Cholesterolosis in patients with chronic acalculous biliary pain

Relations between hepatobiliary scintigraphy findings and histopathological factors in patients with recurrent biliary colic

BACKGROUND/PURPOSE

The aim of the present study was to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic.

METHODS

We retrospectively enrolled 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy. According to the hepatobiliary scintigraphy findings, patients were categorized into a nonvisualization of gallbladder activity (nonvisualized GB) group, low gallbladder ejection fraction (GBEF) group, and normal GBEF group. Differences in histopathologic factors between the three groups were evaluated and multivariate logistic regression analyses were performed to identify histopathological predictors for hepatobiliary scintigraphy findings.

RESULTS

The nonvisualized group had a higher frequency of patients with empyema and severe infiltration by neutrophils, lymphoplasma cells, and eosinophils. The low GBEF group had a higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio of the gallbladder wall than those in the normal GBEF group. On multivariate logistic regression analyses, severe degrees of lymphoplasma cell infiltration and eosinophil infiltration were independent predictors for nonvisualization of gallbladder activity, and a higher muscle-to-fibrosis thickness ratio was an independent predictor for low GBEF.

CONCLUSIONS

In patients with recurrent biliary colic, nonvisualization of gallbladder activity on hepatobiliary scintigraphy was related to the degree of inflammation in the gallbladder, while low GBEF was related to muscular hypertrophy of the gallbladder.

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

BACKGROUND

Gallbladder dyskinesia (gallbladder spasm, biliary dyskinesia or chronic acalculous cholecystitis) is a poorly defined entity which presents as biliary-type pain without any identifiable organic pathology. Abnormal gallbladder ejection fraction (GBEF) is used by some to select those likely to benefit from cholecystectomy. The validity of this approach has been questioned.

AIM

To systematically review the literature and summarise the evidence surrounding the practice of cholecystectomy based on GBEF for gallbladder dyskinesia.

METHODS

We conducted a systematic search of PubMed/MEDLINE and SCOPUS from 1980 to 2016 to identify the relevant literature.

RESULTS

Twenty-nine studies including 2891 patients were included in the final analysis. In comparing cholecystectomy with medical management, patients with a normal GBEF did not benefit from cholecystectomy; whereas those with low GBEF had a higher chance (RR, relative risk = 2.37) of symptomatic improvement following surgery. When those classified as "low" and "normal" GBEF were compared in terms of outcome following cholecystectomy, the rate of improvement following surgery was similar in the two groups (RR 1.09) which suggests a placebo effect of surgery.

CONCLUSIONS

While a low GBEF may provide some guidance in identifying those with gallbladder dyskinesia who may benefit from cholecystectomy, the available data are inconsistent and based on studies of poor quality which are often subject to bias and the impact of confounding factors. For these reasons, we conclude that the role of scintigraphy and cholecystectomy in the definition and management of this disorder remain unclear pending definitive study.

HIDA scan for functional gallbladder disorder: ensure that you know how the scan was done

BACKGROUND

Despite the increasing use of fatty meal (FM) as a substitute for cholecystokinin (CCK) in pain reproduction during hepato-imino-diacetic acid (HIDA) scan in functional gallbladder disorder, there are no studies comparing the differences between CCK and FM. The present study was to compare the efficacy of FM in comparison of CCK in FGBD application.

METHODS

Patients undergoing HIDA scans from August 2013 to May 2014 were divided into two groups: those undergoing CCK-stimulated HIDA scan versus FM-stimulated HIDA scan. These groups were compared according to demographics and HIDA results.

RESULTS

Of 153 patients, 70 received CCK and 83 FM. There was no difference regarding age, gender, gallstones, gallbladder ejection fraction and time to visualization. However, significantly more of the patients receiving CCK than FM experienced pain reproduction (61% vs 30%, P<0.01).

CONCLUSIONS

Stimulation of gallbladder contractility with a FM during HIDA is less than half as likely to reproduce biliary symptoms compared to CCK, despite similar ejection fractions and other parameters. It is essential that providers account for this difference when counseling patients regarding cholecystectomy for functional gallbladder disorder.

Implications of gallbladder cholesterolosis and cholesterol polyps?

BACKGROUND

The clinical significance of cholesterolosis has not been well established but there are some provocative, if not robust, studies of the role it may play in the pathophysiology of pancreatitis and biliary dyskinesia, as well as hypercholesterolemia. Our aim was to take advantage of a very large cholecystectomy (CCY) database to support or refute these potentially important reported associations.

