Vedvarende hikke etter perforert kolecystitt

BACKGROUND

Persistent hiccups lasting more than 48 hours are rare and have numerous possible causes that require further investigation.

CASE PRESENTATION

We present a man in his seventies who was admitted to hospital after 11 days of hiccups. The hiccups were preceded by abdominal pain that spontaneously receded after a few hours. At admission he had no abdominal pain during examination, but a CT scan later suggested that the cause was a perforated cholecystitis with an intra-abdominal abscess. The abscess was drained percutaneously and treated with antibiotics, and the hiccups stopped.

INTERPRETATION

Persistent hiccups warrant thorough examination, and it is recommended to consider CT scans of the head and truncus, cerebral MRI scan and an upper GI endoscopy. Treating the underlying cause of hiccups is the ultimate target, while symptomatic treatment simultaneously is preferred.

Double cholecystectomy of duplex gallbladder associated with chronic cholecystitis in a cat

A 6-year-old female neutered Persian cat presented with hyporexia and gradual weight loss over 6 months. Physical examination revealed cranial abdominal pain. Haematology and serum biochemistry were within normal limits. Abdominal ultrasonography and a computed tomography scan suggested a non-neoplastic mass compressing the gallbladder. During an exploratory laparotomy, a duplex gallbladder with two separate cystic ducts was diagnosed intraoperatively. The mass identified using the imaging techniques was an abnormal right gallbladder which was distended with immobile mucoid bile and a thickened wall. The left gallbladder and cystic duct were grossly normal. A cholecystectomy of both gallbladders was performed. Histopathology of the right gallbladder identified chronic cholecystitis. The cat made a good recovery from surgery and reported complete resolution of its hyporexia and a return to normal body weight. This is the first report of a successful cholecystectomy of a duplex gallbladder with chronic cholecystitis of a single gallbladder.

Gallbladder Pancreatic Heterotopia-The Importance of Diagnostic Imaging in Managing Intraoperative Findings

Pancreatic heterotopy is a rare entity defined as the presence of abnormally located pancreatic tissue without any anatomical or vascular connection to the normal pancreas. Heterotopic pancreatic tissue can be found in various regions of the digestive system, such as the stomach, duodenum, and upper jejunum, with the less commonly reported location being the gallbladder. Gallbladder pancreatic heterotopia can be either an incidental finding or diagnosed in association with cholecystitis. Pancreatitis of the ectopic tissue has also been described. In this context, we report three cases of heterotopic pancreatic tissue in the gallbladder with different types of pancreatic tissue according to the Heinrich classification. One patient was a 24-year-old male who presented with acute pancreatitis symptoms and an ultrasonographical detected mass in the gallbladder, which proved to be heterotopic pancreatic tissue. The other two cases were female patients aged 24 and 32, respectively, incidentally diagnosed on histopathological examination after cholecystectomy for symptomatic cholelithiasis. Both cases displayed chronic cholecystitis lesions; one of them was also associated with low grade dysplasia of the gallbladder. Although a rare occurrence in general, pancreatic heterotopia should be acknowledged as a possible incidental finding in asymptomatic patients as well as a cause for acute cholecystitis or pancreatitis.

Utility of near infrared fluorescent cholangiography in detecting biliary structures during challenging minimally invasive cholecystectomy

BACKGROUND

Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invasive cholecystectomy through technical standardization by means of a precise anatomical landmark identification (Critical View of Safety) and advanced technology for biliary visualization. Among these systems, the adoption of magnified stereoscopic 3-dimensional view provided by robotic platforms and near infrared fluorescent cholangiography (NIRF-C) is the most promising.

METHODS

In this prospective cohort study, we evaluated all consecutive minimally invasive cholecystectomies (laparoscopic and robotic) performed with NIRF-C between May 2022 and January 2023 at General Surgery Unit, Department of Health Sciences, University of Milan, San Paolo Hospital (Milan, Italy). Inclusions criteria were as follows: (1) acute cholecystitis (emergency group), (2) history of chronic cholecystitis or complicated cholelithiasis (deferred urgent group), (3) difficult cases (patients affected by cirrhosis, with scleroatrophic gallbladder or BMI > 35 kg/m2). For each group, the detection rate and visualization order of the main biliary structures were reported (cystic duct, CD; common hepatic duct, CHD; common bile duct, CBD; and CD-CHD junction).

RESULTS

A total of 101 consecutive patients were enrolled, including 83 laparoscopic and 18 robotic cholecystectomies. All patients were stratified into three subgroups: (a) emergency group (n = 33, 32.7%), (b) deferred urgent group (n = 46, 45.5%), (c) difficult group (n = 22, 21.8%). Visualization of at least one biliary structure was possible in 94.1% of cases (95/101). Interestingly, all four main structures were detected in 43.6% of cases (44/101). The CD was the structure identified most frequently, being recognized in 91/101 patients (90.1%), followed by CBD (83.2%), CHD (62.4%), and CD-CHD junction (52.5%). In the subset of patients that underwent emergency surgery for AC, the CD-CHD confluence was identified in only 45.5% of cases. However, early and precise identification of CBD (75.8%) and CD (87.9%) allowed safe isolation, clipping, and transection of the cystic duct. In the deferred urgent group, the CBD and the CD were easily identified as first structure in a high percentage of cases (65.2% and 41.3% respectively), whereas the CD-CHD junction was the third structure to be identified in 67.4% of cases, the highest value among the three subgroups. In the difficult group, NIRF-C did not prove to be a useful tool for biliary visualization. The rates of failure of visualization were elevated: CBD (27.3%), CD (18.2%), CHD (54.5%), and CD-CHD (68.2%).

