Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.

Perforación traumática aislada de la vesícula biliar: revisión de la literatura actual con reporte de un caso / Isolated gallbladder perforation following blunt abdominal trauma: literature review and case report

Resumen Introducción La lesión de la vesícula biliar secundaria a trauma abdominal cerrado constituye un evento infrecuente de perforación traumática de ella, de presentación tardía. Objetivo Revisar la literatura científica actualmente disponible y además describimos un caso. Materiales y Método Utilizando la plataforma PubMed se buscan las siguientes palabras clave: " Blunt abdominal trauma ". Se seleccionan las series con lesiones de la vesícula biliar: " Traumatic gallbladder rupture". Se seleccionan los reportes de lesiones aisladas de la vesícula biliar: " Isolated gallbladder rupture ". Se seleccionan los reportes de presentación tardía de lesiones aisladas de la vesícula biliar: " Delayed presentation of isolated gallbladder rupture ". Resultados De todas estas publicaciones se seleccionan las que a criterio de los autores son relevantes para el presente caso. Discusión La mayoría de las perforaciones de la vesícula biliar se producen en vesículas sanas de paredes delgadas distendidas por el ayuno o el consumo de alcohol. No existe una presentación clínica clásica. Los estudios imagenológicos son inespecíficos y se llega al diagnóstico definitivo durante la exploración quirúrgica. El tratamiento de esta lesión es la colecistectomía. Conclusiones El diagnóstico no es fácil, pero la resolución es relativamente simple y el pronóstico es bueno. El presente caso ilustra este tipo de lesiones en pacientes con trauma abdominal cerrado.

Introduction Gallbladder injury secondary to blunt abdominal trauma is a rare event. Aim Review the current available scientific literature and describe a case. Materials and Method Using the PubMed platform, the following keywords were searched: "Blunt abdominal trauma". Series with gallbladder lesions were selected: "Traumatic gallbladder rupture". Reports of isolated lesions of the gallbladder were selected: "Isolated gallbladder rupture". Reports of late presentation of isolated lesions of the gallbladder were selected: "Delayed presentation of isolated gallbladder rupture". Of all these publications, those that were relevant to the present case were selected according to the criteria of the authors. Case report A 20 years-old male patient suffered an abdominal trauma two weeks before presentation at our Institution. He underwent an exploratory laparotomy showing bilious content and a gallbladder perforation over the peritoneal wall as an isolated injury. Discussion Most isolated gallbladder perforations occur in healthy gallbladders with thin walls and distended because fasting or alcohol consumption. There are no classical clinical features to diagnose this specific injury and radiologic studies are nonspecific. Definitive diagnosis is often reached during surgery as it was with our patient. Recommended treatment is cholecystectomy. Conclusions This case illustrates this unique kind of gallbladder injury in patients with blunt abdominal trauma. A clear diagnosis is not easy however, the treatment is simple and prognosis is good.

Cuerpo extraño intra-abdominal: caso clínico y revisión de literatura / Intra-abdominal foreign body: clinical case and review of the literature

Cases of intra-abdominal foreign bodies are rare and caused mainly by retained elements after surgery and by, in general, accidental swallowing and subsequent perforation of the gastrointestinal tract. We report the case of a 74 year-old female patient, presenting with fever, abdominal pain and weight loss. An abdominal TC showed the presence of a foreign body that had caused a perforation of duodenum and gallbladder neck; surgery showed that it was a 4 cm ‘twist-tie’. The description of the case presents differential diagnoses, based on a review of the literature. This is a rare event and corresponds to the third publication of a case of a twist-tie intra-abdominal foreign body, according to a review of other medical publications.