MATERIALS AND METHODS

A retrospective review of 6868 patients who underwent CCY from 2001-2013 was performed. Comparisons were made using the student t-test for continuous and chi-square analysis for categorical, variables.

RESULTS

Among patients for whom the CCY was the primary operation, 1053 (18%) had cholesterolosis and 4596 did not. Compared to those without cholesterolosis, those with cholesterolosis were no more likely to have elevated cholesterol levels (P = 0.64) nor low gallbladder ejection fraction (P = 0.2). To evaluate cholesterolosis as a cause of pancreatitis, all patients with gallstones were eliminated, leaving 639 patients. Among these, not only was cholesterolosis not associated with more pancreatitis, but rather there was not a single patient with or without cholesterolosis who had pancreatitis.

CONCLUSIONS

Despite prior reports of associations between cholesterolosis and elevated serum cholesterol, depressed ejection fraction, and increased risk of pancreatitis, careful analysis of this current, larger data set does not support these associations. Any patient with stones or sludge, or with biliary dyskinesia, and appropriate symptoms, should be considered for CCY, with or without suspected cholesterolosis.

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.

Acalculous biliary tract disorders: the value of fatty meal-cholescintigraphy

BACKGROUND

The management of patients with symptoms consistent with biliary tract disease but without evidence of cholelithiasis is difficult. This study was undertaken to test the value of cholescintigraphy in predicting the success of cholecystectomy in patients with acalculous biliary tract disorders.

MATERIAL AND METHODS

A prospective study was carried out on 73 patients presenting with recurrent upper quadrant pain without documented evidence of gallstones on ultrasound. Fatty meal-cholescintigraphy was performed on all patients and the gallbladder ejection fraction was calculated. Laparoscopic cholecystectomy was performed in patients with ejection fractions of <40%, followed by histopathological analysis and assessment of symptomatic improvement.

RESULTS

There were 43 men and 30 women with a mean age of 33.4 years. Forty-one patients had abnormal ejection fractions. All except one patient had a laparoscopic cholecystectomy. The pathological diagnosis of chronic cholecystitis was made in 33 patients and acute on chronic cholecystitis documented in four patients. Five patients had cholesterolosis and two of these had associated chronic cholecystitis. All except three patients had complete relief of symptoms post-operatively with a mean follow-up of 10 months.

CONCLUSION

Modified cholescintigraphy is a useful test for predicting which patients with acalculous biliary tract disease benefit from a cholecystectomy.

Biliary dyskinesia in idiopathic slow-transit constipation

BACKGROUND

Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder. We have screened patients referred to surgery for constipation for the presence of biliary dyskinesia.

METHOD

Patients had cholecystokinin-augmented trimethyl-3-bromo iminodiacetic acid scans to measure gallbladder ejection fraction.

RESULTS

There is a significant difference in gallbladder ejection fraction between patients with idiopathic slow-transit constipation (median value, 28.5) compared with patients with other causes of constipation (median value, 71; Mann-Whitney, P = 0.0025).

CONCLUSION

Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder.

Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones

In less than a decade, laparoscopic methods have dramatically improved the safety and convenience of cholecystectomy. As a result, the number of cholecystectomies performed nationwide has increased significantly. Whether this increase is a reflection of any major change in operative indications is unclear; the actual answer may vary from community to community. Silent gallstones continue to represent a sometimes contentious therapeutic dilemma. Because their natural history is unlikely to have changed, the management guidelines previously established for open cholecystectomy continue to have relevance today. Thus, it can be agreed that the majority of patients with silent gallstones do not require a cholecystectomy. The changing risk-benefit ratio suggests that some liberalization of these guidelines may now be in order. Already a number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients who are found to have gallstones during screening. Available evidence also appears to support the use of pre-emptive laparoscopic cholecystectomy for other indications such as in selected women of childbearing age, young children, and patients with very large gallstones. The problem of silent gallstones in diabetics continues to be more enigmatic, but some complicated diabetics are probably best managed with operation. Other patient groups who are at high risk of having adverse outcomes from expectant management will be more precisely identified by future research efforts. Laparoscopic cholecystectomy should also be helpful in patients with various forms of acalculous biliary disease. However, special caution is advisable in approaching chronic acalculous cholecystitis until more specific and reproducible diagnostic methods are further validated.