Gallbladder Wall Research Articles

Unusual and extremely rare sites of metastases in gallbladder carcinoma

Gallbladder carcinoma is an aggressive neoplasm that is often diagnosed only in the later stages of the disease progression. Common sites of distant metastases of primary carcinoma gallbladder include lymph nodes, peritoneum and lung. Only a few cases of metastases to adrenal glands and kidneys have been reported in literature. Cutaneous and muscular metastases from gallbladder cancer are also unusual, and an extensive literature search revealed only a few cases to date. We present two such cases of gallbladder carcinoma which presented with metastases to these rare sites at the time of diagnosis which were detected by 18 fluorodeoxyglucose positron emission tomography/ computed tomography (18F FDG PET/CT). The first case is of a 45-year-old lady who presented to the general surgery department with complaints of abdominal pain, loss of appetite and nausea for 2 months. Conventional imaging with ultrasound and contrast-enhanced computed tomography (CECT) of the abdomen showed asymmetric gallbladder wall thickening occupying the fundus and body with extensive regional lymphadenopathy. 18F FDG PET/CT revealed a metabolically active gallbladder mass with bilateral adrenal gland lesions with cutaneous, muscular and skeletal metastases. The second case is of a 35-year-old lady who complained of left upper quadrant abdominal pain and nausea for one month. Successive CECT and Magnetic Resonance Cholangiopancreatography (MRCP) studies made the radiological diagnosis of gallbladder neoplasm. Pre-operative 18F FDG PET/CT showed a metabolically active gallbladder mass with bilateral adrenal gland lesions, lymph node involvement and bilateral renal metastasis. The Third case was 75 years old male who had incidental carcinoma gall bladder on cholecystectomy and PETCT was done for staging, and it showed metabolically active liver SOL, Bilateral adrenal deposits with mediastinal abdominal, retroperitoneal and lymph nodes. The fourth case is a 55 year old female who was diagnosed as neck gall bladder wall thickening on ultrasonography on further evaluation PETCT was done which showed hypermetabolic gall bladder neck wall thickening along with bilateral adrenal lesion and abdominal, retroperitoneal and retro-crural and right supraclavicular lymph nodes. Adrenal and other metastasis detection on 18F FDG PET/CT led to a change in the management from curative surgery to palliative chemotherapy in all patients. Thus,18F FDG PET/CT is a valuable modality in such type of cases that aids decision making regarding staging, appropriate management and monitoring response to therapy.

Necrotizing Fasciitis Secondary to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A Rare Case Report Presentation

Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.

Effects of laparoscopic and choledochoscopic gallbladder-preserving cholecystolithotomy on levels of operation indicators, gallbladder function, and cholecystokinin type-A receptor in patients with gallstones.

Gallstones are a common digestive system disease. To assess the effects of laparoscopic and choledochoscopic gallbladder-preserving cholecystolithotomy on the levels of operation indicators, gallbladder function, and cholecystokinin type-A receptor (CCKAR) in patients with gallstones. The medical records of 100 patients with gallstones receiving operation from July 2019 to August 2022 were collected for retrospective analysis. They were divided into a laparoscopic group (n = 48) and a laparoscopic + choledochoscopic group (n = 52). The laparoscopic group received totally laparoscopic cholecystolithotomy, while the laparoscopic + choledochoscopic group underwent laparoscopic and choledochoscopic cholecystolithotomy. Their perioperative indicators, gallbladder function, stress indicators (cortisol (Cor), norepinephrine (NE), and C-reactive protein (CRP)), serum biochemical indicators (liver receptor homologue 1 (LRH-1), CCKAR, and vasoactive intestinal peptide (VIP)), and complications were compared. The fasting gallbladder volume and gallbladder contraction rate increased, and the minimum residual volume and gallbladder wall thickness decreased in the laparoscopic + choledochoscopic group in comparison with those of the laparoscopic group 6 months after operation (p < 0.05). The levels of serum Cor, NE, CRP, and CCKAR were elevated, whereas the levels of serum LRH-1 and VIP were lowered in both groups 3 d after operation compared with those before operation (p < 0.05). The levels of serum Cor, NE, CRP, LRH-1, and VIP were lower, and the level of serum CCKAR was higher in the laparoscopic + choledochoscopic group than those in the laparoscopic group 3 d after operation (p < 0.05). Both laparoscopic gallbladder-preserving cholecystolithotomy and laparoscopic and choledochoscopic cholecystolithotomy are effective for treating gallstones. However, the latter combination method is superior in enhancing postoperative gallbladder function, decreasing the recurrence risk, regulating the expressions of LRH-1, CCKAR, and VIP, and promoting the postoperative recovery of gastrointestinal function.

