DOCSLIB.ORG

Gallbladder Disease: an Update on Diagnosis and Treatment

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Gallbladder Disease: an Update on Diagnosis and Treatment REVIEW DAVID P. VOGT, MD CME General and Liver Transplant Surgery, Transplant CREDIT Center, and Department of General Surgery, The Cleveland Clinic Gallbladder disease: An update on diagnosis and treatment ■ ABSTRACT OR THE MANY PATIENTS who present with F acute or persistent symptoms of gallblad- This paper reviews the clinical presentation of gallstone der disease, current diagnostic techniques and disease, acalculous cholecystitis, biliary dyskinesia, and treatments offer results equal to or better than gallbladder cancer, as well as how to make best use of those of earlier methods, are less invasive, and current diagnostic and treatment methods, particularly allow patients to recover faster. ultrasonography, cholescintigraphy, laparoscopic This paper reviews the evaluation and cholecystectomy, and endoscopic retrograde treatment of gallstones, common bile duct cholangiopancreatography. stones, biliary dyskinesia, gallbladder polyps, and gallbladder cancer. ■ KEY POINTS ■ CHOLELITHIASIS (GALLSTONES) Although 10% to 15% of people in the United States About 20 million people in the United States develop gallstones, fewer than half of those with gallstones (10% to 15% of the adult population) develop have symptoms, and fewer than 10% develop potentially gallstones, and the incidence increases with life-threatening complications. age.1,2 Fewer than 50% of those with gall- stones actually have symptoms, and fewer than Ultrasonography and cholescintigraphy are the most helpful 10% develop potentially life-threatening com- imaging studies for the diagnosis of gallstone disease. plications.1 Cholescintigraphy is 95% accurate in the outpatient diagnosis of acute cholecystitis. Clinical presentations of cholelithiasis Biliary colic. From 60% to 70% of people with symptomatic cholelithiasis experience Laparoscopic cholecystectomy has replaced open episodes of biliary colic,1 typically described as cholecystectomy as the gold standard for treating postprandial epigastric or right upper quadrant symptomatic gallbladder disease. pain, sometimes radiating to the back or up to the right shoulder. The pain may last from sev- Endoscopic retrograde cholangiopancreatography with eral minutes to several hours. Intense pain is sphincterotomy is the standard treatment of patients with often accompanied by nausea and vomiting. common bile duct stones (choledocholithiasis). Occasionally, a patient may insist that the pain is in the left upper quadrant. Many Gallbladder cancer is relatively uncommon but often has a patients also complain of belching, bloating, dismal prognosis. dyspepsia, and flatulence, but unless these symptoms are associated with biliary colic, they are not likely to resolve after cholecystectomy. The physical examination may reveal mild epigastric or right upper quadrant ten- derness, but most patients do not have signif- icant physical findings. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 12 DECEMBER 2002 977 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. GALLBLADDER DISEASE VOGT T ABLE 1 during inspiration often causes such severe discomfort that the patient stops inspiring (a The Ranson criteria positive Murphy sign). Local peritoneal signs for prognosis in acute pancreatitis and fever are common. Signs on admission Gallstone pancreatitis. In 10% to 15% of Age > 55 years patients with symptomatic gallstones, the ini- Serum glucose level > 200 mg/dL tial presentation is a complication such as gall- Serum lactate dehydrogenase level > 350 U/L stone pancreatitis or a common bile duct Aspartate aminotransferase level > 250 U/L stone.3 White blood cell count > 16,000 × 109/L Ninety percent of patients with gallstone Signs 48 hours after admission pancreatitis have a “mild” episode, defined as Hematocrit increase > 10 percentage points having no more than three of the 11 Ranson Blood urea nitrogen increase > 5 mg/dL criteria (TABLE 1).4 The symptoms are similar to Serum calcium < 8 mg/dL those of a severe episode of biliary colic. The Partial pressure of arterial oxygen < 60 mm Hg epigastric or right upper quadrant pain lasts for Base deficit > 4 mEq/L several hours and may be associated with nau- Estimated fluid sequestration > 6 L sea and vomiting. Physical examination usual- Mortality increases with the number of signs present; if fewer than ly reveals epigastric fullness and tenderness, three signs are present, the mortality rate is < 5%; if three or four but no peritoneal signs. For most patients, are present, it is 15% to 20% symptoms