Gallbladder Wall Edema Research Articles

Is Routine Ultrasound Examination of the Gallbladder Justified in Critical Care Patients?

Objective. We evaluated whether routine ultrasound examination may illustrate gallbladder abnormalities, including acute acalculous cholecystitis (AAC) in the intensive care unit (ICU). Patients and Methods. Ultrasound monitoring of the GB was performed by two blinded radiologists in mechanically ventilated patients irrespective of clinical and laboratory findings. We evaluated major (gallbladder wall thickening and edema, sonographic Murphy's sign, pericholecystic fluid) and minor (gallbladder distention and sludge) ultrasound criteria. Measurements and Results. We included 53 patients (42 males; mean age 57.6 ± 2.8 years; APACHE II score 21.3 ± 0.9; mean ICU stay 35.9 ± 4.8 days). Twenty-five patients (47.2%) exhibited at least one abnormal imaging finding, while only six out of them had hepatic dysfunction. No correlation existed between liver biochemistry and ultrasound results in the total population. Three male patients (5.7%), on the grounds of unexplained sepsis, were diagnosed with AAC as incited by ultrasound, and surgical intervention was lifesaving. Patients who exhibited ≥2 ultrasound findings (30.2%) were managed successfully under the guidance of evolving ultrasound, clinical, and laboratory findings. Conclusions. Ultrasound gallbladder monitoring guided lifesaving surgical treatment in 3 cases of AAC; however, its routine application is questionable and still entails high levels of clinical suspicion.

Sonographic Evidence of Ascites, Pleura-Pericardial Effusion and Gallbladder Wall Edema for Dengue Fever

Radiographic findings of dengue fever have not yet been clearly elucidated in relation to clinical and serological findings, despite the fact that two-fifths of the world population lives in areas where the virus is endemic. The current study is a retrospective analysis of ultrasonographic (USG) features of patients presenting with probable dengue fever during the outbreak of DF of 2006 in North India. Case records of a 169 patients with probable dengue fever were included. Ten individual sonographic parameters were reviewed vis-à-vis ascites, hepatomegaly, splenomegaly, gall bladder wall edema (GBWE), pleural effusion (right or left or both), pericardial effusion, pericholecystic collection, perinephric collection. Subjects who had GB wall thickness >3 mm as measured on ultrasound were identified as positive for GBWE. The cases were analyzed in view of their serological profile. The mean age of the subjects was 27.9 +/- 13.4 years. The mean value of the platelet count was 57.4 +/- 22.3 x 103/cmm. The most common ultrasonographic feature was ascites (126, 74.6%) followed by gall bladder wall edema (122, 72%), hepatomegaly (78, 46.2%), splenomegaly (66, 39.1%) and pericholecystic collection (63, 37.3%); 48 (28.4%) subjects demonstrated evidence of pleural effusion on the right side, while 19 (11.2%) had bilateral effusion. None of the subjects had an isolated left pleural effusion. Twenty-seven (16%) subjects reported bleeding manifestations in the form of petechiae and five (3%) developed renal dysfunction. Presence of pleural and pericardial effusions was found to be specific while ascites and GBWE were identified as highly sensitive markers for seropositive Primary DF. Ultrasonographic evidence of ascites, pleuro-pericardial effusion, and gallbladder wall edema are rapidly acquired, non-invasive markers of dengue and can be helpful before serological investigations become available. These findings may indicate severity and may herald the onset of bleeding (petechiae) or predict the development of acute renal dysfunction.

