. Results: The average value of ADC from three regions of interests from patients with AC was 1.434 ± 0.31 × 10−3 mm2/s. On the other hand, the average ADC from CC was 2.032 ± 0.31 × 10-3 mm2/s with significant difference (P = 0.013). The AUC was 0.803, 95% confidence interval = 0.702–0.905, P

THE BETTER SURGICAL OPTION FOR CHRONIC CHOLECYSTITITS;

Introduction: Laparoscopic cholecystectomy is a standard and widely usedprocedure in the treatment of chronic cholecystitis for quite a long time now but there is a recentdevelopment in technique because of advent of harmonic scalpel (HS). Thus this study wasconducted with an objective to compare frequency of post-operative complications in patientsundergoing laparoscopic cholecystectomy by conventional versus harmonic technique. DataSource: Primary data based on patients presenting with chronic cholecystitis to the surgicaldepartment at tertiary care hospital. Study Design: Randomized Control Trial. Study Setting:The study was conducted in surgical unit-I, Jinnah Hospital Lahore. Duration of Study:Study was conducted in duration of one year i.e. January 2015 to December 2015. Subjects& Methods: After approval from the hospital ethical review board, 400 patients of either sexwith age from 16 to 60 years and a diagnosis of chronic cholecystitis were included usingpurposive non-probability sampling technique. They were then randomly assigned to eitherconventional or harmonic group for laparoscopic cholecystectomy using lottery method ata ratio 1:1. . Information regarding their demographic characteristics and frequency of gallbladder perforation during surgery along with readmission in patients was noted in a structuredproforma and data was analyzed using SPSS version 21.0. Results: The mean age of patientswas 48.19 ± 6.484 years with about 156 (39%) male patients while 244 patients (61%) werefemale. About 15 (7.5%) patients in harmonic group and 16 (8%) patients in conventionalgroup of laparoscopic cholecystectomy had gall bladder perforation during the procedurewhile 20 (10%) patients of harmonic group and 27 (13.5%) patients in conventional group werereadmitted. On application of chi square test it was seen that the differences were statisticallyinsignificant in both groups for the complications related to the procedure. Conclusion: It canbe concluded from this study that both treatments are equally effective in terms of gall bladderperforation and rate of readmission. Thus, any of the techniques can be selected without muchfear of complications depending upon the health care facility and financial constraints of healthsystem in a resource depleted developing country.

English

Introduction: Laparoscopic cholecystectomy is a standard and widely usedprocedure in the treatment of chronic cholecystitis for quite a long time now but there is a recentdevelopment in technique because of advent of harmonic scalpel (HS). Thus this study wasconducted with an objective to compare frequency of post-operative complications in patientsundergoing laparoscopic cholecystectomy by conventional versus harmonic technique. DataSource: Primary data based on patients presenting with chronic cholecystitis to the surgicaldepartment at tertiary care hospital. Study Design: Randomized Control Trial. Study Setting:The study was conducted in surgical unit-I, Jinnah Hospital Lahore. Duration of Study:Study was conducted in duration of one year i.e. January 2015 to December 2015. Subjects& Methods: After approval from the hospital ethical review board, 400 patients of either sexwith age from 16 to 60 years and a diagnosis of chronic cholecystitis were included usingpurposive non-probability sampling technique. They were then randomly assigned to eitherconventional or harmonic group for laparoscopic cholecystectomy using lottery method ata ratio 1:1. . Information regarding their demographic characteristics and frequency of gallbladder perforation during surgery along with readmission in patients was noted in a structuredproforma and data was analyzed using SPSS version 21.0. Results: The mean age of patientswas 48.19 ± 6.484 years with about 156 (39%) male patients while 244 patients (61%) werefemale. About 15 (7.5%) patients in harmonic group and 16 (8%) patients in conventionalgroup of laparoscopic cholecystectomy had gall bladder perforation during the procedurewhile 20 (10%) patients of harmonic group and 27 (13.5%) patients in conventional group werereadmitted. On application of chi square test it was seen that the differences were statisticallyinsignificant in both groups for the complications related to the procedure. Conclusion: It canbe concluded from this study that both treatments are equally effective in terms of gall bladderperforation and rate of readmission. Thus, any of the techniques can be selected without muchfear of complications depending upon the health care facility and financial constraints of healthsystem in a resource depleted developing country.