CONCLUSIONS

NIRF-C is a powerful real-time diagnostic tool to detect CBD and CD during minimally invasive cholecystectomy, especially when inflammation due to acute or chronic cholecystitis subverted the anatomy of the hepatoduodenal ligament.

Performance of ultrasound in the diagnosis of cholecystitis: not so (ultra)sound?

INTRODUCTION

Ultrasound has long been the radiological investigation of choice for right upper quadrant pain in the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 795 patients.

METHODS

All laparoscopic cholecystectomies at Portsmouth Hospitals University were prospectively logged between 2017 and 2020. Ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics.

RESULTS

In our large patient series, the sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts the Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest when the interval between ultrasound and cholecystectomy is less than 27 days.

CONCLUSIONS

We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder wall on ultrasound can predict a 'difficult cholecystectomy' and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.

Cholecystitis and Cholangitis during Continuous Renal Replacement Therapy in a Patient with Retroperitoneal Hemorrhage Requiring Large Amounts of Contrast Medium for the Assessment and Intervention

Intravenous use of contrast medium (CM), which may cause kidney dysfunction, is admissible for hemodialysis patients because of the efficient removal by hemodialysis. We herein report a 61-year-old woman on hemodialysis who suffered from cholecystitis and cholangitis after large-volume CM administration during continuous renal replacement therapy. After catheter ablation, she developed life-threatening retroperitoneal hemorrhage, which led to the use of 500 mL CM for 5 consecutive days. It should be kept in mind that excessive vicarious CM excretion in the biliary system may become a predisposing factor of cholecystitis and cholangitis in patients who frequently undergo radiological interventions and imaging.

Extrahepatic Biliary Tract Variations is an Effect for Acute Calculous Cholecystitis

OBJECTIVE

To evaluate the anatomy of the extrahepatic bile duct and to reveal its importance in the formation of acute calculous cholecystitis (ACC).

STUDY DESIGN

Case-control study.

PLACE AND DURATION OF STUDY

Department of General Surgery and Radiology, Kanuni Sultan Suleyman Training and Research Hospital of the University of Health Sciences, Turkey, between January 2016 and December 2021.

METHODOLOGY

The data of the patients treated with ACC were analysed on MRCP by an experienced radiologist. The patients were divided into two groups; asymptomatic gallstones (AsGS, control group) and ACC. The cystic duct, common hepatic duct, and common bile duct lengths and variations in cystic duct opening were measured. Receiver operating characteristics (ROC) analysis was conducted to define a cut-off value and compared categorical results of the two groups by Mann-Whitney U test.

RESULTS

One-hundred and seventy-three patients were analysed, one-hundred and seven were females, and 66 were males. The median age was 46 years in the AsGS group and 53 years in the ACC group. It was statistically significant that ACC had a higher median age value than AsGS (p=0.014). In the analysis of extrahepatic variations, cystic duct, common hepatic duct, and common bile duct length, were statistically longer in the calculous cholecystitis group (p<0.001, p=0.022, and p=0.019 respectively). ROC analysis was performed for cystic, common hepatic, and common bile duct length, respectively. Cut-off values ​​were 30.5 mm, 36.5 mm, and 42.5 mm.

CONCLUSION

Extrahepatic bile duct variations are of critical importance in ACC surgery. In the data, as the cystic duct and common bile duct lengthens, the possibility of ACC increases. There is need for studies with larger samples.

KEY WORDS

Acute calculous cholecystitis, Extrahepatic biliary tract, Anatomical variations, Cholelithiasis.

Multidetector Computed Tomography (MDCT) Findings of Complications of Acute Cholecystitis. A Pictorial Essay

Acute cholecystitis stands out as one of the most common surgical pathologies that should always be considered in a right-upper abdominal pain emergency. For this, the importance of a correct diagnosis is well described. However, it has been demonstrated that the simple combination of clinical (pain, Murphy’s sign) and laboratory (leukocytosis) parameters alone does not provide for ruling in or ruling out the diagnosis of this condition, unless accompanied by a radiological exam. For a long time, and still today, ultrasonography (US) is by far the first-to-proceed radiologic exam to perform, thanks to its rapidity and very high sensibility and specificity for the diagnosis of simple acute cholecystitis. However, acute cholecystitis can undergo some complications that US struggles to find. In addition to that, studies suggest that multidetector computed tomography (MDCT) is superior in showing complicated forms of cholecystitis in relation to sensibility and specificity and for its capability of reformatting multiplanar (MPR) reconstructions that give a more detailed view of complications. They have shown to be useful for a precise evaluation of vascular complications, the anatomy of the biliary tree, and the extension of inflammation to surrounding structures (i.e., colitis). Therefore, based also on our experience, in patients with atypical presentation, or in cases with high suspicion for a complicated form, a MDCT abdomen scan is performed. In this review, the principal findings are listed and described to create a CT classification of acute complications based on anatomical and topographic criteria.

