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Abstract
Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.
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Bouguila J, Besbes G, Khochtali H. Skeletal facial deformity in patients with β thalassemia major: Report of one Tunisian case and a review of the literature. Int J Pediatr Otorhinolaryngol 2015; 79:1955-8. [PMID: 26363895 DOI: 10.1016/j.ijporl.2015.08.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 08/16/2015] [Accepted: 08/19/2015] [Indexed: 11/18/2022]
Abstract
β Thalassemia is an inherited genetic disorder of hemoglobin synthesis characterized by a reduction of β chains of globin. Typical features of patients with β thalassemia are skeletal modifications, particularly in the skull and in the facial bones. In thalassemia major, involvement of the facial skeleton can result in severe disfigurement, often referred to as "rodent facies". Various surgical approaches to correct the facial deformity have been advocated; however, treatment remains controversial. The worse the patient's systemic condition, the more unstable and more complicated the surgical procedure. Patient with multisystemic disorder and severe deformity, such as in our case, with a complete lack of cortical bone for bone fixation, might not be amenable to such procedures. Thorough knowledge of the multiple systemic manifestations, therapy, and prognosis of this syndrome is necessary to formulate a safe, comprehensive surgical plan for these patients.
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Affiliation(s)
- Jed Bouguila
- Department of ENT, Maxillofacial and Aesthetic Surgery, La Rabta University Hospital, Tunis, Tunisia; Department of Maxillofacial, Plastic and Aesthetic Surgery, Sahloul University Hospital, Sousse, Tunisia; Laboratory of Oral Health and Facial Rehabilitation, Mounastir University, Tunisia.
| | - Ghazi Besbes
- Department of ENT, Maxillofacial and Aesthetic Surgery, La Rabta University Hospital, Tunis, Tunisia
| | - Habib Khochtali
- Department of Maxillofacial, Plastic and Aesthetic Surgery, Sahloul University Hospital, Sousse, Tunisia; Laboratory of Oral Health and Facial Rehabilitation, Mounastir University, Tunisia
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Elevated tricuspid regurgitant jet velocity in subgroups of thalassemia patients: insight into pathophysiology and the effect of splenectomy. Ann Hematol 2014; 93:1139-48. [PMID: 24577514 DOI: 10.1007/s00277-014-2037-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/13/2014] [Indexed: 01/19/2023]
Abstract
A high tricuspid regurgitant jet velocity (TRV) signifies a risk for or established pulmonary hypertension (PH), which is a serious complication in thalassemia patients. The underlying pathophysiology in thalassemia subgroups and potential biomarkers for early detection and monitoring are not well defined, in particular as they relate to spleen removal. To better understand some of these unresolved aspects, we examined 76 thalassemia patients (35 non-transfused), 25 splenectomized non-thalassemia patients (15 with hereditary spherocytosis), and 12 healthy controls. An elevated TRV (>2.5 m/s) was found in 25/76 (33 %) of the patients, confined to non-transfused or those with a late start of transfusions, including patients with hemoglobin H-constant spring, a finding not previously described. These non or late-transfused patients (76 % splenectomized) had significantly increased platelet activation (sCD40L), high platelet count, endothelial activation (endothelin-1), and hemolysis (LDH, plasma-free Hb), while hypercoagulable and inflammatory markers were not significantly increased. The same markers were increased in the seven patients with confirmed PH on cardiac catheterization, suggesting their possible role for screening patients at risk for PH. A combination of hemolysis and absence of spleen is necessary for developing a high TRV, as neither chronic hemolysis in the non-splenectomized thalassemia patients nor splenectomy without hemolysis, in the non-thalassemia patients, resulted in an increase in TRV.
