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Gallbladder agenesis is a rare congenital entity. The incidence is around 1 per 6500 live births. Around 50-70% patients are asymptomatic and the rest are symptomatic with symptoms mimicking biliary colic. Right upper quadrant ultrasound (US) is usually either misleading or inconclusive. Also advanced diagnostic studies such as hepatobiliary iminodiacetic acid (HIDA) scan and endoscopic retrograde cholangio-pancreatography (ERCP) may show non- visualization of the gallbladder and erroneously lead providers to a diagnosis of cystic duct obstruction rather than Gallbladder Agenesis. So some patients are only finally diagnosed intraoperatively. Surgery in these patients becomes risky because unnecessary dissection while looking for the non-existent gallbladder can result in injury of the biliary tree, hepatic vasculature, or small bowel. Therefore, clinicians should keep Gallbladder Agenesis on their differential diagnosis list and imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) should be obtained when other tests are inconclusive. We report a 48-year-old female presenting with chronic symptoms consistent with biliary colic and an equivocal US reported as cholelithiasis. She underwent laparoscopy during which the absence of the gallbladder was noted.
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Background: Epithelial-mesenchymal transition (EMT) is the heart of invasion. EMT associated with cancer progression and metastasis is known as type III EMT. Beta-catenin, E-cadherin, and MMP9 markers of EMT are routinely employed for diagnostic purposes. Aims: We employed these markers to study EMT by immunohistochemistry (IHC) in gall bladder cancer (GBC) with respect to depth of tumor invasion, clinical outcome, and disease-free survival. Settings and Design: This was a prospective case-control study. Material and Methods: Seventy gall bladders were included (50 GBC and 20 CC). After detailed histology, immunoexpression was studied in terms of percentage and strength of expression. Statistics Analysis Used: Expression was compared between CC and GBC by Student t test and analysis of variance. Kaplan–Meier was used for survival analysis, and the extent of agreement (“Kappa”) was calculated. Results and Conclusions: The age of incidence of GBC was 49.40 (+11.6) years with female predominance (F:M = 4:1). In 88% (44/50) of GBC, the fundus was involved. Moderately differentiated adenocarcinoma was most frequent [54%; 27/50]. Significant downregulation of E-cadherin (P = 0.022) and beta-catenin (P < 0.001) and upregulation in MMP9 (P < 0.001) were seen in GBC with respect to CC with significant association among them. MMP9 expression was significantly associated with higher tumor stage but with chemotherapeutic response. Our results display that epithelial-mesenchymal transition type III plays a role in GBC invasion. MMP9 overexpression and loss of membranous beta-catenin may be considered a marker for poor clinical outcomes and advanced disease.
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Hepatobiliary ascariasis is found in subtropical or tropical countries and is prevalent geo-helminth infection. Ascariasis lumbricoides are found mainly in the small intestine. Rarely the worm may migrate to the pancreatic duct or common bile duct but rarely to the gallbladder due to cystic duct which is strait and tortuous. The gall bladder ascaris can cause obstructive features due to lithiasis or calcified worms. The management is usually conservative if the worm is alive or else it can be removed by surgery
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Background: The present study evaluated the correlation of hepatobiliary toxicity and radiation dose received in patients undergoing neoadjuvant chemoradiotherapy (NACRT) for locally advanced unresectable gall bladder cancers (LAGBC). Methods: Twenty-six patients with LAGBC, treated with NACRT (55–57 Gy/25 fractions/5 weeks and weekly gemcitabine 300 mg/m2) within a phase II study, were included. Whenever feasible, surgery was performed after NACRT. Acute and late hepatobiliary toxicity was recorded. Treatment scans were retrieved to delineate central porto-hepatobiliary system (CPHBS), resected liver surface, segment IV B and V, and duodenum. The doses received by these structures were recorded and correlated with toxicity. Results: Of 26 patients, 20 (77%) had partial or complete response and 12 (46%) had R0 resection. At the median follow-up of 38 months, overall survival was 38%. Eight (30%) patients had post-treatment toxicity, of which most common was biliary toxicity (30%). A correlation was observed between the biliary leak and V45Gy CPHBS >50 cm3 (P = 0.070). Higher toxicity was observed in those with metallic stents (P = 0.072). Conclusion: The incidence of the biliary leak was 46%. CPHBS dose was found to correlate with biliary leaks. Restricting V45Gy CPHBS <50 cm3 and using plastic stent may facilitate a reduction in hepatobiliary toxicity in patients undergoing NACRT and surgery.
