Gallbladder Wall Thickening Research Articles

Grayscale and Spectral Doppler Ultrasound in the Diagnosis of Hepatic Veno-occlusive Disease/Sinusoidal Obstruction Syndrome After Hematopoietic Stem Cell Transplantation in Children

The aim of this study is to determine the ultrasound criteria in the diagnosis of hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) after hematopoietic stem cell transplantation (HSCT) in children. A total of 158 pediatric patients underwent HSCT between January 2016 and January 2018. In all, 71 patients with clinically suspicious hepatic VOD/SOS have been followed with serial ultrasound examinations. Hepatomegaly, gallbladder wall thickening, ascites, pleural effusion, reverse flow in the portal vein, and diameter and peak systolic velocity of the hepatic artery were evaluated. Patients were divided into 2 groups retrospectively: VOD/SOS and non-VOD/SOS. The predictive value of all findings was determined, respectively. Gallbladder wall thickening, increase of diameter and peak systolic velocity of the hepatic artery, and the presence of ascites are highly predictive for VOD/SOS (P=0.001 and < 0.05). The reversed portal venous flow was developed in 3 patients in the VOD/SOS group, no significant difference was found between the 2 groups (P>0.05). Hepatomegaly was recorded in 29 (70.7%) patients in the VOD/SOS group, 13 of them was presented related to a primary disease. Pleural effusion is not associated with the diagnosis of VOD/SOS (P>0.05). Gallbladder wall edema, an increase of peak systolic velocity of the hepatic artery, and the presence of ascites are highly related to the diagnosis of VOD/SOS in children after HSCT. Ultrasound findings must be correlated with clinical criteria.

Pathological gallbladder wall thickening is associated with advanced chronic liver disease and independent of serum albumin.

Increased gallbladder wall thickness (GBWT) is a common finding. Reported causes include advanced chronic liver disease (ACLD), ascites and hypalbuminemia. GBWT is a marker for the prediction of esophageal varices. It remains unclear which of these factors is the decisive driver of GBWT. We aim to investigate whether there is a predominant factor associated with the GBWT. We enrolled 258 patients with ascites, hypalbuminemia and/or ACLD and 98 healthy volunteers that underwent abdominal ultrasound. Differences of mean GBWT in subgroups of patients with ACLD, ascites, and/or hypalbuminemia were analyzed. Correlation between various parameters and GBWT were calculated using multiple regression analysis. GBWT in patients with ACLD + ascites + hypalbuminemia (n=59; 5.70 ± 2.05 mm) was pathologically increased compared to patients with hypalbuminemia + ascites without ACLD (n=36; 2.14 ± 0.66 mm; p < .001) and to patients with only hypalbuminemia (n=76; 2.02 ± 0.80 mm; p < .001). GBWT of patients with ACLD + hypalbuminemia (n=30; 3.42 ± 1.52 mm) and with ACLD and normal albumin level were not different (n=46; 3.10 ± 1.62 mm; p > .999). Significant correlation was seen between GBWT and ACLD (r=.53; p < .001) and ascites (r=.51; p < .001) but not albumin level (r=.04; p=.510). We demonstrate that ACLD is predominantly associated with GBWT. In contrast to the current literature, serum albumin level appears not to be associated with pathological GBWT.

Gallbladder volvulus:\xa0 a\xa0case report

BackgroundGallbladder volvulus is a rare pathology first reported by Wendel in 1898. Although the main pathological process associated with gallbladder volvulus is not known, there is clinical evidence suggesting that lack of gallbladder adhesions to the liver leads to an eventual twisting around the cystic bile duct (a process that seems to favor older female populations).Case presentationIn this report, an 81-year-old Caucasian elderly female presented to the emergency department with acute/severe right upper quadrant pain, which was also accompanied by an elevated leukocyte count. Relevant imaging showed a distended gallbladder with gallbladder wall thickening and a dilated common bile duct. The patient was subsequently admitted to the hospital for acute cholecystitis and scheduled for surgery the next day. Upon laparoscopic surgery, the gallbladder was black and gangrenous with no visible adhesions to the liver. Further inspection demonstrated that the gallbladder had twisted clockwise around the cystic bile duct.ConclusionsWhile many previous cases have been reported since Wendel, further case studies are nevertheless important to help guide proper clinic evaluation and pinpoint the potential for a gallbladder volvulus.

