Gallbladder Wall Abnormalities Research Articles

Spontaneous abdominal effusion in dogs with presumed anaphylaxis.

To describe patient characteristics of dogs developing spontaneous abdominal effusion in association with anaphylaxis. Retrospective study between 2010 and 2018. University teaching hospital and referral specialty private practice emergency departments. Sixteen dogs presenting to the emergency department for clinical signs suggestive of anaphylaxis with peritoneal effusion documented via ultrasonography. None. Dogs presented with clinical signs of anaphylaxis including vomiting 12 of 16 (75%), diarrhea 9 of 16 (56%), and collapse 7 of 16 (44%). Physical examination findings included altered mentation 14 of 16 (88%), erythema 2 of 16 (13%), and urticaria 2 of 16 (13%). Historically, 3 of 16 (19%) had just recently been vaccinated, 1 of 16 (6%) had known contact with an insect, and 8 of 16 (50%) had been outdoors prior to the onset of clinical signs, whereas 5 of 16 (31%) had no known triggering event. At presentation, median systolic arterial pressure was 70mm Hg (range, 30-210mm Hg). Venous blood gas revealed an acidemia with a mean pH of 7.24 ± 0.09, a base deficit of 7.15 ± 7.7mmol/L, and an increased plasma lactate with a mean of 7.35 ± 2.09mmol/L. Bloodwork abnormalities included an increased alanine aminotransferase activity with a mean of 439.2 ± 404.5U/L and an increased gamma-glutamyl transferase activity with a mean concentration of 7.29 ± 4.1U/L. Twelve patients (75%) had gallbladder wall abnormalities on ultrasonography. Eight patients (50%) had abdominocentesis performed. The median PCV of the effusion was 0.29 L/L (29%; range, 4-41) and total plasma protein was 38g/L (3.8g/dL; range, 2.4-6.5). Two dogs (12.5%) were euthanized. The remaining 14 dogs (87.5%) survived to discharge, with a mean hospitalization time of 23.7 ± 16.7hours. Abdominal effusion should be considered a potential sequela of anaphylaxis in dogs. Therefore, serial monitoring for presence or development of spontaneous abdominal effusion should be considered.

Imaging-based algorithmic approach to gallbladder wall thickening.

Gallbladder (GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma (GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities (conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.

31-Year-Old Woman With Jaundice and Abdominal Pain

31-Year-Old Woman With Jaundice and Abdominal Pain

Are all incidental gallbladder cancers truly incidental? Or, are some missed cancers?

Incidental gallbladder carcinoma (IGBC) is an incidental finding of cancer on histopathological examination (HPE) of gall bladder specimen removed for benign gall bladder diseases. The incidence of IGBC ranges from 0.19–3.3%. However, many such tumours are of advanced T stage on HPE. Some of these tumors are possibly missed on either pre-operative evaluation and/or during cholecystectomy. This study was done to find the proportion of patients of IGBC who had preoperative and/or intra-operative suspicious of GBC but underwent simple cholecystectomy. Materials and methods: Data from 56 consecutive IGBC patients presented to our centre between April 2016–May 2017 was analysed. A review of preoperative imaging and operative notes was done to ascertain any suspicion of malignancy-in-retrospect. Results: Preoperative USG was suspicious in 39% (22/56) of patients. CECT scan done in 13 of these patients confirmed gallbladder wall abnormalities in 10 cases. Majority of procedures were open cholecystectomy (39/56), suspicious intraoperative findings were documented in 15 (26.7%) patients. Time to referral after primary surgery was within one month in 30.3% (17/56), between one to two months in 35.7% (20/56), between 2 and six months in 23.3% (13/56) and after six months in 10.7% (6/56). Seventeen patients (30.3%) were advised completion surgery. Seven patients (13%) underwent completion surgery. Rest of the patients were found to be inoperable. Conclusion: Radiologists and surgeons should keep a high index of suspicion of GBC, especially in high incidence areas. Whenever, there is any suspicion, patients should be promptly referred appropriately. Even when detected incidentally, prompt referral maximises chances of curative resection.

Pan-Mesenteric Thrombosis Causing Portal Biliopathy: Case Series from a Tertiary Pancreato-Biliary Center

Purpose: Portal biliopathy is a term used to describe biliary ductal and gallbladder wall abnormalities seen in patients with portal hypertension. These changes are seen in patients with extrahepatic portal vein obstruction (EHPVO). We report a case series of portal biliopathy diagnosed and treated endoscopically in our institution. A 35-year-old male with a past medical history significant for idiopathic portal hypertension requiring splenectomy and splenorenal shunt during childhood and chronic portal vein thrombosis, was found to have elevated ALP of 1,015 U/L on annual check-up without jaundice or pruritus. Exam showed no signs of chronic liver disease. Other liver enzymes were mildly elevated. His liver tests had previously been normal. He underwent magnetic resonance cholangiopancreatography (MRCP), which showed intrahepatic biliary dilatation and mesenteric edema (Figure 1A and 1B). Transabdominal ultrasonography showed cirrhosis and cavernous transformation. Investigations for the etiology of cirrhosis, hypercoagulable state, and myeloproliferative disorders were unremarkable. Endoscopic ultrasonography (EUS) revealed no mass at the stricture. He underwent endoscopic retrograde cholangiopancreatography (ERCP), which showed a highgrade stricture in the distal bile duct that was treated with temporary biliary stenting (Figure 1C). Postoperatively, he had significant improvement in the liver enzyme levels (Figure 1D). He remained asymptomatic at a 2-year follow-up visit. Between 2000 and 2012, we identified four patients with portal biliopathy. Clinical presentation, liver enzymes, and imaging findings are demonstrated in Table 1. This case series highlights the approach to an uncommon cause of biliary obstruction. Portal biliopathy is more common in patients with EHPVO than in patients with idiopathic portal hypertension or cirrhosis. For patients with EHPVO, who develop biliary symptoms, abnormal ALP activity or dilated bile ducts, MRCP is the initial investigation of choice. Patients with evidence of biliary obstruction by MRCP should undergo EUS to delineate the etiology of the obstruction. If portal biliopathy is confirmed, the treatment of choice is porto-caval shunting. ERCP with temporary biliary stent placement is the treatment of choice in patients who are not candidates for the porto-caval shunting.FigureTable 1: Case series of portal biliopathy at University of Minnesota