Delayed presentation of port-site metastasis from an unknown gastrointestinal malignancy following laparoscopic cholecystectomy

Port-site metastasis (PSM) is often encountered during laparoscopic surgery in patients with malignancy. We report a 45-year-old woman who presented with a single PSM from papillary adenocarcinoma after undergoing laparoscopic cholecystectomy for calculus cholecystitis. Post cholecystectomy, a diagnosis of chronic cholecystitis was confirmed on histopathology. The patient presented with a mass at the site of epigastric port 28 months after surgery. PSM was suspected on clinical examination, which was supported by findings on computed tomography and further confirmed by fine-needle aspiration cytology of the lump. The patient underwent surgical clearance of the mass, and histopathological examination proved the lesion to be papillary adenocarcinoma. The site of the primary tumour was not detected even after thorough examination. Based on the histopathology report following local surgical clearance, the patient was started on chemotherapy. This case is unusual because of the long delay prior to the presentation of PSM and the unknown primary malignancy.

Histomorphology Spectrum of Gall Bladder Pathology in Cholecystectomy Specimens with Clinical Diagnosis of Chronic Cholecystitis

Chronic cholecystitis is a common disease in surgery where majority of cholecystectomy are performed. This study was carried out to see histomorphological pattern of gallbladder diseases, staining pattern with various stains and prevalence of carcinoma. This prospective study was conducted in the department of Pathology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal from January to December 2008. A minimum of fifty random samples were included in study. Clinical details and pathological data were retrieved from case sheets and patient's history. All specimens were fixed in 10% formalin. Three sections each from neck, body and fundus were taken. Tissues were processed in an automated tissue processor and paraffin blocks made. The tissue sections were examined under light microscope after hematoxylin-eosin, neutral mucin, sulfated mucin and sialomucin stain. Chronic cholecystitis without cholelithiasis constituted majority of 25(50.0%) cases with M:F of 1:7.1. The gastric and intestinal metaplasias were present in 33.0% and 8.0% of the cases respectively. The neutral, sulfated and sailomucin were positive in 35.0%, 21.0%, 1.0% and 34.0%, 21.0%, 1.0% cases respectively in gastric and intestinal metaplasia. Both gastric and intestinal metaplasia showed significant p-value on sulfated mucin. The increase risk factors for developing of chronic cholecystitis were seen in female gender (86%). The gastric and intestinal metaplasia showed positivity more with neutral followed by sulfated mucin.

Estudio histopatológico de la presencia de bacterias tipo Helicobacter pylori en especímenes quirúrgicos con colecistitis crónica

Introduction Helicobacter species have recently been found to be associated with some diseases of the biliary tree but this relationship remains unclear and further studies are required. The aim of this study was to determine the presence of H. pylori-type bacteria in patients with a diagnosis of chronic cholecystitis through histopathological study of surgical gallbladder specimens. Materials and methods Surgical gallbladder specimens from patients with a diagnosis of chronic cholecystitis were examined histopathologically. The macroscopic characteristics of the specimens were identified. Histopathological slices were stained with hematoxylin-eosin and Giemsa. Results Of the 68 patients who underwent cholecystectomy, 56 (81%) were women and 12 (19%) were men. The mean age was 39.56 + 11.94 years. H. pylori-type bacteria were found in 6%. Conclusions The results of this study do not allow us to conclude that the presence of H. pylori-type bacteria is a major factor in the etiology and/or pathogenesis of chronic cholecystitis. In patients with chronic cholecystitis undergoing cholecystectomy included in the present study, the etiology of the disease may be more closely linked with the presence of gallstones.

Incidental Carcinoma Gall Bladder in Patients Undergoing Cholecystectomy for Chronic Calculus Cholecystit is