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Zhu G, Wu X, Zhang X, Wu M, Zeng Q, Li X. Clinical and imaging findings in thalassemia patients with extramedullary hematopoiesis. Clin Imaging 2012; 36:475-82. [DOI: 10.1016/j.clinimag.2011.11.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 11/21/2011] [Indexed: 11/28/2022]
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Yu N, Kim HR, Cha YJ, Park EK. A novel frameshift mutation at codon 66 (HBB:c.del201A) in the β-globin gene leads to beta-thalassemia. Ann Hematol 2010; 90:243-4. [DOI: 10.1007/s00277-010-1002-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 05/17/2010] [Indexed: 10/19/2022]
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Origa R, Galanello R, Perseu L, Tavazzi D, Domenica Cappellini M, Terenzani L, Forni GL, Quarta G, Boetti T, Piga A. Cholelithiasis in thalassemia major. Eur J Haematol 2008; 82:22-5. [PMID: 19021734 DOI: 10.1111/j.1600-0609.2008.01162.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Aim of this study was to evaluate prevalence and characteristics of cholelithiasis in a large population of patients with thalassemia major (TM). METHODS Data from 858 consecutive patients with transfusion-dependent thalassemia at five major Italian centers were analyzed. In these centers, a complete abdomen ultrasonography is performed yearly after the beginning of the transfusion regimen. The role of co-inheriting Gilbert's syndrome genotype was investigated studying the promoter region of the UGT1-A1 gene by automated sequencing. RESULTS Thirty percent of TM patients had gallstones. The Gilbert's genotype [homozygosity for (TA)(7) motif at UGT1A promoter gene], influenced both the prevalence of cholelithiasis and the age at which it developed. CONCLUSIONS Cholelithiasis has a remarkable frequency and precocity in patients with TM and especially in those with (TA)(7)/(TA)(7) UGT1-A1 genotype. An early biliary ultrasonography is recommended from childhood and a closer follow-up in patients with thalassemia and associated Gilbert's syndrome may be indicated.
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Affiliation(s)
- Raffaella Origa
- Ospedale Regionale per le Microcitemie, ASL Cagliari, Dipartimento di Scienze Biomediche e Biotecnologie, Università di Cagliari, Cagliari, Italy
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Tankanitlert J, Morales NP, Fucharoen P, Fucharoen S, Chantharaksri U. Association between promoter and coding region mutations of UDP-glucuronosyltransferase 1A1 and beta-thalassemia/Hb E with cholelithiasis. Eur J Haematol 2007; 80:351-5. [PMID: 18081723 DOI: 10.1111/j.1600-0609.2007.01010.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Cholelithiasis has been observed with high incidence in beta-thalassemia/hemoglobin E (beta-thal/Hb E). Recent studies have shown that a variant TATA-box in the promoter region of the UDP-glucuronosyltransferase 1A1 (UGT1A1) gene is associated with the development of cholelithiasis. The coding region mutation (G71R) of the UGT1A1 gene was higher in Asians than those in Caucasians. The relationship between the variant UGT1A1 promoter and coding region gene and cholelithiasis in beta-thal/Hb E subjects were investigated. METHODS One hundred and seventeen beta-thal/Hb E subjects entered this study. The TATA-box and G71R mutations were analyzed by fragment size analysis and restriction fragment length polymorphism methods, respectively. RESULTS The incidence of cholelithiasis was higher in heterozygous (68.3%) and homozygous (100%) subjects compared with normal UGT1A1 haplotype (61.4%). Total bilirubin level (6.0 +/- 2.03 mg/dL) in the homozygous group was significantly higher than that of wild type (3.31 +/- 1.83 ng/dL). Prevalence of cholelithiasis increased with age (OR = 1.1, 95% CI = 1.03-1.12, P < 0.001). Female gender (OR = 3.7, 95% CI = 1.3-10.6, P < 0.01) and elevated liver enzyme (OR = 1.02, 95%CI = 1.0-1.04, P < 0.02) were two other risk factors for cholelithiasis in beta-thal/Hb E. CONCLUSION This study shows that the combined TATA-box variants and G71R mutations of the UGT1A1 is associated with cholelithiasis in beta-thal/Hb E.
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Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci 2007; 52:1313-25. [PMID: 17390223 DOI: 10.1007/s10620-006-9107-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 01/12/2006] [Indexed: 12/14/2022]
Abstract
Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, Arkadias 19-21, GR-115 26, Athens, Greece.
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Currò G, Iapichino G, Lorenzini C, Palmeri R, Cucinotta E. Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure? Surg Endosc 2005; 20:252-5. [PMID: 16391956 DOI: 10.1007/s00464-005-0318-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 09/07/2005] [Indexed: 01/19/2023]
Abstract
BACKGROUND The aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing. METHODS From June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) depending on clinical presentation and operation timing, and the respective outcomes were compared. RESULTS Elective LC in asymptomatic children (group A) is safe with no major complications reported. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22-36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC. CONCLUSIONS Elective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.