Lightweight deep neural networks for cholelithiasis and cholecystitis detection by point-of-care ultrasound

BACKGROUND AND OBJECTIVE

Emergency physicians (EPs) frequently deal with abdominal pain, including that is caused by either gallstones or acute cholecystitis. Easy access and low cost justify point-of-care ultrasound (POCUS) use as a first-line test to detect these diseases; yet, the detection performance of POCUS by EPs is unreliable, causing misdiagnoses with serious impacts. This study aimed to develop a machine learning system to detect and localize gallstones and to detect acute cholecystitis by ultrasound (US) still images taken by physicians or technicians for preliminary diagnoses.

METHODS

Abdominal US images (> 89,000) were collected from 2386 patients in a hospital database. We constructed training sets for gallstones with or without cholecystitis (N = 10,971) and cholecystitis with or without gallstones (N = 7348) as positives. Validation sets were also constructed for gallstones (N = 2664) and cholecystitis (N = 1919). We applied a single-shot multibox detector (SSD) and a feature pyramid network (FPN) to classify and localize objects using image features extracted by ResNet-50 for gallstones, and MobileNet V2 to classify cholecystitis. The deep learning models were pretrained using the COCO-2017 and ILSVRC-2012 datasets.

RESULTS

Using the validation sets, the SSD-FPN-ResNet-50 and MobileNet V2 achieved areas under the receiver operating characteristics curve of 0.92 and 0.94, respectively. The inference speeds were 21 (47.6 frames per second, fps) and 7 ms (142.9 fps).

CONCLUSIONS

A machine learning system was developed to detect and localize gallstones, and to detect cholecystitis, with acceptable discrimination and speed. This is the first study to develop this system for either gallstone or cholecystitis detection with absence or presence of each one. After clinical trials, this system may be used to assist EPs, including those in remote areas, for detecting these diseases.

CT and MRI findings of acute calculous cholecystitis and its complications in Singapore: A pictorial review

INTRODUCTION

Acute cholecystitis (AC) is a common problem encountered in surgical practice. This occurs due to obstruction of the cystic duct by calculi resulting in inflammation of the gallbladder. Increasingly, contrast enhanced computed tomography (CECT) and Magnetic Resonance Imaging (MRI) scans are being used for assessment. While the imaging features of AC are well recognized and extensively described in the literature, radiological features of the rarer complications related to AC such as pseudoaneurysm formation and gallbladder volvulus are less well known. We aim to describe these rarer findings in our pictorial review, to better educate the clinician and radiologist, such that timely diagnoses can be reached, and relevant management can be affected.

METHODS

A collection of cases showing the common acute gallbladder pathologies and complications such as acute cholecystitis, gangrenous cholecystitis, emphysematous cholecystitis, haemorrhagic cholecystitis, Mirizzi's syndrome, gallbladder perforation and abscess formation, were collected between July 2016 and March 2018 at two different medical institutions in Singapore. In addition, rarer cases of gallbladder volvulus and vascular complications such as cystic artery pseudoaneurysms and vessel erosions, were also followed up.

RESULTS

The CT and MRI imaging features of these conditions were discussed, with key diagnostic imaging features emphasized.

CONCLUSION

Acute gallbladder pathologies are commonly encountered in day-to-day radiology practice. Knowledge of the rarer gallbladder pathologies and their key imaging features will help the radiologist, in particular, the on call radiologist in training, improve diagnostic accuracy and allow for timely management.

Increased 68Ga-FAPI Uptake in Chronic Cholecystitis and Degenerative Osteophyte

ABSTRACT

68Ga-FAPI PET/CT has been used in the evaluation of a variety of malignancies. An increasing number of case studies on FAPI uptake in nonmalignant diseases is also gaining support and enthusiasm. We present a case of asymptomatic chronic cholecystitis and degenerative osteophyte detected incidentally by 68Ga-FAPI PET/CT.

18F-FDG PET/CT in Hyalinized Cholecystitis

ABSTRACT

Hyalinizing cholecystitis is a rare type of chronic cholecystitis. Moderate patchy transmural especially perivascular lymphoplasmacytic inflammatory cell infiltration is observed in the gallbladder wall. We present the 18F-FDG PET/CT and MRI findings of this rare subtype of chronic cholecystitis. Hyalinizing cholecystitis should be kept in mind in the differential diagnosis of gallbladder wall thickening with intense 18F-FDG uptake.