Carcinoma gall bladder (CaGb) is the most common neoplasm of biliary tract. Aetiology of this tumour is complex, but there is a strong association with gall stones. The symptoms are seldom suggestive of cancer and imaging techniques are usually equivocal. This study was conducted to see the frequency of cancer of gall bladder in patients undergoing surgery for chronic cholecystitis with cholelithiasis in different age and sex groups in our population. An observational study was conducted in the department of surgery unit-II Rajshahi Medical College Hospital and Mukti Clinic Rajshahi on the patients admitted with the diagnosis of chronic cholecystitis with cholelithiasis for surgery. Demographic, clinical presentation, imaging studies, operative intervention and histopathological results were examined. Over the period of 18 months 184 patients were admitted with the diagnosis of chronic calculus cholecystitis for cholecystectomy. 2 (1.09%) patients out of 184 admitted cases were diagnosed as carcinoma gall bladder after histopathology examination. Mean age was 38.5 (41h decade) years and both of them were female. The most common presenting complaints were pain in the right hypocondrium and dyspepsia (51.07%). Normal wall thickness with stone was the most common (63.04%) Ultrasonographic finding. Histologically all CaGb cases were adenocarcinoma. Gall bladder malignancy occurs commonly in 4th decade of life. The patients should be encouraged to have gall bladder surger y once diagnosed as gall stone disease. Every gall bladder specimen should be sent for histopathological examination.TAJ 2009; 22(1): 223-226

A Case of Primary Hyperparathyroidism Associated with Gall-bladder Stone and Chronic Cholecystitis

Primary hyperparathyroidism is caused mainly by a parathyroid adenoma or hyperplasia, and is characterized by hypercalcemia and hypophosphatemia induced by an increased level of parathyroid hormone (PTH). Patients with primary hyperparathyroidism are usually as ymptomatic and the disease is most often detected incidentally. However, patients can present with symptoms of renal stones, peptic ulcer disease, muscle weakness, depression, constipation, and pancreatitis. In addition, it has been reported that choletithiasis can be combined with primary hyperparathyroidism. We report a case of a 49-year-old man with primary hyperparathyroidism accompanied with chronic cholecystitis caused by a gallbladder (GB) stone. The chief complaint was nausea, poor oral intake, abdominal pain, and weight loss. Abdominal sonography was performed and chronic cholecystitis with a GB stone was diagnosed. The serum calcium level was 18.5 mg/dL and the intact parathyroid hormone level was 1,777 pg/mL. A parathyroid mass was detected by neck-computed tomography, neck ultrasonography and a 99m Tc-Tetrofosmin parathyroid scan. The parathyroid mass was removed and the mass was confirmed as a parathyroid adenoma. Cholecystectomy was performed and the diagnosis of chronic cholecystitis was confirmed. After the surgical procedure, the symptoms improved and the calcium level was normalized. (J Kor Endocr Soc 22:470~474, 2007)

Can bile duct injuries be prevented? "A new technique in laparoscopic cholecystectomy"

BackgroundOver the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis. However, the incidence of bile duct injury in laparoscopic cholecystectomy is still two times greater compared to classic open surgery. The development of bile duct injury may result in biliary cirrhosis and increase in mortality rates. The mostly blamed causitive factor is the misidentification of the anatomy, especially by a surgeon who is at the beginning of his learning curve. Biliary tree injuries may be decreased by direct coloration of the cystic duct, ductus choledochus and even the gall bladder.Methodsgall bladder fundus was punctured by Veress needle and all the bile was aspirated. The same amount of fifty percent methylene blue diluted by saline solution was injected into the gall bladder for coloration of biliary tree. The dissection of Calot triangle was much more safely performed after obtention of coloration of the gall bladder, cystic duct and choledocus.ResultsBetween October 2003 and December 2004, overall 46 patients (of which 9 males) with a mean age of 47 (between 24 and 74) underwent laparoscopic cholecystectomy with methylene blue injection technique. The diagnosis of chronic cholecystitis (the thickness of the gall bladder wall was normal) confirmed by pre-operative abdominal ultrasonography in all patients. The diameters of the stones were greater than 1 centimeter in 32 patients and calcula of various sizes being smaller than 1 cm. were documented in 13 cases. One patient was operated for gall bladder polyp (our first case). Successful coloration of the gall bladder, cystic duct and ductus choledochus was possible in 43 patients, whereas only the gall bladder and proximal cystic duct were visualised in 3 cases. In these cases, ductus choledochus visibility was not possible. None of the patients developed bile duct injury.ConclusionThe number of bile duct injuries related to anatomic misidentification can be decreased and even vanished by using intraoperative methylene blue injection technique into the gall bladder fundus intraoperatively.

Cholelithiasis and Cholecystitis

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.

