Thickened Gall Bladder Research Articles

A Case of Xanthogranulomatous Cholecystitis Decreased in Size after Steroid Treatment and Avoided Extended Resection

Xanthogranulomatous cholecystitis is an uncommon destructive inflammatory disease with accumulation of lipid-laden macrophages, fibrous tissue, and inflammatory cells. It is often mistaken for gallbladder cancer due to diffuse wall thickening of gallbladder and infiltration into neighboring organs. And it is usually difficult to distinguish xanthogranulomatous cholecystitis from gallbladder cancer based on clinical, radiographic, or laboratory testing. Patients with xanthogranulomatous cholecystitis often undergo cholecystectomy to confirm the diagnosis, and to exclude gallbladder cancers. We report a case of 69-year-old woman with xanthogranulomatous cholecystitis who had been treated with steroid and avoided extended resection. Korean J Pancreatobiliary 2015;20(1):37-41

Cholecystostomy for acute cholecystitis with Common bile duct exploration for common bile duct stone-a rare surgical procedure

Acute cholecystitis is one of the most common surgical emergencies with mortality risk related to age of the patient. Cholecystostomy has been used as a bridging technique till resolution of sepsis. Cholecystostomy is an alternative treatment for acute cholecystitis with high surgical risk and has lower morbidity and mortality than emergency Cholecystectomy. ERCP is procedure of choice for common bile duct CBD stone extraction but in large and impacted stone with obstructive jaundice open CBD exploration is done. A60-year old female presented with pain abdomen vomiting and fever with progressive jaundice. Ultrasonography USG abdomen showed distended gall bladder with biliary sludge and thickened Gall Bladder wall and dilated CBD with stone measuring 16x10 mm in distal part of CBD. ERCPwas attempted twice but failed to extract stone. Cholecystostomy with CBD exploration and extraction of CBD stone was done with T tube drain in situ. Patient recovered post operatively with removal of Cholecystostomy and T tube drains after 2 weeks and 3 weeks respectively.

Ascaris infestation of biliary tree mimicking gallbladder cancer

A 51-year-old male presented with jaundice for 2 months. He had a history of acute pancreatitis 4 months before and weight loss of 20 kg. Laboratory tests demonstrated elevated total and direct bilirubin (288.6 μmol/L and 232.4 μmol/L, respectively). CA19-9 was also significantly increased (>1200 U/ml). Ultrasound and magnetic resonance imaging both indicated irregular thickening of gallbladder (Fig. 1). Magnetic resonance cholangio-pancreatography (MRCP) revealed marked dilatation of intrahepatic ducts. Therefore, a diagnosis of gallbladder cancer with hilar invasion was made.

An unusual association of pleural effusion with acute viral hepatitis A infection

An unusual association of pleural effusion with acute viral hepatitis A infection Ajaya Kumar Dhakal Arati Shakya, Devendra Shrestha, Subhash Chandra Shah, Henish Shakya Department of Pediatrics, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal Abstract: Hepatitis A virus infection is a common public health problem in developing countries primarily due to poor hygiene and sanitation. The clinical features of hepatitis A virus are mostly related to the derangement of liver function with occasional extrahepatic complications. Herein, a 2.5-year-old girl presented with abdominal pain and decreased appetite for 4 days, high-colored urine for 3 days, and yellowish discoloration of the eyes for 2 days. On presentation, there was icterus along with hepatomegaly and diminished breath sounds on the right side were noted 1 day after admission. Chest X-ray revealed right sided pleural effusion; however, ultrasonography of chest and abdomen displayed bilateral pleural effusion (right more than left) and minimal ascites with thickened gall bladder wall. Immunoglobulin M anti-hepatitis-A virus serology was positive. The pleural effusion in this child resolved spontaneously in 10 days. We report this case to highlight that hepatitis A infection should be considered in the differential diagnosis of pleural effusion in a patient with features of acute hepatitis. However, other common causes of pleural effusion such as tuberculosis and parapneumonic effusions that may coexist with hepatitis, especially in developing world, need to be excluded. Keywords: hepatitis A, pleural effusion, viral hepatitis

