Gallbladder-agenesis—a-rare-case-report

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.

Elevación de las aminotransferasas: una nueva herramienta para el diagnóstico de coledocolitiasis. Un estudio de casos y controles / Elevated transaminases: a new tool for the diagnosis of choledocholithiasis. A case control study

Resumen Introducción: la coledocolitiasis (CDL) afecta al 10 % de los pacientes con cálculos en la vesícula biliar. La obstrucción del colédoco se asocia a pancreatitis, colangitis y ruptura del colédoco. Clásicamente, la obstrucción biliar es considerada cuando se aumentan la fosfatasa alcalina, la γ-glutamil-transpeptidasa (GGTP) y las bilirrubinas. En la última década, se ha encontrado que hasta un 10 % de los pacientes con CDL presentan elevaciones de las aminotransferasas. En Latinoamérica, no se ha estudiado esta alteración. El objetivo del presente trabajo fue determinar la prevalencia de la elevación de transaminasas y su evolución. Metodología: estudio de casos y controles. Se determinó la alanina aminotransferasa (ALT) al ingreso, a las 48 h y a las 72 h. Si la ecografía era normal, se realizó una colangiorresonancia o una ecoendoscopia, así como una colangiopancreatografía retrógrada endoscópica (CPRE) cuando fue necesario. Resultados: se incluyeron 72 pacientes con CDL (casos) y 128 con colecistitis, sin CDL (controles). En los casos, el 83 % tuvo un aumento de ALT, mientras que el 56,9 % presentó una elevación de 2-9 veces, el 16 %, de 10-20 veces, y el 8,3 % mostró una elevación >20 veces. En contraste, a las 48 h, las ALT descendieron al 30 % y a las 72 h al 56 %. Entre tanto, en los controles hubo un aumento de ALT en el 27,3 %, mientras que en el 15,6 % se observó una elevación de 2-9 veces, en el 7,8 %, de 10-20 veces, y >20 veces en el 2,9 %. La combinación de cólico biliar y la elevación de ALT tuvo un valor predictivo positivo (VPP) para CDL del 72 %, así como un valor predictivo negativo (VPN) del 87,7 %. Conclusión: cuando hay un cólico biliar y una elevación de ALT es imperativo descartar una CDL, y si la ecografía es normal, es necesario realizar una colangiorresonancia o una ecoendoscopia biliopancreática.

Abstract Introduction: Choledocolithiasis (CLD) affects 10% of patients with gallstones. Bile duct obstruction is associated with pancreatitis, cholangitis, and rupture of the common bile duct. This condition usually presents with increased alkaline phosphatase, GGTP and bilirubin levels. In the last decade, it has been found that up to 10% of patients with CLD have elevated aminotransferases levels. In Latin America, this alteration has not been studied. The aim of the present work was to determine the prevalence of transaminase elevation and its evolution. Methodology: Case-control study. ALT was measured on admission, at 48 h and at 72 h. If ultrasound was normal, MRCP and/or echo-endoscopy and ERCP were performed, as appropriate. Results: A total of 72 patients with choledocholithiasis (CLD) (cases) and 128 with cholecystitis without choledocholithiasis (controls) were included. Among the cases, 83% had increased ALT levels, which was 2-9 times higher in 56.9%, 10-20 times higher in 16%, and more than 20 times higher in 8.3%. At 48 hours, those levels decreased by 30% and at 72 hours by 56%. In turn, in 27.3% of the controls, ALT was 2-9 times higher in 15.6%, 10-20 times higher in 7.8% and more than 20 times higher in 2.9%. The combination of biliary colic and ALT elevation had a positive predictive value (PPV) for CLD of 72% and a negative predictive value (NPV) of 87.7%. Conclusion: When biliary colic and ALT elevation are reported, it is imperative to rule out choledocholithiasis. If the ultrasound is normal, MRCP and/or biliopancreatic endoscopy should be performed.