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Background : Gall Bladder is the most commonly resected organ for various Pathological conditions and most common specimen received in the laboratory. Cholelithiasis is the most common cause of Cholecystectomy. Association of Cholelithiasis and Gall Bladder Carcinoma is strong. Gall Bladder Adenocarcinoma is a rare malignant tumor with incidious onset, rapid local invasion and progression. The frequency of incidental Carcinoma of Gall Bladder is also increasing and is estimated between 0.2% to 2.8%. Objectives of this study is to determine the various Gall Bladder lesion and detection of incidental Carcinoma in routine Histopathological study of Cholecystectomy specimens in 30-60 years age group. Materials and Methods : Total 556 Cholecystectomy cases were enrolled in the study and it was done for a period of one year from August, 2015 to July, 2016. The specimens received were fixed in 10% formalin and were examine grossly and processed routinely. Sections were stain with Haematoxiline and Eosine stain and Microscopic findings were noted. Results : out of 556 cases 124 were male 432 were female with M:F = 1:3.5. Most commonly affected age group is 30-40 years. Non-neoplastic (98.6%) cases are more than Neoplastic (1.4%) cases. Among Non-neoplastic cases most common Histopathological diagnosis was Chronic Cholecystitis (83.4%). All Neoplastic cases were malignant tumors involving the age group 40-60 years (P=0.04) and M:F=1:7. Histopathologically all were Adenocarcinoma. Prevalence of Gall Bladder Carcinoma was 1.4% and prevalence of incidental Carcinoma was 0.89%. Conclusion : Routine Histopathological analysis of all Gall Bladderr specimens after Cholecystectomy operation is mandatory for detection of various Pathological conditions and diagnosis of Gall Bladder Carcinoma specifically incidental Carcinoma which help in proper management the cases. However more studies with large numbers of cases are recommended for evaluation of incidence of incidental Carcinoma
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Heterotopic pancreatic tissue in the gall bladder is a very uncommon lesion. In most cases, it is an incidental finding. The placement of pancreatic tissue in an organ outside the pancreas is called pancreatic heterotopy. Heterotopic pancreas is commonly found in the stomach, small intestine, and Meckel’s diverticulum. It has rarely been seen in the gall bladder, bile duct, splenic hilum, or liver. We present a case of incidentally discovered heterotopic pancreatic tissue in a case of acute cholecystitis in a 63-years-old lady having a history of pain in the right hypochondriac region
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Background: Gallstone is the most common disease of the gallbladder. The prevalence of gallstone disease varies with age, sex and ethnic group. Laparoscopic cholecystectomy is the treatment of choice done routinely for gallstone disease. Usually, the diagnosis given in most of the cholecystectomy specimens is quite straight forward; that is, chronic cholecystitis. Very rarely cholecystectomy specimen may reveal an unexpected gallbladder carcinoma This Methods: study is a hospital based retrospective study conducted in tertiary care hospital of Nagpur, Orange city hospital over a period of 5 years from 2017 to 2021. Clinical details and histopathology reports were obtained from surgery and pathology departments of hospital. Total 168 cholecystectomies were performed in 5 years. Results: During five year period 168 cholecystectomies were performed. Maximum number of patients were between 40-50 years ( 40.47%). There were 19% males and 81% females. Chronic cholecystitis was the predominant diagnosis (91%), followed by acute on chronic cholecystitis (4.7%), Gangrenous cholecystitis (2.3%) and adenocarcinoma of gall bladder (1.7%). Histopathological s Conclusions: pectrum of gall bladder specimen is extremely variable with chronic cholecystitis is most common diagnosis and prevalent in middle age female gender. Incidence of carcinoma is 1.7% in our study. Despite advances in diagnostic and surgical modalities, gallbladder cancer is still characterized by late diagnosis and poor prognosis except when incidentally diagnosed at an early stage after cholecystectomy for cholelithiasis. Hence, the histopathological examination of every cholecystectomy specimen is of utmost importance