Radiological evaluation of response to treatment in hepatobiliary fascioliasis

PurposeIn this study, we aimed to evaluate the computed tomography (CT) findings of Fasciola hepatica infestations on initial and follow-up imagings after treatment, and also to describe the role of CT during diagnosis. MethodsIn this retrospective study, patients with a diagnosis of fascioliasis by clinical and laboratory examination who underwent initial and follow-up contrast-enhanced abdominal CT scans after treatment (a single oral dose of 10mg/kg Triclabendazole) were included. The CT scans were evaluated regarding liver and spleen sizes, portal and splenic vein diameters, involved hepatic segment numbers and involvement patterns, the presence of focal perihepatic hyperdensity, gallbladder wall thickening, dilatation of the intrahepatic biliary tract, periportal-right subdiaphragmatic lymphadenopathy, hepatic subcapsular and intra-abdominal bleeding, and perihepatic/intraabdominal free fluid. Initial (pre-treatment) and post-treatment CT scans (average 25 months after the treatment) were compared with for these features. ResultsA total of 36 patients with a mean age of 39.28±14.64 [15-83] years, were included in this study. After treatment, marked improvement in liver parenchymal involvement, biliary system findings, hepatomegaly-splenomegaly, periportal-peridiaphragmatic lymphadenopathy, and hepatic subcapsular hematoma were detected and focal perihepatic hyperdensity, free intraperitoneal fluid disappeared. ConclusionContrast-enhanced abdominal CT can be used in the diagnosis and post-treatment follow-up of fascioliasis. Awareness of intrahepatic/extrahepatic lesions and all the complications of fascioliasis can greatly aid the diagnosis and also evaluation of the response to treatment.

S1537 A Case of Gangrenous Cholecystitis Without Acute Cholecystitis

Introduction: Gangrenous cholecystitis (GC) is a serious and the most common complication of acute cholecystitis. We present a case of an incidental finding of GC with negative clinical findings and lab parameters of acute cholecystitis. Case Description/Methods: The patient is an 82 year old female, PMH of obesity hypoventilation syndrome (OHS), hypertension, hyperlipidemia, who presented to the pulmonology clinic for follow-up. Her pulmonary function test (PFT) was pertinent for a non-obstructive pattern with normal lung volumes, and severe diffusion defect. Echocardiography and CT PE protocol was ordered to assess for any pulmonary hypertension, thromboembolic disease, and to rule out interstitial lung disease. Incidentally, the patient was found to have multiple air foci throughout GB on CT, but no PE was identified. The patient deferred hospitalization and pursued outpatient workup with basic labs, MRCP, and general surgery referral. MRCP revealed common bile duct dilation, cholelithiasis, and choledocholithiasis. Within the next ten days, the patient developed sudden onset chest pain, nausea, vomiting, and increased shortness of breath without fevers, chills, or diaphoresis. Serial troponin and EKG were negative. Bilirubin was mildly elevated at 1.1, and she had no leukocytosis, hypotension, or confusion. Ultrasound (USG) abdomen showed cholelithiasis without evidence of acute cholecystitis. She was admitted, started on antibiotics, and underwent ERCP for stone removal and biliary sphincterotomy. She also underwent laparoscopic cholecystectomy with drain placement, and acute on chronic severe gangrenous cholecystitis was noted. Discussion: GC is the final stage of gall bladder (GB) inflammation, characterized by necrosis of the GB wall secondary to ischemia due to progressive vascular insufficiency. GC carries a high mortality rate compared to acute cholecystitis and can lead to deadly complications of GB perforation, abscess formation, and peritonitis. Patients usually have the clinical findings of acute cholecystitis (right upper quadrant pain, fever), elevated WBC count, elevated liver enzymes, USG abdomen finding of inflammation and thickening of GB wall. Imaging findings specific for GC are CT finding of gas in the wall or lumen, intra-luminal membranes, an irregular wall, and pericholecystic abscess. The lack of the findings mentioned above makes our case rare and challenging. Diagnosis and surgical treatment of GC before complication is essential to avoid high morbidity and mortality.

