Small Gallstones Research Articles

Presence of small and multiple gallstones increases the risk of biliary complications

Presence of small and multiple gallstones increases the risk of biliary complications

Increase in acute pancreatitis, especially gallstone related, as the cause for emergency admissions: Temporal trend from Kashmir, India.

The incidence of acute pancreatitis is increasing globally. Gallstones (GS) and ascariasis are the major causes for acute pancreatitis in the Kashmiri population. In recent years, we have observed an increase in the admission rate of acute pancreatitis. Many patients who present first time as gallstone pancreatitis have asymptomatic gallstones. We aimed at studying the etiology and yearly admission rate of acute pancreatitis with main focus on gallstone pancreatitis and the contribution ofasymptomatic gallstones. This was a hospital-based, prospective, observational study from January 2015 to December 2019 for a period of fiveyears. Patients of acute pancreatitis were evaluated for etiology and yearly admission rate. Patients of gallstone pancreatitis were evaluated in terms of clinical profile, risk factors, nature (symptomatic/asymptomatic, known/unknown gallstones), size of stones, treatment and outcome in terms of severity and mortality. The data was analyzed by Statistical Package for the Social Sciences (SPSS) version 20.0, as mean (SD), frequencies and percentages. As many as 702 (8.5%) patients of acute pancreatitis were admitted among 8245gastrointestinal emergencies in fiveyears. The yearly admission rate of acute pancreatitis was 5.6%, 7.3%, 8.7%, 9.5% and 10.3%, respectively (p = 0.013). Gallstones, Ascariasis, alcohol and idiopathic acute pancreatitis were 47.7%, 6.9%, 1.2% and 33.7%, respectively. Gallstone pancreatitis increased from 31% in2015 to 52.4% in 2019 (p = 0.045) and ascariasis-related acute pancreatitis declined from 14.4% to 1.6% (p = 0.034). Asymptomatic gallstones constituted 87.7% of cases. Known/unknown asymptomatic gallstones and symptomatic gallstones were 24.4%, 63.2% and 12.2%, respectively. Gallstones < 5mm and > 5mm were76.1% and 23.8% respectively (p = 0.027). Cholecystectomy rate in index admission was 4.7%. Mild, moderate and severe gallstone pancreatitis was 60.2%, 18.8% and 20.8%, respectively. Mortality in gallstone pancreatitis was 10.4%. The incidence of acute pancreatitis is increasing due to gallstone pancreatitis. Ascariasis-related acute pancreatitis has declined. There is significant contribution of asymptomatic gallstones in patients who present for the first time as acute pancreatitis. Small gallstones < 5mm are likely to be the risk factors for gallstone pancreatitis.

Simultaneous cholecystectomy for asymptomatic gallstones during elective colorectal cancer surgery

Asymptomatic gallstones are commonly detected using preoperative imaging in patients with colorectal cancer (CRC), but its management remains a topic of debate. Clinicopathologic characteristics of patients who had asymptomatic gallstones presenting during the colorectal procedure were retrospectively reviewed. Medical records, including postoperative morbidity, mortality, and long-term gallstone-related diseases, were assessed. Of 134 patients with CRC having asymptomatic gallstones, 89 underwent elective colorectal surgery only (observation group), and 45 underwent elective colorectal surgery with simultaneous cholecystectomy (cholecystectomy group). After propensity score matching (PSM), the complications were similar in the 2 groups. During the follow-up period, biliary complications were noted in 11 patients (12.4%) in the observation group within 2 years after the initial CRC surgery, but no case was found in the cholecystectomy group. After PSM, the incidence of long-term biliary complications remained significantly higher in the observation group than in the cholecystectomy group (26.5% vs 0.0%; P<.01). Multivariable logistic regression analysis identified female gender, old age (≥65 years old), and small multiple gallstones as independent risk factors for the development of long-term gallstone-related diseases in patients from the observation group. Simultaneous prophylactic cholecystectomy during prepared, elective CRC surgery did not increase postoperative morbidity or mortality but decreased the risk of subsequent gallstone-related complications. Hence, simultaneous cholecystectomy might be a preferred therapeutic option for patients with CRC having asymptomatic gallstones in cases of elective surgery, especially for older patients (≥65 years old), female patients, and those with small multiple calculi.