The usage of prior upper gastrointestinal endoscopy among symptomatic patients undergoing cholecystectomy

Background: Cholelithiasis is one of the most common problems encountered in surgery. It is an immense challenge to discriminate between signs and symptoms due to gastrointestinal lesions and gallstones diseases. The objective of this study was to evaluate the usage of pre-operative upper gastrointestinal endoscopy (UGE) as a routine in treating symptomatic gallstone patients.Methods: This prospective hospital based observational study was conducted in the Department of General Surgery at Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar from January 2018 to June 2019. 60 symptomatic gallstone patients were selected for cholecystectomy and preoperative upper gastrointestinal (GI) endoscopy evaluation was done for any associated upper gastrointestinal problems.Results: Out of the total patients, females constituted 85% of overall study patients and majority of the patients presented with atypical biliary colic symptoms (55%, group 2) whereas 45% presented with typical biliary colic symptoms (group 1) (p value=0.009). Relief rate was highest in group 1 with abnormal UGE than with group 2.Conclusions: The routine use of upper GI endoscopy in patients with symptomatic cholelithiasis prior to cholecystectomy will help reduce post-operative persistence of symptoms and thus, it is a useful investigation in the overall treatment of gallstone diseases.

Ehretia microphylla Tablet Formulationfor Biliary and Gastrointestinal Colic:A review of its Phytochemical constituents, pharmacologic activities and clinical researches

@#The persistence of human diseases challenges the current state of the discovery and production of synthetic drugs. Plants are recognized as a great resource to discover chemical compounds that can be used for drug development. In the Philippines, Ehretia microphylla (tsaang gubat) is recognized by the Department of Health as one of the ten recommended medicinal plants. This article aims to provide a comprehensive review of the traditional use, phytochemical constituents, pharmacologic activities as well as the non-clinical and clinical studies leading to the NIRPROMP formulation of the tsaang gubat tablet indicated for biliary and gastrointestinal pain. Among the phytochemical constituents observed were flavonoids, phenolics, triterpenes, and alkaloids. Evidence for other pharmacologic properties such as antibacterial, anti-angiogenesis, anti-oxidant, anti-inflammatory, anti-allergy, folliculogenesis, wound healing and anti-cancer activities are presented. Currently, tsaang gubat tablet has been granted a full patent for its invention as a tablet for relieving symptoms of biliary and gastrointestinal colic and is registered with the Philippine Food and Drug Administration for these indications. The tsaang gubat tablet is listed in the Philippine National Formulary after the conduct of in vitro, in vivo and Phase I-III clinical trials. Future platforms for research include the reformulation of the existing tsaang gubat drug for other indications, determination of the molecular mechanism of action and plans for plant conservation.

Analgesic effect of paracetamol combined with low-dose morphine versus morphine alone on patients with biliary colic: a double blind, randomized controlled trial / 世界急诊医学杂志（英文）

BACKGROUND:Numerous drugs have been proposed to alleviate pain in patients with biliary colic, especially opioids, but still there is a tendency to use less narcotics because of their side effects and the unwillingness of some patients. The present study aimed to compare the analgesic effect of paracetamol combined with low-dose morphine versus morphine alone in patients with biliary colic. METHODS:A randomized double-blind controlled trial was performed in 98 patients with biliary colic, recruited from two emergency departments from August 2012 to August 2013. Eleven patients were excluded and the remaining were randomized into two groups:group A received 0.05 mg/kg morphine+1000 mg paracetamol in 100 mL normal saline and group B received 0.1 mg/kg morphine+normal saline (100 mL) as placebo. Pain scores were recorded using visual analogue scale (VAS) at baseline and 15 and 30 minutes after drug administration. Adverse effects and the need for rescue medication (0.75 μg/kg intravenous fentanyl) were also reported within 60 minutes of drug administration. RESULTS:Before the infusion, the mean±SD VAS scores were 8.73±1.57 in group A and 8.53±1.99 in group B. At 15 minutes after drug administration, the mean±SD VAS scores were 2.16±1.90 in group A vs. 2.51±1.86 in group B; mean difference was –0.35, and 95％CI–1.15 to 0.45 (P=0.38). At 30 minutes the mean±SD VAS scores were 1.66±1.59 in group A vs. 2.14±1.79 in group B; mean difference was –0.48, and 95％CI –1.20 to 0.24 (P=0.19). The mean pain scores in the two groups at 15 and 30 minutes demonstrated no significant difference. CONCLUSION:Paracetamol combined with low-dose morphine may be effective for pain management in patients with biliary colic.