Evaluation of Preoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy (LC) is established as the gold standard for benign gallbladder disease. This study was done for the evaluation of preoperative scoring system given by Randhawa and Pujahari considering various preoperative parameters to predict difficulty in LC. Preoperative prediction of difficult LC using a scoring system considering various preoperative factors in elective/interval LC to predict difficult gallbladder. A prospective study of 120 patients admitted for LC from January 2020 to June 2021 was analyzed. All the patients were evaluated on the basis of Randhawa and Pujahari scoring system with the following variables: age >50 years, male sex, body mass index 25.1-27.5 and >27.5 kg/m2, previous abdominal surgery, prior hospitalization for gallstone disease, palpable gallbladder, gallbladder wall thickening, impacted stone, and pericholecystic collection. Each variable had given a score. Based on these findings, the surgical procedure was defined as easy, difficult, and very difficult. One hundred and twenty cases satisfying the inclusion criteria were studied comparing different variables and assigned preoperative scoring. A score >5 was considered significant and compared with intraoperative findings. Out of 53 patients having preoperative scores >5, 40 were difficult gallbladders and 13 were easy to operate. Prediction came true in 93.0% of difficult cases and 83.1% of easy cases. From this study, we can conclude that the preoperative scoring system is statistically reliable to predict difficulty in LC in the majority of the cases (area under receiver operator characteristics = 0.935).

C-reactive Protein-to-Albumin Ratio Predicts Conversion from Laparoscopic to Open Cholecystectomy in Acute Cholecystitis.

The aim of this study was to identify predictors of conversion from laparoscopic to open cholecystectomy, and to determine whether pre-operative C-reactive protein-to-albumin ratio (CAR) can predict conversion from laparoscopic to open cholecystectomy, in patients with acute cholecystitis diagnosed according to the Tokyo Guidelines 2018. We retrospectively analysed 231 patients who underwent laparoscopic cholecystectomy for acute cholecystitis between January 2012 and March 2022. Two hundred and fifteen (93.1%) patients were included in the laparoscopic cholecystectomy group; sixteen (6.9%) patients were included in the conversion from laparoscopic to open cholecystectomy group. In univariate analysis, significant predictors of conversion from laparoscopic to open cholecystectomy included the interval between symptom onset and surgery (>72 h), C-reactive protein (≥15.0 mg/l) and albumin (<3.5 mg/l) levels, pre-operative CAR (≥5.54), gallbladder wall thickness (≥5 mm), pericholecystic fluid collection, and pericholecystic fat hyperdensity. In multivariate analysis, elevated pre-operative CAR (≥5.54) and the interval between symptom onset and surgery (>72 h) were independent predictors of conversion from laparoscopic to open cholecystectomy. Pre-operative CAR as a predictor of conversion from laparoscopic to open cholecystectomy may be useful for pre-operative risk assessment and treatment planning.