improve significantly over 3 to 4 days with supportive therapy alone. ADAPTED FROM RANSON JHC, RIFKIND KM, ROSES DF, FINK SD, ENG K, SPENCER FC. PROGNOS- TIC SIGNS AND THE ROLE OF OPERATIVE MANAGEMENT IN ACUTE PANCREATITIS. Patients with common bile duct stones SURG GYNECOL OBSTET 1974; 139:69–81. often have jaundice and fever in addition to pain. The pain of biliary colic is from contrac- Laboratory tests for cholelithiasis tion of the gallbladder, which cannot empty Laboratory tests should include a complete Biliary colic is because the cystic duct is obstructed by a blood count, liver function tests, and serum intermittent; stone. The gallbladder is stimulated to con- amylase and lipase levels. tract primarily by cholecystokinin, which is In chronic, episodic biliary colic, most acute released from the small bowel mucosa. The patients have normal laboratory values, partic- cholecystitis is pain resolves after the gallbladder stops con- ularly if they have no symptoms at the time of tracting or when the cystic duct becomes their office visit. However, patients with acute persistent patent again. pain at the time of evaluation may have ele- Acute cholecystitis is the initial presenta- vated levels of liver enzymes (aspartate amino- tion of symptomatic gallstones in 15% to 20% transferase, alanine aminotransferase, alkaline of patients.3 phosphatase) and bilirubin, particularly if bile Patients with acute cholecystitis experi- duct stones are present. ence severe pain that persists for several hours, In gallstone pancreatitis, patients have until they finally seek help at a local emer- elevated levels of both serum amylase and gency room. lipase, as well as abnormal liver function tests. Whereas in biliary colic the cystic duct In acute cholecystitis, leukocytosis obstruction is transient, in acute cholecystitis should be expected, and up to 15% of patients it is persistent. Persistent cystic duct obstruc- may have mild elevations of aspartate amino- tion, in combination with chemical irritants transferase, alanine aminotransferase, alkaline in the bile, results in inflammation and edema phosphatase, and bilirubin if the stone is not of the gallbladder wall. Nausea and vomiting in the common bile duct. are common. Physical examination usually reveals Imaging studies for cholelithiasis marked tenderness in the right upper quad- Ultrasonography and cholescintigraphy are rant, often associated with a definite mass or the imaging studies most helpful and most fullness. Palpation of the right upper quadrant often used in the diagnosis of gallstone disease. 978 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 12 DECEMBER 2002 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. ■ Ultrasonography aids the diagnosis of gallstones Key findings of acute cholecystitis Thickened gallbladder wall include a thickened gallbladder wall and the presence of pericholecystic fluid Stone in cystic duct Ultrasonic image of stones in the gallbladder Multifaceted stones in the gallbladder Common bile duct Pancreatic duct Distal common bile duct stone Ampulla Ultrasonic image of stones in the common bile duct CCF ©2002 FIGURE 1 Ultrasonography is safe, fast, and relatively Cholescintigraphy is accurate in diagnos- inexpensive and involves no radiation expo- ing acute cholecystitis in ambulatory patients sure. It is the study of choice for patients with more than 95% of the time.6,7 When com- suspected biliary colic. Positive findings include bined with cholecystokinin injection, it is stones, thickening of the gallbladder wall, peri- helpful in assessing patients with possible bil- cholecystic fluid, and a positive Murphy sign on iary dyskinesia.8 contact with the ultrasonographic probe5 (FIG- Cholescintigraphy provides the function- URE 1). The latter three findings are particularly al information that the cystic duct is obstruct- indicative of acute cholecystitis. ed, which is a necessary component in the A drawback to ultrasonography is that it pathogenesis of calculous cholecystitis. How- is only as accurate as the person who performs ever, it has a false-positive rate of 30% to 40% and interprets it. in patients who have been hospitalized for CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 69 • NUMBER 12 DECEMBER 2002 979 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. GALLBLADDER DISEASE VOGT other medical problems for several weeks, par- These patients should undergo laparo- ticularly if they have been on parenteral nutri- scopic cholecystectomy with intraoperative tion. In these patients, ultrasonography is cholangiography within a month to prevent more accurate.5 further episodes of pancreatitis. They should Computed tomography is not as accurate not undergo preoperative ERCP, as it may as ultrasonography in detecting gallstones and exacerbate the pancreatitis.9 If bile duct is therefore not a good screening study in
