History Of Gallbladder Disease Research Articles

Risk Factors Associated with Cholelithiasis during Pregnancy and Postpartum

Gallbladder disease is the most common non-obstetrical cause of maternal hospitalization in the first year postpartum. Many risk factors have been associated with gallbladder disease in pregnancy including body mass index, prenatal weight gain, prenatal physical activity, dietary fat, age, parity, a history of gallbladder disease and the number of previous pregnancies were significant factors related to new gallstones and biliary sludge formation in the pregnant group. The aim of this study is to evaluate the risk factors for gallstones formation in pregnancy and one year after labour. The study included 328 female patients (pregnant or postpartum) divided into two groups; patient group (164 patient) that are pregnant or postpartum patient have gallstones and control group (164 patient) that are pregnant or postpartum patient does not have gallstones. All patients were subjected to full history taking; especially about risk factors predisposing for gallstones, physical examination and pre-operative routine laboratory investigations and imaging as abdominal ultrasound study (U/S). Obesity, young age, history of gallbladder disease and use of estrogen and progesterone are the main risk factors that increase incidence of gallstones during pregnancy or one year postpartum. Use of vit C, iron, drinking coffee and practicing regular physical activity are considered protective factors.

Association between the use of hormonal contraceptives and risk of cholecystectomy in women of reproductive age.

Previous studies have indicated an increased risk of gallbladder disease with hormonal contraceptives although with discordant results. The potential increased risk of gallbladder disease with hormonal contraceptives is concerning given that women are at increased risk of this disease. Thus, the aim of this study was to examine risk of surgery-confirmed gallbladder disease (cholecystectomy) with oral contraceptives, intrauterine devices, and injectable hormonal contraceptives. We conducted a retrospective cohort study. Females aged 15-45 who initiated hormonal contraceptive use were identified in the United States IQVIA Ambulatory electronic medical record database between 2008 and 2018. Cox proportional hazards models were used to estimate adjusted hazards ratios and 95% confidence intervals for cholecystectomy with eight formulations of contraceptives compared with levonorgestrel and ethinyl estradiol combined oral contraceptive. Sensitivity analysis was conducted by lagging exposure by 90days and by excluding patients with history of gallbladder disease. Secondary analyses were conducted by cumulative duration of use. We identified 1,425,821 females who initiated the use of hormonal contraceptives and generated 4417 cholecystectomy events. Overall, the use of medroxyprogesterone acetate (HR: 1.22, 95% CI: 1.07-1.40) and at least 1year of levonorgestrel intrauterine device use (HR: 1.74: 95% CI: 1.19-2.54) were associated with increased risk of cholecystectomy when compared with levonorgestrel and ethinyl estradiol combined oral contraceptive. However, we did not observe an increased risk with other hormonal contraceptives. Consistent results were observed across sensitivity analyses. In this large population-based study, there was an increased risk of cholecystectomy with medroxyprogesterone acetate and intrauterine device but not other hormonal contraceptives. Additional large observational studies are required to corroborate these findings.

S1505 Choledochoduodenal Fistula: An Old Complication of Choledocholithiasis With a New Presentation