Bile Leak After Cholecystectomy

Introduction: A 59-year-old male with history of hypertension, diabetes and arthritis was admitted with complaints of right upper quadrant abdominal pain, fatigue, jaundice and weight loss of almost 20 lbs. Initial work-up showed a thickened gall bladder on ultrasound and he underwent a cholecystectomy. Three weeks later, the patient presented to the ER with worsening abdominal distension. CT scan of the abdomen showed the patient had a 4.5x3.5 cm pancreatic head mass with large volume ascites concerning for malignant ascites. The tumor was abutting and penetrating into the superior mesenteric vein. Ascitic fluid studies showed an albumin of 1.0 g/dL, WBC -0 k/mm3, and RBC 15,000 k/mm3 and bilirubin of 7.9 mg/dL. Cytology of the peritoneal fluid was negative for malignant cells. Serum albumin was 3.2 g/dL, AST-19 U/L, ALT-27 U/L, alkaline phosphatase-1507 U/L, serum bilirubin-2 mg/dL. Patient was deemed a non-surgical candidate due to the SMV penetration and ascites. EUS was done to take a biopsy of the pancreas and ERCP due to suspected compression of the CBD from the head mass. ERCP showed a biliary stricture and a bile leak from a possible duct of Luschka. (Figure 1) The leak resolved after stenting of the biliary stricture. (Figure 2)Figure 1Figure 2Duct of Luschka or supravesicular ducts are small ducts that originate from the right hepatic lobe and course along the gall bladder fossa to drain directly in the gall bladder or extrahepatic ducts. Post surgical removal of the gall bladder these ducts may remain open and if the CBD gets obstructed due to stones or stricture, it may lead to leakage of bile in the peritoneal cavity due to the back flow. Physicians need to be aware of this complication in the appropriate setting to prevent any delays in starting necessary work-up and treatment.

Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis?

Gangrenous cholecystitis is difficult to diagnose clinically and carries risk of morbidity and mortality if not treated urgently. Complex scoring systems exist to predict the condition. C reactive protein may be a single independent predictor as suggested in this small study. BackgroundGangrenous cholecystitis (GC) is a serious sequel of acute cholecystitis occurring in 2–30% patients and has a mortality of 0.2–0.5%. Urgent surgical intervention is important to reduce morbidity and mortality therefore it is important to identify patients with GC from non-severe cholecystitis. The aim of this study is to determine biochemical and radiological markers, which is associated with the development GC and the value of C-reactive protein (CRP) at different cut-offs in predicting GC. MethodsThis is an observational cohort study of all consecutive patients who presented with biliary symptoms to the emergency department in a large NHS Hospital in the UK, from January to December 2012. They had cholecystectomies performed either during index admission or electively at later date by a team of 4 upper gastrointestinal surgeons. The gangrenous nature of the gallbladder was determined by operative findings and/or histopathology results. Parameters including age, gender, albumin, jaundice, gallbladder wall thickness on ultrasound scan, highest preoperative white blood count (WBC) and CRP value, were examined for their predictive value. Results141 patients presented with acute biliary problems. 22 underwent emergency cholecystectomy and 119 were discharged and called back for elective surgery. Of these, 16 were gangrenous (11%). Patients with GC were significantly older (p = 0.016), had significantly higher CRP (p < 0.001) and WBC (p = 0.001), significantly lower albumin levels (p < 0.001) and higher percentage with thick walled gallbladder (p < 0.001). We found that a CRP value of more than 200 mg/dL has a 50% positive predictive value and 100% negative predictive value in predicting gangrenous cholecystitis with 100% sensitivity and 87.9% specificity. ConclusionsIn this study CRP on its own has been shown to have high predictive value in predicting GC, but larger studies are needed to validate this finding. Monitoring trend of CRP in patients with acute cholecystitis may help early diagnosis and decision for early surgical intervention.