391 Routine Hatobiliary Iminodiacetic Acid Scan of All Suspected Cases of Acute Cholecystitis

Cholecystitis is the second-most common surgical admission from emergency departments and represents a large health burden. Different imaging modalities are utilized to evaluate this disease while hepatobiliary iminodiacetic acid (HIDA) scans are reported to be more sensitive and specific for acute cholecystitis because it is a functional evaluation of the gallbladder and can demonstrate cystic duct obstruction. Most emergency departments obtain a HIDA scan when the clinical diagnosis is equivalent. At our center, the primary general surgery group requires routine HIDA scans on all suspected cases of acute cholecystitis before deciding operative management. The purpose of this study was to perform a retrospective review of all HIDA scans performed in 2018 among emergency department cases of suspected cholecystitis. The specific aim was to evaluate the agreement between ultrasound (US) and HIDA scan findings and their association with operative decision-making. Secondary objectives were to evaluate discrepancies, insurance status, age, sex, ED length-of-stay, operative outcomes, and costs. HIDA scans were identified from our imaging record system from January 1, 2018 to December 31, 2018. An abnormal US (US+) was defined as the presence of gallstones plus either of the following: gallbladder wall thickening, pericholecystic fluid, sonographic Murphy’s, or common bile duct dilatation. An abnormal HIDA (HIDA+) scan was defined as cystic duct obstruction and/or failure to visualize the gallbladder. Qualitative reviews of specific cases were summarized. STATA (College Station, TX) was used for statistical analysis. N = 550 patients who received both HIDA scan and gallbladder US. There were 348 cases of US+ and 234 cases of HIDA+. There was a 59.3% agreement between US and HIDA findings. n = 169 of US+ and HIDA- and n = 55 of US- and HIDA+. Pairwise correlation 0.236 (p<0.001). There was a net decrease in operative care of 114 cases by adding HIDA. 550 HIDA scans have an estimated aggregate charge of $773,300 whereas 114 fewer laparoscopic cholecystectomies would have an aggregate savings of $2,101,932. This is the largest single-center study of comparison between HIDA and US in emergency department patients. The use of HIDA scans suggested 49% of patients with US+ findings may not require urgent surgery whereas 27% of patients with non-diagnostic US demonstrated the need for surgical intervention. The routine use of HIDA scans may have a significant impact on costs and reimbursements for this common etiology. The clinical suspicion is the main driver of resource utilization and routine HIDA scans increase immediate costs, ED length-of-stay, and can result in a net decrease of costs for urgent operative care.

S1601 An Unusual Case of Acute Cholecystitis and Bradycardia (Cope's Sign)

Introduction: Patients with acute cholecystitis present with right upper quadrant or epigastrium pain, nausea, and vomiting. Fever, leukocytosis, and a positive Murphy's sign support the diagnosis. Oftentimes, acute cholecystitis may mimic cardiovascular disease. Bradycardia is one of the rare presentations of cholecystitis and is called the "Cope's sign." Sir Zachary Cope was the first patient who presented with cardio-biliary reflex in 1970. Very few cases have been reported. Case Description/Methods: A 55-year-old male presented with retrosternal chest pain, diaphoresis, and vomiting followed by epigastric pain. Symptoms started one night prior to admission and he thought they were attributed to the raw chicken he ate for dinner. Examination showed a diaphoretic man with abdominal tenderness and bradycardia. His symptoms were concerning because the chest pain and bradycardia were compatible with inferior-wall Ml. However, troponins were negative. EKG showed sinus bradycardia with 42 beats/min (Figure 1). To further aid investigation, abdominal US was ordered which revealed gallstones, pericholecystic fluid and gallbladder wall thickening. He was diagnosed as a case of acute cholecystitis which presented as a cardio-biliary reflex and bradyarrthythmia. He was treated with IV fluids, pain control, and antibiotics. Surgery recommended urgent cholecystectomy. Discussion: Cardio-biliary reflex exists and can result in serious consequences. Bradyarrhythmia is the most common presentation of cardio-biliary reflex. Cardio-biliary reflex is believed to be vagally mediated and notably has been triggered by pain in the gallbladder via autonomic vagal innervations. A case-control study by Kaufman and Lubera reported that the increased vagal tone caused by the gallbladder could mimic myocardial infarction or cause bradyarrhythmia and even complete heart block. Patients with acute cholecystitis having abnormal ECG changes should be managed cautiously to avoid possible complications. This case highlights the rare case of acute cholecystitis with cope sign. Clinicians should have a high suspicion and order appropriate studies since these patietns can present as myocardial infarction.Figure 1.: EKG showed sinus bradycardia with 42 beats/min.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters.