INTRODUCTION: Enterobiliary fistulas were first described in 1654 with 68% of cases occurring between the gallbladder wall and duodenum. Choledochoduodenal fistulas (CDF) are less common (8.6%) and most are asymptomatic. This case highlights a rare presentation of pneumobilia, cholangitis, and pyogenic hepatic abscesses in a patient with CDF. CASE DESCRIPTION/METHODS: A 68 year old male with a past medical history of diabetes presented with rigors and fevers for one day. He denied abdominal pain, history of gallbladder disease, or recent travel history. Vitals signs were notable for BP 70/40, HR 110, T 101 F. Physical exam was remarkable for scleral icterus, but no abdominal tenderness or altered mentation. Lab results revealed WBC 31,000, creatinine 3.94, total bilirubin 9.6, direct bilirubin 7.9, AST 117, ALT 94, ALP 484, lactate 7.4, and positive blood cultures for Escherichia coli. CT abdomen without contrast revealed marked intra and extrahepatic bile duct dilatation with multiple focal densities identified in the liver and pneumobilia at the level of the distal common bile duct (CBD) (Figure 1). Antibiotics were started and he underwent ERCP which revealed a suprapapillary CDF with significant stone burden and pus in the CBD. Sphincterotomy was performed to the level of the CDF. Many stones were removed and two plastic stents were placed to ensure drainage. Follow up liver MRI revealed numerous hepatic abscesses. The patient’s vitals and laboratory markers improved with antibiotics, and he was scheduled for follow up outpatient ERCP to complete endotherapy. DISCUSSION: CDF can be caused by choledocholithiasis, duodenal ulcers, tumor invasion, or post-cholecystectomy complications. Most cases of CDF are asymptomatic and incidentally detected. However in the subset of symptomatic cases, cholangitis is the most common presentation. Furthermore, chronic cholangitis due to reflux of duodenal contents with bacterial flora may cause hepatic abscesses, though this has only been documented in case reports. Diagnosis can be achieved by ERCP with direct visualization of CDF and successful cholangiography through the papilla and fistula orifice. With few studies investigating this entity, proposed treatment options are conflicting. Some advocate for less invasive measures, such as endoscopic interventions for asymptomatic patients or distal CDF. Others regard CDF as a biliary abnormality that predisposes to recurrent infections and increases the risk for malignancy, and thus advocate for surgical management.Figure 1.: This sagittal view of a noncontrast CT abdomen/pelvis delineates hepatic abscesses, pneumobilia at the level of the choledochoduodenal fistula, and dilated intra and extrahepatic bile ducts.

Abstract D109: Helicobacter pylori infections in Navajo communities of Northern Arizona

Abstract Background: Helicobacter pylori (Hp) is a gastric pathogen associated with development of duodenal or stomach ulcers, stomach cancer, and mucosa associated lymphoid-tissue (MALT) lymphomas. While Hp prevalence is declining in many regions, it remains the leading infectious cause of cancer worldwide. In the United States prevalence varies by geographic location, ethnic background, socioeconomic status, and age. This pilot project seeks to understand the role of Hp infection in the development of stomach cancer among Native Americans of Northern Arizona, where stomach cancer incidence rates are approximately three times higher than the general Arizona population and it is the leading cause of cancer mortality. Methods: A cross-sectional survey based on a random sample of households selected using census block vectors for tribal lands overlaid onto satellite imagery. Potential household structures were marked and randomly sorted with recruitment goals set to be proportional to underlying population size. Houses were ‘ground-truthed’ for eligibility and residents approached for participation. A total of 72 households were recruited between June-August 2018 with 105 self-identified Navajo >18 years old living in three communities in northern Arizona participating. Participants were assessed on household and individual level factors associated with infection. A urea breath test (UBT) was performed to test for active infection. We used logistic regression, adjusted for household clustering, to calculate odds ratios (aOR) and 95% confidence intervals (CI) for associations between UBT results and individual and household factors. Results: Active Hp infection was found in 66 of the 101 participants with valid UBT, crude prevalence of 65.4%. Male participants were more likely to be positive (aOR=2.89, 95% CI, 1.03-8.09). Participants with an unregulated household water source had the highest odds for positive UBT (aOR=8.85, 95% CI, 1.50-53.38). There was no association with age or education and a modest association with history of gallbladder disease. Only 23.8% reported they had ever heard of Hp infections and 12.9% previously tested for the infection. Conclusion: Prevalence of Hp is high among individuals in these Navajo communities. Use of household water that was not regulated, was strongly associated with active Hp infection. Further work is needed to determine if there is geographic variation and what Hp substrains are involved for this population. Attention also needs to focus on developing strategies to reduce the infection and target earlier detection. Citation Format: Robin B Harris, Rachel Begay, Priscilla R Sanderson, Carmenlita Chief, Fernando Monroy, Heidi E Brown, Eyal Oren. Helicobacter pylori infections in Navajo communities of Northern Arizona [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D109.