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Affiliation(s)
- G Currò
- Department of Human Pathology, University of Messina, Via Nina da Messina, 2, 98121, Messina, Italy
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Katz R, Goldfarb A, Muggia M, Gimmon Z. Unique Features of Laparoscopic Cholecystectomy in ?? Thalassemia Patients. Surg Laparosc Endosc Percutan Tech 2003; 13:318-21. [PMID: 14571167 DOI: 10.1097/00129689-200310000-00006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Beta Thalassemia patients suffer from a high incidence of gallstones as well as systemic complications of iron overload. We performed laparoscopic cholecystectomy in 8 beta thalassemia patients and describe their specific features. Diagnosis was based on patients' clinical presentation and sonography. Trocars were readjusted due to the hepatomegaly. No intraoperative cholangiograms were performed. Follow-up included clinical assessment and abdominal sonography. All procedures were completed laparoscopically. Pigment cirrhosis and fibrosis around the cystic duct were noted in all patients. No biliary injury occurred. Post operatively, 4 patients suffered fluid leakage through the trocar site, treated conservatively. No major cardiopulmonary complications occurred. During a mean follow-up time of 65 months, all patients are symptom free and without evidence of biliary lithiasis. Thalassemia patients are difficult and often high-risk patients. Improvement in anesthesia and monitoring enables better management of these patients. Laparoscopic cholecystectomy should be advised in carefully selected thalassemia patients.
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Affiliation(s)
- Ran Katz
- Departments of General Surgery, Hadassah Medical Center, Hebrew University, Ein Kerem, Jerusalem, Israel.
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Kok KYY, Yapp SKS. Techniques and clinical outcomes of laparoscopic cholecystectomy in adult patients with beta-thalassemias. Surg Laparosc Endosc Percutan Tech 2003; 13:168-72. [PMID: 12819500 DOI: 10.1097/00129689-200306000-00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Beta-thalassemia, which results from a reduced production of beta-globin chain of hemoglobin, is a common single gene disorder with an extremely heterogeneous clinical picture. Its presentation may vary from mild anemia in beta-thalassemia minor to severe and life-threatening anemia in beta-thalassemia major. Recent advances in supportive treatment of beta-thalassemia major have resulted in substantial increase in survival in these patients, and an increasing number of these patients reach adolescence and adulthood. The incidence of cholelithiasis is reported to be increased in these patients. Although laparoscopic cholecystectomy (LC) has become the gold standard treatment of symptomatic gallstone disease, its experience in adult beta-thalassemic patients has been limited. From May 1992 through April 2000, 10 consecutive adult beta-thalassemic patients with symptomatic gallstone underwent LC at our institution. Data were obtained on the type of beta-thalassemia, presentation, preoperative laboratory findings, history of preoperative transfusion, postoperative complications, postoperative analgesic requirement, length of hospital stay, and follow-up. All operations were completed laparoscopically. The mean operative time was 98.5 minutes. The postoperative analgesic requirement was minimal. There was no mortality. One patient developed fever postoperatively due to lung atelectasis that was managed conservatively. The mean hospital stay was 3 days. Laparoscopic cholecystectomy is feasible, safe, and effective in the treatment of adult beta-thalassemic patients with symptomatic gallstone disease. Technical adjustments are required when operating on patients with beta-thalassemia major.
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Affiliation(s)
- Kenneth Y Y Kok
- Department of General Surgery, Ripas Hospital, Bandar Seri Begawan, Brunei.
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Galanello R, Piras S, Barella S, Leoni GB, Cipollina MD, Perseu L, Cao A. Cholelithiasis and Gilbert's syndrome in homozygous beta-thalassaemia. Br J Haematol 2001; 115:926-8. [PMID: 11843828 DOI: 10.1046/j.1365-2141.2001.03200.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cholelithiasis has been reported with a variable incidence in homozygous beta-thalassaemia, the reasons for which have only partially been defined. Disease-associated factors or specific modifier genes may be implicated. We assessed the prevalence of cholelithiasis and the effect of co-inherited Gilbert's syndrome genotype on its development in 261 thalassaemia major (TM) and 35 thalassaemia intermedia (TI) patients. Cholelithiasis was found in 20.3% of TM and in 57.1% of TI patients. Its incidence was higher (P < 0.05) in patients homozygous for the (TA7) motif in the promoter of the UGT1-A1 gene, the genotype associated with Gilbert's syndrome, which seems to be a risk factor for the development of gallstones in TM and TI patients.
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Affiliation(s)
- R Galanello
- Ospedale Regionale Microcitemie, Dipartimento di Scienze Biomediche e Biotecnologie, University of Cagliari, Via Jenner s.n. 09121, Cagliari, Italy.