Lessons Learned From Quality Assurance: Errors in the Diagnosis of Acute Cholecystitis on Ultrasound and CT

The purpose of this article is to study errors in the diagnosis of acute cholecystitis reported in the online departmental quality assurance (QA) database. The departmental QA database was searched from October 2005 to April 2010 for cases of acute cholecystitis. Errors were classified into overcalls and undercalls. We identified 14 cases of misdiagnosis involving acute cholecystitis. Three cases were classified as overcalls (21%) and eleven as undercalls (79%). Eight cases of misdiagnosis involved ultrasound studies (57%) and six cases involved CT studies (43%). Cases of overcall on ultrasound showed gallbladder wall edema, but none portrayed distention of the gallbladder. The final diagnosis in these cases included hepatitis, sepsis, and a case of chronic cholecystitis. All misinterpretations of CT cases were classified as undercalls. Contributing factors to misdiagnosis were lack of recognition of wall edema (n = 6), gallbladder distention (n = 4), absence of gallbladder wall edema (n = 1), lack of conclusion in the report (n = 2), and hospitalization in the ICU (n = 2). A possible case clustering was observed just after July almost every year. An important pitfall in the diagnosis of acute cholecystitis is lack of recognition of gallbladder wall edema on CT. A relaxed (nondistended) gallbladder provides important evidence against the diagnosis of acute cholecystitis. Intensive care patients with sepsis often have no specific signs for diagnosis of acute cholecystitis, making diagnosis especially challenging.

Laparoscopic Cholecystectomy In Acute Cholecystitis – Experience From A Single Centre

A total of 140 patients with acute inflammation of the gall bladder were subjected to laparoscopic cholecystectomy. The majority of the patients (62.85%) were in the third and fourth decade of their life with 88 females and 52 males. Pain in the right hypochondrium (RHC), nausea/vomiting, and tenderness of the RHC were present in all patients. Fever (>100F) was noted in 80%, Murphys sign in 71.4%, and a lump in the RHC in14.2% of the cases.All the patients had a total leukocyte count (TLC) of >10,000/cu mm and 11.4% had elevated serum bilirubin, transaminases, and alkaline phosphatase (ALP). Ultrasonography revealed edematous gallbladder (GB) with thickened wall, GB distension, gall stones, and sonographic Murphys sign in all patients. Six (8.57%) cases had mucocele of the GB. A stone impacted at the neck of the GB was seen in 85.7%. The majority of the patients (77.1%) were operated within 48 to 72 hours of admission and the rest before 48 hours. Intra-operative findings included adhesions (100%), distended GB (77.1%), edematous GB wall (97.1%), inflamed GB(100%), and pericholecystic edema (42.8%). Mucocele was present in 8.5% and GB empyema in 68.5% of cases. All patients had gall stones of which 97.1% had them impacted at the neck of GB. Significant bleeding from the liver bed occurred in 34.2% and a short cystic duct was encountered in 5.7%. GB inflammation involved only fundus and body in 71.2%, extending up to the neck in 22.8% and further up to the cystic duct in 5.7%. During surgery, modifications in operative technique included GB decompression in 60%, closed suction drain used in 97.1%, and haemostatic agent used in 24.3%. The procedure was converted to open cholecystectomy in four (2.85%) patients. The mean operative time was 69.2± 8.9 min. Postoperative complications included abdominal pain in 12 (8.57%), fever in 16 (11.4%), basal pneumonitis in 4 (2.85%), biliary fistula in 4 (2.85%) and faecal fistula in 1 (0.71%) of the patients. The mean hospital stay was 5.4±3.7 days.

F-18 FDG PET/CT Findings in A Case of T-Cell Lymphoma-Associated Hemophagocytic Syndrome With Liver Involvement

Abstract:This is a report of fluoro-deoxy-glucose positron emission tomography/computed tomography (F-18-FDG PET/CT) findings in a case of T-cell lymphoma-associated hemophagocytic syndrome, with “periportal low attenuation” and edematous gall-bladder wall thickening. FDG PET/CT showed diffuse inten

63: Can Emergency Physicians Utilize the Stone in Gallbladder Neck (SIN) Phenomenon to Accurately Diagnose Cholecystitis?