Medical Management of Uncomplicated Symptomatic Small Gallstones in Elderly

Medical Management of Uncomplicated Symptomatic Small Gallstones in Elderly

Endoscopic stenting of bile ducts for preventing mechanical jaundice recurrence in gallstone migration

Aim. To study the reasons for stone migration from the gallbladder into the main bile ducts after endoscopic lithoextraction and to develop methods for preventing recurrent mechanical jaundice before performing the cholecystectomy.Material and methods. Delayed cholecystectomy was recommended for 328 patients with calculous cholecystitis and mechanical jaundice after endoscopic papillosphincterotomy, lithoextraction and restoration of adequate bile outflow. 23 patients were readmitted to hospital with recurrent mechanical jaundice caused by recurrent choledocholithiasis. All patients underwent duodenoscopy, endoscopic retrograde cholangiography and lithoextraction within 12 hours after admission. The size of the gallstones, the diameter of the cystic duct, the level of its insertion into the common hepatic duct, and the length of the previously performed papillotomy were considered as possible causes of recurrent choledocholithiasis.Results. Multiple gallstones of 2–4 mm and low cystic duct insertion into the common hepatic duct were detected in all 23 patients. An increase in the diameter of the cystic duct &gt;5 mm was revealed in 18 patients. In 10 patients, the initial papillotomy was &lt;8 mm.Conclusion. The factors predisposing to recurrent mechanical jaundice due to migration of gallstones into the bile duct and indications for its stenting after lithoextraction before cholecystectomy are ultrasound signs of multiple small gallstones, low insertion the dilated cystic duct into the bile duct, and partial, non-extended papillotomy.

Minimally invasive treatment of cirrhotic secondary hypersplenism with high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) has been reported to be a minimally invasive effective method for the treatment of secondary hypersplenism. However, neither the short-term efficacy nor the indications and/or contraindications have been described in patients with cirrhosis. From October 2019 to May 2021, eleven cases of patients with cirrhotic secondary hypersplenism were enrolled. The blood counts, liver function tests and abdominal ultrasound and/or MRI scans of all patients were closely evaluated. Among these 11 patients, eight (72.7%) patients were classified as Child–Pugh A, and the other 3 (27.3%) patients were Child–Pugh B; Five (45%) patients were diagnosed with gallstone, including multiple small stones in 2 patients and single stone in 3 patients. HIFU was performed successfully in all 11 patients. After HIFU, hematologic parameters and liver function were significantly improved in all 11 patients (p < 0.05). The HIFU ablated volume to spleen volume rate was 35–61%. Complications were ecchymosis of the waist in 7 (63.3%) patients, ablated area pain in 3 (27.3%) patients, and choledocholithiasis in 2 (18.2%) patients with multiple small gallstones. All of them recovered smoothly without additional treatment except for 2 patients with choledocholithiasis recovered with risky endoscopic retrograde cholangiopancreatography (ERCP) treatment. This series suggested that HIFU is an effective and safe treatment for cirrhotic secondary hypersplenism in patients classified as Child–Pugh A or B. However, multiple small gallstones could be a relative contraindication for it.

Treatment of asymptomatic gallstones in children with hereditary spherocytosis requiring splenectomy

BackgroundGallstones are common in hereditary spherocytosis (HS) and other chronic hemolytic diseases, with most affected patients being asymptomatic. Whether and how asymptomatic gallstones should be treated is controversial. MethodsWe conducted a retrospective cohort study of pediatric patients with HS and asymptomatic gallstones to compare the clinical outcomes between the observation group (followed up with gallstones in situ) and the intervention group (cholecystectomy or cholecystolithotomy). The primary outcome was the composite of adverse outcomes, including gallstone-associated, gallbladder surgery-associated, and splenectomy-associated events. Secondary outcomes included the changes in the size and number of gallstones and the recurrence of gallstones. ResultsFifty-two patients were included (38 in the observation group and 14 in the intervention group), with a mean follow-up length of 5.2 years. Patients in the intervention group had a lower incidence of primary outcomes (7.1% vs. 42.1%) than patients in the observation group (OR, 0.12; 95%CI, 0.01–0.99). Patients with gallstones >5 mm in diameter had the highest risk of adverse events (47.4%). In the observation group, gallstone growth, disappearance, and stability were observed in 19.4%, 29.0%, and 51.6% of splenectomized HS patients, respectively. Small gallstones (diameter ≤5 mm) or sludge were more likely to be associated with disappearance (P = 0.04). ConclusionsMost asymptomatic gallstones grow or persist in splenectomized HS patients for an extended period. Surgical treatment of asymptomatic gallstones in HS patients requiring splenectomy is associated with a lower risk of adverse outcomes. Levels of evidenceIII (retrospective comparative study).