Load more

Recommended publications
  • April Is IBS Awareness Month
    4/19/2021 Irritable Bowel Syndrome (IBS) in Women: Today’s approach Kathryn Hutchins, MD Assistant Professor University of Nebraska Medical Center Division of Gastroenterology & Hepatology Irritable Bowel Syndrome • No disclosures April is IBS awareness month Objectives Define Irritable Bowel Syndrome (IBS) including its subtypes Describe the current criteria and diagnostic approach for IBS Discuss the management approach to IBS 1 4/19/2021 Clinical Scenarios • 18 y/o female reports longstanding history of GI troubles. She comes to clinic because she is having bouts of diarrhea. Diarrhea is most often when she is nervous or stressed. Diarrhea is more common in the days prior to having her period. Imodium helps to slow the diarrhea • 38 y/o female reports bloating and discomfort most days and especially after eating. She reports having a bowel movement once every 3‐4 days and typically stools are small balls. Bowel movements alleviate bloating. When she travels, she is especially miserable with constipation and bloating. • 41 y/o female with 2 year history of RUQ abdominal pain and frequent loose stools. Gallbladder removed years earlier for different symptoms. Evaluation has included EGD, colonoscopy, endoscopic ultrasound, ERCP x 2 with stent placement and subsequent removal. Countless appointment with evaluations in 3 different states. Irritable Bowel Syndrome defined • IBS is one of the functional gastrointestinal disorders (FGID). Functional bowel disorders (FBD) are FGID of the lower GI tract. • The FGID are also referred to disorder of the brain –gut interaction (DBGI). • IBS is a common of disorders of the brain –gut axis • Chronic symptoms of abdominal pain, bloating, diarrhea, and constipation • No identified structural or lab abnormality to account for recurring symptoms*** Gastroenterology 2020;158:1262–1273 Disorders of the Brain –Gut Interaction Functional Gastrointestinal Disorders Functional Bowel Disorders 2 4/19/2021 How common and who does it affect Clinical visits • 12% of primary care visits.
    [Show full text]
  • Gallbladder Disease in Children
    Seminars in Pediatric Surgery 25 (2016) 225–231 Contents lists available at ScienceDirect Seminars in Pediatric Surgery journal homepage: www.elsevier.com/locate/sempedsurg Gallbladder disease in children David H. Rothstein, MD, MSa,b, Carroll M. Harmon, MD, PhDa,b,n a Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222 b Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York article info abstract Biliary disease in children has changed over the past few decades, with a marked rise in incidence— — Keywords: perhaps most related to the parallel rise in pediatric obesity as well as a rise in cholecystectomy rates. In Cholelithiasis addition to stone disease (cholelithiasis), acalculous causes of gallbladder pain such as biliary dyskinesia, Biliary dyskinesia also appear to be on the rise and present diagnostic and treatment conundrums to surgeons. Pediatric biliary disease & 2016 Elsevier Inc. All rights reserved. Gallbladder Acalculous cholecystitis Critical view of safety Introduction In these patients, the etiology of the gallstones is supersaturation of bile due to excess cholesterol, and this variety is the most The spectrum of pediatric biliary tract disease continues to common type of stone encountered in children today. The prox- change. Although congenital and neonatal conditions such as imate cause of cholesterol stones is bile that is saturated with biliary atresia and choledochal cysts remain relatively constant,
    [Show full text]
  • Diseases of the Gallbladder
    Curtis Peery MD Sanford Health Surgical Associates Sioux Falls SD 605-328-3840 [email protected] Diseases of the Gallbladder COMMON ISSUES HEALTH CARE PROVIDERS WILL SEE!!! OBJECTIVES Discuss Biliary Anatomy and Physiology Discuss Benign Biliary disease Identify and diagnose common biliary conditions Clinical Scenarios Update in surgical treatment Purpose of Bile Aids in Digestion Bile salts aid in fat and fatty vitamin absorption Optimizes pancreatic enzyme function Eliminates Waste Cholesterol Bilirubin Inhibits bacterial growth in small bowel Neutralizes stomach acid in the duodenum Biliary Anatomy Gallbladder Function Storage for Bile Between Meals Concentrates Bile Contracts after meals so adequate bile is available for digestion CCK is released from the duodenum in response to a meal which causes the gallbladder to contract Gallbladder Disease Gallstones- Cholesterol or pigment stones from bilirubin Cholelithiasis- gallstones in the gallbladder Biliary colic- pain secondary to obstruction of the gallbladder or biliary tree Choledocholithiasis – presence of a gallstone in the CBD or CHD Cholecystitis- Inflammation of the gallbladder secondary to a stone stuck in the neck of the gallbladder Cholangitis- infection in the biliary tree secondary to CBD stone(May result in Jaundice) Gallstone Pancreatitis- pancreatitis secondary to stones passing into the distal CBD Biliary dyskinesia- disfunction of gallbladder contraction resulting in biliary colic GALLSTONES Typically form in the gallbladder secondary