Los cuerpos extraños intraabdominales son infrecuentes y se deben en gran medida a accidentes quirúrgicos y a ingesta, en general, accidental y posterior perforación del tracto digestivo. Se reporta un caso de una mujer de 74 años con fiebre, dolor abdominal y baja de peso, cuyo estudio mediante tomografía computada de abdomen muestra un cuerpo extraño que perfora duodeno y el bacinete. La cirugía demostró que se trataba de un “twist tie” de 4 cm que perforaba esas estructuras. En la descripción del caso se plantean los diagnósticos diferenciales basados en revisión de la literatura. Se presenta este caso por ser muy infrecuente, correspondiendo a la tercera publicación de un cuerpo extraño intra-abdominal por twist tie, de acuerdo con la revisión de las publicaciones médicas.

Vólvulo de vesícula biliar / Gallbladder volvulus

Paciente femenina de 84 años de edad, raza blanca, con antecedentes de hipertensión arterial, cardiopatía isquémica y de litiasis vesicular de alrededor 40 años de evolución. Acude al cuerpo de guardia del hospital por presentar dolor abdominal en hipocondrio derecho tipo cólico de 3 días de evolución que comienza después de la ingestión de una comida abundante; refiere además náuseas y escalofríos. Se encontró vesícula biliar muy distendida de color oscuro con líquido serohemático abundante perivesicular, por lo que se le diagnosticó vólvulo vesicular biliar. Se le realizó colecistectomía laparoscópica satisfactoria y tuvo una evolución favorable.

Female patient aged 84 years, Caucasian, with a history of blood hypertension, ischemic cardiopathy and vesicular lithiasis for 40 years. She went to the emergency room of the hospital because she felt abdominal pain in right hypochondrium and cholic for 3 days after having had an abundant meal. She also felt nauseas and shrivelling. The diagnosis was dark coloured, much distended gallbladder with abundant serohematic fluid around the bladder, leading to gallbladder volvulus. She underwent laparoscopic cholecistectomy and recovered satisfactorily.

Isolated rupture of the gallbladder following blunt abdominal trauma: case report / Ruptura isolada de vesícula biliar após trauma abdominal fechado: relato de caso

Gallbladder rupture following blunt abdominal trauma is a rare event recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. The clinical presentation of gallbladder injury is variable, resulting in a delay in diagnosis and treatment. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma.

A ruptura da vesícula biliar após trauma abdominal fechado é um evento raro, identificada apenas durante laparotomia para avaliar e tratar outras lesões viscerais. A ruptura isolada da vesícula biliar secundária a traumatismo abdominal fechado é ainda mais rara. A apresentação clínica da lesão da vesícula biliar é variável, resultando em um atraso no diagnóstico e tratamento. Relata-se um caso de ruptura isolada da vesícula biliar devido a um trauma abdominal fechado.

Safety of ultrasonic dissection versus conventional electrocautery dissection during laproscopic cholecystectomy in terms of gall bladder perforation

To compare the safety of ultrasonic and electrocautery method of dissection in terms of gallbladder perforation. This randomized controlled trial included 128 patients, which were divided into two groups, ultrasonic dissection [A] and electrocautery dissection [B]. GB perforation [if any] was noted intraoperatively, and all the data was recorded on a structured questionnaire. Data was analyzed using SPSS. The incidence of GB perforation was significantly lower in ultrasonic dissection [10.9%] than electrocautery methods of dissection [29.7%], hence the safety of ultrasonic dissection in terms of gallbladder perforation, was significantly higher than electrocautery dissection [89.1% vs. 70.3% p-value=0.007]. Ultrasonic dissection is safer modality of dissection in terms of gall bladder perforation and its use should be encouraged as routine method of dissection during LC

Los nuevos problemas: fístula lumbarsecundaria a litiasis biliar abandonada durante cirugía laparoscópica / New problems: lumbar fistula secondary to biliary lithiasis abandoned during laparoscopic surgery