The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes. A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion. The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%. Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

S2867 Turmeric-Induced Hepatitis

Introduction: Dietary supplementation use has been on an exponential rise for the past few years. Turmeric is one of the most used, with curcumin being its major active ingredient. Recently, cases of turmeric induced autoimmune hepatitis as well as herbal induced liver injury (HILI) have been documented. We present a case of turmeric induced hepatotoxicity in a 64-year-old female. Case Description/Methods: A 64-year-old female with a history of hypertension, presents with jaundice and abdominal discomfort. Vitals were normal. Exam showed scleral icterus with an unremarkable abdominal exam. Lab findings revealed a normal CBC, INR, and a negative blood alcohol level, a total bilirubin of 13.6 mg/dl with a direct bilirubin of 9.2 mg/dl, an ALP of 248 IUnits/L, a GGT of 616 Units/L, an AST of 2789 IUnits/L, and an ALT of 3296 IUnits/L. Hepatitis panel with HEV were negative. ANA, AMA, ASMA, tTg antibody, Ig levels, TSH, and T4 were all negative or within normal limits. Patient had a normal iron saturation, negative ceruloplasmin, Tylenol and ASA levels. COVID19 PCR test was negative. CT abdomen/pelvis was non-diagnostic. An EGD/EUS/ERCP showed a mildly thickened gallbladder wall. Liver biopsy showed portal and lobular hepatitis with spotty necrosis, without evidence of an autoimmune process, suggesting a drug induced liver injury. Patient then admitted to the use of turmeric in the past 3-4 weeks. Turmeric was discontinued and patient’s lab values normalized within 1 month. Discussion: Turmeric has been used for thousands of years as a spice, and has been linked to antioxidant, anti-inflammatory and anti-cancer effects. Clinical studies have popularized its use for patients with immune disorders such as autoimmune thyroiditis, and rheumatoid arthritis, despite the associated risk of autoimmune hepatitis in such patients. Curcumin is the major active ingredient in turmeric, however when taken alone, it has a poor bioavailability, with extensive 1st pass metabolism. Turmeric contains Piperine (a black pepper extract), that augments and increases curcumin doses up to 2000-fold by inhibiting hepatic drug-metabolizing enzymes. Multiple RCTs have studied the safety of curcumin showing minimal side effects. In 2013, HILI accounted for 20% of drug-induced liver injury cases. Liver enzymes resolve within 1 month of discontinuation. Due to turmeric’s possible increased risk for hepatotoxicity, clinicians should highlight this to their patients and make them aware of the potential risks that exist when using turmeric.Figure 1.: 400x H&E stain): The portal areas are expanded by predominantly lymphocytic inflammation with scattered eosinophils and rare plasma cells. Figure 2 (400 x PAS): There is spotty necrosis. There is no steatosis, ballooned hepatocytes, granulomas, or viropathic changes. Figure 3 (400x): The Reticulum stain shows a mild increase in portal/periportal fibrosis.Table 1.: RUCAM (Roussel Uclaf Causality Assessment Method) Score: Method for detecting drug-induced liver injury or herb-induced liver/hepatocellular injury (modified) ALT: Alanine Transaminase, AST: Aspartate Transaminase, EBV: Epstein-Barr Virus, HSV: Herpes Simplex Virus, VZV: Varicella-Zoster Virus, PSC: Primary Sclerosing Cholangitis.