    [Show full text]
  • Clinical Management of Gastroesophageal Reflux Disease
    Osteopathic Family Physician (2011) 3, 58-65 Clinical management of gastroesophageal reflux disease Renata Jarosz, DO,a Thomas G. Zimmerman, DO, FACOFP,b Daniel Van Arsdale, DOc From aStanford Hospital Physical Medicine and Rehabilitation Residency Program, Redwood City, CA, bSouth Nassau Family Medicine, Oceanside, NY, and cSouthampton Hospital, Southampton, NY. KEYWORDS: Gastroesophageal reflux disease (GERD) is a common problem that occurs in both adult and pediatric Gastroesophageal; populations and can significantly degrade patients’ quality of life and lead to life-threatening complications. Reflux; A prudent course of management in a patient with classic GERD symptoms would be to empirically Disease; prescribe lifestyle modifications and a proton pump inhibitor (PPI) for six to eight weeks. Osteopathic GERD; manipulative treatment may also be a useful adjunct. If the patient is unable to afford a PPI, a histamine Current; type-2 receptor antagonist may be substituted (although they are much less effective). If resolution of Treatment; symptoms occurs, the therapeutic response can confirm the diagnosis of uncomplicated GERD. If the patient Diagnosis; has recurrent or intractable symptoms, the next step would be to order pH monitoring, manometry, or Management; endoscopic evaluation of the esophagus and stomach (esophagogastroduodenoscopy [EGD]). If there are Osteopathic; any atypical symptoms such as persistent cough, asthma, melena, sore throat, or hoarse voice, EGD should Manipulative; be ordered immediately. Patients with chronic esophagitis or extra-esophageal symptoms who have failed Treatment; (or refused) medical management should consider fundoplication. OMT; © 2011 Elsevier Inc. All rights reserved. Barrett; Medical; Medications Gastroesophageal reflux disease (GERD) is a common evaluate and manage GERD. Table 1 outlines some key points problem that occurs in both adult and pediatric populations in of information for readers to consider.
    [Show full text]
  • Sphincter of Oddi: ERCP Plus Sphincterotomy – Yes Or No
    Sphincter of Oddi: ERCP Plus Sphincterotomy – Yes or No Note: For debate purposes, the pro and con positions for patient management will be taken by the invited authors. However, actual decisions regarding patient care must involve discussion of the risks and benefits of each treatment considered. Case Presentation – Case developed by Ihab I. El Hajj, MD, MPH, Indiana University, Indianapolis, IN A 57-year-old Caucasian female with history of smoking and COPD, was in her usual state of health until two years ago, when she experienced recurrent “attacks” of right upper quadrant pain, nausea and occasional vomiting, suggestive of biliary colic. The patient was evaluated by her primary care physician and initial work- up, which included basic blood work, liver chemistries and transabdominal ultrasound, were negative. The patient responded partially to prn Zofran and omeprazole 40 mg once then twice daily. With the persistence of her symptoms, the patient was referred to a gastroenterologist. Esophagogastroduodenoscopy (EGD) with gastric biopsies revealed chronic inactive gastritis without Helicobacter pylori. HIDA scan suggested biliary dyskinesia with an ejection fraction of 22%. An elective laparoscopic cholecystectomy was performed. An intra- operative cholangiogram showed no filling defect in the common bile duct (CBD) and pathology demonstrated chronic cholecystitis with no gallstones. The patient was symptom-free for six months after surgery. She subsequently developed vague upper abdominal pain, intermittent nausea and irregular bowel movements. Labs, colonoscopy and repeat EGD were ASGE Leading Edge — Volume 4, No. 4 © American Society for Gastrointestinal Endoscopy normal. The patient was treated for suspected irritable bowel syndrome. She failed several medications including hyoscyamine, dicyclomine, amitriptyline, sucralfate, and GI cocktail.