A Case of Endoscopically Collected Cholelith with Cholecystogastric Fistula

A 74-year-old man, who had a history of choledocho-lelithiasis with obstructive jaundice treated by endoscopic papillary balloon-dilation method, admitted to our hospital, because of treatment of diabetes mellitus. Abdominal CT showed cholelithiasis and wall thickening of the gallbladder. We suspected gallbladder cancer, and performed endoscopic retrograde cholangiography (ERC) . When we inserted endoscope, cholelith was found in the antrum of the stomach, and ERC visualized common bile duct (CBD) , atrophic gallbladder and also the stomach. We found fistula on the greater curvature of the antrum, and injected contrast agents under balloon-occlusion, therefore atrophic gallbladder and CBD was seen, and made confirmation as cholecystogastric fistula. Then we collected cholelith endoscopically. Surgical operation was performed with a diagnosis of chronic cholecystitis. Cholecystogastric fistula is very rare among the spontaneous internal biliary fistulae. It is difficult to make a preoperative diagnosis of cholecystogastric fistula, but in our case, we timely performed an examination of ERC, therefore we found cholelith and fistula in the stomach, and were able to confirm as cholecystogastric fistula.

Laparoscopic Cholecystectomy in Situs Viscerum Inversus Totalis

A 45-year-old female Saudi with a known diagnosis of situs viscerum inversus and chronic myeloid leukemia, for which she had completed her chemotherapy course, presented to the medical services with recurrent attack of left upper quadrant abdominal pain and vomiting, with no history of jaundice. All her hematological and biochemical profiles were reported to be normal. Her radiological investigations confirmed situs viscerum inversus totalis with thick-walled gallbladder, containing multiple stones and normal caliber common bile duct (CBD). After clearly defining the anatomy of the biliary tract by operative cholangiogram and careful dissection, cholecystectomy was carried out as a mirror image of the usual laparoscopic cholecystectomy done for the right side of the gallbladder (Figure 1). Intraoperative cholangiogram showed filling defects in the distal part of CBD (Figure 2). An endoscopic retrograde cholangiopancreatography (ERCP) performed in the immediate postoperative period showed no stones, but histopathology confirmed the diagnosis of chronic cholecystitis.

Laparoscopic cholecystectomy in children and adolescents.

During the period between August 1991 and November 1995, seven patients under age 17 were submitted to videolaparoscopic cholecystectomy (LC). Two were males and five females with ages ranging from 12 to 16 years (mean 13.8 years). The diagnosis of chronic cholecystitis with gallstones was made by the clinical history and physical and ultrasonographic examinations. There was no evidence of an association with hemolytic diseases, familial hyperlipidemia or Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The surgery was performed under general anesthesia and the abdomen approached by four ports: a 10 mm umbilical incision, a 5 mm cystic, a 5 mm one at the xiphoid appendix and a 10 mm one at the left lateral margin of the left rectus abdominal muscle between the umbilical scar and the xiphoid appendix. Operative time averaged 120 minutes (105-150 min). One case required conversion to laparotomic approach because of Mirizzi's Syndrome, which was diagnosed by intraoperative cholangiography performed in all cases. There were no deaths or major postoperative complications. Hospital stays ranged from 1-3 days in the six patients submitted to LC. Thus LC in children can be considered a good method, requiring only more care regarding the use of proper equipment, complete and careful dissection of the biliary hilus, and intraoperative cholangiography. The latter is indispensable, as these children can present a higher rate of anatomic anomalies. The advantages of this techniques include a less painful postoperative period with a faster recovery, and it is especially recommended in children, who are less tolerant to physical restriction and pain than adults.

Comparison of ultrasonography, computerized tomography, and radionuclide imaging in the diagnosis of acute and chronic cholecystitis

Seventy-five patients with abdominal pain in the right upper quadrant who were subsequently confirmed operatively and histologically to have acute or chronic cholecystitis underwent radionuclide imaging of the biliary tree, ultrasonography, and/or computerized tomography before operation. Fiftyeight of the patients had acute cholecystitis and 17 had chronic cholecystitis and cholelithiasis. Analysis of our data indicates that ultrasonography is an accurate and better screening test than cholescintigraphy in the diagnosis of chronic cholecystitis and cholelithiasis, but it is less accurate in the detection of acute cholecystitis. On the other hand, radionuclide imaging is highly sensitive and specific in the early diagnosis of acute cholecystitis, but it is poor in the diagnosis of chronic cholecystitis and cholelithiasis unless the cystic duct is obstructed. CT scanning is more expensive than ultrasonography but may be extremely helpful in problematic cases such as the diagnosis of the cause of biliary obstruction or in imaging of the pancreas.

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