AN OBSERVATIONAL STUDY ON PREDICTION OF DIFFICULTIES DURING LAPROSCOPIC CHOLECYSTECTOMY IN CASES OF CHOLELITHIASIS BY PREOPERATIVE ULTRASONOGRAPHY

BACKGROUND: Laparoscopic cholecystectomy has become the treatment of choice for cholelithiasis. Some reliable factors are needed to predict difficulties during laparoscopic cholecystectomy. So, our aim was to study various preoperative ultrasonographic parameters which may predict difficulties in performing laparoscopic cholecystectomy. METHOD: One twenty five patients of cholelithiasis admitted for elective laparoscopic cholecystectomy were studied. Preoperative ultrasonographic parameters such as gall bladder(GB) wall thickness, transverse diameter of GB, pericholecystic fluid collection, gall stone mobility, number of stones & size of largest stone, common bile duct(CBD) diameter and emphysematous cholecystitis were given a score of 0 or 1 based on findings being negative or positive respectively. Total score was correlated with the difficulties faced during laparoscopic cholecystectomy. RESULT: Out of 125 cases, 42(33.6%) cases were found to be difficult during laparoscopic cholecystectomy and 6 cases (4.8%) required conversion to open cholecystectomy. GB wall thickness (p value= 0.00001), transverse diameter of GB (p value= 0.001), pericholecystic fluid collection (p value= 0.00001), dilated CBD (p value=0.007), size of stone (p value= 0.007) found to be statistically significant in predicting difficulties during laparoscopic cholecystectomy. Higher the preoperative USG score, higher were the chances of difficult laparoscopic cholecystectomy and conversion to open cholecystectomy. CONCLUSION: Pre operative ultrasonography in the form of a formulated score is a good predictor of difficulties during laparoscopic cholecystectomy.

Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after the acute presentation

Background: Approximately 15% of adults in the United Kingdom (UK) are predicted to have gallstone disease, with about 80% of these having asymptomatic gallstones. Patients with symptomatic gallstone disease are recommended to undergo cholecystectomy. Currently, in the UK approximately 60,000 cholecystectomies are performed. During complex laparoscopic cholecystectomies, surgeons may still need to resort to historic procedures such as an open cholecystectomy (5-10%) or even a cholecystostomy. Alternatively considering a subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure. The aim of our study is to identify pre-operative factors that would predict the need for a subtotal cholecystectomy.Methods: A retrospective study, over a period of 01 March 2019 to 29 February 2020 was undertaken at one of London’s major tertiary centres. We reviewed all adult patients that had undergone laparoscopic cholecystectomies and subtotal cholecystectomies.Results: 243 patients were included in the study after being vetted through the inclusion and exclusion criteria, 95 males and 148 females. 243 patients were identified initially for elective cholecystectomy. 230 were managed surgically, 208 with a total laparoscopic cholecystectomy, and 22 with subtotal laparoscopic cholecystectomy. 243 patients were identified initially for elective cholecystectomy. 230 were managed surgically, 208 with a total laparoscopic cholecystectomy, and 22 with subtotal laparoscopic cholecystectomy.Conclusions: Age, male sex, body mass index (BMI) greater than 30 kg/m2 patients, previous endoscopic retrograde cholangiopancreatography (ERCP), thickened gallbladder walls, and raised preoperative leucocytosis were associated with a greater risk of patients consented for laparoscopic cholecystectomies to undergo a conversion to a subtotal cholecystectomy.

Predictive Factors for the Complications of Dengue Fever in Children: A Retrospective Analysis.

Background and objective Dengue fever (DF) and its complications - dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) - are major public health problems in Southeast Asia. Predicting the development of DHF and DSS using hematological parameters and ultrasonic signs of vascular leakage will help in reducing morbidity and mortality associated with these diseases. Hence, this study aimed to test the association of platelets and packed cell volume (PCV) on day one (D1) of admission with gallbladder wall thickness (GWT) and ascites, which heraldthe onset of DHF and DSS. Methods The electronic health records of 52 pediatric patients admitted during a mini-outbreak were analyzed to assess platelets and PCV on D1, laboratory and ultrasonography findings, and outcomes. Correlations between D1 hematological parameters and GWT and ascites were tested. Results There was a positive correlation between GWT of more than 5 mmand ascites. However, there was no significant correlation of platelets and PCV on D1 with either GWT or ascites and consequently DHF or DSS. All the patients responded to fluid, blood, and supportive therapy. There were no mortalities. Conclusion Patients who develop GWT after DF are at an increased risk of developing ascites that deteriorate to DHF and DSS. D1 platelets and PCV are not reliable indicators for predicting the progression or worsening of the disease in the pediatric population.