English

Dengue is the arthropode borne viral infection transmitted by mosquitoes to humans. AIM: To study the various clinical manifestations and acute complications of dengue fever. METHODS: 100 cases of confirmed dengue infection admitted to KIMS, Bangalore between December 2009 and September 2011 were studied. A detailed clinical history and physical examination was done and baseline investigations were performed. The cases were followed-up daily for the clinical and laboratory parameters and were treated according to WHO guidelines. The data related to each of these cases was collected, compiled and analyzed. RESULTS: of the total 100 cases there were 61 male and 39 female. Age group of 21-30 (41) was most commonly affected Maximum number of patients was seen in the September, October, august, July. Commonest presentation was Fever (100%) followed by Headache (78%), Myalgia (70%), Arthralgia (66%), low back ache (60%). On examination patients found to have icterus (22%), bleeding spots (26%), rashes (50%), Splenomegaly (18%), Hepatomegaly (15%) and Ascites (9%), pleural effusion (16%), crepitations (7%). Platelet count was not very well correlated with the bleeding tendencies. Incidence of DHF was more with secondary Dengue infection than the primary dengue infection. The frequency of complications was high in the patients with secondary dengue infection than the primary infection. CONCLUSION: In our present study classical dengue fever was most common presentation followed by DHF and DSS. Hypotension, hemorrhagic spots, positive tourniquet test, jaundice, pleural effusion, ascites, neck stiffness are the common findings on examination associated with complicated forms of dengue. Bleeding, shock, hepatitis, polyserositis, meningitis, pneumonia are the complications seen in severe forms. On investigation Deranged liver function test, renal function test, secondary dengue infection, thickened gall bladder wall, hepatosplenomegaly on ultrasound abdomen, pleural effusion and bronchopneumonia on chest radiogram are associated with DHF and DSS. INTRODUCTION: Dengue fever is an arthropod borne viral fever. It is acquiring epidemic proportion in this part of the world and it has become major public health problem with high mortality. Estimates suggest that 50 million cases of dengue infection and 500, 000 cases of dengue hemorrhagic fever occur in Asian countries 1 . It is vital to recognize at the earliest the signs and symptoms, alteration in biochemical parameters and multisystem involvement pattern in dengue to reduce the mortality. In 1998 WHO reported, around 1.2 million cases of Dengue fever and DHF with 3, 442 deaths. In 2001 alone, there were more than 609 000 reported cases of dengue in the Americas, of which 15 000 cases were DHF and incidence is increasing in 2001, Brazil reported over 390 000cases including more than 670 cases of DHF. About 2500 million people are now at risk from dengue. WHO currently estimates there may be 50 million cases of dengue infection every year, with 400, 000 cases of DHF, out of whom more

Accumulation of Bile in the Gallbladder: Evaluation by means of Serial Dynamic Contrast-Enhanced Magnetic Resonance Cholangiography with Gadolinium Ethoxybenzyl Diethylenetriaminepentaacetic Acid.

The aim of this study was to evaluate the process of biliary excretion of gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) into the biliary tract and to assess the accumulation patterns in the gallbladder using MR cholangiography obtained with Gd-EOB-DTPA which is a liver-specific hepatobiliary contrast agent. Seventy-five patients underwent Gd-EOB-DTPA enhanced MR imaging. Serial multiphasic hepatobiliary phase imaging was qualitatively reviewed to evaluate the process of the biliary excretion of contrast agent into the bile duct and the gallbladder. The accumulation pattern of contrast agent into gallbladder was classified into two groups (group 1 = orthodromic type and group 2 = delayed type). Furthermore, the results in differences of the presence of T1 hyperintense bile or sludge of gallbladder, gall stones, wall thickening of gallbladder, chronic liver disease, and liver cirrhosis between two groups were compared. Forty-eight of 75 patients (64%) were included in group 1, and remaining 27 (36%) were in group 2. The frequency of the presence of T1 hyperintense bile or sludge of gallbladder was significantly higher in patients with group 2 than that in patients with group 1 (P = 0.041). MR cholangiography obtained with Gd-EOB-DTPA showed that there may be an association between the biliary accumulation pattern in the gallbladder and the pathological condition.