    [Show full text]
  • Gallbladder Disease in the Aged Patient- a Comprehensive Diagnosis and Treatment Approach
    Review Article Adv Res Gastroentero Hepatol Volume 8 Issue 1 - November 2017 Copyright © All rights are reserved by Zvi Perry DOI: 10.19080/ARGH.2017.08.555730 Gallbladder Disease in the Aged Patient- A Comprehensive Diagnosis and Treatment Approach Sharon Ziskind1, Uri Netz2, Udit Gibor2, ShaharAtias2, Leonid Lantsberg2 and Zvi H Perry1,2* 1Soroka University Medical Center, Israel 2Department of Epidemiology and Health Management, Ben-Gurion University of the Negev, Israel Submission: September 01, 2017; Published: November 22, 2017 *Corresponding author: Zvi Perry, MD, MA, Surgical Ward A, Soroka University Medical Center PO Box 151, Beer-Sheva 64101, Israel, Tel: +972-8-6400610; Fax: +972-8-6477633; Email: Abstract The improvements in life expectancy combined with aging of the baby boomer generation will result in a rapid increase in the population older than 65 years in the next few decades, and thus an increase in the need to take care of elderly patients. The authors of this chapter were born and raised in Israel, a country in which due to the holocaust and the fact it was a young nation, was not accustomed to elderly patients. But, in the last decade the percentage of patients older than 65 has crossed the 10% mark of the entire population and we were forced to learn elderly patients and the know how in treating them is not the same as the 30 years old patient. It is important to do so, because It is expected and to find ways to care and treat older patients. As the saying in pediatrics, that a child is not a small adult, the same rule applies seemingly to that by 2030 one in five people will be older than 65 years, with the most rapidly growing segment of this older population being persons older than 85.
    [Show full text]
  • Gastroesophageal Reflux Disease
    The new england journal of medicine clinical practice Gastroesophageal Reflux Disease Peter J. Kahrilas, M.D. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastroin- testinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment? The Clinical Problem From the Division of Gastroenterology, Gastroesophageal reflux disease is the most common gastrointestinal diagnosis re- Feinberg School of Medicine, Chicago. Ad- corded during visits to outpatient clinics.1 In the United States, it is estimated that dress reprint requests to Dr. Kahrilas at the Feinberg School of Medicine, 676 St. Clair 14 to 20% of adults are affected, although such percentages are at best approxima- St., Suite 1400, Chicago, IL 60611-2951, tions, given that the disease has a nebulous definition and that such estimates are or at [email protected]. based on the prevalence of self-reported chronic heartburn.2 A current definition of N Engl J Med 2008;359:1700-7. the disorder is “a condition which develops when the ref lux of stomach contents causes Copyright © 2008 Massachusetts Medical Society. troublesome symptoms (i.e., at least two heartburn episodes per week) and/or complications.”3 Several extraesophageal manifestations of the disease are well rec- ognized, including laryngitis and cough (Table 1).