Gallstones: The thing in itself.

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Inflammatory falciform ligament mass post gallstone pancreatitis

A falciform inflammatory mass following gallstone pancreatitis is a rare complication reported in adults, which we present here occurring in a paediatric patient. A 10yr old female patient presenting initially with features consistent with gallstone pancreatitis, with confirmed multiple small gallstones on ultrasound, was brought forward for expedited laparoscopic cholecystectomy. Intraoperatively an inflammatory mass of the falciform ligament was identified, drained and partially resected prior to cholecystectomy. She made a successful recovery with subsequent ultrasound showing features consistent with postoperative changes alone. • Cholelithiasis is an increasingly common paediatric condition requiring surgical intervention. • Gallstone pancreatitis can lead to the formation of an inflammatory falciform ligament mass in the paediatric population. • Diagnosis can be difficult, and may only be made intraoperatively. • Excision and drainage are effective treatment.

Cholelithiasis-diagnostic approach: are clinical presentations in children different?

Cholecystitis has been considered an uncommon entity in children, but it’s incidence is reportedly increasing which may be attributed to widespread use of diagnostic imaging (ultrasonography). A healthy 11-year-old female Indian child presented to the emergency department with a chief complaint of abdominal pain. The pain was at the epigastric region and accompanied with vomiting. As per the complete examination and findings, a diagnosis of constipation colic was made. A month later, the patient presented with the same chief complaint, but general physical examination revealed tenderness at the right hypochondrium, and Murphy’s sign was positive. Upon performing an abdominal ultrasound, multiple small gallstones were noted in an otherwise normal gallbladder. No biliary obstruction was seen. A diagnosis of acute cholecystitis was made. Patient was then admitted and treated with a course of antibiotics. The incidence of cholelithiasis in children has not been sufficiently studied. The incidence of cholecystitis in India was found to be 0.3% with the incidence in age group 0-10 being less than 0.1%. In contrast to adult cholecystitis, it has been found that there is female predominance of cholecystitis in children. In children, 20% to 50% gallstones are radiopaque. Unknown causes are still prevalent in stone formation. Hence, the purpose of this paper was to increase awareness about the diagnosis of cholelithiasis in children. The probability of cholecystitis in children should not be ignored. Cholelithiasis should always be considered as a differential diagnosis when children present with complaints of abdominal pain.

282 Cholecystoappendicular Fistula- 1st Ever Reported Case

Abstract A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones. The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy. During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula. An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases. No case of cholecystoappendicular fistula has been reported so far.

Prognostic Significance of Ultrasound Findings of Acute Acalculous Cholecystitis for Elderly Long-Term Bedridden Patients.

Background: Acute acalculous cholecystitis (AAC) is characterized by the development of cholecystitis in the gallbladder without gallstones or with small gallstones unrelated to inflammatory diseases. This disease is not rare in the elderly bedridden patients with co-morbidities and prone to develop life-threatening gangrene or perforation of gallbladder. Early imaging is essential for detecting and effectively treating AAC. This study aimed to evaluate the use of ultrasound diagnostic criteria for the diagnosis and prognosis of elderly long-term bedridden patients with suspected AAC.Methods: We retrospectively studied 374 elderly bedridden patients with clinical manifestations of AC at the acute stage of the disease. Gallbladder anomalies were found in 92 patients by ultrasound examination, which correlated with the duration time of clinical manifestations, complications, as well as therapeutic prognosis. The major and minor ultrasound criteria of AAC were made according to the Tokyo Guidelines 2018. Ultrasound results were thought to be AAC positive when they met two major criteria or one major and two minor criteria.Results: Forty-three (46.7%) of the 92 patients presented with AAC (+) test results based on the ultrasound criteria, with a higher incidence of complications (27.9%) than AAC (–) patients (0%; P < 0.001). The median length of symptoms (8 vs. 4 days, P < 0.001) and duration of antibiotic therapy (13 vs. 5 days, P < 0.001) were longer in the AAC (+) group.Conclusions: The ultrasound-based AAC (+) group often had a worse prognosis than the AAC (–) group. Therefore, patients from the AAC (+) group should receive a follow-up ultrasound examination to detect disease progression early.