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Background : Gall Bladder Polyps are mucosal lesions that project from the Gall Bladder wall into the Gallbladder lumen. They form morphologically distinct lesion/s with internal characteristics different than that of neighboring structures as verified by microscopic examination. About 4-6% are picked up clinically, 2-12% in Cholecystectomy specimens and 4% on Ultrasound. Materias and Methods : A three calendar year retrospective single surgical unit study compromised of 1442 cholecystectomies performed for benign Gall Bladder Disease. The patient were subjected to Ultrasound of abdomen for diagnosis and routine clinic work up. The Gall Bladders Harboring Polyps were examined grossly for site ,number, and microscopy for histological details. Results : In a total number of 40 cases of Gall Bladder Polyp, females outnumbered males. This series spreads over age groups of 3rd decade - 9th decade, most of the patients were seen in 6th decade of life. Youngest patients were 27 years old and oldest one was 85 years old. Incidentally, none of the old patients had evidence of malignancy on histopathology in their Gall Badder Polyp, only 2% were necessitated for a pre-operative diagnosis of Gall Bladder Polyps alone. Rest required it for presence of Gallstones with or without Polyp. None of >10mm size showed any malignant change on histopathological examination. On the Contrary, among the polypoid lesions <10mm size, one polypid lesion (7mm) showed a malignant change (Carcinoma in situ) Conclusion : A predictive model for neoplastic potential of Gall Bladder Polyp may support clinical decision to achieve an ideal therapeutic outcome. Hence a need for reappraisal of management guidelines.
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Background: Laparascopic cholecystectomy is one of the commonly performed surgery and is the procedure of choice for gall bladder disease. Time to time advancements are being made in this procedure to ease this surgery and also decrease its complication rate. And with the same purpose, a special technique named as 揊lip Technique� has been introduced in which, in order to make the dissection of gall bladder easier near the fundus, the gall bladder is flipped over the liver surface after initial dissection of the gall bladder from the liver bed. The study to find out the feasibility of this flip technique of gall bladder removal in laparoscopic cholecystectomy was done in 100 patients admitted in department of general surgery, Govt Medical College and Rajindra Hospital, Patiala. Aim: This study aims to evaluate the feasibility of Flip technique for dissection of gall bladder from the liver bed in laparoscopic cholecystectomy with regard to operative time, intraoperative bleeding, bile duct injury, liver bed injury, injury to gall bladder wall, duration of hospital stay and mortality (if any).Methods:The present study was prospective, observational and comparative trial and was conducted on 100 patients of either sex diagnosed as case of GBD and planned for laparoscopic cholecystectomy, admitted in surgical ward of Rajindra Hospital, Patiala.Results:Latrogenic GB rupture occurred in 2% of patients in group A (cases) and 12% of patients in group B (control). The difference was statistically significant (p value 0.05). Site of rupture in group A is fundus of gall bladder in 2% of patients and none of gall bladder rupture is seen at body or Hartman抯 pouch. In group B gall bladder rupture was found at fundus in 6% of patients, at body in 4% patients and Hartman抯 pouch in 2% of patients.Conclusions:The use of Flip technique was more advantageous as compared to standard method of gall bladder dissection from liver bed in laparoscopic cholecystectomy with the mean duration of surgery being shorter in Flip technique.