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Aessopos A, Karabatsos F, Farmakis D, Katsantoni A, Hatziliami A, Youssef J, Karagiorga M. Pregnancy in patients with well-treated beta-thalassemia: outcome for mothers and newborn infants. Am J Obstet Gynecol 1999; 180:360-5. [PMID: 9988801 DOI: 10.1016/s0002-9378(99)70214-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Our purpose was to investigate the course and outcome of pregnancy in women with well-treated beta-thalassemia. STUDY DESIGN Twenty-two pregnancies, including one twin pregnancy, in 19 women were studied. Pregnancy was advised when patients had received a prolonged intensive treatment with hypertransfusions and iron chelation and had echocardiographically normal resting left ventricular performance. All conceptions were spontaneous. Cardiac function, along with hematologic, endocrinologic, and hepatic parameters were initially assessed and monitored throughout pregnancy and for 2 to 9 years post partum. Babies were delivered by elective cesarean section. RESULTS Twenty-one healthy newborn infants were delivered. A spontaneous abortion and a case of exomphalos also occurred. Gestation, delivery, and recovery were surprisingly uneventful, and no significant cardiac complications were encountered. CONCLUSION Pregnancy can be safe for mothers and babies, provided that women with thalassemia have been started early on intensive treatment and have a normal resting cardiac performance.
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Affiliation(s)
- A Aessopos
- First Department of Internal Medicine, University of Athens School of Medicine and "Laiko" General Hospital, Athens, Greece
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Katz M, De Sanctis V, Vullo C, Wonke B, McGarrigle HH, Bagni B. Pharmacokinetics of sex steroids in patients with beta thalassaemia major. J Clin Pathol 1993; 46:660-4. [PMID: 8157756 PMCID: PMC501398 DOI: 10.1136/jcp.46.7.660] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIMS To assess the pharmacokinetics of oral, intramuscular, or transdermal hormone replacement in patients with beta thalassaemia major. METHODS Oral (testosterone undecanoate 40 mg) and intramuscular (testosterone propionate 15 mg, phenylpropionate 30 mg, isocaproate 30 mg and decanoate 50 mg) testosterone and transdermal (17 beta oestradiol 25 micrograms and 50 micrograms) oestradiol were evaluated in 21 male (16-29 years) and 11 female (19-26 years) patients with beta thalassaemia major and various forms of hypogonadism. RESULTS In male patients given oral testosterone, peak testosterone concentrations were observed either two to four hours or seven hours after administration; intramuscular testosterone produced peak values seven days after injection. Transdermal 17 beta oestradiol given to female patients produced a biphasic pattern with an initial peak concentration occurring at 36 hours and a secondary rise at 84 hours. CONCLUSIONS The results indicate that oral androgens should be given twice daily in cases of hypogonadism, and where growth is incomplete, lower than recommended doses. If intramuscular testosterone is used, smaller doses of 10-25 mg should be given every one to two weeks. Transdermal administration of 25-50 micrograms 17 beta oestradiol generally produces a plasma E2 value in the early to mid-follicular phase range (100-300 pmol/l). This is appropriate in adults but excessive for prepubertal girls. Diffuse iron infiltration of tissues does not seem to interfere with the absorption of androgens and oestrogens from the gut, muscle, or skin.
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Affiliation(s)
- M Katz
- Department of Obstetrics and Gynaecology, University College and Middlesex Medical School, London
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Senaati S, Gumruk FU, Delbakhsh P, Balkanci F, Altay C. Gallbladder pathology in pediatric beta-thalassemic patients. A prospective ultrasonographic study. Pediatr Radiol 1993; 23:357-9. [PMID: 8233686 DOI: 10.1007/bf02011957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Eighty-three beta-thalassemic patients, aged 1.5-19 years, were prospectively studied for evidence of gallbladder pathology by real-time, high-resolution ultrasound. Cholelithiasis was present in 7 patients (8.4%). Sludge, a clinical entity that, when it persists, can be a predisposing factor for cholelithiasis and cholecystitis, was detected in 29 patients (34.9%). Prevalence of sludge to this extent has not been reported in the literature and we believe this is due to better technology offered by modern ultrasound equipment. Pseudo-sludge, a condition that is created by a beam averaging effect (partial-volume phenomenon), at the diverging portion of the ultrasound beam, has always been confusing and a source of difficulties in the ultrasound examination of the gallbladder. For the first time, a method is described, to easily differentiate between true sludge and pseudo-sludge.
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Affiliation(s)
- S Senaati
- Department of Diagnostic Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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