Incident Gallstones During Somatostatin Analog Treatment are Associated with Acute Biliary Complications Especially After Discontinuation.

IntroductionGallstones are a known adverse effect of somatostatin analogs, but the exact incidence and clinical implications are unknown.ObjectivesThe aim of this study was to investigate the incidence of gallstones on imaging and related complications in unbiased trial data.MethodsData from the DIPAK 1 trial, in which 305 polycystic kidney disease patients were randomized to standard of care (SoC) or lanreotide for 120 weeks, were used. Magnetic resonance imaging (MRI) was performed at baseline and end of treatment and was assessed for the presence, number, and size of gallstones. For all patients who had gallstones at the end of the trial, we obtained follow-up after the trial.ResultsOf 249 patients with data available, 11 patients randomized to lanreotide and four randomized to SoC had gallstones at baseline. During the study, new gallstones were formed in 19/124 patients using lanreotide (15%) and 1/125 patients receiving SoC (1%). The odds ratio for gallstone formation with lanreotide use was 25.9 (95% confidence interval 3.37–198.8; p < 0.001). Gallstones during lanreotide treatment were multiple (> 20 stones in 69% of patients) and small (≤ 3 mm in 63% of patients). Of the 19 patients with incident gallstones during lanreotide treatment, 9 experienced gallstone-associated complications, 8 of whom experienced gallstone-associated complications after discontinuation of treatment (median time after discontinuation 2.5 years). In patients with gallstones at baseline and in patients receiving SoC, no complications occurred.ConclusionsTreatment with a somatostatin analog leads to the formation of multiple, small gallstones that are associated with severe complications, especially after discontinuation of therapy.Clinical Trial Registry Website and Trial NumberClinicalTrials.gov (https://clinicaltrials.gov); NCT01616927.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40268-021-00342-7.

GALLBLADDER STONES SPECTRUM IN SAUDI POPULATION BY USING ULTRASONOGRAPHY

Objective:This study was designed with an aim to determine the incidence of gallbladder stonesandto evaluate the accuracy of ultrasonography in the diagnosis of calculus, occur in Saudi patients whom presents at the Radiology and Ultrasound Department. Materials and method: Retrospective study in the period 22 August 2020 to 22 December 2020, a total of 108 patientsunderwentultrasound. When the gallbladder is investigated using ultrasound imaging (US) modality. Ultrasound instrument used was spatial digital U22 Philips Convex probe 3.5 Data analysis performed using the tables and computerized systems,ultrasound using different types of ultrasound units with 3.5 MHz and 5 MHz curve linear probes.Statistical analysis was performed using Microsoft Excel Software and the Standard Statistical Package for the Social Sciences version 15 for windows. Result: Out of 108 examined samples [mean age of 29 years male to female ratio of .9:1].Gallstones in this study were more common in the age range from 2 to 39, (58.3%).The most common causes of gallbladder stones are, 0ral contraceptives44(40.7%),Cholesterol28 (25.9%),Biliary dyskinesia 17 (15.7%),Diabetes 12 (11.1%),and Spinal cord injury7 (6.5%)one of the commonest complaints is upper abdominal pain,52(48.1%) and in majority of the cases the etiology is treatable,Nausea30 (27.8%) andVomiting 26(24.1%).Confirmation is done by CT scan 20 (18.5%) for the cases of small gall stones (&lt;2mm) and impacted stones in cystic duct and operations, Cholecystectomy 14(13%) were done for stones large than (&gt;2 cm), who have a nonfunctional or calcified (porcelain) gallbladder and patients for spinal cord injured. Conclusion: Ultrasound (US) is the preferred method for evaluating gallstones with 96% accuracy. The number, size and calcification can be evaluated by virtue of US inversion and attenuation. If there are more than five stones, the accuracy decreases.