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Septate gallbladder is a rare congenital anomaly, which can present a challenge for the surgeon who performs laparoscopic cholecystectomy. The common first line modality for screening in symptomatic gallbladder pathology is still ultrasonography. Preoperative diagnosis of this anomaly is not common. Pre- operative diagnosis and being acquainted with this anomaly decreases the possibility of injury to the biliary tract, the number of postoperative complications and the possible need for further surgical procedures. We present a case of septate gallbladder, which was diagnosed during the operative procedure. Despite the finding of a septate gallbladder, the performance of laparoscopic cholecystectomy was uneventful.
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Background: Laparoscopic cholecystectomy is a well-established procedure for gallbladder disease. Pain in laparoscopic cholecystectomy is associated with multiple factors: somatic, visceral, and phrenic nerve irritation. Effective analgesic support should, therefore, be a multimodal approach following laparoscopic surgery for better patient compliance.Methods: A prospective, randomized observational study was undertaken at a tertiary research center for a period of two years (2018-2020). 160 patients undergoing laparoscopic cholecystectomy were chosen and randomized using a computer program into 2 groups. No infiltration was given in the control population. The study group was irrigated with a 0.5% bupivacaine solution (20cc in 30 ml normal saline).Results: The bupivacaine group required fewer analgesics in comparison to the control faction, with less pain at 6 hrs. The timing of oral intake and ambulation were comparable in both factions.Conclusions: Combined bupivacaine use led to a considerable decrease in postoperative pain thereby leading to decreased analgesic use.
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Background: The objective of the study was to present our clinical experience with gall bladder perforation cases. This may help in the management and decision making of such cases.Methods: Records of 480 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our hospital between 2007 and 2014 were reviewed retrospectively. Twenty nine (6%) of those patients had gall bladder perforation. Original Niemeier’s classification of gall bladder perforation used to describe the type of perforation. The parameters including age, gender, duration of symptoms, diagnostic procedures, medical or surgical or radiological interventional treatment used, morbidity and mortality were evaluated.Results: Out of the 29 patients, 25 patients had subacute type of gall bladder perforation (Niemeier type II) and 4 patients had chronic (Niemeier type III) perforation. None of the patients encountered had generalized peritonitis (Niemeier type I). The diagnosis in all these patients was established on admission to the hospital by means of abdominal ultrasound and computed tomography. Twelve (43%) patients underwent early surgery. The rest (58.6%) either underwent conservative medical line of management or pigtail catheter insertion in the collection followed by interval cholecystectomy. Three (10.7%) patients died of sepsis and associated comorbid condition.Conclusions: Early diagnosis of gall bladder perforation is of critical importance. Abdominal ultrasound coupled with computerized tomography is useful in diagnosis of gall bladder perforation. Management strategies include early surgery in patients with generalized peritonitis or suspicion of gall bladder necrosis, and initial conservative line of management and/or pigtail insertion in surgically high risk patients which can be followed up by interval cholecystectomy.
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Background: Gallbladder carcinoma (CA) is the most common primary biliary carcinoma and fifth most common malignancy of the gastrointestinal tract. Patients are usually asymptomatic early in the course of the disease and as a result, therapeutic window is usually missed. Authors discuss spectrum of imaging findings in CA gall bladder with multidetector computed tomography (CT) as modality of choice.Methods: Retrospective cross-sectional study conducted at Shaukat Khanum memorial hospital and research centre. Data from January 2019 to January 2020 which included 70 patients was collected from HIS. Patients with imaging findings of CA gall bladder were examined who had undergone contrast enhanced CT. Institutional review board approved this study.Results: Out of 70 cases in this study, cholelithiasis was present in 60%. The commonest MDCT finding was mass replacing GB (78.6%), followed by eccentric/diffuse gall bladder wall thickening. Extension to porta hepatis was noted in 25 (35.7%) cases. Antroduodenal involvement was noted in 11 (15.8%), hepatic flexure involvement in 8 (11.4%). Vascular encasement/thrombosis of the portal vein noted in 6 (8.6%). Metastasis at presentation was seen in 16 patients i.e., 22.9%. Majority patients presented with stage III and IV disease.Conclusions: Single-center tertiary care oncology hospital study gives insight about imaging findings of carcinoma gallbladder. Authors conclude that multidetector CT is the diagnostic tool of choice in detection of gall bladder carcinoma, locoregional disease, distant metastasis and hence operability and non-operability of the disease.