Usefulness of two-dimensional shear wave elastography in diagnosing hepatic veno-occlusive disease in pediatric patients undergoing hematopoietic stem cell transplantation.

This study aimed to evaluate the usefulness of two-dimensional shear wave elastography (2D-SWE) in diagnosing hepatic veno-occlusive disease (VOD) in pediatric patients. This study retrospectively included pediatric patients who underwent hematopoietic stem cell transplantation (HSCT) between November 2019 and January 2021. All 34 patients (8.7±5.0 years) were examined using 2D-SWE for an initial diagnosis. A subgroup analysis was performed using the data from follow-up examinations of patients diagnosed with VOD. The characteristics of the initial VOD diagnosis were compared with the longitudinal changes observed in VOD patients who underwent multiple ultrasound examinations. In total, 19 patients were diagnosed with VOD at 17.6±9.4 days after HSCT. All VOD patients showed hepatomegaly, ascites, and gallbladder wall thickening. Liver stiffness was higher in VOD patients than in non-VOD patients (12.4±1.1 vs. 6.3±0.8 kPa, P<0.001). Liver stiffness values above 7.2 kPa showed 84.2% sensitivity and 93.3% specificity in distinguishing VOD from non-VOD (area under the curve, 0.925; 95% confidence interval, 0.780 to 0.987; P<0.001). A subgroup analysis of 11 patients showed a linear decrease in liver stiffness values after VOD diagnosis with treatment (first, second, and third follow-ups; 13.5±1.7, 11.3±1.4, and 9.5±0.8 kPa, respectively), but without statistical significance in the pairwise analysis. Liver stiffness measured using 2D-SWE increased in pediatric patients who develop VOD after HSCT. Therefore, liver stiffness can be a predictive and quantitative parameter for diagnosing VOD.

Gallbladder wall thickness adversely impacts the surgical outcome.

To evaluate surgical outcomes of patients with gallbladder wall thickness (GBWT) > 5 mm. Patients who underwent cholecystectomy were classified into two groups according to their GBWT status (GBWT+ vs. GBWT-). Among 1,211 patients who underwent cholecystectomy, GBWT+ was seen in 177 (14.6%). The GBWT+ group was significantly older with more males, higher ASA score, higher alkaline phosphatase level, higher international normalized ratio, and lower albumin level than the GBWT- group. On ultrasound, GBWT+ patients had larger stone size, more pericholecystic fluid, more common bile duct stone, and more biliary pancreatitis. Compared with the GBWT- group, the GBWT+ group had more urgent surgeries (12.4% vs. 3.2%, p = 0.001), higher conversion rate (4.5% vs. 0.3%, p = 0.001), prolonged operative time (67 ± 38 vs. 54 ± 29 min; p = 0.001), more bleeding (3.4% vs. 0.5%, p = 0.002), and more need of drain (21.5% vs. 10.5%, p = 0.001). By multivariate analysis, factors associated with increased length of hospital stay were GBWT+ (HR: 1.97, 95% CI: 1.19-3.25, p = 0.008), urgent surgery (HR: 10.2, 95% CI: 4.07-25.92, p = 0.001), prolonged surgery (HR: 1.01, 95% CI: 1.0-1.02, p = 0.001), and postoperative drain (HR: 11.3, 95% CI: 6.40-20.0, p = 0.001). Variables such as GBWT ≥ 5 mm, urgent prolonged operation, and postoperative drains are independent predictors of extended hospital stay. GBWT+ patients are twice likely to stay in hospital for more than 72 hours and more prone to develop complications than GBWT- patients.