S1622 Acute Acalculous Cholecystitis: An Unusual First Manifestation of COVID-19

Introduction: COVID-19 pandemic has become a major global health challenge, with more than 178 million confirmed cases and over 3.86 million deaths to date. While general and respiratory symptoms are common, it may have atypical GI involvement. We chronicle here an extremely rare case of acute acalculous cholecystitis (AAC) in a patient with COVID-19. Case Description/Methods: A previously healthy 35-year-old male presented to the emergency room with abdominal pain and non-biliary vomiting. He was nonsmoker, nonalcoholic, and drug-free. His vitals revealed: temperature 37.1°C, heart rate 82 bpm, blood pressure 114/72 mm Hg, respiratory rate 16/minute, and an oxygen saturation of 99% in room air. Physical examination revealed a positive Murphy's sign. Laboratory parameters revealed leukocytosis and high CRP level. Abdominal ultrasound showed marked gallbladder wall thickening, normal CBD, with no cholelithiasis or sludge formation. EUS also ruled out stones in the gallbladder. Therein, coronavirus rRT-PCR came back positive. CT chest revealed bilateral patchy peripheral ground-glass opacities in the lungs, consistent with COVID-19. Based on these findings and exclusion of probable causes of AAC, COVID-19-related AAC was diagnosed. The patient was initiated on standard COVID-19 treatment for the mild disease and conservative treatment for AAC. His hospital course remained unremarkable, except for fever and dyspnea on day 4 of admission. He remained hemodynamically stable. On day 7 of admission, his abdominal pain, vomiting, and fever disappeared with treatment. On day 9 of admission, he was afebrile, dyspnea had resolved, and had no abdominal pain. He was then discharged home in a stable condition. He continues to do well for 2 months now. Discussion: Published medical literature is bereft of reports on the association between AAC and COVID-19. A PubMed search was conducted for all case reports of AAC amidst COVID-19 till June 2021. Search terms included ‘’acalculus cholecystitis’’ and ‘’COVID-19’’. The search resulted in only 4 case reports to date. This case highlights that the GI symptoms may precede the pulmonary manifestations of COVID-19. It further provides the clinical evidence behind a causal relationship between SARS-CoV-2 infection and biliary involvement. The extrapulmonary symptomology of this infection has not been extensively studied, warranting a high index of suspicion for rare manifestations like AAC. Thus, new-onset GI symptoms may indicate COVID-19, requiring prompt testing for SARS-CoV-2.

S1545 Acute Acalculous Cholecystitis Leading to the Diagnosis of Systemic Lupus Erythematosus

Introduction: Acute acalculous cholecystitis (AAC) involves inflammation of the gallbladder without the presence of gallstones, and is commonly seen in ill hospitalized patients. We present a case of acalculous cholecystitis as the initial presentation of systemic lupus erythematosus (SLE). Case Description/Methods: A 34-year-old woman presented with two weeks of fever, epigastric pain with nausea, and a 10-pound weight loss. Review of systems was positive for dry eyes, dry mouth, and myalgias. Past medical history was notable for miscarriage. Complete blood count was notable for thrombocytopenia, normocytic anemia, and neutropenia (with absolute neutrophil count of 660 10*3/uL). Comprehensive metabolic panel was notable for an elevated protein gap and slightly abnormal AST 161 IU/L and ALT 61 IU/L. CT abdomen demonstrated gallbladder wall thickening, with no evidence of cholelithiasis. RUQ ultrasound confirmed the absence of gallstones. HIDA scan showed non-visualization of the gallbladder consistent with cystic duct obstruction. Erythrocyte sedimentation rate was elevated at 56 mm/hr and ferritin was greater than 4000 ng/ml. Further testing revealed positive testing for ANA, double-stranded DNA, anti-ro, and lupus anticoagulant. Given the predominant autoimmune symptoms, she was started on prednisone 60 mg for newly diagnosed lupus with improvement of her symptoms. After discharge she was started on plaquenil and azathioprine, and steroids were tapered. Repeat testing confirmed persistent antibodies for antiphospholipid syndrome. She was lost to follow up 6 months after discharge. Discussion: GI manifestations of lupus can be vast, and include oral ulcers, mesenteric vasculitis, intestinal pseudo-obstruction, protein losing enteropathy, lupus associated pancreatitis, and serositis. Hepatobiliary manifestations include primary sclerosing cholangitis and autoimmune cholecystitis. The pathogenesis of AAC in SLE typically involves vasculitis, serositis, or thrombosis, and gallbladder histology often shows vasculitis of small vessel arteries and venules. Treatment typically involves percutaneous cholecystostomy tube placement or cholecystectomy; however, there have been case reports of successful treatment of AAC in SLE with high dose corticosteroids, often in combination with antibiotics or other immunosuppressants. Our case demonstrates the importance of considering underlying autoimmune conditions in patients presenting with gastrointestinal symptoms.