An Unusual Presentation of Auto-immune Hepatitis

Purpose: A 26-year-old Caucasian male with no significant history presented with new onset jaundice for 3 weeks. Two weeks prior to admission, he developed daily nausea and vomiting. One week prior to admission, he developed night sweats, anorexia, constipation, and generalized pruritis. In addition, he began to experience a post-prandial right upper quadrant abdominal pain with no radiation, and a 16-pound weight loss, which prompted presentation to the hospital. His medications included occasional acetaminophen/ diphenydramine PRN for insomnia. Family history was significant for cholelithiasis in his mother and lung cancer in multiple family members. The patient's social history included consumption of approximately 5 oz of spirits per week, a remote tobacco history, experimentation with intravenous heroin, as well as multiple professionally-obtained tattoos. Pertinent physical exam findings included stable vital signs, icterus, a soft and non-tender abdomen with liver edge palpated two cm below the costal margin, and percussed splenomegaly. No lymphadenopathy or asterixis were appreciated. Laboratory findings were significant for AST of 825 U/L, ALT of 596 U/L, total bilirubin of 26 mg/dL with a direct bilirubin of 20 mg/DL, and alkaline phosphatase of 118 U/L. His INR was 1.46 with a PT of 17.4, albumin of 3.1 g/dl, and total protein of 6.8 g/dl. Abdominal ultrasound revealed a nodular liver surface, hepatosplenomegaly, marked gallbladder thickening, and enlarged peripancreatic lymph nodes consistent with acute hepatitis. Hepatitis A, B, and C serologies were negative. His ferritin was 423 ng/mL with a percent saturation of 38. Anti-mitochondrial antibody, anti-LKM and alpha 1 anti-trypsin titers were within normal limits. His total IgG was 2,657 (reference range 650-1,600.) Anti smooth muscle antibody titers were measured at 36 U (reference range <20.) Given his clinical picture, along with an international autoimmune hepatitis group scoring of 10, treatment was started for autoimmune hepatitis with corticosteroids. His clinical picture improved soon thereafter. Discussion: This case represents an unusual presentation of autoimmune hepatitis. Autoimmune hepatitis is typically diagnosed in the fourth or fifth decade of life, and more commonly affects females. It typically presents with markedly elevated ASTs, compared to bilirubin and alkaline phosphatase, as was seen in this case. This presentation demonstrates, however, that this condition can present at any age, and can also affect males. Autoimmune hepatitis should, therefore, remain high on the differential in young males with hepatitis.

A Comparison of Hepatic Sonographic Features and Histopathologic Diagnosis in Canine Liver Disease: 138 Cases

Ultrasound examination is commonly used in the diagnostic evaluation of liver disease in dogs. To determine if hepatic sonographic features were predictive of findings on liver histopathology. We hypothesized that there would be a relationship between sonographic features and the category of liver disease based on histologic assessment. One hundred and thirty-eight dogs in which the liver was evaluated by both abdominal ultrasound examination and histopathologic examination. Twenty-five dogs were included in each of the following categories based on histopathology: normal, degenerative, vascular, inflammatory, and neoplasia. Thirteen dogs had nodular regeneration. Retrospective study. Medical records of dogs from 2005 to 2010 were searched for cases in which the liver was evaluated by abdominal ultrasound examination as well as by histopathology. After independent evaluation of ultrasound images, the recorded sonographic features were analyzed to identify abnormalities associated with each histopathologic diagnosis or degree of fibrosis. Sixty-four percent of sonographically unremarkable livers had histologic abnormalities. Both microhepatia and the identification of abnormal vasculature were significantly associated with a histopathologic diagnosis of vascular disease. Hepatic masses were significantly associated with a diagnosis of neoplasia. Dilated common bile duct and thickened gall bladder wall were significantly associated with hepatitis. There were no sonographic findings consistently present with hepatic fibrosis. Although some ultrasonographic findings, including masses, microhepatia, anomalous veins, and biliary changes, are associated with specific histopathologic abnormalities, sonographic findings are inconsistently detected in many disorders. Overall, hepatic ultrasonographic abnormalities have substantial limitations in predicting the underlying disease.

Early Detection of Anomalous Arrangement of the Pancreaticobiliary Ductal System by Conventional US