Emergency physicians (EPs) currently use focused abdominal ultrasonography to diagnose acute cholecystitis. We propose that emergency physicians can utilize ultrasound to diagnose cholecystitis based solely on the Stone in Neck (SIN) phenomenon. We have defined SIN as the lack of an anechoic space between the gallbladder neck and the immobile stone it contains, without other ultrasonographic evidence of cholecystitis. Ultrasonographic findings of cholecystitis include: sonographic Murphy's sign, anterior gallbladder wall thickening, pericholecystic fluid, hydropic gallbladder and gallbladder wall edema.

Fulminant hepatic failure in children: Etiology, histopathology and MDCT findings

Introduction The purpose of this study is to determine the etiologies, histopathology and MDCT findings of children with fulminant hepatic failure admitted to our institution. Materials and methods Between June 2004 and November 2006, 15 children with fulminant hepatic failure who underwent MDCT were included retrospectively in this study. Twelve patients had liver biopsies. The patients were divided into three groups as hyperacute (Group I), acute (Group II) and subacute (Group III) depending on onset of hepatic encephalopathy. Results Hepatitis A in 4 patients, non-A, non-E hepatitis in 4; mushroom poisoning in 3; fulminant Wilson's disease in 2; autoimmune hepatitis in 1; and both hepatitis B and toxic hepatitis (with leflunomide treatment) in 1 patient were detected. MDCT of all three groups revealed diffuse reduction in hepatic attenuation in 11 patients; ascites in 9; periportal edema in 6; edema of gallbladder wall in 6; splenomegaly in 6; heterogeneous hepatic parenchyma in 6; hepatomegaly in 3; irregular contours of liver in 2; multiple micronodules in 1 and necrotic areas and regeneration in liver parenchyma in 2 patients. Histopathologic evaluation of liver biopsies showed massive hepatic necrosis, inflammatory cell infiltration and ductular proliferation in 8 patients, periportal edema in 6, edema of gallbladder wall in 5, regenerating nodules and fibrous septa consistent with cirrhotic pattern in 2, and regenerating nodules and necrotic areas in 2 patients. Conclusion The most common MDCT findings in fulminant hepatic failure were diffuse reduction in hepatic attenuation and ascites. Massive hepatic necrosis was the most common histopathologic finding.

The Short-Term Effects of Balloon-Occluded Retrograde Transvenous Obliteration, for Treating Gastric Variceal Bleeding, on Portal Hypertensive Changes: a CT Evaluation

ObjectiveWe wanted to evaluate the short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) for treating gastric variceal bleeding, in terms of the portal hypertensive changes, by comparing CT scans.Materials and MethodsWe enrolled 27 patients who underwent BRTO for gastric variceal bleeding and they had CT scans performed just before and after BRTO. The pre- and post-procedural CT scans were retrospectively compared by two radiologists working in consensus to evaluate the short-term effects of BRTO on the subsequent portal hypertensive changes, including ascites, splenomegaly, portosystemic collaterals (other than gastrorenal shunt), the gall bladder (GB) edema and the intestinal wall edema. Statistical differences were analyzed using the Wilcoxon signed rank test and the paired t-test.ResultsFollowing BRTO, ascites developed or was aggravated in 22 (82%) of 27 patients and it was improved in two patients; the median spleen volumes increased from 438.2 cm3 to 580.8 cm3, and based on a 15% volume change cut-off value, splenic enlargement occurred in 15 (56%) of the 27 patients. The development of new collaterals or worsening of existing collaterals was not observed in any patient. GB wall edema developed or was aggravated in four of 23 patients and this disappeared or improved in five; intestinal wall edema developed or was aggravated in nine of 27 patients, and this disappeared or improved in five. Statistically, we found significant differences for ascites and the splenic volumes before and after BRTO (p = 0.001 and p < 0.001, respectively).ConclusionSome portal hypertensive changes, including ascites and splenomegaly, can be aggravated shortly after BRTO.