Rare Case of Gall Bladder Perforation following acute Calculus Cholecystitis in a Elderly Male: A Case Report

Perforation of the gallbladder is a rare but dreaded complication following cholecystitis.1 Spontaneous perforation is most commonly seen in the elderly, and in patients suffering from diabetes mellitus.2 The most common site of perforation is the fundus of gall bladder.3 The gall bladder distension and edema associated with acute inflammation leads to venous and arterial obstruction. Subsequently, this leads to ischaemia and necrosis of the gall bladder wall. The fundus is most susceptible to this injury due to maximum distance from the cystic arterial supply. Aggravating factors include atherosclerosis, focal vasospasm and localized vasculitis. If diagnosed and treated late, perforation of gallbladder may be associated with high chances of morbidity and mortality.4-6 Here, we report a case of a 66-year-old male with perforation of gallbladder following acute calculous cholecystitis.

225: HYPERTHYROIDISM MASKED BY ACUTE CHOLECYSTITIS WITH RESULTING THYROID STORM

Introduction: Thyroid storm is an extremely rare & severe form of hyperthyroidism, and when left untreated can lead to multiorgan failure and death. In this case, we present a 52-year-old female whose hyperthyroidism-like symptoms were thought to be due to acute cholecystitis, with post-operative course complicated by delirium & hemodynamic instability likely due to thyroid storm. Description: Patient is a 52-year-old female with a history of HIV, nephrolithiasis, hypertension, and migraine headaches who presents with right upper quadrant abdominal pain, nausea and vomiting for 2 weeks. She endorses poor appetite for 4 weeks with 30-pound weight loss in that period. In the ED, she was hypertensive and tachycardic. Labs are significant for hypokalemia and leukocytosis of 12.9. CT abdomen/pelvis demonstrated gallbladder wall thickening, trace pericholecystic fluid, right hydronephrosis, and acute cholecystitis. The patient underwent laparoscopic cholecystectomy with postoperative course complicated by acute delirium. She continued to deteriorate with BP 177/101, HR 181, and RR 31. She was given neuroleptics without improvement and transferred to the ICU for further management. Thyroid studies revealed hyperthyroidism; thyroid ultrasound revealed multiple isoechoic circumscribed thyroid nodules consistent with thyroid goiter. Burch criteria for thyroid storm was 70, highly suggestive of the condition. The patient was treated with esmolol and dexmedetomidine drips, propranolol for tachycardia, PTU to block conversion of T4 to T3, thionamide & iodine solution to block synthesis & secretion of T4, and hydrocortisone to reduce inflammation & block synthesis of T4 to T3. Discussion: The main challenge in this case is recognizing the overlap of symptoms of acute cholecystitis with underlying and undiagnosed hyperthyroidism. Thyroid storm usually presents as mimic, with this patient experiencing predominantly neuro-type presentations with delirium. The presence of new-onset delirium with hemodynamic instability post-operatively should raise a high index of suspicion for thyroid storm and must be treated without delay. Maintaining a broad differential prior to surgical intervention, a known trigger, could propel the clinician into considering underlying thyroid pathologies and prevent thyroid storm altogether.

Morphological substantiation of ultrasonographic criteria of an acute cholecystitis and its paravesical complications