PurposeThough anomalous arrangement of the pancreaticobiliary ductal system (AAPBDS) is a very rare condition, biliary cancer develops frequently in patients with AAPBDS. So, it is very important to screen AAPBDS patients using an easy and noninvasive method. We focused on the thickening of the gallbladder wall often found ultrasonographically in patients with AAPBDS.Material & MethodsWe compared the thickness of the gallbladder wall measured before breakfast ultrasonographically using 3.5MHz probe between 15 patients with AAPBDS and 100 controls. Histological differences of the gallbladder wall of 13 patients with AAPBDS and 16 controls were examined.ResultsIn conventional ultrasonograph (US), thickened gall bladder wall (≥3mm) was observed in 87% of patients with AAPBDS (13 of 15), but only in 4% of controls (4 of 100) (P < 0.001). Histological examination revealed that the gallbladder mucosa was thicker in patients with AAPBDS than in controls (1.13±0.35mm vs 0.56±0.14mm, P < 0.001). Hyperplastic mucosa of the gallbladder was characteristic and the cause of wall thickening in patients with AAPBDS, but that change was not recognized in controls. No difference was seen in muscle layer between the two groups.ConclusionThickened gall bladder wall of unknown cause found by ultrasonography may be a clue to detect AAPBDS which is normally accompanied by hyperplastic thickened gallbladder mucosa. PurposeThough anomalous arrangement of the pancreaticobiliary ductal system (AAPBDS) is a very rare condition, biliary cancer develops frequently in patients with AAPBDS. So, it is very important to screen AAPBDS patients using an easy and noninvasive method. We focused on the thickening of the gallbladder wall often found ultrasonographically in patients with AAPBDS. Though anomalous arrangement of the pancreaticobiliary ductal system (AAPBDS) is a very rare condition, biliary cancer develops frequently in patients with AAPBDS. So, it is very important to screen AAPBDS patients using an easy and noninvasive method. We focused on the thickening of the gallbladder wall often found ultrasonographically in patients with AAPBDS. Material & MethodsWe compared the thickness of the gallbladder wall measured before breakfast ultrasonographically using 3.5MHz probe between 15 patients with AAPBDS and 100 controls. Histological differences of the gallbladder wall of 13 patients with AAPBDS and 16 controls were examined. We compared the thickness of the gallbladder wall measured before breakfast ultrasonographically using 3.5MHz probe between 15 patients with AAPBDS and 100 controls. Histological differences of the gallbladder wall of 13 patients with AAPBDS and 16 controls were examined. ResultsIn conventional ultrasonograph (US), thickened gall bladder wall (≥3mm) was observed in 87% of patients with AAPBDS (13 of 15), but only in 4% of controls (4 of 100) (P < 0.001). Histological examination revealed that the gallbladder mucosa was thicker in patients with AAPBDS than in controls (1.13±0.35mm vs 0.56±0.14mm, P < 0.001). Hyperplastic mucosa of the gallbladder was characteristic and the cause of wall thickening in patients with AAPBDS, but that change was not recognized in controls. No difference was seen in muscle layer between the two groups. In conventional ultrasonograph (US), thickened gall bladder wall (≥3mm) was observed in 87% of patients with AAPBDS (13 of 15), but only in 4% of controls (4 of 100) (P < 0.001). Histological examination revealed that the gallbladder mucosa was thicker in patients with AAPBDS than in controls (1.13±0.35mm vs 0.56±0.14mm, P < 0.001). Hyperplastic mucosa of the gallbladder was characteristic and the cause of wall thickening in patients with AAPBDS, but that change was not recognized in controls. No difference was seen in muscle layer between the two groups. ConclusionThickened gall bladder wall of unknown cause found by ultrasonography may be a clue to detect AAPBDS which is normally accompanied by hyperplastic thickened gallbladder mucosa. Thickened gall bladder wall of unknown cause found by ultrasonography may be a clue to detect AAPBDS which is normally accompanied by hyperplastic thickened gallbladder mucosa.

Index of Suspicion * Case 1: Abdominal Pain, Vomiting, and Weakness in an Obese Adolescent * Case 2: Bowlegs in a Toddler * Case 3: Cyclical Abdominal Pain and Urinary Symptoms in a Teenage Girl

A 15-year-old girl is hospitalized with right upper quadrant abdominal pain, vomiting, and weakness of 3 days' duration. She has a history of hyperlipidemia, polycystic ovary syndrome (PCOS), metabolic syndrome, and left ovarian cystadenectomy. She has been taking oral contraceptives (OCPs) and metformin for the past 2 years and started spironolactone 8 weeks ago. She experienced menarche at age 12 years and had one menstrual cycle for the whole first year. There is no history of dysmenorrhea or menorrhagia. Her family history is positive for type 2 diabetes mellitus (DM), obesity, and gallstones. On physical examination, her body mass index (BMI) is 28.0 kg/m2 (95th percentile), and she is in mild distress due to pain. Her blood pressure is 128/76 mm Hg (90th percentile for age and height); the remainder of her vital signs are normal. She has acanthosis nigricans and hirsutism. She is at Sexual Maturity Rating 5. She has mild tenderness in the right upper abdominal quadrant, but there is no organomegaly or rigidity. The rest of the physical findings are normal. Laboratory results reveal serum amylase of 660 units/L, lipase of 263 units/L, AST of 868 units/L, ALT of 1,573 units/L, cholesterol of 216 mg/dL (5.6 mmol/L), triglycerides of 181 mg/dL (2.0 mmol/L), high-density lipoprotein (HDL) cholesterol of 33 mg/dL (0.9 mmol/L), and glucose ranging from 120 to 148 mg/dL (6.7 to 8.2 mmol/L). Ultrasonography shows multiple cholesterol gallstones and a thickened gall bladder. Additional investigation reveals the diagnosis. A healthy 2-year-old girl presents to the clinic for evaluation of bowlegs. She was born at term and had a birthweight of 6 lb 11 oz. Her development has been normal, and she eats a regular diet. However, the bowing of her legs has increased progressively since she started walking at 1 year of age. There is …