La colecistectomía laparoscópica como tratamiento de la litiasis de la vía biliar accesoria se ha visto acompañada de una nueva complicación relacionada al abandono de la litiasis y clips en la cavidad peritoneal. La misma se vincula a la perforación accidental de la vesícula,ya sea durante la colecistectomía o la extracción de la misma. En el presente trabajo se comunica un caso clínico en el cual el abandono de litiasis vesicular, producida por la rotura de la bolsa de nailon durante la extracción vesicular en ocasión de una colecistectomía laparoscópica de coordinación 22 meses previo a la consulta, determinó un absceso lumbar derecho que se drenó espontáneamente, a partir de lo cual se constituyó un trayecto fistuloso con supuración persistente. Durante la exploración intraoperatoria de la fístula se constató una litiasis biliar de 5 mm que se extrae, completando el procedimiento con la fistulectomía,lo que permitió la cicatrización y consecuentemente la resolución definitiva del cuadro.

Cholecystechtomy laparoscopy to treat lithiasis of the accessory bile duct has been seen to be accompanied bya new complication resulting from abandoning the lithiasis and clips in the peritoneal cavity. This complication isalso related to the accidental perforation of the gall bladder, either during cholecystechtomy or its removal. Thisstudy presents a clinical case where abandonment of the biliary lithiasis which resulted from breaking the nylonbag during vesicular removal in a laparoscopic cholecystechtomy coordinated 22 months prior to consultation, determined a right lumbar abscess which spontaneously drained causing a fistulous tract with constantdrainage. During intraoperative exploration of the fistula, a 5 mm biliary lithiasis was found and removed, and theprocedure was completed with a fistulectomy, what enabled scarring and consequently, the final resolution ofthe symptoms.

O tratamento da litíase da via biliar acessória por colecistectomia laparoscópica apresenta uma nova complicação relacionada ao abandono da litíase e/ou do clips na cavidade peritoneal, vinculada a perfuração acidental da vesícula durante a colecistecomia ou durante sua extração. Neste trabalho relatamos um caso clínico no qual o abandono da litíase vesicular produzida pela ruptura dosaco plástico durante a extração da vesícula durante uma colecistectomia laparoscópica de coordenação realizada22 meses antes da consulta da paciente, causou um abscesso lombar direito que foi drenado espontaneamente através de uma fistula com supuração persistente. Durante a exploração intra-operatória da fistula se encontrou uma litíase biliar de cinco mm que foi extraída e se realizou a fistuletomia que permitiu a cicatrização e a resoluçãodefinitiva do quadro.

Anestesia conductiva en colecistectomías abiertas: una mejor alternativa en cirugía y relación costo beneficio / Conductive anesthesia in open cholecystectomies: a better alternative in surgery and cost-benefit relationship

Se realizó un estudio retrospectivo de tipo descriptivo, con la revisión de 180 historias médicas de pacientes que ingresaron por el servicio de cirugía, a los cuales se les practicó colecistectomia abierta con anestesia subdural, en el Hospital Fundahosta para el período enero del 2000 hasta enero del 2004, los datos fueron obtenidos de acuerdo a la recolección de 10 parámetros, correspondientes al año de la intervención quirúrgica, edad, sexo, diagnóstico preoperatorio, postoperatorio, modalidad de anestesia, número de aguja subdural, complicaciones, tiempo de estancia, hospitalaria y costo del servicio. Nuestro objetivo es dar a conocer las ventajas que ofrece la anestesia conductiva subdural en relación a la reducción del tiempo operatorio, escasas complicaciones, mejor relación costo beneficio con el que cuenta la institución y garantizar la eficacia de las intervenciones electivas a los pacientes que serán sometidos a este procedimiento.