    [Show full text]
  • Cholecystitis
    Cholecystitis Information for patients This leaflet can be made available in other formats including large print, CD and Braille and in languages other than English, upon request. This leaflet tells you about cholecystitis. What is cholecystitis? Cholecystitis is the medical term for inflammation (swelling and redness) of the gallbladder. The gallbladder is a small sac, 3 - 4 inches, (7.5 - 10 cm) long. It lies under your ribs at the front on your right hand side, below your liver and above your small bowel. The gallbladder is connected to the liver by the bile duct (small tube). See diagram below. What does the gallbladder do? The gallbladder stores bile (a yellow / green fluid) which is produced by the liver. Bile helps digest the food you eat, especially fatty food. After eating a meal, your gallbladder contracts (squeezes) and pushes bile into your bile duct (see diagram) and then into your duodenum (small bowel) to help the digestion of your food. It is not a vital organ and it can be surgically removed if it causes problems. Surg/107.4 (2017) Page 1 of 6 For Review Spring 2020 Cholecystitis What causes cholecystitis? Inflammation of the gallbladder is often caused when gallstones irritate the gallbladder and sometimes cause an infection. Gallstones are formed in the gallbladder or bile duct and develop when bile forms crystals. Over time these crystals become hardened and eventually grow into stones but they do not always cause problems. However, gallstones can cause: jaundice. If the stones move from your gallbladder and block your bile duct jaundice can occur.
    [Show full text]
  • ACR Appropriateness Criteria® Right Upper Quadrant Pain
    Revised 2018 American College of Radiology ACR Appropriateness Criteria® Right Upper Quadrant Pain Variant 1: Right upper quadrant pain. Suspected biliary disease. Initial imaging. Procedure Appropriateness Category Relative Radiation Level US abdomen Usually Appropriate O CT abdomen with IV contrast May Be Appropriate ☢☢☢ MRI abdomen without and with IV May Be Appropriate contrast with MRCP O MRI abdomen without IV contrast with May Be Appropriate MRCP O Nuclear medicine scan gallbladder May Be Appropriate ☢☢ CT abdomen without IV contrast May Be Appropriate ☢☢☢ CT abdomen without and with IV Usually Not Appropriate contrast ☢☢☢☢ Variant 2: Right upper quadrant pain. No fever or high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound. Procedure Appropriateness Category Relative Radiation Level MRI abdomen without and with IV Usually Appropriate contrast with MRCP O CT abdomen with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without IV contrast with Usually Appropriate MRCP O Nuclear medicine scan gallbladder May Be Appropriate ☢☢ CT abdomen without IV contrast May Be Appropriate ☢☢☢ CT abdomen without and with IV Usually Not Appropriate contrast ☢☢☢☢ Variant 3: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Procedure Appropriateness Category Relative Radiation Level MRI abdomen without and with IV Usually Appropriate contrast with MRCP O CT abdomen with IV contrast Usually Appropriate ☢☢☢ Nuclear medicine scan gallbladder Usually Appropriate ☢☢ MRI abdomen without IV contrast with May Be Appropriate MRCP O CT abdomen without IV contrast May Be Appropriate ☢☢☢ CT abdomen without and with IV Usually Not Appropriate contrast ☢☢☢☢ ACR Appropriateness Criteria® 1 Right Upper Quadrant Pain Variant 4: Right upper quadrant pain.
    [Show full text]
  • Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement
    Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement Harvey A. Ziessman, MD; Douglas A. Jones, MD; Larry R. Muenz, PhD; and Anup K. Agarval, MS Department of Radiology, Georgetown University Hospital, Washington, DC Fatty meals have been used by investigators and clini- The purpose of this investigation was to evaluate the use of a cians over the years to evaluate gallbladder contraction in commercially available lactose-free fatty-meal food supple- conjunction with oral cholecystography, ultrasonography, ment, as an alternative to sincalide cholescintigraphy, to de- and cholescintigraphy. Proponents assert that fatty meals velop a standard methodology, and to determine normal gall- are physiologic and low in cost. Numerous different fatty bladder ejection fractions (GBEFs) for this supplement. meals have been used. Many are institution specific. Meth- Methods: Twenty healthy volunteers all had negative medical histories for hepatobiliary and gallbladder disease, had no per- odologies have differed, and few investigations have stud- sonal or family history of hepatobiliary disease, and were not ied a sufficient number of subjects to establish valid normal taking any medication known to affect gallbladder emptying. All GBEFs for the specific meal. Whole milk and half-and-half were prescreened with a complete blood cell count, compre- have the advantage of being simple to prepare and admin- hensive metabolic profile, gallbladder and liver ultrasonography, ister (4–7). Milk has been particularly well investigated. and conventional cholescintigraphy. Three of the 20 subjects Large numbers of healthy subjects have been studied, a were eliminated from the final analysis because of an abnormal- clear methodology described, and normal values determined ity in one of the above studies.