S3379 Acute Renal Failure in a Patient With Salmonella Gastroenteritis

INTRODUCTION: Salmonella is a common cause of gastroenteritis worldwide. Typically, this condition is self-limited, and resolves within seven to ten days without severe complications. However, patients with CKD are susceptible to developing acute renal failure. This has been attributed to shock, dehydration, or rhabdomyolysis as well as immunologic mechanisms. Our case follows a patient who developed Salmonella gastroenteritis prior to hospital admission and presented with severe dehydration and decreasing urinary output. Although the patient’s renal function and diarrhea resolved after aggressive fluid resuscitation, it is crucial to initiate early treatment and to be cognizant of the potential of co-morbidities associated with Salmonella gastroenteritis. CASE DESCRIPTION/METHODS: A 77 year old female with a past medical history of CKD IV, type II DM, HTN presented to the emergency department with a chief complaint of abdominal pain along with 5 to 6 diarrheal episodes for the preceding week. Symptoms started after eating a hamburger at a restaurant. The patient also endorsed a fever, decreased oral intake and urinary output for the three days prior to the emergency department visit. At admission, labs revealed a BUN/Cr of 86/10.63 with a GFR of 3. CT abd/pelv w/out contrast revealed a distended gallbladder with a small gallstone, duodenal diverticulum, and fluid in the colon reflecting a diarrheal state. Aggressive rehydration was initiated and stool studies were obtained. Nephrology consultation was placed for further evaluation. During the first two days of admission, the patient remained oliguric with < 1L of output. A temporary trialysis catheter was placed in preparation for hemodialysis on day two of admission, however the patient was unable to undergo dialysis due to clot formation in the catheter. At that time, the patient’s diarrhea continued and she was treated with Lomotil along with continued hydration with renal function steadily improving. On day six of admission, stool studies resulted revealing Salmonella enterica. As the patient was afebrile and showed clinical improvement, no antibiotics were initiated. On day eight, the patient was discharged, with plan for outpatient Nephrology follow up. Labs revealed a BUN/Cr of 49/2.16 with a GFR of 23.0 on day of discharge. DISCUSSION: Initiating early aggressive rehydration may help to reduce significant co-morbidities associated with the development of renal pathology in Salmonella infection and to avoid the need for hemodialysis and further workup.

S1531 Hard to Stomach: Gallstone Ileus as a Result of Mirizzi-Induced Bouveret Syndrome

INTRODUCTION: Appropriate escalation of care in acute cholecystitis can be both lifesaving and cost-effective. We report a patient with Bouveret syndrome as an unintended consequence of Mirizzi type Vb with subsequent development of gallstone ileus. It is known that Bouveret syndrome is a particularly rare form of gallstone ileus that results as a result of a cholecysto-enteric fistula entering into either the duodenum or stomach. And while gallstone ileus represents 0.3%-0.5% of all mechanical small bowel obstructions, Bouveret syndrome represents approximately 1%-3% of those gallstone ileus cases. Mirizzi syndrome and its stages are sequela of a single, large, or many small gallstones impacted in Hartmans’s pouch or in the gallbladder infundibulum and cystic duct. When chronic or unaddressed, this pathology progresses insidiously to present as in the case of our patient. CASE DESCRIPTION/METHODS: A 73 year old female presented to the ED with a 3-week history of right-upper quadrant pain. Subsequent workup revealed a chronic cholecystitis with cholelithiasis. She was stabilized and instructed to follow up with a surgeon for elective cholecystectomy at a later day. A year later she presented again with severe abdominal pain with emesis. Imaging showed a large stone causing gastric outlet obstruction and the presence of a cholecystoduodenal fistula. A nasogastric tube was placed and the patient had an emergent EGD performed to remove the stone however it was unable to dislodged despite two separate attempts. Consequently, she went for an ex-lap where a gastro-jejunostomy was performed due the severely friable state of the gastric tissue surrounding the impacted stone. Patient recovered well until her fifth day post-op when she developed significant abdominal distention and pain; imaging now revealed a terminal ileum gallstone ileus. She successfully underwent another laparotomy and was discharged home. DISCUSSION: This patient developed advanced and exceptionally rare intra-abdominal pathology that was difficult to treat as a result of delayed surgical intervention. The chronicity of her cholecystitis led to an advanced stage of Mirizzi syndrome that dovetailed with a gastric-outlet obstruction. Patients cannot be relied upon to follow up diligently in the outpatient setting and therefore need prompt evaluation on initial presentation. Had this patient received specialty consultation at her initial encounter, the potentially disastrous and financially burdensome chain-of-events, may have been avoided.Figure 1.: CT scan showed a large stone causing gastric outlet obstruction and cholecysto-duodenal fistula.Figure 2.: Impacted gallstone causing gastric outlet obstruction.