Granulomatous gall bladder: A surgico-pathological challenge

Granulomatous gall bladder: A surgico-pathological challenge

Early clinical and biological features of severe clinical manifestations of dengue in Vietnamese adults

Background Dengue is a major public health problem in both children and adults in Vietnam, but dengue severity in adults has been poorly investigated. Objectives To describe severe manifestations of dengue in Vietnamese adults and to identify early indicators of these manifestations. Study design A prospective longitudinal study was carried out from July to October, 2007, in People's Hospital 115, Ho Chi Minh City, Vietnam. Results One hundred ninety-five clinically suspected dengue patients were enrolled. 151 of these were laboratory-confirmed using serum samples on day 3 after onset of fever for RT-PCR and/or virus isolation. Dengue was associated with plasma leakage in 51 patients (33.8%), gallbladder thickening in 30 patients (20%), spontaneous bleeding in 127 patients (84.1%), and internal bleeding in 37 patients (24.5%). Several early indicators were associated with severe manifestations of dengue. Frequent vomiting (≥3 times a day), marked lymphopenia, thrombocytopenia, and elevated liver enzymes on day 3 after onset of fever were significantly associated with plasma leakage and gallbladder thickening. Increased alanine aminotransferase level in plasma on day 3 was significantly associated with internal bleeding. Gallbladder thickening and internal bleeding were more common with specific serotypes. Conclusion Several severe manifestations of dengue were observed in Vietnamese adults. These manifestations were associated with early clinical and biological indicators. This information may be useful for clinicians to better monitor adult dengue patients, particularly in tropical areas where health resources may be limited.

HP30P XANTHOGRANULOMATOUS CHOLECYSTITIS: A CLINICOPATHOLOGICAL STUDY FROM A TERTIARY CARE HEALTH INSTITUTION

Background: Xanthogranulomatous cholecystitis (XGC) is an unusual and destructive form of chronic cholecystitis and is indistinguishable from other forms of cholecystitis.Objectives: To review the demographic and clinical aspects of XGC; to study the possibility of preoperative diagnosis and to identify the causes for difficult surgery.Materials and Methods: Cases histopathologically diagnosed as XGC over a period of six years from October 1999 to September 2005 were included in the study.Results: A total of 615 patients underwent cholecystectomy out of which 33 (5.2%) were diagnosed to have XGC. USG showed gallbladder wall thickening in 19 (57.5%) cases and gallstones in 32 (96.9%). Thirty (90.9%) underwent open cholecystectomy. Gallbladder could be removed totally in 25 (75.6%) cases whereas five (15.2%) had to undergo partial cholecystectomy and in one patient, only cholecystostomy could be performed due to dense adhesions. Laparoscopic cholecystectomy was attempted in 11 patients but successful only in two patients with a conversion rate of 81.8%. Postoperative wound infection was seen in five (15.1%) patients and one (3%) had minor biliary leak which was treated conservatively. Histologically, XGC was associated with malignancy in one (3.03%) patient. There was no mortality.Conclusion: Clinical presentation of XGC was indistinguishable from chronic cholecystitis. USG reveal only non‐specific findings of calculi and thickened gall bladder wall. Hence preoperative diagnosis is unlikely. Cholecystectomy was usually difficult owing to dense adhesions of gallbladder and Calot's triangle. Conversion rate of laparoscopic cholecystectomy is higher. Morbidity associated with surgery is significant.

