Symptoms Of Biliary Tract Disease Research Articles

Elevated Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case Report

Disorders of gall bladder are common and remain as one of the main patients’ chief complaints that might lead to surgical interventions. High level of bilirubin causes gallstones in patients with hereditary spherocytosis (HS). It is often misdiagnosed, because these deposits of bilirubin can be easily broken down in the gallbladder. Gallstones develop in less than half of patients with mild HS and do not always cause symptomatic biliary tract disease. HS is a genetic defect in red blood cells, caused by defects in structural membrane proteins. It is characterized by a decrease the surface area to volume ratio in erythrocytes due to the heterogeneous changes in the various genes that encode for proteins. A 14-year old male was brought to Medical Park hospital/Turki at the emergency room with a sudden onset of pain in the right upper quadrant, vomiting, anemia and jaundice. The patient was diagnosed with gallstone due to obstruction in common bile duct (CBD),with elevated bilirubin as a result for mild HS. This case report study highlight on the role of hereditary spherocytosis in forming many abdominal problem such as gallstone due to high level of heamolysis and elevated of bilirubin. How to Cite this Article Pubmed Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case SRP. 2020; 11(6): 341-346. doi:10.31838/srp.2020.6.54 Web Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case http://www.sysrevpharm.org/?mno=116258 [Access: March 29, 2021]. doi:10.31838/srp.2020.6.54 AMA (American Medical Association) Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case SRP. 2020; 11(6): 341-346. doi:10.31838/srp.2020.6.54 Vancouver/ICMJE Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case SRP. (2020), [cited March 29, 2021]; 11(6): 341-346. doi:10.31838/srp.2020.6.54 Harvard Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein (2020) Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case SRP, 11 (6), 341-346. doi:10.31838/srp.2020.6.54 Turabian Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. 2020. Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case Systematic Reviews in Pharmacy, 11 (6), 341-346. doi:10.31838/srp.2020.6.54 Chicago Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. Elevated Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case Report. Systematic Reviews in Pharmacy 11 (2020), 341-346. doi:10.31838/srp.2020.6.54 MLA (The Modern Language Association) Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein. Elevated Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case Report. Systematic Reviews in Pharmacy 11.6 (2020), 341-346. Print. doi:10.31838/srp.2020.6.54 APA (American Psychological Association) Style Najlaa Abdulameer Ali Al-Dahhan, Hawraa Abdulameer Ali Al-Dahhan, Bayan Jebur Hussein (2020) Bilirubin Level Increase the Risk of Gallstone Disease in Pediatric Hereditary Spherocytosis Patients: A Case Systematic Reviews in Pharmacy, 11 (6), 341-346. doi:10.31838/srp.2020.6.54

Analysis of related factors for hepatic alveolar echinococcosis and gallbladder complications of children in Qinghai Province

To investigate the distribution characteristics of gallbladder diseases in children with hepatic alveolar echinococcosis, and to analyze the related factors for hepatic alveolar echinococcosis and gallbladder diseases. The clinical data of hepatic alveolar echinococcosis patients under 18 years were collected in Qinghai Provincial People's Hospital-from January 2012 to December 2017, and the gallbladder-related complications in the surgically treated patients with hepatic al-veolar echinococcosis were analyzed. The clinical data of 51 child patients with hepatic alveolar echinococcosis were collected and analyzed. According to the PNM classification criteria of WHO, P1, P2 and P3 in the 51 patients accounted for 37.25% (19/51), 41.18% (21/51) and 19.60% (10/51), respectively. According to the diagnostic criteria (WS 257-2006) of China for echinococcosis, the patients of infiltration type, calcification type and liquefaction cavitary type accounted for 66.67% (34/51), 21.57% (11/51) and 11.76% (6/51), respectively. Among the 51 patients, 78.43% (40/51) of the patients had clinical symptoms of biliary tract disease, and 58.82% (30/51) had gallbladder-related complications. The operations were performed on 40 patients, and 77.50% (31/40) of them had the postoperative complications. The results of binary multivariate logistic regression analysis showed that the clinical image classification, the liver segment distribution, size, location and number of lesions of hepatic alveolar echinococcosis were important correlative factors for the occurrence of gallbladder complications in hepatic alveolar echinococcosispatients. The incidence of complications related to gallbladder diseases is higher in the children with hepatic alveolar echinococcosis in Qinghai Province, and it has great influence on the operation mode and the occurrence and prognosis of postoperative complications. The early diagnosis and treatment of alveolar echinococcosis in children is particularly important.