Ursodeoxycholic acid and its unexpected application areas

Introduction. Ursodeoxycholic acid (UDCA) came into modern medicine in the 1970s as a potential solvent for small gallstones. But as early as the 1980s, there were clinical studies to improve biochemical indices when using UDCA in other liver diseases. These studies initiated a worldwide active study of the clinical possibilities and various therapeutic effects of UDCA in various diseases, including those beyond the liver. Today, worldwide, UDCA drugs are the lifelong basis for the treatment of primary sclerosing cholangitis (PSC). It is indicated for all types of hepatitis: infectious, toxic, drug-induced, autoimmune and others. It can be stated that the history of study and introduction of UDCA drugs in medicine is the history of the expansion of its application areas, which continues to this day. The purpose of the review is to present the results of the use of UDCA drugs outside the traditional circle of cholestatic liver diseases, the causes and possibilities of their use in other areas of medicine. Main principles. It has been shown that UDCA, originally designed for the treatment of cholestatic liver diseases, along with the known antioxidant, antifibrotic and immunomodulatory effects has a proven fundamental apoptosis regulatory effect. This allows it to have as a possible therapeutic target a whole range of extrahepatic diseases, such as gastrointestinal lesions (IBD, clostridi-osis, radiation and medical intestinal lesions, etc.), diseases of the cardiovascular system, neurodegenerative diseases (Alzheimer’s disease, Parkinson’s disease, ALS), prion diseases (Kuru, Creutzfeldt-Jakob disease) and a number of others. Conclusion. According to modern views, UDCA can be considered as a unique drug of universal cytoprotective action, the expansion of its therapeutic possibilities is promising and is subject to further multilateral study.

Wandering Gallbladder: A Case Report

Wandering gallbladder is a variation in the biliary anatomy described in the literature as being attached only by the cystic duct and its mesentery. Its propensity for torsion places it at risk for necrosis. There have been over 500 cases of gallbladder torsion reported in the literature but less than 10 reports of wandering gallbladder. To our knowledge there have been no reports of cholecystectomy for wandering gallbladder found incidentally. A 51-year-old male from Pakistan with hypertension, gastroesophageal reflux disease, high cholesterol, and renal stones presented with a chief complaint of right upper quadrant abdominal pain. Abdominal ultrasound was significant for a mildly distended gallbladder with small gallstones in the gallbladder fundus. The patient was discharged with a diagnosis of cholelithiasis and scheduled for laparoscopic cholecystectomy as an outpatient. During the procedure, upon entering the abdominal cavity, a gallbladder was not seen in the gallbladder fossa. It was attached to the cystic duct, thickened with a long mesentery and not attached to the liver. There were no signs of torsion. The patient was treated successfully and discharged home with an uncomplicated hospital course. Diagnosis can be challenging because the clinical presentation can be variable. Fewer than a dozen cases have been reported where the diagnosis was made preoperatively. Early diagnosis of gallbladder torsion with cholecystectomy is essential to avoid the deadly complications of perforation and bilious peritonitis. Understanding the pathophysiology, clinical findings, and treatment can have a broad impact across biliary surgery in preventing these complications.