Objective. To improve quality of diagnosis of paravesical complications in patients, suffering an acute cholecystitis, using demonstration of interrelationship of changes in the gallbladder wall histostructure and its echogram data.&#x0D; Materials and methods. Comparative analysis of the gallbladder wall echogram and results of the gallbladder wall morphological investigation was conducted in 520 patients with an acute cholecystitis to determine the kind of paravesical complications.&#x0D; Results. Morphological investigation of the gallbladder wall have shown that the gallbladder dimensions and the wall thickness enhancement are not universal characteristic features for an acute cholecystitis. To determine the kind of its inflammation (phlegmonous, gangrenous or catarral) is also impossible. In accordance to ultrasonographic criteria an acute cholecystitis diagnosis is established, аnd patho-morphologist determines the inflammation form. Sclerotic processes with overgrowth of dense connective tissue were revealed in the gallbladder wall while presence of a long-term inflammatory process. That's why in the patients, suffering an acute cholecystitis, the gallbladder wall echograms may show excessively white signal with delineated contours, but at the same time the gallbladder volume may be not changed or even reduced. This data may impact the choice of operative procedure. Ultrasonographic signs of presence of paravesical infiltrate and abscess were established as well.&#x0D; Conclusion. Echographic changes of the gallbladder wall indicates its inflammation, but do not give possibility to find which form it has. The gallbladder volume may be reduced in an acute cholecystitis, if inflammation occurs on background of recurrent process. The gallbladder wall demonstrates excessively white positive echographic signal, if in its structure connective tissue and collagen fibers prevail.

Tibetan medicine Si-Wei-Qiang-Wei Powder ameliorates cholecystitis via inhibiting the production of pro-inflammatory cytokines and regulating the MAPK signaling pathway

Ethnopharmacological relevanceSi-Wei-Qiang-Wei Powder (SWQ) is a formulated traditional Tibetan medicine preparation that has been used clinically to treat liver and gallbladder diseases for centuries. Previous work has confirmed its clinical effectiveness, however, the specific mechanism of SWQ is still unknown.Aim of the study: This study aims to explore the anti-inflammatory effect of SWQ on cholecystitis and its possible mechanism. Materials and methodsThe main chemical components of SWQ were analyzed by HPLC. The network pharmacology database was used to screen and construct the network of the main components and molecular targets of SWQ, and to predict the molecular pathways of its core targets. Cholecystitis guinea pig model and LPS stimulated cultured human gallbladder epithelial cells (HGBEC) were used, as in vivo and in vitro methods respectively, to study the anti-cholecystitis activity of SWQ. Specifically, gallbladder wall thickness, hematoxylin-eosin (H&E) staining, and liver function indexes were used to evaluate the anti-inflammatory activities of SWQ in cholecystitis; qRT-PCR and ELISA were used to detect the changes of the production of inflammatory cytokines; Western blot analysis was used to analyze the effects of SWQ on phosphorylation of P38, ERK1/2, JNK and AKT. ResultsSWQ decreased the indexes of ALT, AST, TBA, CHOL, DBIL in serum and TBIL, TC and Ca2+ in bile, and alleviated the wall thickness of gallbladder and hepatobiliary fibrosis in LCA-induced guinea pigs. In addition, SWQ attenuated the expression and production of TNF-α, IL-6, IL-1β, COX-2 both in liver and gallbladder. Moreover, SWQ reversed the up-regulation of p-P38, p-ERK1/2, and p-JNK in animals with cholecystitis and LPS-induced HGBEC. Furthermore, mechanistic studies indicated that SWQ inhibited the activation of ERK1/2, thereby decreasing the expression of TNF-α, IL-6, IL-1β and phosphorylation P38 and JNK. ConclusionIn summary, our research showed that SWQ relieves gallbladder inflammation by inhibiting the MAPK pathway.