Gall bladder carcinoma: Aggressive malignancy with protean loco-regional and distant spread.

The most common malignancy of biliary tract is gallbladder cancer (GBC) which is the third most common cancer in gastrointestinal tract. It is a lethal disease for most patients in spite of growing awareness and improved diagnostic techniques. GBC has a very poor prognosis and the 5 year survival rate is < 10%. Although etiology of the carcinoma of the gallbladder is still obscure, various factors have been implicated, cholelithiasis being the most frequent. The incidence of GBC worldwide is based on the gender, geography and ethnicity which suggest that both genetic and environmental factors can cause GBC. The major route of spread of gallbladder cancer (GC) is loco-regional rather than distant. It spreads by lymphatic, vascular, neural, intraperitoneal, and intraductal routes. Sonography is usually the most common imaging test to evaluate symptoms of biliary tract disease including suspected GC. With recent advances in imaging modalities like multi-detector computed tomography (CT) scanners, magnetic resonance imaging-positron emission tomography/CT diagnosis of gallbladder cancer has improved. Studies have also targeted molecular and genetic pathways. Treatment options have included extended and radical surgeries and adjuvant chemotherapy. This review article deals in detail with important aspects of carcinoma gallbladder and its manifestations and challenges. Role of various imaging modalities in characterization and accurate staging has been discussed. The loco-regional spread of this aggressive malignancy is dealt explicitly.

High rates of recurrent biliary tract obstruction in children with sickle cell disease

Individuals with sickle cell disease (SCD) have an increased risk of cholelithiasis from bilirubin stones. Symptomatic biliary tract disease (BTD) includes acute and chronic cholecystitis, obstruction of the common bile duct (CBD), cholangitis, and gallstone pancreatitis. Cholecystectomy is the main treatment strategy for symptomatic patients; however, the prevalence of recurrent BTD following cholecystectomy has not been systematically evaluated. We conducted a retrospective cohort study to describe the recurrence of BTD after cholecystectomy and characterize risk factors for recurrent disease. We identified patients <22 years of age who presented to the Johns Hopkins Children Center with symptomatic BTD from July 1993 to June 2008. We identified 56 patients with a total of 76 episodes of symptomatic BTD (median age at first event 15.9, range 4.6-21.5 years). Eleven of the 56 patients (19.6%) had at least one episode of recurrent symptomatic BTD (median follow-up of 5.3 years). Baseline characteristics were similar between the patients with a single episode of BTD and those with recurrent BTD. These results demonstrate that recurrent BTD is a frequent complication of SCD (20% by age 4 years) and often presents as CBD obstruction by stone, despite cholecystectomy. In our cohort, recurrence was not associated with age at first episode, baseline total bilirubin, gender, or genotype of SCD.

Laparoscopic Cholecystectomy and Newer Techniques of Gallbladder Removal

To describe the surgical complications associated with laparoscopic cholecystectomy, as performed by a single surgeon over an 8-year period and to discuss how this compares to newer methods of cholecystectomy, such as single-incision surgery and natural orifice transluminal endoscopic surgery. The charts of 1000 consecutive patients who underwent consecutive cholecystectomies were reviewed to gather the following information: age, sex, prior abdominal procedures, type of procedure performed (laparoscopic vs open, with or without cholangiography), pre and postoperative diagnosis, and complications directly related to surgical technique, such as biliary injury, bile leak, infection, trocar-related injury, and incisional hernia. The laparoscopic approach was attempted in all but one patient and was successful in 94.1% of patients. The conversion rate was higher with acute cholecystitis than with other forms of biliary tract disease. Successful cholangiography was accomplished in over 97% of patients. Nineteen complications directly related to the surgical procedure were found, including one bile duct injury. Laparoscopic cholecystectomy continues to offer a safe and effective treatment for patients with symptomatic biliary tract disease. Although other forms of minimally invasive cholecystectomy are being studied, there is little data to suggest any additional benefit, other than a slight improvement in cosmesis. Until larger series demonstrate that these techniques have a complication rate similar to those cited in the surgical literature, traditional 4-port laparoscopic cholecystectomy should remain the standard of care.