Intramuscular Metastasis of Gallbladder Carcinoma

Introduction: Gallbladder cancer is a highly fatal malignancy. Even though it is a rare malignancy, it is the most common biliary tract malignancy in USA. Majority of the patients are asymptomatic and among symptomatic patients, the most common complains include pain, anorexia, nausea or vomiting. Patients with GBC may also present with obstructive jaundice, either from direct invasion of the biliary tree or from metastatic liver diseases. Gall bladder carcinoma mainly metastasizes to liver, intra-abdominal LNs and biliary tract. Intramuscular and subcutaneous manifestations are very rare from gallbladder carcinoma. In this article we present a rare case of Intramuscular metastasis of gallbladder carcinoma in an African American lady with no other history of gallbladder disease. Case narration: 55 year old African American lady with history of poly-substance abuse disorder presented to Boston Medical Centre with 2 months of progressive Right Upper Quadrant abdominal pain. She had CT scan showing 6.3 cm mass in gallbladder invading into the liver which on biopsy was consistent with adenocarcinoma of gallbladder. She presented again in the Emergency Department with a new 3 x 3 cm lump in her left arm and 5 x 5 cm lump in her left thigh. A CT Scan of the thigh mass showed an extensive lesion in her left thigh muscles again which on USG guided biopsy confirmed intramuscular metastasis with IHC positive for CK7, AE1:3 and CAM5.2 consistent with metastatic gallbladder adenocarcinoma. Conclusion: Although rare, intramuscular lesions should raise suspicion of metastatic disease in the gall bladder carcinoma patients. In our case, patient reported two new rapidly growing lesions consistent with rapid progression of disease. Palliative radiation therapy should be considered in patients with severe pain associated with intramuscular metastasis. Intramuscular metastasis is usually associated with poorer prognosis

Abstract 5046: Gallbladder disease and the risk of hepatocellular carcinoma: US case-control study

Abstract BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver with a five-year survival rate of less than 5 percent. Gallbladder disease (GBD) is defined as the presence of cholelithiasis or cholecystitis. Both cholelithiasis and cholecystitis have been reported as risk factors in the development of gastrointestinal cancers, such as biliary tract and pancreatic cancers. Moreover, patients with GBD tend to develop chronic liver diseases, which may progress to cirrhosis. However, the role of GBD in the development of non-cirrhotic related HCC has not been elucidated. We aimed to investigate the role of GBD and the risk of HCC development in the absence of cirrhosis. METHODS: We conducted a case-control study at The University of Texas M.D. Anderson Cancer Center. Cases were defined as pathologically confirmed HCC. Controls were healthy individuals without prior history of cancer, who were spouses of other cancer patients seen at MD Anderson. All subjects were USA residents. Participants were personally interviewed for prior history of GBD and for several HCC risk factors (environmental, behavioral, chronic medical conditions, and family history of cancer). Blood samples of all participants were tested for markers of hepatitis B and C viruses. We reviewed the pathology and radiology records of HCC patients to assess presence and absence of cirrhosis. Multivariable logistic regression analysis was conducted to estimate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for the association between GBD and HCC in the absence of cirrhosis and with adjustment for potential confounders. RESULTS: Between 2000 and 2017, a total of 1333 cases and 1104 controls were enrolled in the study. After review, 347 HCC case patients showed no evidence of cirrhosis and were eligible for this analysis. The prevalence of GBD based on the participants’ recall during personal interview was 22.7% in the cases. Upon further assessment by review of medical records, the prevalence of GBD was 40.3% in the cases. Individuals with GBD were two times more likely to develop HCC than individuals with no history of GBD (AOR = 2.0; 95% CI: 1.4 – 2.8). The estimated AOR did not meaningfully change when we rely on the prevalence of GBD recalled by cases (22.7%) versus prevalence of GBD obtained from medical records (40.3%). The association between GBD and HCC continue to be significant in the absence of viral hepatitis, through a restricted analysis among non-viral non-cirrhotic population after controlling for age, sex race, alcohol use, cigarette smoking, diabetes mellitus, and family history of cancer. CONCLUSIONS: We conclude that GBD is a significant risk factor for HCC development in absence of cirrhosis. Future research aiming at investigating the underlying mechanism of GBD-induced HCC in absence of cirrhosis should be warranted. In addition, patients with GBD should be screened for evidence of cirrhosis. Citation Format: Kenda Al-Assi, Rikita Hatia, Vijayashri Rallapalli, Yehia I. Abugabal, Ahmed Abdelhakeem, Reham Abdel-Wahab, Kanwal Raghav, Prasun K. Jalal, Ahmed Kaseb, Asif Rashid, Donghui Li, Manal Hassan. Gallbladder disease and the risk of hepatocellular carcinoma: US case-control study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5046.