    [Show full text]
  • The Spectrum of Gallbladder Disease
    The Spectrum of Gallbladder Disease Rebecca Kowalski, M.D. October 18, 2017 Overview A (brief) history of gallbladder surgery Anatomy Anatomical variations Physiology Pathophysiology Diagnostic imaging of the gallbladder Natural history of cholelithiasis Case presentations of the spectrum of gallstone disease Summary History of Gallbladder Surgery Gallbladder Surgery: A Relatively Recent Change Prior to the late 1800s, doctors treated gallbladder disease with a cholecystostomy, due to the fear that removing the organ would kill patients Carl Johann August Langenbuch (director of the Lazarus Hospital in Berlin, Germany) practiced on a cadaver to remove the gallbladder, and in 1882, performed a cholecystectomy on a patient. He was discharged after 6 weeks in the hospital https://en.wikipedia.org/wiki/Carl_Langenbuch By 1897 over 100 cholecystectomies had been performed Gallbladder Surgery: A Relatively Recent Change In 1985, Erich Mühe removed a patient’s gallbladder laparoscopically in Germany Erich Muhe https://openi.nlm.ni h.gov/detailedresult. php?img=PMC30152 In 1987, Philippe Mouret (a 44_jsls-2-4-341- French gynecologic surgeon) g01&req=4 performed a laparoscopic cholecystectomy In 1992, the National Institutes of Health (NIH) created guidelines for laparoscopic cholecystectomy in the United Philippe Mouret States, essentially transforming https://www.pinterest.com surgical practice /pin/58195020154734720/ Anatomy and Abnormal Anatomy http://accesssurgery.mhmedical.com/content.aspx?bookid=1202&sectionid=71521210 http://www.slideshare.net/pryce27/rsna-final-2 http://www.slideshare.net/pryce27/rsna-final-2 http://www.slideshare.net/pryce27/rsna-final-2 Physiology a http://www.nature.com/nrm/journal/v2/n9/fig_tab/nrm0901_657a_F3.html Simplified overview of the bile acid biosynthesis pathway derived from cholesterol Lisa D.
    [Show full text]
  • The Diagnosis of Acute Cholecystitis: Sensitivity of Sonography
    The Diagnosis of Acute Cholecystitis: Sensitivity of Sonography, Cholescintigraphy and Computed Tomography Patthisak Changphaisarnkul MD*, Supakajee Saengruang-Orn PhD*, Trirat Boonya-Asadorn MD* * Division of Radiology, Phramonkutklao Hospital, Bangkok, Thailand Objective: To compare the sensitivity of sonographic, cholescintigraphic, and computed tomographic examination of acute cholecystitis to the pathology result, which is considered the Gold Standard. Material and Method: A retrospective analytic study was conducted among 412 patients, aged between 15 and 98 years, who underwent cholecystectomy surgeries, and whose pathology results indicated acute cholecystitis between July 2004 and May 2013. The sensitivity and the differences between sensitivity of the three methods were calculated in all patients. Complicated acute cholecystitis cases were analyzed separately. Results: The three methods demonstrated statistically significant differences in sensitivity (p-value = 0.017), with the cholescintigraphy as the most sensitive method (84.2%), followed by computed tomography (67.3%), and sonography (59.8%). Concerning the samples with the pathology result indicating complicated acute cholecystitis, computed tomography was statistically significantly more sensitive than sonography in detecting acute cholecystitis, whether or not the complications were identified (100% and 63.6%, respectively, with p-value = 0.0055). None of the patients with the pathology result of complicated acute cholecystitis case was examined by cholescintigraphy, thus, no calculation was possible. Regarding the ability to detect the complications of acute cholecystitis, computed tomography had a sensitivity of 35.71% (5 in 14 patients), while sonographic examinations could not detect any of the complications. Conclusion: Cholescintigraphy is a more sensitive method than computed tomography and sonography, but the three methods have its own advantages, disadvantages, and limitations, which must be considered for each individual patient.
    [Show full text]