Pediatric cholelithiasis and laparoscopic management: A review of twenty two cases

AIM:To evaluate the role of laparoscopic cholecystectomy (LC) in the management of cholelithiasis in children.MATERIALS AND METHODS:A retrospective review of our experience with LC for cholelithiasis at our institution, between April 2006 and March 2009 was done. Data points reviewed included patient demographics, clinical history, haematological investigations, imaging studies, operative techniques, postoperative complications, postoperative recovery and final histopathological diagnosis.RESULTS:During the study period of 36 months, 22 children (10 males and 12 females) with cholelithiasis were treated by LC. The mean age was 9.4 years (range 3 to 18 years). Twenty-one children had symptoms of biliary tract disease and one child was incidentally detected with cholelithiasis during an ultrasonogram of the abdomen for an unrelated cause. Only five (22.7%) children had definitive etiological risk factors for cholelithiasis and the remaining 13(77.3%) cases were idiopathic. Twenty cases had pigmented gallstones and two had cholesterol gallstones. All the 22 patients underwent LC, 21 elective and one emergency LC. The mean operative duration was 74.2 minutes (range 50-180 minutes). Postoperative complications occurred in two (9.1%) patients. The average duration of hospital stay was 4.1 days (range 3-6 days).CONCLUSION:Laparoscopic chloecystectomy is confirmed to be a safe and efficacious treatment for pediatric cholelithiasis. The cause for an increased incidence of pediatric gallstones and their natural history need to be further evaluated.

Laparoscopic cholecystectomy for cholelithiasis in children

Aim:To evaluate the role of laparoscopic cholecystectomy (LC) in the management of cholelithiasis in children.Methods:A retrospective review of our experience with LC for cholelithiasis at our institution, between April 2006 and November 2008, was done. Data included patient demographics, clinical history, hematological investigations, imaging studies, operative technique, postoperative complications, postoperative recovery, and final histopathological diagnosis.Results:During the study period of 32 months, 18 children (8 males and 10 females) with cholelithiasis were treated by LC. The mean age was 9.4 years (range 3–18). Seventeen children had symptoms of biliary tract disease and 1 child had incidentally detected cholelithiasis during an ultrasonography of abdomen for unrelated cause. Only 5 (27.8%) children had definitive etiological risk factors for cholelithiasis and the remaining 13 (75.2%) cases were idiopathic. Sixteen cases had pigmented gallstones and 2 had cholesterol gallstones. All the 18 patients underwent LC, 17 elective, and 1 emergency LC. The mean operative duration was 74.2 min (range 50–180). Postoperative complications occurred in 2 (11.1%) patients. The average duration of hospital stay was 4.1 days (range 3–6).Conclusion:Laparoscopic chloecystectomy is a safe and efficacious treatment for pediatric cholelithiasis. The cause for increased incidence of pediatric gallstones and their natural history needs to be further evaluated.

Significance of Preoperative Ultrasound Measurement of Gallbladder Wall Thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.

Laparoscopic common bile duct exploration.

Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients ( n = 2530)--that is, those not undergoing LCBDE or any other additional procedure--was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.

BILIARY TRACT DISEASE IN PREGNANCY

Cholelithiasis is a common biliary tract disease in the United States, and more than 75% of the gallstones are composed of cholesterol. 17 There is considerable evidence that pregnancy is a predisposing factor in the formation of cholesterol gallstones. Sex steroids cause an alteration in biliary lipid composition and gallbladder motility leading to an increase in cholesterol gallstone synthesis. Gallstone disease is observed in 3.3% to 12.2% of pregnant women. 9,53,79,88 Complications of gallstones represent the second most common nongynecological condition requiring surgery in pregnancy 89 ; yet, clinically apparent disease is rare. The management of symptomatic gallstone disease during pregnancy is controversial. It is important for clinicians caring for pregnant patients to recognize the signs and symptoms of biliary tract disease during pregnancy and understand the management options.

The clinical utility of quantitative cholescintigraphy: the significance of gallbladder dysfunction.