Utility of pre-operative abdominal ultrasound to predict conversion to open cholecystectomy

Background: Many factors like unclear Calot triangle anatomy, intensely inflamed and thick gallbladder, dense adhesions in the operative area, obscure biliary tree anatomy, local inflammation like pancreatitis contribute to the conversion of laparoscopic cholecystectomy to open cholecystectomy. The aim of the present study was to find the utility of abdomen sonography parameters that predict the conversion from laparoscopic to open cholecystectomy.Methods: Ninety patients aged between 20 and 75 years with the diagnosis of cholelithiasis/cholecystitis were included in this observational study. Every patient underwent ultrasonography (USG). The USG findings such as gallbladder wall thickness, presence or absence of stones, number of calculi, size of the calculi, presence of abdominal adhesions, size of the common bile duct was recorded. If feasible, laparoscopic cholecystectomy was done. If not, the procedure was converted to open cholecystectomy. Association of USG findings was correlated with conversion to open cholecystectomy. The comparison of the qualitative variables was done using Fisher’s exact test. Results: Of 90 patients, 7 (7.8%) had a conversion to open cholecystectomy. There was no statistically significant difference of USG parameters studied such as gallbladder wall thickness &gt;4 mm, pericholecystic fluid collection, common bile duct diameter &gt;7 mm, presence of calculus, number of calculi, size of calculus &gt;6 mm and adhesions/fibrosis in patients who required conversion to open cholecystectomy and who were operated laparoscopically.Conclusions: Pre-operative USG parameters did not predict conversion to open cholecystectomy.

The Role of Endoscopic Ultrasound in the Diagnosis of Gallbladder Lesions.

Gallbladder (GB) diseases represent various lesions including gallstones, cholesterol polyps, adenomyomatosis, and GB carcinoma. This review aims to summarize the role of endoscopic ultrasound (EUS) in the diagnosis of GB lesions. EUS provides high-resolution images that can improve the diagnosis of GB polypoid lesions, GB wall thickness, and GB carcinoma staging. Contrast-enhancing agents may be useful for the differential diagnosis of GB lesions, but the evidence of their effectiveness is still limited. Thus, further studies are required in this area to establish its usefulness. EUS combined with fine-needle aspiration has played an increasing role in providing a histological diagnosis of GB tumors in addition to GB wall thickness.

Gall bladder Wall Thickness as Non-invasive Predictor of Oesophageal Varices in Cirrhotic Patients

Gall bladder Wall Thickness as Non-invasive Predictor of Oesophageal Varices in Cirrhotic Patients

Клініко-сонографічні особливості стеатозу підшлункової залози у дітей з надмірною вагою та ожирінням

Актуальність. Своєчасна діагностика стеатозу підшлункової залози (ПЗ) є необхідною умовою виявлення раннього метаболічного ризику та зниження захворюваності на хронічну гастроентерологічну патологію. Мета. Вивчення клініко-інструментальних особливостей стеатозу ПЗ у дітей із надмірною вагою та ожирінням. Матеріали та методи. У 53 дітей із функціональними розладами шлунково-кишкового тракту визначали наявність стеатозу ПЗ за допомогою ультразвукового дослідження. Розподіл за групами відбувся на основі наявності стеатозу ПЗ, ожиріння та надмірної ваги: 1 групу становили 24 пацієнти зі стеатозом ПЗ, ожирінням та надмірною вагою, 2 групу — 18 дітей з ожирінням і надмірною вагою без ознак стеатозу ПЗ, контрольну групу — 11 пацієнтів без стеатозу ПЗ, які мали нормальну вагу. Результати. Клінічна картина у дітей зі стеатозом ПЗ у більшості пацієнтів пояснювалась наявністю супутньої гастроентерологічної патології; 29,1 % хворих основної групи скаржились на біль у лівому підребер’ї. При аналізі диспептичних скарг слід відзначити, що пацієнти зі стеатозом ПЗ частіше скаржились на нудоту (58,3 %), метеоризм (45,8 %) проти пацієнтів, які мали нормальну вагу, однак значущість відмінностей не була достатньою. У пацієнтів 1 групи частіше виявлялась болісність при пальпації за ходом кишечника проти пацієнтів 2 групи. Болісність при пальпації в панкреатичних точках була вірогідно вищою у пацієнтів 1 групи (54,1 %) проти 3 групи. Підвищення ехогенності печінки в 2,4 раза частіше зустрічалось у пацієнтів 1 групи проти 2 групи та в 7 раз частіше, ніж у 3 групі. Зокрема, зміни зернистості печінки втричі частіше зустрічались у пацієнтів зі стеатозом ПЗ (p &lt; 0,05), ніж у пацієнтів без стеатозу та з трофічними розладами, а також дітей, які мають нормальну вагу. Зміни ПЗ при її стеатозі проявлялись не лише змінами ехогенності, але й у майже половини пацієнтів (45,8 %) наявністю нечітких контурів органу, підвищенням зернистості (65,5 %). Об’єм і товщина стінки жовчного міхура були вірогідно вищими у групі дітей зі стеатозом ПЗ проти контрольної групи. Ознаки біліарного сладжу вдвічі частіше зустрічались у дітей зі стеатозом проти групи дітей без стеатозу та в 4 рази частіше, ніж у дітей, які мають нормальну вагу (43,87 % у 1 групі, 21 % у 2 групі та 9 % у 3 групі). Висновки. Клінічні та сонологічні зміни у пацієнтів зі стеатозом ПЗ свідчать про можливість запальних змін у паренхімі залози, що пов’язані із системним запаленням на фоні стеатозу та супутньою патологією органів шлунково-кишкового тракту.