Macrolipasemia due to Crohnʼs Disease

Purpose: In a patient presenting with epigastric pain, emesis, and elevation of lipase, a diagnosis of pancreatitis may seem inevitable. But in spite of its specificity, the elevation of lipase in the context of a normal amylase value merits further investigation into other potential etiologies. A 56-year-old female with a history of longstanding severe Crohn's disease requiring multiple small bowel resections was initially seen in 2010; remission was maintained with certolizumab pegol. However, a few months later she started to experience epigastric and periumbilical pain, so cerrtolizumab pegol was boosted and split, deferring dual therapy with a thiopuine due to prior infections. Despite initial improvement, she was admitted two months later for emesis and severe periumbilical pain; lipase was elevated at 7000 U/L with a normal amylase. She did not consume alcohol, have a history of gallbladder disease, or take any known pancreatotoxins. Ultrasound and MRI demonstrated a normal pancreas; CT suggested a slightly plump pancreas, but IgG4 was negative. Serum trypsin, urinary lipase, fecal elastase, and serum amylase were all negative or normal. Colonoscopy revealed inflammation at the ileocolonic anastomosis causing significant narrowing. Based on this investigation, it was determined that the patient had macrolipasemia due to Crohn's disease. Isolated macrolipasemia is a rare finding that has been observed in celiac disease, cryptogenic liver cirrhosis, non-Hodgkin's lymphoma, and Crohn's disease. Although significantly more uncommon than hyperamylasemia, a solitary increase in lipase values in patients without pancreatitis has been reported in the literature; there has been only one such documented case of macrolipasemia and Crohn's disease. Laboratory measurements of lipase account for all forms of the enzyme regardless of composition. Macroenzyemes are formed by either self polymerization or the creation of a complex consisting of the physiologic enzyme and immunoglobulin; there have been reports of such complexes in association with autoimmune phenomena. The increased molecular mass of these macroenzymes does not allow for physiologic filtration and removal of the enzyme via the kidney, thereby accounting for the accumulation of the enzyme in serum levels and lack of presence in the urine. Currently, no evidence has been found to suggest that macroenzymes play a compelling role in the cause of disease, nor do they require treatment. Therefore, in a patient with repeated episodes of abdominal pain and isolated elevation of lipase, consider alternatives to the diagnosis of pancreatitis, particularly when another known abdominal disease exists.

Transforming growth factor-β pathway is activated in cholecystolithiasis

The etiopathogenesis of cholecystolithiasis is not well defined. Primary dysmotility of the organ, due to fibrosis of the gallbladder wall or muscular dysfunction, is suggested as a crucial factor. Transforming growth factor-beta (TGF-beta) and connective tissue growth factor (CTGF) are involved in several fibrotic disorders and play a critical role in fibrogenesis, thereby changing the physiological function of the organs. In the present study we analyzed the role of TGF-beta and its downstream target CTGF in patients with cholecystolithiasis. Gallbladders were obtained from 16 individuals undergoing surgery for symptomatic cholecystolithiasis. Normal human gallbladder tissue samples from five individuals without any history of gallbladder disease were obtained through an organ donor transplantation program. Northern blot analysis, in situ hybridization, and immunohistochemistry were used to analyze the expression of TGF-beta1 and CTGF in the gallbladder tissue samples. By northern blot analysis there was an enhanced TGF-beta1 mRNA expression (eightfold increase; P < 0.04) in the cholecystolithiasis tissue samples in comparison with normal controls. There was also a concomitant increase in CTGF (41-fold increase; P < 0.01). By in situ hybridization and immunohistochemistry, CTGF mRNA was localized mainly in the mucosa layer, while intensive staining of the smooth muscle cells with TGF-beta1 and CTGF was observed. In addition, TGF-beta1 immunoreactivity was also localized in the fibroblasts and inflammatory cells. TGF-beta1 m-RNA levels showed a significant relationship with the degree of fibrosis in the tissue samples (P < 0.04, r = 0.5). Our data indicate that TGF-beta and CTGF are involved in ultrastructural tissue changes in patients with cholecystolithiasis. Activation of the "TGF-beta pathway," predominantly in the remaining mucosa and submucosal layer, indicates that extracellular matrix (ECM) synthesis with subsequent gallbladder wall fibrosis is an important step in gallbladder dysfunction in this disorder.