Cholelithiasis is a common disorder occurring in over 20 million people in the United States and resulting in approximately 600,000 cholecystectomies annually. Although over 95% of biliary tract disease is caused by gallstones, the vast majority (>80%) of cholelithiasis cases are asymptomatic. The purpose of this study is to evaluate the utility of quantitative cholescintigraphy in detecting symptomatic biliary tract disease and predicting clinical relief after cholecystectomy. Fifty-two patients with clinical symptoms of chronic cholecystitis were evaluated by cholescintigraphy with a gallbladder ejection fraction calculated after the intravenous administration of cholecystokinin. A gallbladder ejection fraction of > or =35% was considered a normal physiologic response. Forty-one of the patients subsequently underwent cholecystectomy, whereas the remaining 11 subjects were diagnosed and treated for non-biliary disorders that did not require cholecystectomies. After clinical follow-up including histopathological gallbladder findings, all subjects' final diagnoses were established and correlated with their quantitative cholescintigram study. Twenty-six of twenty-eight patients who had an abnormal quantitative cholescintigram demonstrated evidence of chronic cholecystitis by histopathologic criteria after cholecystectomy. Furthermore, 27 of these 28 patients (96%) experienced complete relief of their clinical symptoms after surgery. Functional cholescintigraphy is a safe, accurate, and useful test for detecting symptomatic gallbladder disease, and appears reliable in predicting symptomatic relief after cholecystectomy.

Management of gallstones in pregnancy

Biliary disease during pregnancy is rare and the management of cholecystitis during pregnancy is controversial. Cholecystectomy in the pregnant patient has generally been avoided because of the reported high incidence of associated fetal loss. Recent developments relating to diagnostic and anaesthetic management have altered the overall approach to symptomatic biliary tract disease in pregnant patients. The literature was reviewed using Medline searches for cholelithiasis in pregnancy, to include pathophysiology, diagnosis and management. Surgery should be performed only for complicated non-resolving biliary tract disease during pregnancy as in over 90 per cent of patients the acute process will resolve with conservative management. For patients requiring operative intervention, laparoscopic cholecystectomy has emerged as a safe and effective method of treatment.

A prospective examination of octreotide-induced gall-bladder changes in acromegaly

We wished to determine the effects of octreotide acetate, a somatostatin analogue, on gall-bladder function during treatment of acromegaly. We used a prospective, open label trial of somatostatin analogue. Seventeen patients with acromegaly took part. Ultrasonographic evaluation of gall-bladder contents were performed pretreatment, after 1 month, and subsequently at intervals of 3-6 months. Non-shadowing floating echogenic particles were observed in the gall-bladder in 12 of 17 patients after (mean +/- SEM) 2.5 +/- 0.6 months of treatment. During long-term treatment (mean 20.8 +/- 4.3, median 13, range 1-59 months), ultrasound evidence for cholelithiasis was observed in four patients after 20 +/- 4 months (range 4.2-43) months of octreotide therapy. No symptoms of biliary tract disease have been observed. Duration of acromegaly, average GH, average IGF-I, gender, age at entry, dose of analogue, and concurrent use of non-steroidal anti-inflammatory drugs did not affect the occurrence of sludge or gallstones. Formation of non-shadowing, floating echogenic particles occurs commonly during the first 6 months of treatment with octreotide acetate. Cholelithiasis is a risk of long-term treatment.

Biliary Surgery After Cardiac Transplantation

Many patients have undergone successful cardiac transplantation. These patients are at risk of developing the same surgical diseases as the general population. The side effects of immunotherapy may mandate intervention at a different point in the natural history of these processes. From February 1984 through December 1989, 24 patients underwent an operative biliary tract procedure following cardiac transplantation. Seventeen patients underwent elective cholecystectomy with intraoperative cholangiography. The mean hospital stay was 5.4 days, and there was no morbidity or mortality. Seven patients underwent urgent procedures; four of them developed severe complications and three died as a result of their biliary tract disease. Two patients in the urgent group had previously exhibited symptoms of biliary tract disease, and five were previously asymptomatic. There was no significant difference in time from transplantation to biliary procedure between the elective group (mean, 17 months; range, 3 weeks to 47 months) and the urgent group (mean, 18 months; range, 3 weeks to 44 months). Patients who undergo cardiac transplantation should be screened for cholelithiasis. The presence of symptoms should not be required before recommending operative intervention.