Lack of phospholipids in bile enhances cholesterol cholelithogenesis in the ATP‐binding cassette transporter B4 (Abcb4) knockout mice

BackgroundBiliary phospholipids play a key role in transporting cholesterol (Ch) by forming unilamellar and multilamellar vesicles that display a significantly higher ability to solubilize Ch in bile compared to simple and mixed micelles. The ATP‐binding cassette transporter B4 (ABCB4) is responsible for hepatic phospholipid secretion and its deletion in the liver causes a lack of phospholipids in bile of mice. Our aim is to explore whether targeted deletion of the Abcb4 gene in the liver leads to more rapid Ch crystallization and gallstone formation in Abcb4 knockout (KO) mice fed even a low Ch diet compared to wild‐type (WT) mice.MethodsThe critical role of biliary phospholipids in Ch crystallization and gallstone formation was investigated by physical‐chemical methods in male Abcb4 KO vs WT mice fed a chow diet (on day 0) and a special diet containing 0.1% Ch, 15% butterfat and 0.25% cholic acid for 4 wk.ResultsOn the chow diet (day 0), biliary phospholipids are 18.1±0.3 mM in pooled gallbladder bile of WT mice. However, no phospholipids are detected in Abcb4 KO mice fed either the chow or the special diet. After 1 wk of feeding the special diet, phase diagram analysis finds that lipid composition of pooled gallbladder bile of Abcb4 KO mice is located in crystallization region A. Moreover, many needle‐like Ch crystals, typical Ch monohydrate crystals, sandy stones and small gallstones (0.1–0.2 mm in diameter), but not liquid crystals, are detected in bile by phase contrast and polarizing light microscopy. This shows that lack of phospholipids in bile produces anhydrous crystalline metastable intermediates that rapidly evolve to Ch monohydrate crystals from supersaturated bile. In contrast, lipid composition of pooled gallbladder bile of WT mice is still within the micellar zone, indicating that bile is unsaturated with Ch. After 4 wk of feeding the special diet, lipid composition of pooled gallbladder bile of Abcb4 KO mice still stays in crystallization region A, with many larger gallstones (0.3–0.6 mm in diameter) being formed in the gallbladder. Notably, lipid composition of pooled gallbladder bile of WT mice enters crystallization region C, as analyzed by phase diagram. Thus, many liquid crystals (i.e., unilamellar and multilamellar vesicles) and classical solid plate‐like Ch monohydrate crystals, but not gallstones, are found in the gallbladder of WT mice. These results indicate that solid Ch crystals are formed through the liquid crystalline pathway in WT mice.ConclusionsLack of biliary phospholipids caused by the Abcb4 deletion in the mouse liver is a critical risk factor for Ch gallstone disease by significantly reducing Ch solubility in bile through disrupting the liquid crystalline pathway, whereas it leads to more rapid Ch crystallization via the anhydrous crystalline pathway. Our findings provide novel insight into the pathophysiological mechanisms of why Ch gallstones are rapidly formed in patients with the ABCB4 mutations, thereby leading to low phospholipid‐associated cholelithiasis, a rare biliary disease caused by a single‐gene mutation.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Gallstone Ileus: An Uncommon Cause of Acute Abdomen

Gallstone ileus is a rare cause of acute abdomen, representing less than 1% of intestinal obstruction. It is due to mechanical small bowel obstruction (SBO) by a migrated gallstone. we report this observation to illustrate the imaging findings especially in CT scan. A 62-year-old woman was admitted to emergency for acute bowel obstruction. The CT scan has confirmed jejunal bowel distension with fluid levels upstream endoluminal formation which was rounded and well limited, measuring 5 cm of long axis. This training was slightly hyperdense with hypodense areas of fat density. Moreover, there was aerobilia with multiple fistulas between the duodenum (D1) and gallbladder, which was empty. The triad of aerobilia, small bowel obstruction and migrant gallstone was suggestive of gallstone ileus diagnosis. The patient was operated with good evolution. Gallstone ileus is an uncommon presentation of gallstone disease. It is frequently observed in elderly patients with a history of cholelithiasis or cholecystitis. Early diagnosis is crucial and would avoid morbidity and mortality related to this disease. CT scan shows the classical triad of Rigler with pneumobilia, an ectopic stone and mechanical ileus. CT may improve the diagnosis providing important information regarding the exact number, size, and location of ectopic stones and the site of intestinal obstruction or direct visualization of a biliary–enteric fistula, to help clinicians in the therapeutic management of patients.