Urgent and early cholecystectomy for acute gallbladder disease.

A retrospective study of 645 cholecystectomies performed in a surgical unit over a 10-year period is presented, of which 236 were carried out during an acute admission. Of these 236 cholecystectomies, 195 were performed for acute cholecystitis and 41 for acute gallstone pancreatitis. In the acute cholecystitis group the proportion of patients over 70 years of age was significantly higher (35 per cent) than the corresponding elective group (10.3 per cent). Of those patients presenting with complications (empyema, gangrene, perforation, and biliary peritonitis) 51 per cent were over the age of 70 years. The most valuable investigation in the diagnosis of acute cholecystitis was ultrasound carried out within the first 48 h, with positive results in 83 per cent of those examined. The mortality for elective cholecystectomy was 0.5 per cent rising to 4.7 per cent in the urgent/early cholecystectomy group. The mean age of the 11 patients who died was 76 years, 8 of these patients being over the age of 70 years. The mortality in the subgroup of patients over 70 years was 10 per cent rising to 20 per cent in the over-80 age group. There were no deaths in the acute gallstone pancreatitis group. We conclude that emergency or early cholecystectomy is a safe procedure in patients under 70 years of age. However, patients over 70 years present with more serious complications of acute gallbladder disease which necessitate urgent surgery. We therefore recommend early cholecystectomy in patients over 70 years despite the high attendant mortality.

A study of colovesical fistulae in a district hospital.

A retrospective study of 32 patients with colovesical fistula was carried out. The most frequent presenting symptoms were urinary; an abdominal mass was found in 40% of patients. Urine culture grew bowel organisms in 93% of patients and the diagnosis was most accurately confirmed by barium enema which showed evidence of a fistula in 55% of patients examined. Surgical treatment varied from staged resection to primary resection and anastomosis, disconnection of the fistulous tract or colostomy alone. The results are compared and suggest a higher success rate with a multi-staged procedure. Different methods of diagnosis are discussed as well as possible causes for varying success rates among the surgical procedures.

Presentation and prognosis of malignant tumours of the thyroid gland in the West Riding of Yorkshire.

Fifty cases of malignant tumours of the thyroid gland presenting over a 15 year period (1963 1978) in a large district general hospital are reviewed. The distribution of histological types, presenting symptoms and the outcome of treatment are discussed.

Pseudo-obstruction of the large bowel.

Thirty patients with acute pseudo-obstruction of the large bowel are presented, and the aetiology and diagnosis of this recognized clinical entity are described. Emergency barium enema examination is recommended in patients with symptoms and signs of large bowel obstruction. When no mechanical blockage is found a diagnosis of pseudo-obstruction can be made. The management of pseudo-obstruction is conservative, with nasogastic suction, intravenous fluids and the treatment of any associated condition such as cardiac failure and inflammatory conditions. The indications for surgery in pseudo-obstruction are discussed.

Abdominal tuberculosis--a disease revived.

Abdominal tuberculosis was common in the United Kingdom in the 18th and 19th centuries and in the first half of the 20th century. During the 1950's the recognition of Crohn's disease, the use of streptomycin and other drugs, and the pasteurisation of milk led to the virtual disappearance of abdominal tuberculosis in the western world. During the last two decades a new type, mycobacterium tuberculosis hominis, has appeared mainly in the immigrant population, especially in those from the Indian subcontinent. A retrospective review of 68 patients with abdominal tuberculosis is presented. The pathology, diagnosis and management of these cases is discussed, together with the differential diagnosis of Crohn's disease. It is suggested that the immigrant brings the disease into the United Kingdom in his mesenteric glands and that the disease is reactivated or 'revived' at some later date due to some modification of the immune process.

The clinical value of ultrasound in biliary tract and pancreatic disease.

The use of ultrasound in the non-invasive investigation of the biliary tract and pancreas is discussed. Its accuracy in detecting gallstones in the non-acute condition is as accurate as conventional radiography, which is dependent on the excretion of contrast medium by the liver. Ultrasound is not dependent on liver function and has become the best initial investigation in persistent jaundice, acute cholecystitis, acute pancreatitis, and chronic pancreatic disease. In a retrospective study of 75 patients with acute pancreatitis liver function tests were found to be abnormal in 67% and contrast radiography proved to be of limited value. Ultrasonography performed shortly after admission showed an overall accuracy of 82% correct findings. The identification of gallstones in pancreatitis and cholecystitis permits early surgery, which reduces morbidity, improves prognosis, and is now being accepted as the treatment of choice.

The value of ultrasonic B-mode scanning in the diagnosis of persistent jaundice.

The use of ultrasonic B-mode scanning of the liver and biliary tract in patients with persistent jaundice is described. Sixty-seven consecutive jaundiced patients have been scanned. A correct diagnosis was obtained in 66 per cent, useful information in 26 per cent and in only 8 per cent was the information misleading or of no diagnostic value. In our opinion this simple and non-invasive technique is of great value in the definite diagnosis of persistent jaundice and should allow earlier surgery in the obstructive cases.

Tension pneumoperitoneum: a report of 4 cases.

Four cases of tension pneumoperitoneum are described. In 3 patients this condition followed a perforation of a grossly distended caecum. In 2 of these patients there was an associated malignant neoplasm of the pelvic colon with obstruction. The third patient had a pseudo-obstruction of the transverse colon. The fourth patient had a tension penumoperitoneum with associated surgical emphysema in the neck and subcutaneous tissues of the abdomen and chest walls, following perforation of a duodenal ulcer. The aetiology, presentation and management, together with the mechanism of tension pneumoperitoneum, are discussed.

Evaluation of biliary tract disease by ultrasonic B-mode scanning.

To establish the value of diagnostic ultrasound (sonar) in the diagnosis of bilitary tract disease, 140 patients were scanned and also had a plain film of the biliary tract. Of these, 105 had contrast radiography and 123 were subjected to laparotomy. The results obtained suggest that in the absence of jaundice, sonar compares well with oral cholecystography in demonstrating the gallbladder, but is not as good as intravenous cholangiography in showing the duct system. In the presence of jaundice, however, sonar is considered the imaging investigation of choice.