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Cholecystectomy preferably laparoscopy is gold standard treatment for symptomatic cholelithiasis. However for some anatomical and/or pathological reasons the procedure is converted to open. Conversion rates at high volume centres is <5%. We present a case report of 48 aged lady, previously operated multiple times for hydatid liver and lung with symptomatic cholelithiasis. She was planned for laparoscopic cholecystectomy. During the procedure, inadvertent anatomy of “the wandering gallbladder” was noted. Here we describe the management approach selected for this type of unusual presentation. We recommend noting down detailed past history (preferably surgical) and preoperative consideration of deviant anatomical location and findings of gallbladder. We should maintain a low threshold for conversion to open.
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Disseminated blood-borne metastases from carcinoma of the gall bladder are uncommon and usually occur late. The most common site of extra-abdominal metastasis is lung followed by brain. Skeletal metastases in carcinoma gall bladder are very rare. To date there have only been a few case reports of bone metastasis in carcinoma gall bladder at the time of presentation. Authors here present a rare case of carcinoma gall bladder that progressed to isolated sacrum metastasis.
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Background: Gall bladder diseases are a very common health problem that affects millions of people throughout the world. Cholelithiasis is commonly associated with carcinoma gallbladder. Cholecystectomy is the most commonly performed surgical procedure done for gall bladder disease.Methods: A total of 161 cases of gall bladder lesions were evaluated from January 2017 to December 2018 which were sent to department of pathology. Specimens were fixed in 10% formalin. Appropriate areas were selected from the specimen and grossed, processed, sectioned, stained using haematoxylin and eosin and were observed under microscope.Results: Out of 161 cases, 105 were female (65.22%) and 56 cases were male (34.78%).Histopathologically, the most common diagnosis was Chronic calculus cholecystitis (57.76%) followed by chronic acalculus cholecystitis (22.36%). Remaining cases were of Acute on chronic cholecystitis (6.21%), Acute on chronic cholecystitis with cholelithiasis (4.96%), Acute on chronic cholecystitis with perforation peritonitis (1.24%), Acute suppurative cholecystitis with perforation peritonitis (0.62%), Biliary Atresia (1.24%), Chronic cholecystitis with choledochal cyst (1.24%), Follicular cholecystitis (1.24%), Adenocarcinoma (0.62%), Adenosquamous carcinoma (0.62%) and one case was inconclusive (0.62%).Conclusions: The incidence of chronic calculus cholecystitis was found to be 57.76% with female preponderance and mostly in third decade. Malignancy of gall bladder is a rare condition. Routine histopathological examination of all cholecystectomy specimens is strongly recommended for the detection of various variants of chronic cholecystitis and also of incidental carcinoma of gall bladder which helps in their treatment and prognosis.
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Blunt trauma abdomen leading to gallbladder perforation is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. The gallbladder is relatively a well-protected organ. Isolated gallbladder perforation is extremely rare. The clinical presentation is variable, early diagnosis and treatment is of extreme importance to reduce morbidity and mortality associated with gallbladder perforation. We report a case of a patient who sustained isolated gallbladder injury following blunt trauma abdomen to emergency department in Safdarjung Hospital, New Delhi.