Risk factors for cholelithiasis in pregnancy

This study was designed to examine the relationships of demographics, anthropometrics, prenatal physical activity, serum cholesterol, and nutrient intakes to symptomatic cholelithiasis (gallstone) occurrence in 128 northern plains pregnant women. Data collected at 14 and 26 weeks of pregnancy and 4 weeks after delivery, indicated 25.8% of the Native American and 8.3% of the Caucasian pregnant women experienced symptoms of cholelithiasis. Body mass indices (BMIs) were significantly higher in the pregnant women who experienced cholelithiasis than in those who did not have cholelithiasis, and prenatal physical activity was significantly lower in those same women. History of gallbladder disease (beta=.73; p=.001), BMI (beta=.33; p=.01), and prenatal physical activity (beta=-.20; p=.04) were predictive of increased occurrence of cholelithiasis during pregnancy.

Increased risk of symptomatic gallbladder disease in adults with Down syndrome.

Previous reports have documented an increased prevalence of asymptomatic cholelithiasis among children with Down syndrome. Whether this predisposes adults with Down syndrome to symptomatic gallbladder disease has not been studied. A case control study compared the rate of symptomatic gallbladder disease in 28 index cases of adults with Down syndrome and that of sex-matched controls. The rate of gallbladder disease was 25% among the Down syndrome group, compared to 4.5% among the control group (P = 0.002). Patients with Down syndrome were also more likely to have a family medical history of gallbladder disease. Utilizing logistic regression analysis, the adjusted relative risk for gallbladder disease among individuals with Down syndrome was 3.52.

Dietary intake and the prevalence of gallbladder disease in Mexican Americans

Mexican Americans have a high prevalence of gallbladder disease. We examined the contribution of ethnic preferences in food intake to the risk of gallbladder disease in Mexican Americans and non-Hispanic whites. Participants in a population-based health survey were questioned about any history of gallbladder disease, and were interviewed to determine their dietary intake. After adjusting for age, body mass index, and ethnic group, we found that women with the highest intake of total fat and linoleic acid had reduced risks of gallbladder disease, although an opposite trend was observed in men. High levels of sucrose intake and low levels of cholesterol intake were associated with an increased risk for both sexes, but the odds ratios were not statistically significant. Although Mexican Americans and non-Hispanics differed in their intake of several nutrients, the elevated risk of gallbladder disease in Mexican American women was unchanged after ethnic differences in food intake were taken into account. Although the dietary preferences of Mexican Americans as reflected in 24-h diet recall interviews do not appear to explain their high prevalence of gallbladder disease, this finding should be interpreted with caution because of methodologic limitations in measuring habitual food intake.

Gallbladder disease—I. Assessment of validity and reliability of data derived from a questionnaire: A study of 62,739 weight-conscious women

This study included 62,739 women who belong to TOPS ( Take Off Pounds Sensibly), and this is perhaps the largest study of gallbladder disease in women ever conducted. The main findings of this study are: 1. 1. The prevalence of gallbladder disease, adjusted for over- and underreporting, was calculated to be 15.1 per 100 women and was not appreciably different from the unadjusted rate of 15.7 previously reported [6]. 2. 2. The estimated reliability of the gallbladder question was found to be 87%. 3. 3. When a small sample of doctors whose questionnaire indicated absence of gallbladder disease and therefore, disagreed with the patient's history of gallbladder disease were requestioned, they changed their response. 4. 4. There was 98% physician confirmation (telephone interviews) of positive diagnosis of gallbladder disease for women who completed the narrative section of the question; 68% of the positive diagnosis of gallbladder disease for women without the narrative section of the questionnaire could be confirmed by the physician. 5. 5. Underreporting of gallbladder disease was conservatively estimated to be 1.6% of the total number with disease. 6. 6. Overreporting of gallbladder disease was estimated to be 12.7% of the total number with disease.