Gallbladder wall thickening in patients with IgG4-related diseases, with special emphasis on IgG4-related cholecystitis

Objectives Gallbladder (GB) wall thickening sometimes occurs in patients with autoimmune pancreatitis (AIP), a condition for which the name, IgG4-related cholecystitis, was proposed. We examined the radiological findings of the GB in patients with IgG4-related diseases and clinical features of patients with GB wall thickening and presented a hypothesis of its pathogenesis. Materials and methods GB wall thickening was defined by thickness ≥ 4 mm. GB wall thickness was examined in 258 patients with IgG4-related disease. Clinical and imaging findings of 200 patients with AIP with and without GB wall thickening were then compared. Results GB wall thickening was detected in 58 patients (29%) with AIP and two patients with isolated IgG4-related sclerosing cholangitis. In the 60 GBs examined, wall thickening was diffuse, with the walls possessing a smooth inner surface. No GB wall thickening was detected among the 56 patients with IgG4-related disease without AIP or IgG4-related sclerosing cholangitis. Bile duct stenosis was detected in 56 patients (97%) with AIP with GB wall thickening. Intraductal ultrasonography indicated cystic duct wall thickening connected to bile duct wall thickening in 11 of 14 (79%) patients with AIP or IgG4-related sclerosing cholangitis with GB wall thickening. Forty-eight patients in whom IgG4-related cholecystitis was diagnosed experienced resolution of the GB wall thickening after receiving steroid therapy. Conclusions Most cases of GB wall thickening in IgG4-related diseases are closely associated with IgG4-related sclerosing cholangitis and may be a manifestation of IgG4-related disease throughout the biliary tract, including the bile duct, cystic duct, and GB.

Clostridium perfringensによるガス産生性肝膿瘍の1例(A case of gas–forming liver abscess caused by Clostridium perfringens)

要旨ガス産生性肝膿瘍は致死率の高い疾患である。起因菌はKlebsiella pneumoniaeが主体であるが, 稀にC. perfringensによるものがある。急性胆嚢炎に伴いC. perfringensによるガス産生性肝膿瘍を発症し, 敗血症となりDICを合併したが, 救命し得た1例を経験したので報告する。症例は83歳の男性で, 腹痛と発熱を主訴として受診した。来院時，白血球増多と肝逸脱酵素の上昇および黄疸を認めるとともに, 低酸素血症を認めた。線溶系も亢進しており，画像上は，胆嚢頚部に胆石嵌頓が疑われるとともに, 肝右葉に内部不均一なガスを伴う膿瘍形成を認め，門脈ガス血症も伴っていた。急性胆嚢炎に伴うガス産生性肝膿瘍と診断した。カルバペネム系の抗菌薬投与を含む全身的なケアを行い，第10病日に開腹下膿瘍ドレナージおよび胆嚢摘出術を施行した。術後は順調に経過し，第65病日に自宅退院となった。C. perfringensによるガス産生性肝膿瘍は, 高齢者に多くみられる非外傷性の深部組織の感染症で, しかも進行が早いことから救命が難しい病態である。しかし, 画像診断の活用が救急外来においてもさらに進むことにより, 早期に診断される例も増加すると考えられる。今後, 救命への手がかりが蓄積して系統的なアプローチが整備されることが期待される。

The Utility of Hepatobiliary Scintigraphy Scans in the Tokyo Guidelines Era for Acute Cholecystitis