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Objective To investigate the clinical significance of serum miR-187 and miR-143 in the development and diagnosis of gallbladder cancer.Methods 75 serum samples in patients with gallbladder cancer were selected as gallbladder cancer group.75 serum samples in patients with gallbladder benign disease and 45 serum samples in healthy physical examinations at same period were selected as the benign gallbladder disease group and healthy control group.Quantitative RT-PCR was used to detect the serum miR-187 and miR-143 expression in each group,and the expression of those related with the clinicopathological factors,the proliferation and migration of gallbladder cancer cells,and the efficacy in diagnosis of gallbladder cancer was observed.Results The serum miR-187 expression in gallbladder cancer group was significantly higher than that in benign gallbladder disease and healthy control;the serum expression of that in benign gallbladder disease was significantly higher than that in healthy control;after surgery,the expression of that was significantly lower than that before treatment (all P ＜ 0.05).The serum expression of miR-143 in gallbladder cancer group was significantly lower than that in benign gallbladder disease and healthy control;the serum expression of that in benign gallbladder disease was significantly lower than that in healthy control;after surgery the serum expression of that was significantly higher than that before surgery (all P ＜0.05).The serum expression levels of miR-187 and miR-143 in gallbladder cancer were not correlated with gender and age (both P ＞ 0.05),and were significantly correlated with Nevin stage,TNM stage,differentiation and lymphatic metastasis (all P ＜ 0.05).Furthermore,it was confirmed that miR-187 promoted the proliferation and migration of gallbladder cancer cells in vitro,while miR-143 inhibited the proliferation and migration.In the diagnosis of gallbladder,the diagnostic efficacy of miR-187 and miR-143 was significantly better than that of CA199 and CA242 (both P ＜ 0.05).Combined detection could further improve the efficacy in diagnosis of gallbladder cancer.Conclusions miR-187 and miR-143 are involved in the development of gallbladder cancer.Combined detection of serum miR-187 and miR-143 in gallbladder cancer has a high diagnostic efficiency in the diagnosis of gallbladder cancer.
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Background: Antibiotic policy and appropriate antibiotic prophylaxis cannot be designed unless data is available about bacteria colonizing the bile associated with gall bladder disease. Authors aim was to assess the clinical profile and pattern of bacterial isolates from bile aspirates of cholecystectomy patients seeking care at a tertiary care teaching hospital.Methods: Patients who underwent cholecystectomy for various hepatobiliary ailments during year 2017-18 formed the study population. Bile aspirates were collected during cholecystectomy and sent to the microbiology laboratory. Ultrasonography, computed tomography and MRCP were done to confirm the gall bladder pathology before surgery.Results: Out of total eighty-six patients, bacterial growth was observed in 28 (32.56%) subjects. As per division of bile samples, maximum number of study participants (39.29%) having bactibilia were seen in Group II. Group with second highest number of patients showing bactibilia was Group III with 9 subjects (32.14%). Eight subjects (28.57%) exhibited bacterial growth in bile aspirates in Group I subjects. Three patients (10.71%) showed bile infected with multiple bacteria i.e. polymicrobial infection. The gram-negative preponderance was seen in all the three groups with Escherichia coli being most common in group I and II. Pseudomonas aeruginosa was isolated in majority of the patients in group II and III.Conclusions: It is advised that all patients undergoing cholecystectomy must have their bile aspirated during cholecystectomy and sent for microbiological examination and culture. It will help in choosing appropriate antibiotic to prevent infection.
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Gallbladder perforation usually occur in acute obstructive (calculus) cholecystitis, and its incidence is high in patients with diabetes mellitus, recent severe trauma, critical illness, severe burn. 2-11% patients of acute cholecystitis progress to gallbladder perforation. Acute cholecystitis is a rare complication of enteric fever and perforation of gallbladder in such cases is an uncommon occurrence in pediatric population. Clinical features of spontaneous gall bladder perforation are non-specific especially in children. Ultrasound as well as computerized tomography (CT) abdomen and pelvis lack specificity for detecting gallbladder perforations in enteric fever. Diagnosis is usually confirmed intraoperatively when the gallbladder is visualized and perforation is seen. Hence the treating surgeon must consider this rare condition in differential diagnosis while treating any child with acute abdomen.