OGBN P11 Gallbladder polyps: an audit of management in an NHS trust

Abstract Background Gallbladder polyps are elevations in the gallbladder wall which project into the lumen. These can be either true polyps or “pseudopolyps” (such as cholesterol or inflammatory deposits or focal adenomyomatosis). Polyp prevalence has been estimated as high as 9.5% in some studies, of which 70% may be pseudopolyps. A small minority of true polyps may display malignant potential. Gallbladder malignancy is aggressive, especially when diagnosed at later stages of disease with poor treatment options and survival outcomes. However, Stage I disease has excellent 5 year survival rates, nearing 100%. Early identification of patients at risk of gallbladder malignancy is highly important and may detect curable disease. Joint guidelines between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery (EAES), International Society of Digestive Surgery – European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE) have outlined best practice in regards to management of gallbladder polyps. This audit compared the current practice in a NHS healthcare trust against these guidelines in order to develop trust-wide consensus and guidelines for future management. Methods A PACS based radiology search was conducted, identifying all patients who underwent an ultrasound between 10th December 2020 and 10th December 2021, whose imaging report used the term “gallbladder polyp(s)” within a hospital trust. Patients without a diagnosis of gallbladder polyp were excluded from the audit. Historical patient records were accessed via the trust-based online patient database (Clinical Portal). Data were collected and analysed using Microsoft excel. Patient management was compared against the following ESGAR/EAES/EFISDS/ESGE guidelines: Results A total of fifty six patients fit the inclusion criteria, with an age range of 8 to 96 years. The majority were female (63%). Polyp size ranged from &amp;lt;2mm to 14mm. Patients were predominantly managed by Upper GI surgery, gastroenterology and general practice with the Radiology department performing and reporting ultrasounds and advising management or follow up. Results showed that 86% of patients were appropriately offered surgery for polyps ≥ 10mm. However, 40% of patients with polyps &amp;gt;5mm with risk factors, were not offered cholecystectomy and 44% of those without risk factors were not offered appropriate follow up. The majority of patients with polyps ≤ 5mm with risk factors were not offered ultrasound surveillance. All patients without risk factors with polyps ≤ 5mm were appropriately managed. Conclusions Key findings suggest discrepancies in the management of patients with gallbladder polyps in a NHS Trust. In particular, patients with risk factors and polyps between 6–9mm were not always identified as requiring operative management. Likewise, over half of those without risk factors were not offered surveillance imaging. Poor management and lack of follow up may put patients at risk. The results of this audit demonstrate the need for unified local or national guidelines concerning management of gallbladder polyps and consensus across multiple disciplines.

Acute acalculous cholecystitis in a patient with dengue fever: A case report

and importance: Although dengue fever classically presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and vomiting, it can have unusual manifestations like acalculous cholecystitis. The study highlights the importance of atypical presentations of dengue fever in suspecting dengue earlier, especially during outbreaks. Herein, we report a case of a 29 years old female who presented with fever for 5 days which was associated with headache, body ache, vomiting, and abdominal pain in the right hypochondriac region. Lab results came positive for dengue NS1 antigen, and ultrasonography showed features suggestive of acalculous cholecystitis. She was managed conservatively after which her symptoms resolved gradually. Acute acalculous cholecystitis in dengue could be due to increased vascular permeability leading to edematous thickening of the gall bladder wall. It should be suspected if a patient presents with fever, right upper quadrant pain, abnormal liver function tests, and thickened gall bladder wall without stones on abdominal ultrasonography. Acute acalculous cholecystitis is an atypical presentation of dengue fever. Awareness of atypical presentations of dengue helps in identifying dengue earlier and preventing complications.

Cystadenocarcinoma of the gallbladder: A case report

Cystadenoma and cystadenocarcinoma of the biliary duct remain a rare diagnosis, the localization is intrahepatic in 97% of the cases and extrahepatic in 3%of them [1]. Cystadenocarcinoma of the gallbladder is the rarest localization, it's usually diagnosed late because of the poor symptoms and the nonspecific lesions in the different imaging.Only hundreds of cases have been reported for cystadenocarcinoma of the gallbladder.This case report has been reported in line with the SCARE Criteria. We present a 70-year-old woman, with no family or personal history, who was complaining of pain in the right hypochondrium and an altered general well-being, with no other clinical abnormalities.The imaging including abdominal sonography, CT scan, and MRI concluded at a budding lesion formed in the gallbladder wall which measured 65×15mm.Cancer of the gallbladder was suspected and the patient was operated. A resection of segment s4b and 5 of the liver was performed with lymphadenectomy. The post-operative clinical course was uneventful.The diagnosis of cystadenocarcinoma of the gallbladder was confirmed on an anatomopathological exam of the specimen. Cystadenocarcinoma is a rare diagnosis.There are no specific symptoms or lesions at the imaging.The confirmation is obtained on an anatomopathological study of the specimen.