Complicated Cholecystitis

Acute cholecystitis is a common cause of abdominal pain in the Western world. Unless treated promptly, patients with acute cholecystitis may develop complications such as gangrenous, perforated, or emphysematous cholecystitis. Because of the increased morbidity and mortality of complicated cholecystitis, early diagnosis and treatment are essential for optimal patient care. Nevertheless, complicated cholecystitis may pose significant challenges with cross-sectional imaging, including sonography and computed tomography (CT). Interpreting radiologists should be familiar with the spectrum of sonographic findings seen with complicated cholecystitis and as well as understand the complementary role of CT. Worrisome imaging findings for complicated cholecystitis include intraluminal findings (sloughed mucosa, hemorrhage, abnormal gas), gallbladder wall abnormalities (striations, asymmetric wall thickening, abnormal gas, loss of sonoreflectivity and contrast enhancement), and pericholecystic changes (echogenic fat, pericholecystic fluid, abscess formation). Finally, diagnosis of complicated cholecystitis by sonography and CT can guide alternative treatments including minimally invasive percutaneous and endoscopic options.

Portal biliopathy: a multitechnique imaging approach

Portal biliopathy (PB) is a disorder characterized by biliary ductal and gallbladder wall abnormalities seen in patients with extrahepatic portal vein obstruction. These abnormalities consist mainly of bile duct compression and tethering, stenoses, fibrotic strictures and dilatation of both extrahepatic and intrahepatic bile ducts, as well as gallbladder varices. In this pictorial essay, we describe the imaging findings of PB, which allow differentiation of this entity from other diseases that may have similar imaging findings including cholangiocarcinoma, extrinsic compression of the bile duct caused by metastatic adenopathy or sclerosing cholangitis.

Elevation of alanine transaminase and gallbladder wall abnormalities as biomarkers of anaphylaxis in canine hypersensitivity patients

The purpose of the study was to evaluate alanine transaminase (ALT) and gallbladder wall abnormalities as possible biomarkers for anaphylaxis in dogs presented for acute hypersensitivity reactions. Pilot study. A private practice, small animal, 24-hour emergency and specialty hospital. Ninety-six dogs presenting 101 times on an emergency basis for hypersensitivity reactions from March 2007 through March 2009. Veterinarians acquired a history, physical exam, serum chemistry panel, blood pressure, and ultrasound image of the gallbladder. Dogs were then divided into 2 groups: dogs fulfilling the definition for anaphylaxis (moderate and severe systemic hypersensitivity) and dogs that did not fulfill the definition and were classified as allergic reactions (local hypersensitivity and mild systemic hypersensitivity). Elevated ALT was significantly associated with anaphylaxis (P<0.001). Increased gallbladder wall thickness and a striated wall pattern were significantly associated with anaphylaxis (P<0.001) and these changes were readily apparent to first-responder veterinarians. Decreased body temperature (P<0.001) and hypothermia (P=0.006) were significantly associated with anaphylaxis. There was no significant difference between groups regarding age, heart rate, or presence of respiratory signs. Lower blood pressure was significantly associated with anaphylaxis (P<0.001) but hypotension was not significantly different (P=0.09) between groups. Cutaneous signs were significantly associated with the allergic reactions group (P<0.001) and, when seen with anaphylaxis, were subtle. This study showed an elevated ALT and an abnormal gallbladder wall to be biomarkers significantly associated with anaphylaxis in dogs with acute hypersensitivity reactions.

Portal biliopathy in a 13-year-old Asian girl: A case report and review of literature

Portal biliopathy (PB) is a term used to describe biliary ductal and gallbladder wall abnormalities seen in patients with portal hypertension. The pathogenesis of PB is not well known. It has been postulated that external pressure of portal cavernoma and/ or ischemia may play a role. We report a case of a patient with PB presenting with obstructive jaundice that involved endoscopic sphincterotomy and stenting.

Portal biliopathy.

In patients with portal hypertension, particularly with extrahepatic portal vein obstruction, portal biliopathy producing biliary ductal and gallbladder wall abnormalities are common. Portal cavernoma formation, choledochal varices and ischemic injury of the bile duct have been implicated as causes of these morphological alterations. While a majority of the patients are asymptomatic, some present with a raised alkaline phosphatase level, abdominal pain, fever and cholangitis. Choledocholithiasis may develop as a complication and manifest as obstructive jaundice with or without cholangitis. Endoscopic sphincterotomy and stone extraction can effectively treat cholangitis when jaundice is associated with common bile duct stone(s). Definitive decompressive shunt surgery is sometimes required when biliary obstruction is recurrent and progressive.