Solitary Plasmacytoma and Obstructive Jaundice

To the Editor:— Multiple myeloma is a disseminated or multicentric neoplasm of plasma cells or related elements with usually a rapid fatal outcome. Textbooks also describe solitary plasmacytomas, mostly in the upper respiratory tract and rarely in the kidney, lung, and mediastinum. Recently, lesions in the central nervous system1and testis2have been observed. To date, apparently no example of solitary plasmacytoma in the liver has been described. This report describes such a case associated with obstructive jaundice. Report of a Case:— A 76-year-old white man was admitted to the Cedars of Lebanon Hospital with a two-week history of jaundice, anorexia, pruritus, clay-colored stools, and dark urine. He had had hepatitis without sequelae as a youth. There was no history of gallbladder disease. Physical examination revealed a cytic mass in the right upper quadrant thought to be a distended gallbladder. Laboratory studies included numerous bilirubin determinations, giving average

Intestinal obstruction caused by gallstones

Intestinal obstruction caused by gallstones is not particularly uncommon, yet rarely do few individual surgeons have the opportunity of becoming familiar with the disease through personal experience. Slightly more than 700 cases have been reported to date. As the condition becomes better known, it is presumed that it will be more frequently encountered by the general surgeon. The disease has been attended by a mortality of 40 to 50 per cent, entirely out of keeping with that of other types of intestinal obstruction. Incorrect diagnosis, procrastination in instituting therapy and improper surgical management are considered largely responsible. Careful evaluation of history, clinical and radiologic findings should permit at least a presumptive diagnosis with institution of definitive therapy earlier in the course of the disease. Clinical features suggesting obstruction caused by a gallstone are: (1) a history of gallbladder disease, (2) symptoms and signs of intermittent, recurrent and progressive obstruction, and (3) radiologic demonstration of air in the biliary tree, distended loops of bowel, a radiopaque stone and changing level of obstruction. Treatment consists of surgical removal of the obstructing stone after restoration of the patient to optimal condition by hydration, intestinal decompression and correction of electrolyte deficiencies. No surgery on the gallbladder or fistula need be considered unless persisting symptoms demand it. The former high mortality has been reduced to 26.1 per cent during the past seven years through earlier diagnosis, prompt and aggressive treatment, better pre- and postoperative care, stabilization of concomitant disease, better anesthesia and limitation of surgery to only that necessary to relieve the obstruction. It is hoped that re-emphasis of these aspects of gallstone obstruction may enable those physicians who encounter it to recognize the condition early, and to institute proper therapy before the patient reaches an irreversible stage of toxemia. By this means it should be possible to reduce mortality to a figure comparable to that in other types of intestinal obstruction.

Gallstone impacted in the duodenal cap.

Biliary calculi discovered radiographically within the alimentary tube are usually located either at the duodenojejunal flexure or at the ileocecal junction (1, 3, 4). An infrequent site for impaction of a gallstone has been the duodenal cap. A number of instances of this occurrence have been recorded at surgery and autopsy (5, 6), but rarely has the condition been roentgenographieally documented. Reports of only 4 cases with preoperative radiographic demonstration of a gallstone in the cap are available in the world literature (2, 5–7). So far as could be determined, none has heretofore been presented in the American literature. Case Report T. K., a white, Russian-Jewish housewife, aged 50, was seen in the Emergency Room of the Henry Ford Hospital the evening of Nov. 11, 1949, complaining of the sudden onset that day of severe epigastric pain and the vomiting of food and “greenish material.” This was the first such attack, although she had been troubled for some time by vaguely described upper abdominal distress and food intolerances. The patient was in acute distress. There was no jaundice. Tenderness was noted in the right upper quadrant. For a week the temperature spiked daily to 102°. Blood counts revealed a polymorphonuclear leukocytosis, with some counts as high as 20,000. Antibiotic and supportive measures weie followed by subsidence of fever and leukocytosis. Cholecystography, after priodax, showed no concentration of medium in the gallbladder. Roentgenograms and fluoroscopy revealed a normal stomach and duodenal cap (Fig. 1). The patient was discharged on Dec. 1, with the diagnosis of “subsided acute cholecystitis.” Followed in the outpatient department, she had only minor complaints. Surgery was advised but repeatedly refused. On the evening of May 13, 1951, the patient again presented herself at the Emergency Room, describing bouts of nausea and vomiting for a week. Again no jaundice was demonstrated and there was only slight upper abdominal tenderness. She was hospitalized and on May 17 passed, per rectum, a large, cholesterol gallstone measuring 2 cm. in diameter. Radiographic examination on May 18 showed a large speckled, oval, radiolucent defect, freely movable within the duodenal cap. Barium flowed past it into the descending portion of the duodenum. There was also a flow of barium through a short fistulous pathway into a small, irregular, contracted cavity in juxtaposition to the cap, presumed to be the gallbladder. This contained several small radiolucent shadows. The examination was repeated on May 23 and the findings duplicated. Review of the cholecystographic films of 1949, at this time, revealed a suggestion of calculus in the right upper quadrant (Fig. 2). In view of the known history of gallbladder disease, the passage per rectum of the calculus, and the obvious roentgen findings, a diagnosis was made of cholecystoduodenal fistula with calculus in the duodenal cap.