A Rare Ultrasonographic Finding of Emphysematous Cholecystitis: The Champagne Sign

BACKGROUND

Emphysematous cholecystitis (EC) is a form of cholecystitis with high mortality rates more commonly seen in patients with medical histories such as diabetes, hypertension, and peripheral vascular disease. The common features of these medical diseases are impaired pain perception, particularly abdominal pain, due to advanced age and peripheral neuropathies. Accurate evaluation of characteristics observed at ultrasonography, the method of first choice in the diagnosis of EC, is therefore highly important in these patients.

CASE REPORT

This study reports a case of the champagne sign, rarely seen in EC, together with other EC findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The champagne sign is a little-known sonographic finding that is evidence of the presence of gas in the gallbladder. The champagne sign that will be detected while evaluating the hepatobiliary system on bedside ultrasound is one of the valuable findings in the diagnosis of emphysematous cholecystitis with high mortality.

Imaging-based algorithmic approach to gallbladder wall thickening

Gallbladder (GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma (GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities (conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.

Effectiveness of near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary study

INTRODUCTION

Bile duct injury represents the most serious complication of LC, with an incidence of 0.3-0.7% resulting in a significant impact on quality-of-life, overall survival, and frequent medico-legal litigations. Near-infrared fluorescent cholangiography (NIRF-C) represents a novel intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. The role of routine use of pre-operative magnetic resonance cholangio-pancreatography (MRCP) to better clarify the biliary anatomy before laparoscopic cholecystectomy is still a matter of debate. The primary aim of this study was to evaluate the effectiveness of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in comparison with pre-operative MRCP.

METHODS

Data from 26 consecutive patients with symptomatic cholelithiasis or chronic cholecystitis, who underwent elective laparoscopic cholecystectomy with intra-operative fluorescent cholangiography and pre-operative MRCP examination between January 2018 and May 2018, were analyzed. Three selected features of the cystic duct-common hepatic duct anatomy were identified and analyzed by the two different imaging methods: insertion of cystic duct, cystic duct-common hepatic duct junction, and cystic duct course.

RESULTS

Fluorescent cholangiography was performed successfully in all twenty-six patients undergoing elective laparoscopic cholecystectomy. The visualization of cystic duct was reported in 23 out of 26 cases, showing an overall diagnostic accuracy of 86.9%. The level of insertion, course, and wall implantation of cystic duct were achieved by NIRF-C with diagnostic accuracy values of 65.2%, 78.3%, and 91.3%, respectively in comparison with MRCP data. No bile duct injuries were reported.

CONCLUSION

Fluorescent cholangiography can be considered a useful imaging diagnostic tool comparable to MRCP for detailed intra-operative visualization of the cystic duct-common hepatic duct anatomy during elective laparoscopic cholecystectomies.

A Female with Right-Sided Thoracic Kidney with Bochdalek Hernia: A Case Report

The thoracic kidney is the rarest form of an ectopic kidney that usually present on the left thoraxand twice more common in males. No case has been reported from Nepal and very few cases arereported worldwide. We report a 24 years-old female with right thoracic kidney with Bochdalekhernia diagnosed incidentally. We have included clinico-radiological and surgical findings of thecase with a review of the literature.

The diagnostic use of magnetic resonance imaging for acute abdominal and pelvic pain in pregnancy

OBJECTIVES

Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. In many cases, radiological and laparoscopic diagnostic modalities are hazardous or contraindicated. Magnetic Resonance Imaging (MRI) is not commonly used for this indication and the results are not widely published.

DESIGN AND SETTING

A single-center retrospective observational study.

POPULATION

34 cases of pregnant women with abdomino-pelvic pain who underwent MRI as an additional modality when clinical, laboratory and ultrasound (USS) findings were indeterminate.

METHODS

Case notes were reviewed where pregnant women underwent a MRI investigation for abdominal-pelvic pain. Primary Obstetric indications for an MRI eg placenta accreta were excluded.

MAIN OUTCOME MEASURES

The differential diagnosis after; 1) history and physical examination and 2) with the addition of USS and 3) with the further addition of an MRI were all individually compared to the eventual diagnosis.

RESULTS

The diagnoses reached by MRI corresponded with the final diagnosis in 22 out of 23 cases. In the remaining 11 cases MRI accurately ruled out presence of pathology. MRI was inaccurate in 1 case.

CONCLUSION

The additional use of MRI was more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 cases is particularly significant. MRI should be considered in cases of abdomino-pelvic pain in pregnant women.

Usefulness of Ultrasound in Differentiating Xanthogranulomatous Cholecystitis from Gallbladder Carcinoma

Our study was aimed at finding the ultrasound (US) features of xanthogranulomatous cholecystitis (XGC) and evaluating the usefulness of US in differentiating XGC from gallbladder carcinoma (GBC). Through use of an electronic medical record system and the picture archiving and communication system, 31 cases of XGC and 52 cases of GBC with both sonograms and pathologic results were identified. Sonographic features of the abnormal gallbladder were evaluated. The smooth and intact interface between gallbladder lumen and mucosa was observed in most XGC cases (23/31, 74.2%) but in no GBC cases. XGC featured hyper-echoic foci, small hypo-echoic nodules and a layered appearance in the lesion, which were more frequently seen in the XGC group than in the GBC group. In conclusion, US may prove useful in the differential diagnosis of XGC and GBC, but more studies are required.