BackgroundHepatobiliary Scintigraphy (HIDA) aids the diagnosis of acute cholecystitis (AC) but has limitations. We sought to design a model based on the Tokyo Guidelines 2018 (TG18) to predict HIDA results. MethodsA retrospective review of patients who underwent a HIDA scan during the evaluation of AC was performed. Using logistic regression techniques incorporating the TG18 criterion and additional readily available patient characteristics, a prediction model was created to identify patients likely to test negative for acute cholecystitis by HIDA scan. ResultsIn 235 patients with suspected AC, a HIDA scan was performed. Variables associated with positive HIDA results were male gender (RR 2.0 (CI 1.33-2.99), age (OR 1.02 (CI 1.01-1.04), right upper quadrant tenderness (RR 1.7 (CI 1.1-2.8)), clinical Murphy's sign (RR 2.2 (CI 1.5-3.4)), ultrasound findings suggestive of AC by any of its components (RR 3.2 (CI 1.6-6.5)), gallbladder wall thickening (RR 2.0 (CI 1.3-3.1)), and gallbladder distention (RR 1.9 (CI 1.3-2.9)). These variables allowed for creation of a model to predict HIDA results. The model predicted HIDA results in 36.9% of patients with an area under the curve of 0.81. ConclusionsIn the era of TG18, HIDA is probably over utilized. We developed an accurate, simple model based on TG18 that identifies a group of patients for whom a HIDA scan is unnecessary to establish the diagnosis of AC.

The management of xanthogranulomatous cholecystitis.

Xanthogranulomatous cholecystitis (XGC) is a rare variant of chronic cholecystitis. This rare pathology is characterized by severe and progressive fibrosis of the gallbladder wall as well as infiltration of fat-laden macrophages. The final pathology report of 8213 cholecystectomies performed between 2011 and 2019 was evaluated retrospectively, and patients whose pathology result was reported as XGC were included in the study. Patients' demographic characteristics, pathology results, and surgical methods were evaluated. Logistic regression analysis was performed for risk factors on conversion to open cholecystectomy. The rate of XGC among cholecystectomies was 0.91%. Mean age of the patients was 57.32 years. Laparoscopic cholecystectomy was applied to 92% (n: 69) of the patients. None of the patients had cancer suspicion in the preoperative period, but cancer suspicion was found in 10.6% of the patients during the operation. With the frozen test, unnecessary surgeries were prevented in these patients. Conversion rate to open cholecystectomy was found to be 26.09%. The most common reason for conversion to open cholecystectomy (66.7%) was intense fibrosis. Increased gallbladder wall thickness and acute cholecystitis were found to be statistically significant risk factors in ultrasonography (p <0.05). Total complication rate in XGC cases was 3.9%. XGC is an extremely rare disease and is difficult to diagnose before cholecystectomy. Especially in preoperative USG, in cases with no suspicion of malignancy, but with suspected malignancy during the operation, histopathological examination with frozen method before extensive surgery may prevent unnecessary dissection and related morbidities.

PARP1 rs1136410 (A/G) polymorphism is associated with early age of onset of gallbladder cancer

Evaluation of the association of PARP1 rs1136410 (A/G) polymorphism with gallbladder cancer susceptibility and its prognosis in the Indian population of eastern Uttar Pradesh and western Bihar. PARP1 rs1136410 was genotyped by PCR-RFLP and its association with the prognosis of gallbladder cancer patients were analyzed using Kaplan-Meier plot and log-rank tests. Our results demonstrate that minor allele G is more frequent in gallbladder cancer patients than controls. The frequencies of minor allele G and GG genotype are significantly associated with increased risk of gallbladder cancer. Our data suggest that the minor allele G and homozygous genotype GG are significant predisposing factors for the early age of onset of gallbladder cancer. Similarly, women patients having AG and GG genotypes demonstrate an increased risk of gallbladder cancer. The risk group genotypes (AG + GG) are significantly more frequent in patients with thick gallbladder wall, with jaundice and with the presence of lymph node than in patients with normal gallbladder wall thickness, without jaundice and absence of lymph node involvement. Survival analysis data suggest that patients with risk group genotype (AG + GG) presenting jaundice have shorter overall survival. Our study suggests that the minor allele G of PARP1 rs1136410 (A/G) is a predisposing factor for gallbladder carcinogenesis and is significantly associated with early onset of the disease. Interestingly, the minor allele G is significantly more frequent in the patients with jaundice, lymph node metastasis and gallbladder wall thickness.