Incidental Findings of Gallbladder and Bile Ducts-Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening-A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper.

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.

Sonographic Assessment of Acute Versus Chronic Cholecystitis: An Ultrasound Probability Stratification Model.

What sonographic variables are most predictive for acute cholecystitis? What variables differentiate acute and chronic cholecystitis? The surgical pathology database was reviewed to identify adult patients who underwent cholecystectomy for cholecystitis and had a preceding ultrasound of the right upper quadrant within 7 days. A total of 236 patients were included in the study. A comprehensive imaging review was performed to assess for gallstones, gallbladder wall thickening, gallbladder distension, pericholecystic fluid, gallstone mobility, the sonographic Murphy's sign, mural hyperemia, and the common hepatic artery peak systolic velocity. Of 236 patients with a cholecystectomy, 119 had acute cholecystitis and 117 had chronic cholecystitis on surgical pathology. Statistical models were created for prediction. The simple model consists of three sonographic variables and has a sensitivity of 60% and specificity of 83% in predicting acute versus chronic cholecystitis. The most predictive variables for acute cholecystitis were elevated common hepatic artery peak systolic velocity, gallbladder distension, and gallbladder mural abnormalities. If a patient had all three of these findings on their preoperative ultrasound, the patient had a 96% chance of having acute cholecystitis. Two of these variables gave a 73-93% chance of having acute cholecystitis. One of the three variables gave a 40-76% chance of having acute cholecystitis. If the patient had 0 of 3 of the predictor variables, there was a 29% chance of having acute cholecystitis. Gallbladder distension, gallbladder mural abnormalities, and elevated common hepatic artery peak systolic velocity are the most important sonographic variables in predicting acute versus chronic cholecystitis.

Prognostic clinical indexes for prediction of acute gangrenous cholecystitis and acute purulent cholecystitis

BackgroundPreoperative prediction of severe cholecystitis (SC), including acute gangrenous cholecystitis (AGC) and acute purulent cholecystitis (APC), as opposed to acute exacerbation of chronic cholecystitis (ACC), is of great significance, as SC is associated with high mortality rate.MethodsIn this study, we retrospectively investigated medical records of 114 cholecystitis patients, treated in Shanghai No. 6 People’s Hospital from February 2009 to July 2020. Gallbladder wall thickness (GBWT), indexes of blood routine examination, including white blood cell (WBC), alkaline phosphatase (ALP), the percentage of neutrophil, alanine transaminase (ALT), aspartate aminotransferase (AST), fibrinogen (FIB), gamma-glutamyl transferase, prothrombin time and total bilirubin were evaluated. One-way analysis of variance (ANOVA) was used to evaluate significant differences between a certain kind of SC and ACC to select a prediction index for each kind of SC. Receiver operating characteristic (ROC) curve analysis was conducted to identify the prediction effectiveness of these indexes and their optimal cut-off values.ResultsHigher WBC and lower ALP were associated with AGC diagnosis (P < 0.05). Higher percentage of neutrophils was indicative of APC and AGC, while higher GBWT was significantly associated with APC diagnosis (P < 0.05) The optimal cut-off values for these indexes were established at 11.1*109/L (OR: 5.333, 95% CI 2.576–10.68, P < 0.0001, sensitivity: 72.73%, specificity: 66.67%), 79.75% (OR: 5.735, 95% CI 2.749–12.05, P < 0.0001, sensitivity: 77.92%, specificity: 61.9%) and 5.5 mm (OR: 22, 95% CI 4.757–83.42, P < 0.0001, sensitivity: 78.57%, specificity: 85.71%), respectively.ConclusionWe established a predictive model for the differentiations of APC and AGC from ACC using clinical indexes, such as GBWT, the percentage of neutrophil and WBC, and determined cut-off values for these indexes based on ROC curves. Index values exceeding these cut-off values will allow to diagnose patients as APC and AGC, as opposed to a diagnosis of ACC.