Significant lamotrigine overdose associated with acute pancreatitis

In March 2007, a 24-year{old woman was admitted via the Emergency Department after an act of deliberate self{harm. Five hours prior to admission she had taken 4200 mg of lamotrigine. She denied taking any other medication at the time of this overdose. Her relevant medical history included two previous episodes of mixed overdoses (July 2002 and May 2006), depression and a psychotic episode for which she was treated with mirtazepine 30 mg once daily, lamotrigine 100 mg twice daily and risperidone 2 mg twice daily. At the time of admission she reported a regular intake of two 750 mL bottles of wine per evening, but had no previous history of alcohol{related liver or pancreatic problems. She had drunk two bottles of wine with her overdose. On admission, she was tachycardic, lethargic, dehydrated, showed slurred speech, with cerebellar signs of nystagmus and ataxia. She had no evidence of abdominal tenderness. Arterial blood gas measurements revealed a compensated metabolic acidosis. Full blood count, urea, electrolyte and liver function tests were normal. Her blood alcohol level was 100 mg/100 mL. Paracetamol and salicylate were not detected. A lamotrigine level was not taken because it is not routinely available in our institution. An electrocardiogram showed a sinus tachycardia only. Within 24 hours of admission she complained of upper abdominal pain and vomiting. Serum amylase was 1043 U/L (0–110 U/L). Liver transaminase, full blood count, calcium, glucose, urea and electrolyte levels were within reference ranges. The patient was diagnosed with acute pancreatitis, and at 48 hours achieved a Ranson score of 1 on assessment of severity, predicting a good prognosis, with less than 1% mortality. General supportive treatment was started with intravenous fluid resuscitation, analgesia and antiemetics. Abdominal ultrasound two days after onset of symptoms showed a thickened gall bladder wall, with some surrounding fluid and no evidence of gallstones. Her symptoms as well as amylase levels settled within three days and the patient was discharged five days after the initial overdose. An endoscopic ultrasound of the pancreas was performed six weeks after discharge. This showed a normal gallbladder and common bile duct. The pancreas had no features of chronic pancreatitis and had a normal calibre pancreatic duct. In the 12 months following discharge she was seen twice in the Emergency Department with symptoms and signs consistent with significant alcohol abuse, however on both occasions her amylase was normal.

Abdominal wall abscess – More Than Meets The Eye

An 83-year-old, mildly demented rest home resident presented to the emergency department with a 2 day history of a right sided abdominal wall mass. He had a mechanical fall 2 days previously and landed on his right side and had attributed the mass to this. He had no symptoms apart from feeling bloated and not being able to pass wind for a day. He had passed a normal bowel motion the day before presentation. On abdominal examination there was an 11 × 4 cm mass in the right lower quadrant. It was firm in consistency, non-fluctuant and non-tender to touch. There was mild erythema over the area but no skin breaks. Chest radiograph was unremarkable. The abdominal film showed dilated small bowel and no large bowel could be seen. A computed tomography (CT) scan showed a thick walled gallbladder with multiple calculi and air present. There was also an extensive air and fluid collection in the layers of the abdominal wall and subcutaneous fat which arose from a perforation of the gallbladder. The patient was not a surgical candidate due to multiple comorbidities. The patient was treated with antibiotics and underwent a CT guided percutaneous cholecystostomy. Despite the radiological intervention and antibiotics the patient progressively deteriorated and died peacefully 5 days after admission.