A man in his seventies with spinal cord injury, fever and delirium

INTRODUCTION

Spinal cord injury includes damage to the motor, sensory and autonomic nervous system.

CASE PRESENTATION

A man in his seventies was admitted to hospital after an acute traumatic incomplete cervical spinal cord injury. Over the following weeks, he experienced multiple febrile episodes with CRP elevated to 100 – >300 mg/L, but few other symptoms. Two weeks after admission, he was febrile with neuropathic pain, and oxygen saturation spontaneously decreased from 98 % to 87 %. Chest X-ray showed pneumonia, which was treated with antibiotics. Four weeks after the injury he again experienced fever and increased spasticity. Clinical examination revealed dull abdominal pain on palpation in the left upper quadrant. The same day, a PEG placement procedure had been performed. CT abdomen, chest X-ray and microbiological investigation revealed no clear infectious origin. The patient was treated with antibiotic coverage for presumed abdominal infection, with successful recovery. Two months after his injury, the patient became febrile and delirious. Clinical examination revealed mild pain on palpation in the upper right quadrant. CT abdomen revealed cholecystitis.

DISCUSSION

Diagnosis of acute serious illness in a patient with spinal cord injury may be challenging due to scarce and atypical clinical presentation. Prevalence of gallstones is increased after spinal cord injury.

Detection and monitoring of postinterventional success and complications of the liver using contrast-enhanced ultrasound (CEUS) - a case report after interventional treatment of a giant hemangioma

This case report relates the use of contrast-enhanced ultrasound (CEUS) for the assessment and treatment of a postinterventional cholecystitis, a rare but important complication after transcatheter arterial embolization of a giant hemangioma. Regarding the imaging diagnosis, hemangiomas have specific features allowing a fast recognition by all radiological modalities,and in recent years, especially by CEUS.

Differentiation of acute cholecystitis from chronic cholecystitis: Determination of useful multidetector computed tomography findings

The purpose of this study was to determine the diagnostic value of multidetector computed tomography (MDCT) imaging findings, to identify the most predictive findings, and to assess diagnostic performance in the diagnosis and differentiation of acute cholecystitis from chronic cholecystitis.In this retrospective study, we enrolled 382 consecutive patients with pathologically proven acute or chronic cholecystitis who underwent computed tomography (CT) within 1 month before surgery. The CT findings were compared and logistic regression analysis was used to identify significant CT findings in predicting acute cholecystitis. Diagnostic performance of each CT finding and of combined findings was also assessed.Statistically significant CT findings distinguishing acute cholecystitis from chronic cholecystitis were increased gallbladder dimension (85.5% vs 50.6%, P < .001), increased wall enhancement (61.8% vs 78.9%, P = .001), increased wall thickness (67.9% vs 31.1%, P < .001), mural striation (64.9% vs 28.3%, P < .001), pericholecystic haziness or fluid (66.4% vs 21.2%, P < .001), increased adjacent hepatic enhancement (80.0% vs 32.4%, P < .001), focal wall defect (9.2% vs 0, P < .001), and pericholecystic abscess (10.7% vs 0, P < .001). Subsequent multivariate logistic regression analysis revealed that increased adjacent hepatic enhancement [P = .006, odds ratio (OR) = 3.82], increased gallbladder dimension (P = .027, OR = 3.12), increased wall thickening or mural striation (P = .019, OR = 2.89), and pericholecystic haziness or fluid (P = .032, OR = 2.61) were significant predictors of acute cholecystitis. When 2 of these 4 CT findings were observed together, the sensitivity, specificity, and accuracy for the detection of acute cholecystitis were 83.2%, 65.7%, and 71.7%, respectively. When 3 of these 4 CT findings were observed together, the sensitivity, specificity, and accuracy were 56.5%, 84.5%, and 74.9%, respectively. When none of these 4 CT findings were observed, the negative predictive value was 96.4%.Increased adjacent hepatic enhancement, increased gallbladder dimension, increased wall thickening or mural striation, and pericholecystic fat haziness or fluid were the most discriminative MDCT findings for the diagnosis and differentiation of acute cholecystitis from chronic cholecystitis.

Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: A retrospective study

Intraoperative cholangiography involving the excretion of fluorescent indocyanine green (ICG) into the bile is used to determine biliary anatomy in laparoscopic cholecystectomy (LC). This study aimed to evaluate the features of intraoperative ICG cholangiography, in LC with cholecystitis, and compared the delineation of the cystic duct (CD) between ICG cholangiography and magnetic resonance cholangiopancreatography (MRCP).Participants comprised 65 patients undergoing LC using ICG cholangiography.Fifty-eight patients (89.2%) were diagnosed with gallbladder stones and 32 (49.2%) with acute cholecystitis. ICG cholangiography identified CD in 54 patients (83.1%) and did not identify CD in 11 patients (16.9%). The mean value of the fluorescence intensity in the identified CD group by ICG cholangiography was 87.6 ± 31.5 arbitrary unit and that in the not identified CD group by ICG cholangiography was 24.4 ± 10.1 arbitrary unit (P < .001). Compared with the patients in the identified CD group, those in the not identified CD group had higher incidence of acute cholecystitis (P < .001), and higher conversion rates (P = .003). A correlation between the delineation of CD by ICG cholangiography and MRCP was analyzed, and it revealed a correlation between each other (P = .002)Inflammation had harmful effects with regard to the passing of CD. If we can identify CD or common bile duct with ICG cholangiography, we may be able to perform LC with confidence, even in the presence of severe inflammation.