Safety and Efficacy of Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. However its safety, efficacy, and morbidity have yet to be fully evaluated. During the first 6 months of 1990, we performed 100 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 8% (8 of 100 patients; 4 major, 4 minor). There were 81 women and 19 men, with a mean age of 46.1 years (range, 17 to 84 years). All patients had a preoperative history consistent with symptomatic biliary tract disease, and most had proved gallstones by sonography. This included four patients with acute cholecystitis. Mean operating time improved significantly from month 1 to month 6 (122 +/- 45.4 minutes versus 78.5 +/- 30 minutes, respectively), indicating a rapid learning curve. Mean hospital stay was 27.6 hours, reflecting a policy of overnight stay. Postoperative narcotic requirements were limited to oral or no medications in more than 70% of patients. A regular diet was tolerated by 83% of the patients by the morning following the procedure. Median time of return to full activity was 12.8 +/- 6.8 days after operation. In addition analysis of the hospital costs of these 100 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 58) (mean, $3620.25 +/- $1005.00 versus $4251.76 +/- $988.00). There was one minor bile duct injury requiring laparotomy and t-tube insertion, two postoperative bile collections, and one clinical diagnosis of a retained stone that passed spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. Laparoscopic cholecystectomy should be performed by surgeons who are trained in biliary surgery and knowledgeable in biliary anatomy, and, as with all operations, it should be performed with meticulous attention to technique.

Therapeutic options for gallstones.

Patients with asymptomatic gallstones should not be considered surgical candidates; patients with defined symptoms of biliary tract disease, however, should be advised not to postpone surgery or endoscopic sphincterotomy with stone retrieval. A smaller group of patients who fulfill specific criteria may benefit from chenodiol (Chenix) therapy and long-term follow-up. Such experimental techniques as dissolution with methyl tert-butyl ether and fragmentation with extracorporeal shock waves hold exciting promise for the future.

SPLENECTOMY IN SPHEROCYTOSIS: IS IT WORTH THE RISK?

Splenectomy reduces the incidence of gallstone formation in patients with hereditary spherocytosis (HS). However, this surgical procedure carries an operative risk as well as the risk of postsplenectomy sepsis (PSS). Furthermore, gallstones do not always cause symptomatic biliary tract disease. Using decision analysis, a quantitative approach to problem solving under conditions of uncertainty, we have examined the relative merits of two approaches to patients with mild HS: (1) routine splenectomy in childhood or (2) cholecystectomy for symptomatic gallstones in adulthood. Probability values for critical events were obtained from the medical literature; final outcome is recovery or death. The analysis shows the risk of death associated with the choice of splenectomy to be 40 times greater than the risk of cholecystectomy for symptomatic gallstones (.0245 vs .0006). Sensitivity and threshold analyses show that the decision to avoid splenectomy remains unaltered even if the risk of death from PSS (.022) is reduced four-fold or if the risk of developing gallstones (including symptomatic and silent stones) is increased from .43 to 1.0. The choices become equivalent only if the risk of developing symptomatic gallstones increases from .08 to .50 while the risk of PSS falls from .022 to .001. On the basis of the best data currently available, the preferable course for patients with HS and mild anemia is careful surveillance for symptomatic biliary tract disease rather than routine splenectomy to prevent gallstones.

Cholecystectomy in elderly patients

Cholecystectomy was performed in 93 patients over the age of 70 years with an overall mortality of 7.5 percent. Complications occurred in 28 percent. Patients who underwent elective operations fared far better than those who required emergency surgery. Of the 50 patients who underwent elective cholecystectomy, there was 1 death (2 percent), and 10 patients (20 percent) experienced complications. In contrast, of the 43 patients who required emergency operation, 6 died (14 percent). Complications occurred in 14 (33 percent). Elective cholecystectomy in the elderly patient with symptomatic biliary tract disease is advocated before acute complications that necessitate emergency operation develop.

Biliary tract surgery in the elderly

A series of patients aged 80 years and older who underwent biliary tract procedures over a 6 year period (January 1973 to December 1978) is presented. Emergency operations were performed in most of these patients, with a mortality of 12.5 percent. Elective procedures were well tolerated, with no mortality. Elective cholecystectomy should not be denied to elderly patients with symptomatic biliary tract disease.

Correlation of Ultrasonic Gallbladder Studies With Operative Findings

In a retrospective study to correlate preoperative ultrasonic findings with operative findings in 80 patients with symptoms of biliary tract disease, ultrasound was 75% accurate in predicting the presence or absence of gallstones. Of all positive ultrasonic studies, 95% correlated with gallbladder disease of some kind. The diseased gallbladder without stones may still produce ultrasonic abnormalities, allowing detection of inflammatory changes. Ultrasound is indicated in acute conditions of the abdomen, in patients with jaundice or allergy to contrast agents, and as an adjunct to other diagnostic modalities.