Giant Focal Nodular Hyperplasia Presenting as Pseudo-Mirizzi Syndrome

Purpose: Focal nodular hyperplasia (FNH) is a relatively rare benign tumor of the liver typically seen in young to middle aged women. It is usually an incidental finding, with most patients being asymptomatic. We describe a previously unreported presentation of a FNH causing a Mirizzi like syndrome. Methods: An 18 year-old white female presented with two days of right upper quadrant and epigastric pain associated with nausea, vomiting and chills. She had no prior medical history other than eczema and asthma. She denied taking any prescription or over the counter medications including oral contraceptives. Liver biochemistries revealed elevated total bilirubin 2.9 gm/dL, alkaline phosphatase 270 U/L, AST 104 U/L, ALT 171 U/L and a normal alpha feto-protein. CT with contrast showed gallbladder thickening and a 9.0 × 7.4 cm mass in segment 4 of the liver demonstrating hyper enhancement on arterial phase with a central hypodense stellate focus (Fig. 1). An MRI revealed a 9.2 × 7.8 cm mass with a T2 hyperintense central scar with enlarged gallbladder with wall thickening. Finally, a hepatobiliary scan demonstrated radiotracer throughout the liver, prompt gallbladder visualization and a 0% gallbladder ejection fraction. Given the typical radiographic features of FNH seen with the above studies her mass was felt to be FNH presenting with a Mirizzi like syndrome.Figure 1: CT arterial phase showing giant FNH with central stellate scarResults: Due to the large size of FNH potentially leading to technical difficulty in performing a cholecystectomy, a cholecystostomy tube was placed to allow for gallbladder decompression. Subsequently, a right sided portal vein embolization was performed to allow left lobe hypertrophy of liver prior to successfully performing a right trisegmentectomy. The resected specimen revealed a 10.4 × 9.5 × 7.6 cm tan, heterogeneous, firm, diffusely nodular, well delineated mass with a central scar abutting the capsule and histology confirmed the presence of FNH. Gallbladder specimen did not reveal choleliths. Her post operative course was uncomplicated. Conclusion: This is the first case reported of a giant FNH presenting with Pseudo-Mirizzi syndrome.

Role of color Doppler flow imaging in predicting difficulties of laparoscopic cholecystectomy

Objective To evaluate the color Doppler flow imaging (CDFI) findings in predicting possible difficulties of laparoscopic cholecystectomy (LC). Methods A total of 99 patients with acute cholecystitis received CDFI examination, and were divided into easy LC group (n=67) and difficult LC group (n=32) according to the indexes including the volume of gallbladder, the thickness of gallbladder wall, the condition of arterial flow in the gallbladder wall, the condition of gallbladder cavity and fossa, and of the intra-and extra-hepatic bile duct. After LC, all the patients were redivided into easy LC group and difficult LC group according to a difficulty scoring system of LC. The relationship among imaging results, operation difficulties and operation findings was investigated. Results According to the final score of difficulty scoring system of LC, the number of patients in easy LC group and difficult group was 61 and 38, respectively. Compared with easy LC group, patients in difficult LC group had bigger gallbladder volume [(39.5±13.2)am3 vs(32.6±10.4)cm3], thicker gallbladder wall [(10.1±4.0)mm vs(3.8±0.9)mm], more stone incarceration in the neck of gallbladder, abundant color blood flow signal of the gallbladder wall and more severe adhesion of gallbladder to the adjacent tissues, with statistical difference between the 2 groups (t=-2.820,-12.318,-3.952,x2=33.548,19.461,P<0.05). Using gallbladder volume, the thickness of gallbladder wall, infarction of stones in the neck of gallbladder and adhesion of gallbladder to the adjacent tissues as prediction indexes, the accuracy of CDFI in predicting the possible difficulties of LC was 94% (93/99). Conclusion Preoperative CDFI is helpful in predicting difficulties of LC for acute cholecystitis. Key words: Color Doppler flow imaging; Cholecystitis; Laparoscopic cholecystectomy; Prediction

Eosinophilic gastroenteritis with eosinophilic infiltration of the gall bladder.

Eosinophilic gastroenteritis (EG) is a rare disease of unknown etiology characterized by eosinophilic infiltration of the gastrointestinal tract wall with various gastrointestinal manifestations. Several organs in the digestive tract may be involved by EG, but biliary tract involvements are rare. We report here a case of EG with eosinophilic infiltration of the gall bladder. A 57-year-old man was admitted to the hospital complaining of abdominal pain and diarrhea. As ultrasonography and magnetic resonance imaging showed thickened gall bladder wall and debris in the neck of gall bladder, we performed cholecystectomy, but his symptoms were not improved. Esophagogastroduodenoscopy showed multiple erosions, redness and edema in the duodenum and stomach. Biopsy specimens from the duodenum and stomach showed infiltration of eosinophils, plasma cells and lymphocytes. Microscopic findings of resected gall bladder showed eosinophilic infiltration into the all layers of gall bladder wall without vasculitis. Based on these findings, EG with eosinophilic infiltration of the gall bladder was diagnosed. Following oral steroid administration, clinical symptoms were immediately improved. One month after the therapy, esophagogastroduodenoscopy did not show any findings of gastritis or duodenitis, and there were no eosinophilic infiltrations in biopsy specimens from duodenum and stomach.