[Gallbladder Malignant Lymphoma Diagnosed after Surgery for Acute Cholecystitis - A Case Report]

An 84-year-old man visited our hospital with epigastralgia.Levels of hepatic and biliary enzymes and CRP were elevated, as detected by a blood test.On a CT scan, a swollen gallbladder with stones was detected.The patient was admitted to the hospital with a diagnosis of Grade I acute cholecystitis.Conservative treatment was continued with antibiotic administration and the patient was discharged from the hospital with improvement on day 6 after admission.Three months later, the patient underwent laparoscopic cholecystectomy.In the gallbladder, a 45×45 mm tumor was found.Upon pathological examination, diffuse proliferation of lymphocyte-like heterotypic cells and subserosal invasion were observed.Immunohistochemistry results were negative for MUM1 and positive for CD10 and Bcl6 markers.A malignant diffuse large B-cell lymphoma was diagnosed.We experienced a case of malignant lymphoma of the gallbladder diagnosed after surgery for acute cholecystitis, which we herein report with literature consideration.

Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum, provoked biliary dilatation and jaundice, and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder, extrahepatic bile duct, and hilar lymph nodes, as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases, the best option may be radical resection following oncological principles performed by expert surgeons, in order that postoperative complications may be minimized if not avoided altogether.

[A Case of Xanthogranulomatous Cholecystitis That Changed Over Time and Was Difficult to Distinguish from Advanced Gallbladder Cancer]

A 70-year-old man was referred because of suspected gallbladder cancer and gallstones. Contrast-enhanced CT, EOB-MRI and PET-CT could not completely rule out gallbladder cancer. The patient preferred follow-up without surgery. At 4 months after initial examination, the gallbladder wall thickening showed improvement, but appeared worse at 9 months after initial examination. Therefore, we decided to perform surgery. Since malignant findings were not observed on rapid intraoperative pathology, we performed a cholecystectomy and right hemicolectomy because of inflammation in the transverse colon. Pathological examination diagnosed xanthogranulomatous cholecystitis. The imaging appearance of xanthogranulomatous cholecystitis varies, and also changes over time, making it difficult to distinguish from advanced gallbladder cancer. We experienced a case of xanthogranulomatous cholecystitis that changed over time, and report this case with a review of the literature.

Right Upper Quadrant Pain: Ultrasound First!

Acute right upper quadrant (RUQ) pain is a common presenting symptom in emergency departments and outpatient medical practices, and is most commonly attributable to biliary and hepatic pathology. Ultrasound should be used as a first-line imaging modality for the diagnosis of gallstones and cholecystitis, as it allows the differentiation of medical and surgical causes of upper abdominal pathology, and in many circumstances is sufficient to guide patient management. Knowledge of strengths and limitations of ultrasound in the evaluation of RUQ is paramount in correct diagnosis. A spectrum of RUQ pathology for which a RUQ ultrasound examination should reasonably be considered as the initial imaging modality of choice will be reviewed.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

AIM

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy.

METHODS

We present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed.

RESULTS

We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve.

CONCLUSION

We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

MR imaging in clinically suspected acute cholecystitis: A comparison with ultrasonography

Purpose: The diagnostic value of fast pulse sequences in MR imaging was compared with US in patients with clinically suspected acute cholecystitis.

Material and Methods: In a prospective study of 94 patients, 35 were examined with both MR and US within 24 h.

Results: MR diagnoses were acute cholecystitis in 23, gallbladder and common bile duct stones in 3, other pathologic conditions of the abdomen in 7 and normal in 2 patients. US diagnoses were acute cholecystitis in 17, gallbladder stones in 8, other pathologic conditions of the abdomen in 2, normal in 5 and non-conclusive in 3 patients.

Conclusion: MR has a higher sensitivity than US for diagnosing acute cholecystitis and, with increased accessibility, may be the first imaging method.

Clinical Importance and Natural History of Biliary Sludge in Outpatients

OBJECTIVES

Gallbladder sludge is a common diagnosis on routine abdominal sonography, yet its clinical importance is uncertain, especially in outpatients. To determine its natural history and potential future complications in this setting, we reviewed the imaging and clinical histories of nonhospitalized patients with a diagnosis of sludge on sonography.

METHODS

We conducted a retrospective search of our institutional radiology information system for all sonographic reports using the key words "biliary sludge without gallstones" over a 3-year period. For each of the 104 patients with isolated biliary sludge on initial sonography, we reviewed the electronic medical records and all imaging for the development of pancreaticobiliary complications.