Gallbladder perforation and stone spillage during laparoscopic cholecystectomy

To determine the frequency of gallbladder perforation and stone spillage during laparoscopic cholecystectomy [LC], and its subsequent complication and management. Descriptive case-series. This is a prospective analysis of laparoscopic cholecystectomies performed at Surgical Unit I, Civil Hospital Karachi, from 1st September 1997 to I5th June 2005. There were 1246 patients in the study, who underwent LC. The inclusion criteria for LC were: patients of all ages and both sexes, symptomatic gallstone disease, recurrent attack while waiting for interval LC, normal levels of blood complete picture and liver function tests, and ultrasound abdomen demonstrating gallstone disease. There were 107 cases of gallbladder perforation, ie a frequency of 8.59%. In 24 of these patients gallstones spillage also occurred, ie a frequency of 1.92%. An effort was made in each case to remove the spilled stones laparoscopically, but in seven patients unretrieved stones were left [ie a frequency of 0.56%]. One patient developed pelvic abscess, presenting with post-operative diarrhea and fever on day 5 and confirmed by ultrasound; it was left to drain in the rectum and treated by broad-spectrum antibiotics. Four patients developed sub-hepatic abscess, presenting with right hypochondria! and shoulder tip pain and fever on day 3; they were confirmed by ultrasound, with subsequent ultrasound guided drainage and broad-spectrum antibiotics. Three patients developed epigastric port site infection; two were treated successfully by daily wound care and appropriate antibiotics after culture and sensitivity. One developed persistent epigastric sinus, and a gallstone was retrieved on exploration. There was no mortality and long-tertn morbidity. Gallbladder perforation and stone spillage are frequent occurrence during laparoscopic cholecystectomy. Active laparoscopic retrieval of spilled stones and thorough irrigation of sub-hepatic area reduces the risk of subsequent complications

Traction as a cause of gallbladder avulsion.

Following isolated blunt trauma to the abdomen, a 25-year-old man developed peritonitis. Laparotomy revealed a band between the transverse colon and gallbladder, with partial avulsion of the latter. Avulsion of the gallbladder is a rare injury and, to the best of our knowledge traction has not been described as a mechanism of injury.

Tratamento das lesões polipoides da vesícula biliar: tecendo considerações sobre o tema / Treatment of polypoid lesions of the Gallbladder: considerations about the subject

Os pólipos da vesicula biliar são detectados em 4 a 5% da população, sendo benignos na maioria dos casos. Entretanto, podem ser malignos e com prognóstico sombrio. Assim como em outros cânceres, o tratamento em um estágio precoce é considerado essencial para a melhora da sobrevida. Os autores discutem a classificação histopatológica dos pópilos e as indicações cirúrgicas, quando existentes. Propõem um algaritmo com o fito de auxiliar na conduta a ser tomada frente a um paciente portador de pópilo na vesícula biliar.

Ruptura traumática de vesícula biliar com eliminação de cálculo para a cavidade peritoneal / Gallbladder traumatic rupture with gallstone elimination to the peritoneal cavity

Introdução:As lesões da via biliar extra-hepática e da vesícula biliar por trauma abdominal fechado são raras, costumam estar associadas a lesões de outras estruturas e estão relacionadas a um aumento da mortalidade dos traumatisados.Objetivo:Apresentar os achados operatórios de um caso clínico de uma paciente vítima de traumatismo abdominal fechado, que sfreu ruptura de vesícula biliar com eliminação de cálculo para a cavidade peritoneal. Método:Os dados contidos no trabalho foram obtidos através de registro fotográfico, anamenese e exame da paciente, revisão do prontuário e consulta à literatura científica. Considerações finais:Um inventário minucioso e um elevado grau de suspeita são elementos importantes para o diagnóstico e o tratamento precoces em casos de lesões traumáticas da vesícula biliar

Conversión de la colecistectomía videoendoscópica: nuestra experiencia / Conversion of video-assisted cholecystectomy: new experience

En el período comprendido entre marzo de 1996 y junio de 2002 se operaron 2 508 pacientes de forma electiva, con el diagnóstico de enfermedad orgánica benigna de la vesícula biliar, en el Hospital General de Santiago de Cuba. A todos se les realizó colecistectomía videoendoscópica, de ellos fue necesario convertir a la técnica clásica o tradicional a un total de 57 pacientes, para el 2,2 (por ciento). La conversión predominó en los enfermos del sexo masculino, en los mayores de 51 años y como principales causas tenemos la dificultad anatómica plastrón vesicular crónica(AU)