CT Features of Hepatic Venoocclusive Disease and Hepatic Graft-Versus-Host Disease in Patients After Hematopoietic Stem Cell Transplantation

We conducted this study to evaluate whether CT scans could be used to differentiate hepatic venoocclusive disease from hepatic graft-versus-host disease in patients treated with hematopoietic stem cell transplantation. We retrospectively evaluated 18 patients (eight women, 10 men; mean age, 42.4 years) after hematopoietic stem cell transplantation with biopsy-proven hepatic venoocclusive disease (n = 5), hepatic graft-versus-host disease (n = 6), or both (n = 7). Two radiologists reviewed abdominal and pelvic CT scans for hepatomegaly (> 18 cm), splenomegaly (> 13 cm), size of main portal and right hepatic veins, presence of periportal edema, gallbladder wall edema, hydropic gallbladder, ascites, and small-bowel wall thickening. CT and histopathology findings were correlated using analysis of variance and Fisher-Free-man-Holton tests. Ascites and periportal edema were present in all five patients with venoocclusive disease, but of six patients with graft-versus-host disease, ascites was seen in two (p < 0.05) and periportal edema in only one (p < 0.05). Small-bowel wall thickening was encountered in five patients with graft-versus-host disease and in none with venoocclusive disease (p < 0.05). The right hepatic vein diameter in patients with venoocclusive disease (mean, 0.27 cm) was significantly smaller than the right hepatic vein diameter in patients with graft-versus-host disease (mean, 0.87 cm; p < 0.05). In patients treated with hematopoietic stem cell transplantation, CT findings of periportal edema, ascites, and a narrow right hepatic vein suggest venoocclusive disease rather than graft-versus-host disease. Small-bowel wall thickening suggests graft-versus-host disease.

Hemophagocytic syndrome after Kawasaki disease.

Hemophagocytic syndrome (HPS) is a rare and life-threatening disease in which a generalized histiocytic proliferation results in hemophagocytosis and up-regulation of inflammatory cytokines. This syndrome has been associated with infections, malignancy, drugs and immunologic triggers such as Kawasaki disease (KD). We describe the clinical and laboratory features of two children with HPS after KD and review the three previously reported pediatric cases of recrudescence of HD leading to HPS.

Laparoscopie ou laparotomie dans la cholécystite aiguë (200 cas). Comparaison des résultats et facteurs prédisposant à la conversion

Study aim The aim of this prospective study was to compare the results of cholecystectomy for acute cholecystitis through laparoscopic and open approach and to assess factors responsible for conversion into laparotomy. Patients and methods From January 1991 to October 1997, 200 patients with calculous acute cholecystitis were operated on in the same center, 100 through laparoscopy and 100 through laparotomy. Choice between these two procedures was only dependent on the disponibility of videolaparoscopic material. Comparison between laparoscopy and laparotomy groups concerned postoperative mortality and morbidity rates, hospital stay duration and late results. Intraoperative conversion into laparotomy occurred in 24 patients and factors responsible for conversion were assessed with univaried and multivaried analysis. Results Both groups were comparable with regard to sex ratio, age, ASA score but associated diseases incidence, plastron, fever above 38 ° C and leucocytosis were significantly more frequent in the laparotomy group and delay between diagnosis and surgery was significantly longer in the laparoscopic group. There were two postoperative deaths in the laparotomy group, 0 in the laparoscopic group (NS). Morbidity rate was higher (32% versus 10%) (p=0.0002) and hospital stay longer (12 ± 10 days, versus 5 ± 3) in the laparotomy group (p=0.00005). Late results were similar in both groups. Conversion rate into laparotomy was 24%. Factors predisposing significantly to conversion were in univaried analysis : plastron, fever above 38 ° C, leucocytosis, delay between diagnosis and surgery above 4 days, presence on ultrasonography of pericholecystic liquid and gallbladder wall edema, presence of ≪Klebsiella≫ in gallbladder bile. With multivaried analysis, leucocytosis and delay between diagnosis and surgery were the only independent factors. Conclusion Videolaparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, with a lower postoperative morbidity rate and a shorter hospital stay. Conversion rate into laparotomy is significantly dependant on leucocytosis and delay between diagnosis and surgery. Laparoscopic cholecystectomy should be performed as soon as possible in acute cholecystitis.