RESULTS

We found an overall prevalence of biliary sludge in outpatients of 1.8%. Of the 104 patients reviewed with a mean follow up of 630 days (21 months), 25 developed a pancreaticobiliary complication, including cholelithiasis, cholecystitis, choledocholithiasis, and pancreatitis. The most frequent complication was cholecystitis, with a total of 14 diagnoses (12 chronic acalculous and 2 acute with gallstones). An additional 6 patients developed gallstones without cholecystitis features; 4 patients developed pancreatitis; and 1 developed choledocholithiasis. Biliary sludge remained quiescent or resolved in 76% of patients.

CONCLUSIONS

Biliary sludge always represents a pathologic process, but its clinical implications among outpatients have not been previously investigated. Our ambulatory population developed pancreaticobiliary complications at similar rates as prior mixed-patient setting studies. Regardless of the patient setting, biliary sludge is likely of more clinical importance than previously regarded.

Xanthogranulomatous cholecystitis: contrast-enhanced ultrasound features and differential diagnosis from wall-thickening gallbladder carcinoma

OBJECTIVE

The purpose of this study is to evaluate the value of contrast-enhanced ultrasound (CEUS) in differential diagnosis of Xanthogranulomatous cholecystitis (XGC).

MATERIAL AND METHODS

Patients of 17 XGCs and 43 wall-thickening gallbladder carcinomas (GBCs) were enrolled in this study. Firstly, we compared the ability of conventional ultrasound (CUS) and CEUS in detecting gallbladder (GB) features. Secondly, XGCs and GBCs features were compared on CEUS. Finally, all valuable indicators were ranked by Odds ratio.

RESULTS

Significant differences were found in detecting GB wall thickness, GB stones, and hypoechoic nodules frequencies by CEUS and CUS. The mean GB wall thickness was 8.53 mm on CEUS, whereas the thickness measured 9.47 mm on CUS (p=0.011). GB stones and hypoechoic nodules were detected in 43 cases (71.7%) and 21 cases (30.0%) on CEUS, respectively, compared to 29 cases (48.3%) and 8 cases (13.3%) on CUS (p=0.009, p=0.027), respectively. Secondly, hypoenhancement time was longer in XGC (mean 78.9 s) than in GBC (mean 56.0 s) (p=0.002). Diffuse GB wall thickening, continuous inner wall, and hypoechoic nodules in the GB wall were observed in 12 patients (70.6%), 12 patients (70.6%) and 10 patients (58.8%) with XGC, respectively, compared to detection in 10 patients (23.3%), 4 patients (9.3%) and 11 patients (25.6%) by GBC (p=0.001, p=0.000 and p=0.015), respectively. Thirdly, the continuous inner wall was the most valuable indicator, with ORs of 23.4. The second valuable indicator was hypoenhancement time >80.5 s, with ORs of 11.9.

CONCLUSIONS

CEUS demonstrated superior detection of GB wall thickness, GB stone and hypoechoic nodules compared to CUS. A continuous inner wall, hypoenhancement times greater than 80.5 s, diffuse thickening, and hypoechoic nodules were valuable indicators in XGCs.

Sonographic Diagnosis of Complicated Cholecystitis

OBJECTIVES

Early detection of the complications of cholecystitis is important for clinical management, yet only a small percentage of patients have a correct diagnosis before surgery. The purpose of our study was to identify sonographic findings that are associated with complicated cholecystitis.

METHODS

Sonographic, surgical, and pathologic reports were reviewed for 70 patients who underwent early cholecystectomies from January 2010 to August 2014. Sonograms were assessed for 16 independent variables. Statistical analyses were performed to evaluate associations between various sonographic features and complicated cholecystitis.

RESULTS

Sonographic signs associated with complicated cholecystitis (P< .05) were a greater short-axis gallbladder diameter (mean, 4.4 versus 4.0 cm), a greater mean wall thickness (5.6 versus 4.2 mm), and the likelihood of wall striations, gallbladder echogenic content, pericholecystic free fluid, and local inflammatory fat changes. Specific sonographic signs, such as sloughed intraluminal membranes, were detected in a small percentage of cases (10%). None of the sonographic features evaluated in this study was found to be sensitive and specific enough to indicate complicated cholecystitis. In most cases, sonograms reflected severe inflammation, with multiple sonographic signs.

CONCLUSIONS

Although multiple sonographic signs are associated with complicated cholecystitis, none of them is sensitive and specific enough to definitively diagnose it. Sonograms usually reflect severe inflammation, with numerous sonographic signs. Thus, in the right clinical context, sonograms of severe cholecystitis should alert radiologists to the possibility of complications.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: An analysis of 42 cases

AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis (XGC) clinically.

METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma (GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section (FS) analysis and surgical procedure data of these patients were collected and analyzed.

RESULTS: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven (17%) cases presented with mild jaundice without choledocholithiasis. Thirty-five (83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29 (69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40 (95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon’s macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon’s macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups (21% vs 20%, P > 0.05).

CONCLUSION: Neither clinical manifestations and laboratory tests nor radiological methods provide a practical and effective standard in the differential diagnosis between XGC and GBC.