2 508 patients with the diagnosis of benign organic disease of the gall bladder were electively operated on at the General Hospital of Santiago de Cuba from March, 1996, to June, 2002. All of them underwent video-assisted cholecystectomy. In 57 of these patients, it was necessary to turn it into the classical or traditional technique, accounting for 2.2 percent. The conversion predominated in male patients over 51. The chronic vesicular plastron anatomical difficulty was the main cause(AU)

Eletrocirurgia: análise comparativa das lesões provocadas pelos bisturis monopolares e bipolares no fígado de ratos / Eletrosurgery: comparative analysis os lesions caused by monopolar and bipolar scalpels in mice livers

Cerca de 20 milhões de pessoas, em todo o mundo, säo portadoras de cálculos biliares e, aproximadamente, seiscentas mil vesículas säo removidas anualmente. A colecistectomia videolaparoscópica tem-se confirmado como a técnica preferida de se extirpar a vesícula biliar na maioria dos países desenvolvidos. Nessa técnica, o uso insidioso do eletrocautério tem sido relacionado com lesões sérias intra-operatórias, tais como: queimaduras intestinais, do ducto biliar, risco de hemorragia intra-operatória e infecçäo. O presente estudo foi desenvolvido para avaliar a extenso das lesões macroscópicas e microscópicas, provocadas pelos bisturis elétricos monopolares e bipolares no fígado de ratos. Foram utilizados quatro grupos de ratos, cada um com 16 animais, que foram submetidos à eletrocauterizaçäo hepática. Nos grupos 1 e 2, utilizou-se bisturi monopolar, ajustado nas intensidades 30w e 40w respectivamente; enquanto nos grupos 3 e 4, usou-se o bipolar nas intensidades 30w e 40w. Os animais foram sacrificados aos pares, de acordo com a seguinte cronologia: DO, D3, D6, D9, D12, D15, D20 e D30. As peças cirúrgicas foram analisadas macroscopicamente, utilizando-se uma lupa e paquímetro, e histologicamente, por meio de uma lente milimetrada. A extensäo da lesäo microscópica do fígado foi maior no grupo 2 (2m84mm ñ 0,91) que no 4 (2,55mm ñ 1,31) (p<0,05); a lesäo macroscópica do fígado no grupo 4 (6,68 ñ 2,35) foi maior que no 3 (5,18mm ñ 1,27) (p<0,05). Na intensidade de 30w, näo existe diferença significativa entre os bisturis monopolares e bipolares, enquanto na intensidade de 40w, a lesäo hepática foi maior quando se utilizou o bisturi monopolar

Elimination of biliary stones through the urinary tract: a complication of the laparoscopic cholecystectomy

The introduction and popularization of laparoscopic cholecystectomy has been accompanied with a considerable increase in perforation of gallbladder during this procedure (10 percent - 32 percent), with the occurrence of intraperitoneal bile spillage and the consequent increase in the incidence of lost gallstones (0.2 percent - 20 percent). Recently the complications associated with these stones have been documented in the literature. We report a rare complication occurring in an 81-year-old woman who underwent laparoscopic cholecystectomy and developed cutaneous fistula to the umbilicus and elimination of biliary stones through the urinary tract. During the cholecystectomy, the gall bladder was perforated, and bile and gallstones were spilled into the peritoneal cavity. Two months after the initial procedure there was exteriorization of fistula through the umbilicus, with intermittent elimination of biliary stones. After eleven months, acute urinary retention occurred due to biliary stones in the bladder, which were removed by cystoscopy. We conclude that efforts should be concentrated on avoiding the spillage of stones during the surgery, and that no rules exist for indicating a laparotomy simply to retrieve these lost gallstones.