Postoperative acute pancreatitis and lower nephron syndrome.

Acute pancreatitis occurring during surgery in regions remote from the biliary tract or as a postoperative complication of such surgery apparently is rare. A search of the literature has revealed only two case reports. 1 In the case which is the subject of this report the symptoms of acute pancreatitis first manifested themselves in the operating room during a transurethral resection in a patient who gave no history of gallbladder disease, who did not imbibe alcoholic beverages, and in whom at autopsy no evidence of biliary tract disease could be found. The case is of special interest because of the coexistence of the lower nephron syndrome. Although the lower nephron syndrome is not an uncommon complication of acute pancreatitis, the almost simultaneous occurrence of the two conditions in a patient subjected to transurethral resection provokes the thought that the two pathological processes may have had a common etiology and, further,

History of gall bladder disease

History of gall bladder disease

History of gall bladder disease

The gall bladder patient is a distinct entity. He has local phenomena of a certain type and owing to the peculiar nature of his illness involving, in nearly every instance, organs other than the biliary tract, he is likely to present subjective phenomena of a general as well as a local order. Apart from the more or less specific character of the attack with its more or less typical localization and radiation, he belongs to a certain group which has in the majority of instances certain things in common. In three out of four cases, he is constipated and in nearly the same number he is subject to nervous disorders. In four out of five instances, he suffers from some form of flatulent indigestion, while distress is found in 71.1 per cent and a history of pain in 75.9 per cent. These patients are subject to headache in 61.7 per cent, dizziness in 51.3 per cent, biliousness, cardiovascular phenomena in 39.6 per cent with dyspnea occasionally, transitory or on extertion in 52.2 per cent and they complain of rheumatic phenomena whether involving nerves, muscles or joints in 31.7 per cent. They are frequently infected, 48.4 per cent showing nose and throat complaints, 24 per cent are subject to colds—10 per cent showed infected tonsils, 25 per cent infected teeth (a figure too low); sinus disease was common in all of this group. We know that they fatigue easily, sleep poorly, and show a distinct aversion or rather mishandling for fats. Furthermore, they are inclined to neurasthenic, melancholic hypochondriacal and psychotic manifestations, many of which are directly linked up with faulty metabolism or the result of a systemic toxemia incident to some local focus. In conclusion I would point out that gall bladder disease, as commonly met with, nearly always is an end result, of many years in duration and that not infrequently the “agent provacateur” still is in the system.

Cases of chronic infection apparently focal in the gall bladder

Abstract One of the interesting features connected with these cases is that they came to autopsy almost at the same time. Another feature is that one might suspect that the lobar pneumonia in Case I was the result of alcoholism and exposure, rather than of metastatic infection. Perhaps this was really so, but in the second case there was no exposure or alcoholism and the evidences point to metastasis facilitated by trauma as the essential factor. Taken together these cases suggest the definite relation existing between chronic foci of infection and a terminal acute metastatic infection. In neither case was there any history of gall bladder disease.