Ultrasonographic Gallbladder Abnormality of Primary Epstein-Barr Virus Infection in Children and Its Influence on Clinical Outcome

The incidence of pediatric acute inflammatory gallbladder (GB) disease without gallstone such as acute acalculous cholecystitis has increased with the development of improved diagnostic modalities. Although Epstein-Barr virus (EBV) infection is common in general population, only few cases of GB diseases caused by EBV infection have been reported. This study analyzed ultrasonographic characteristics of primary EBV infection in children and evaluated the influence of EBV-associated GB disease on clinical course and outcome of EBV infection.Between March 2004 and January 2013, 94 of 287 pediatric patients with EBV infection underwent abdominal ultrasonography (USG); clinical features, laboratory data, and USG findings were collected and analyzed retrospectively.Of 94 children, ultrasonographic thick GB wall was observed in 24 (25.3%). Platelet counts were lower in the thickened GB wall group than in the normal GB wall thickness group (P = 0.004). Direct bilirubin, alanine aminotransferase, and γ-glutamyl transferase levels were higher in the thickened GB wall group (P = 0.000, P = 0.041, and P = 0.001, respectively). The duration of hospitalization was longer in patients with thickened GB wall (P = 0.043).Radiologic findings of acute acalculous inflammatory GB disease such as thickened GB wall caused by primary EBV infection are more common than previously reported. Consideration of EBV infection in the differential diagnosis of children suspected with acute acalculous GB diseases may avoid unnecessary surgical intervention.

Bedside gallbladder ultrasound for the primary care physician

Modern ultrasound machines are relatively inexpensive to own and simple to operate. Basic ultrasound exams can be easily learned and mastered. As with any clinical exam skill, practice makes perfect. Providers interested in learning ultrasound should seek hands-on guidance from an expert in the field. There are several quality hands-on ultrasound courses (http:// emergencyultrasound.com/) as well as free online videos (http:// emergency ultrasound teaching.com/index.html). The emergency ultrasound team at UMMC will be offering a hands-on ultrasound training course in the spring of 2015. Please contact Dr Brian Tollefson for specific dates and times of the course (btollefson@umc.edu).

[Problematic treatment of cholecystitis in a gastric bypass patient after abdominoplasty]

Gastric bypass patients are at risk of late procedure-related complications, e.g. internal hernia or cholecystolithiasis. These complications may be important to identify before other surgical procedures are performed. The treatment of cholecystitis based on cholecystolithiasis in a patient who had recently undergone abdominoplasty may be highly problematic and may lead to an exacerbated situation.

Differential diagnosis of gallbladder wall thickening: the usefulness of contrast-enhanced ultrasound

he purpose of this study was to evaluate the usefulness of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of gallbladder wall (GBW) thickening and determine the predictors of malignant GBW thickening. One hundred fifty-nine patients with GBW thickening, including 76 men and 83 women, from eight institutions were enrolled. CEUS was performed after injection of a sulfur hexafluoride microbubble-based ultrasound contrast agent. Multiple logistic regression analysis was used to reveal independent predictor sassociated with malignant GBW thickening. The final diagnoses were 48 gallbladder carcinomas and 111 benign gallbladder diseases.Maximal thicknesses of the GBW in malignant and benign GB Wthickening were 17.3 ± 5.2 (6 – 30) mm and 8.6 ± 5.1 (4 – 26) mm respectively (p , 0.001). CEUS revealed significant differences in intralesional vessels, enhancement homogeneity, time to hypo-enhancement, inner layer discontinuity, outer layer discontinuity and adjacent liver involvement (all p-values , 0.05) between malignant and benign GBW thickening. Patient age . 46.5 y, focal GBW thickening, inner layer discontinuity and outer layer discontinuity were found to be associated with malignancy by multiple logistic regression analysis (all p-values , 0.05). Receiver operating characteristic curve analysis revealed Az values for patient age, focal GBW thickening, inner wall discontinuity and outer wall discontinuity of 0.709 (95%confidence interval [CI]: 0.627–0.790), 0.714 (95% CI: 0.630–0.798), 0.860 (95%CI: 0.791 – 0.928) and 0.858 (95% CI: 0.783 – 0.933), respectively. CEUS is useful in the differential diagnosis between malignant and benign GBW thickening. Focal GBW thickening, inner wall discontinuity and outer wall discontinuity observed on CEUS are diagnostic clues for malignant GBW thickening.

Hemobilia and other complications caused by percutaneous ultrasound-guided liver biopsy

Hemobilia accounts for approximately 3% of all major percutaneous liver biopsy complications, and rarely results from arterioportal fistula. We report a patient who suffered from four complications over 11 d after ultrasound-guided percutaneous liver biopsy: hemobilia, acute pancreatitis, acute cholecystitis, and multiple stomach ulcers. Digital subtraction angiography was done after consultation with doctors, and showed obvious arteriovenous fistula of the right liver. The hepatic artery was selected and embolized by spring orbs. The active bleeding was stopped after embolization of the hepatic artery. The patient was discharged home on day 12 after embolization and remained well.