Natural history of asymptomatic gallstones: differential behaviour in male and female subjects

Objective: The natural history of asymptomatic (silent) gallstones has been inadequately studied. Existing information derives from studies based on oral cholecystography or relatively small sample sizes. We planned a retrospective cohort study in subjects with gallstones to determine conversion rates from asymptomatic to symptomatic. Methods: We extracted data from computerised databases of one government hospital and two private clinics in Malaysia. Files were scrutinised to ensure that criteria for asymptomatic gallstones were fulfilled. Patients were called on telephone, further questioned to confirm that the gallstones at detection were truly asymptomatic, and asked about symptoms that were consistent with previously defined criteria for biliary colic. Appropriate ethical clearances were taken. Results: 213 (112 males) patients fulfilled the criteria for asymptomatic gallstones and could be contacted. 23 (10.8%) developed pain after an average follow up interval of 4.02 years (range 0.1-11 years). Conversion rates from asymptomatic to symptomatic gallstones were high in the first two years of follow up, averaging 4.03±0.965 per year. Over time the conversion rates slowed, and by year 10 the annual conversion rate averaged only 1.38±0.29. Conversion rates were much higher for females compared to males (F:M hazard ratio 3.23, SE 1.54, p>z 0.014). The lifetime risks for conversion approached 6.15% for males, and 22.1% for females. Conclusion: In conclusion, asymptomatic gallstones are much more likely to convert to symptomatic in females than in males. Males in whom asymptomatic stones are discovered should be advised conservative treatment. Surgery may be preferable to conservative management if the subject is a young female.

Ascaridiasis biliar en un paciente pediátrico. Reporte de caso

La ascaridiasis, es la parasitosis intestinal más frecuentes en humanos, con una alta prevalencia en países subdesarrollados. La migración a vesícula es poco frecuente en niños y cuando esto ocurre el tratamiento por lo general es endoscópico o quirúrgico. Caso clínico: paciente femenino de 13 años de edad, quien presentó dolor abdominal recurrente en cuadrante superior derecho. Los hallazgos de laboratorio revelaron elevación de enzimas hepáticas y leucocitosis. El ultrasonido abdominal (USA) evidenció imagen longitudinal y móvil en el interior de la vesícula, así como dilatación del colédoco. Se hospitaliza con el propósito de realizar colagiopancreatografía retrógrada endoscópica (CPRE) al siguiente día; la paciente expulsa espontáneamente áscaris por boca el mismo día, por lo que se difiriere la CPRE. Se practicó un segundo USA sin evidencia de áscaris. Se complementa tratamiento médico con albendazol vía oral. El ultrasonido abdominal es un método efectivo y poco costoso en la confirmación diagnóstica y monitorización de la ascaridiasis biliar. La ascaridiasis biliar no complicada debe tratarse de manera conservadora ya que la eliminación espontánea de Ascaris lumbricoides puede suceder hasta en 80 % de los casos.

ascariasis is the most frequent intestinal parasitosis in humans, with a greater prevalence in undeveloped countries. Hepatobiliary migration of ascaris in children is uncommon, when it occurs; treatment is generally endoscopic or surgical. Clinical case: we present the case of a 13 year old female patient admitted to the emergency room with right upper quadrant persisting pain, of 1-month duration. Laboratory tests revealed elevation hepatic enzymes and WBC. Abdominal ultrasonography (AUS) showed a long, linear, moving echogenic structure in the distended lumen of the gallbladder, with an abnormal dilation of the choledochus. An Endoscopic Retrograde Cholangiopancreatography (ERCP) was programmed for the following day. However, the patient spontaneously expelled a long ascaris orally the same day. Another AUS was performed with no evidence of ascaris in the gallbladder or the choledochus; thus the ERCP was differed. Medical treatment was complemented albendazole given orally. AUS is an effective and low cost method in the diagnostical confirmation and monitorization of biliary ascariasis, given the symptoms of pain, cholangitis and acute cholecystitis. Non complicated biliary ascariasis must be treated in a conservative manner given that spontaneous elimination can occur in up to 80% of the cases.