Clinical Review and Case Report of Ceftriaxone-associated Gallbladder Pseudolithiasis in Adult / 대한소화기학회지

Although ceftriaxone can be used safely in most instances, it can sometimes induce biliary sludge or stone formation. Most of the patients remain asymptomatic and children are more susceptible to develop this condition, but adults can be affected as well. Because sludge or stones disappear after discontinuing ceftriaxone, this condition is referred to as ceftriaxone-associated pseudolithiasis. A 54-year-old woman was admitted to a local clinic for management of ileus. During admission, she had received ceftriaxone and metronidazole, and had been on nil per os for the past 6 days. She was then referred to our hospital for cholecystectomy due to persistent right upper quadrant pain. Although imaging studies showed gallbladder sludge, pseudolithiasis was suspected because of ceftriaxone administration history and prolonged fasting. After careful watch-and-wait, the condition resolved spontaneously after ceftriaxone discontinuation. Our clear understanding on ceftriaxone-associated gallbladder pseudolithiasis allowed us to avoid an unnecessary cholecystectomy. Herein, we report the case of a 54-year-old woman with ceftriaxone-associated gallbladder pseudolithiasis that was successfully managed by ceftriaxone discontinuation alone.

Gastric heterotopia together with squamous metaplasia in the gallbladder / Heterotopía gástrica y metaplasia escamosa en la vesícula biliar

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with squamous metaplasia in the gallbladder of a 47-year-old female patient who experienced an intensive abdominal pain. He was admitted to the hospital for clinical treatment without any improvement. Ultrasonography showed a stone located in the gallbladder neck and dilatation of intrahepatic bile ducts, both hepatic ducts and common hepatic duct. Laparoscopic cholecystectomy was performed. In the microscopical examination, the epithelium of the gallbladder revealed an unspecified chronic cholecystitis. Besides, at the level of the gallbladder body, a heterotopic gastric mucosa contain chief, parietal and mucosal cells with cystic glands and squamous metaplasia was found. Actually the patient is in long-time follow-up, asymptomatic. We also review 96 other reports of HGM in the gallbladder in the international medical literature from 1934. As heterotopic tissue may promote carcinogenesis of the gallbladder, close attention should be paid to any occurrence of such lesions in this anatomical region. It appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.

La heterotopía de la mucosa gástrica (HGM) en vesícula biliar es extremadamente rara. En este estudio, reportamos un caso de heterotopía gástrica junto con metaplasia escamosa en vesícula biliar de un paciente femenino de 47 años que experimentó un dolor abdominal intenso. Lo admitieron al hospital para el tratamiento clínico sin ninguna mejoría. Ultrasonografía demostró un cálculo situado en el cuello de la vesícula y dilatación de conductos biliares intrahepáticos, los conductos hepáticos y conducto hepático común. Se realizó la colecistectomía por vía laparoscópica. En el exámen microscópico el epitelio reveló una colecistitis crónica inespecífica. Además, en el nivel del cuerpo de la vesícula biliar fue hallada una mucosa gástrica heterotópica con células principales, parietales, células mucosas con las glándulas enquistadas y metaplasia escamosa. El paciente está en el seguimiento a largo plazo, asintomático. Revisamos 96 informes de HGM en vesícula biliar en la literatura médica internacional a partir de 1934. El tejido heterotópico puede promover la carcinogénesis de la vesícula biliar, por lo cual se debe prestar atención a cualquier ocurrencia de tales lesiones en esta región anatómica. La colecistectomía laparoscópica puede ser inevitable para los pacientes afectados por la mucosa gástrica heterotópica actualmente y todo cuidado debe ser tomado cuando se hace un diagnóstico por secciones congeladas intraoperatorias.

Low pressure pneumoperitoneum laparocopic cholecystectomy is appropriate procedure for cholecystolithiasis in cirrhotic patients

This study aimed to evaluate the feasibility and outcome of laparoscopic cholecystectomy [LC] in cirrhotic patients. All patients presented by symptomatic cholecystolithiasis; the diagnosis was mainly according to the disease history and ultrasound, CT and esophageal barium swallow examination results. Preoperative hepatic function protection and supporting, ascites controlling and portal vein pressure reduction were considered individually for most cases of Child-Pugh [CP] class B and C with attempts to improve the hepatic function of class C patients to near class B level. Only after that, surgical operations arranged were allowed for a safer elective operation. A standard four ports laparoscopic procedure was performed according to the European ifour-puncturet technique using low-pressure pneumoperitoneum [7-9 mmHg]. Conversion rate, duration of surgical procedure, incidence of intra- and postoperative complications, and mean hospital stay were recorded. Patients were followed up for a period of 6 months after surgery. The study included 16 patients; 9 females and 7 males with mean patients' age was 53.5 +/- 5.8; range: 42-61 years. Clinical signs included splenomegally in 12 cases [75%], widened po.tal vein with diameter >14 mm in 10 cases [62.5%], ascites in 5 cases [31.3%], varices of esophagus and gastric fundus veins in 6 cases [37.5%]. Eight patients were class A, 7 were class B and one patient was class C. No conversion to open cholecystectomy [OC], need for a second surgical intervention or perioperative mortality occurred. The average surgical procedure duration was 69.2 +/- 1 Imin; 2 patients [12.5%] had liver bed bleeding and required transfusion of one bag of blood during surgery. The mean time to resume diet was 19.6 +/- 5.8 hours and mean hospital stay was 4.3 +/- 1.4 days. Three patients [18.75%] had postoperative complications: 2 [12.5%] suffered from ascites leading to a worsening of the CP score in one of them, and the third had ischemic chest pain. It could be concluded that LC at low-pressure pneumoperitonium [7-9 mmHg] is an appropriate line of management of cholecystolithiasis in cirrhotic patients and is associated with no mortality or need for return to operating room and acceptable low morbidity rate

The management of bile duct stones.

Bile duct stones are almost always associated with gallbladder stones and coexist with gallbladder stones in approximately 10% of patients. The frequency of coexisting bile duct stones increases with advancing age. In patients with stones in both the gallbladder and bile duct, therapeutic options for the latter include laparoscopic or open exploration of the bile duct, and pre-operative and post-operative endoscopic sphincterotomy and stone extraction. Endoscopic sphincterotomy remains the treatment of choice for bile duct stones after cholecystectomy. However, management algorithms in individual institutions will be influenced by surgical and endoscopic expertise and by other factors such as overall costs. After surgical or endoscopic removal of bile duct stones, estimates of the lifetime risk of recurrent stones range from 5%-20%. Increased life expectancy and the apparent absence of simple preventative measures indicate that the burden of bile duct stones on health expenditure is likely to increase in many countries.