Periportal lymphatic distension resulting from cardiac tamponade: CT findings and clinical-pathologic correlation

Purpose: To correlate computed tomography (CT) findings with clinical-pathologic results and discuss the possible significance of periportal hypodensity in patients with clinical cardiac tamponade secondary to acute proximal thoracic aortic dissection, aneurysm, or heart rupture. Materials and methods: In a retrospective review of thoracoabdominal CT scans and records of 17 consecutive patients with hemopericardium, 10 patients with clinical signs of cardiac tamponade associated with hypodensity around the portal vein were selected; at surgery or autopsy all 10 patients had a thoracic aortic aneurysm, dissecting aneurysm, and heart rupture. The ratio of transverse inferior vena cava diameter to the diameter of the aorta at the level of the right adrenal gland was determined. Results: Abdominal CT scans showed focal (n = 1) or diffuse (n = 9) areas of hypodensity around the portal vein associated with pericaval hypodensity in four cases. Other abdominal abnormalities included persistent enhancement of renal parenchyma (n = 5), and gallbladder wall edema (n = 2); in nine cases the inferior vena cava diameter was significantly increased compared with that of patients with normal findings on CT scans (P < 0.01). Pathologic correlation, available in nine cases by autopsy, showed evidence of periportal lymphatic vessel dilatation and lymphedema. Conclusions: Periportal hypodensity on CT scans corresponds to the histopathologic picture of dilated lymphatic vessels or hepatic lymphedema; a diagnosis of hepatic lymphedema may be considered on the basis of CT scans in patients with pericardial effusion.

Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis.

A positive sonographic Murphy sign, the presence of maximal tenderness elicited over a sonographically localized gallbladder, has been reported to be a helpful adjunctive finding in patients with proven acute cholecystitis who are evaluated with ultrasonography. We evaluated 200 patients with right upper quadrant pain, thought to be acute cholecystitis. Results of ultrasound examinations and subsequent follow-up were tabulated. The sensitivity of the sonographic Murphy sign in acute cholecystitis was 86% with a specificity of 35%, positive predictive value of 43%, and negative predictive value of 82%. The sensitivity of the sonographic findings, including stones, gallbladder wall edema, and pericholecystic fluid collections, was 93%, a specificity of 53%. The combination of the Murphy sign accompanied by gallstones yielded a specificity of 77%. The large number of false positives, and only moderate improvement in specificity when accompanied by gallstones, makes this sign unreliable in separating acute from chronic cholecystitis.

Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results.

Two hundred and twenty patients with a total of 412 gall bladder stones of between 8 and 38 mm in size were treated with extracorporeal shock wave lithotripsy, using the overhead module Lithostrar Plus. Fifty six per cent of stones were solitary (mean (SD) diameter 23 (5) mm) and 9.5% of the patients had more than three stones. Stones were successfully disintegrated in 218 patients (fragmentation size less than 5 mm in 80%, less than 10 mm in 19%). Some 65% of patients required one treatment and the rest two or three. A mean (SD) of 4100 (1800) shock waves with a pressure of 700 bar were applied. Twenty four to 48 hours after lithotripsy a transient but significant increase in serum transaminase activities (31%) and in bilirubin (29%), urinary amylase (27%), and blood leukocyte (62%) values was observed. In 29% of patients there was a transient microhaematuria, in 2% transient macrohaematuria, and in 25% painless petechiae of the skin. Ultrasound showed temporary gall bladder wall oedema in 13%, temporary distension of the gall bladder in 11%, and transient common bile duct distension in 8% after treatment. After discharge from hospital, 31% of patients complained of recurrent colic that responded to simple analgesics. Four to eight weeks after therapy, four patients developed biliary pancreatitis and 11 biliary obstruction that was managed by endoscopy. To date, 105 patients have been followed for over 12 months. Sixty one of these had a solitary stone, 17 had two, and 27 had three or more stones. A total of 59 patients, including 44 with a primary solitary stone, eight with two stones, and seven with three or more stones are completely stone free.