A Prospective Observational Study of Clinicopathological and Biochemical Profile of Patients with Cholecystitis Visiting a Teaching Tertiary Care Centre of Haryana

Introduction Gallstone diseases constitute a major part of patients visiting hospitals, and more than 50% of operation theaters are occupied by it or diseases related to it. It also imposes significant financial burden on health resources. The 21st century has opened with an improved foundation to our understanding of the basis of bile formation by defining the key transporters of the lipids in bile and the responsible genes. The specter of obesity as an epidemic in developed countries, and the recent recognition of the metabolic syndromes and their links to gallstone formation, emphasize the expectation of a rise in the frequency of cholesterol cholelithiasis. Materials and Methods Data pertaining to patients who were admitted/received surgery for a diagnosis of gallstone diseases at the Department of General Surgery of BPS GMC Khanpur Kalan was collected.The collected data was entered in a Microsoft Excel spreadsheet. Mean ± standard deviation (SD) was calculated for quantitative data, using Student’s “t” test/Kruskal test. Chi-square test was used to find out the association for categorical data. Results and Discussion Most of the patients were experiencing right hypochondriac pain (79.23%) as presenting complaints, with the most common age range being 31 to 40 years, followed by 41 to 50 years, that is, 31.85% and 20.74%, respectively. Females were most commonly affected, approximately 90%, and only 10% of patients with gallstones visiting our hospital were males. Maximum patients had chronic cholecystitis (80%) on histopathological examination, followed by cholesterosis (6.15%). As much as 82.6% of patients presented with mixed gallstones, followed by cholesterol stones, that is, 10.43%. All types of stones are more common in patients with abdominal adiposities, that is, having waist-to-hip ratio more than 0.85, and these findings are statistically significant. Conclusion Our study concluded that gallstones were more common in females of younger population (31–40 years) with right hypochondriac pain as presenting complaints. The most common histopathology was chronic cholecystitis with mixed types of stones, which is associated with increased waist-to-hip ratio. All biochemical markers were within normal range.

Extreme hyperbilirubinaemia associated with choledocholithiasis without ascending cholangitis

Introduction: Charcot’s triad was traditionally used to diagnose ascending cholangitis. However it is already proven that only minority of patients with ascending cholangitis who fulfill the triad of fever, jaundice and right hypochondriac pain. Aim: We would like to highlight the rarity of severe hyperbilirubinaemia secondary to benign cause as most of the incidence raised more suspicion for primary liver disease or malignancy. Case study: We presented a case report of a 58-year-old male patient with no comorbid who presented to us with right hypochondriac pain and obstructive jaundice with severe hyperbilirubinaemia (total bilirubin 1025 µmol/L), without fever or leukocytosis. Results and discussion: We presented a case report of a 58-year-old male patient with no comorbid who presented to us with right hypochondriac pain and obstructive jaundice with severe hyperbilirubinaemia (total bilirubin 1025 µmol/L), without fever or leukocytosis. Conclusions: Benign conditions such as common bile duct stones still can lead to severe hyperbilirubinaemia even though it is very rare. The usage of appropriate imaging is needed to exclude malignant causes.

Evidence-Based Case Report of Hydatid Cyst

Hydatid disease is a parasitic infestation in humans caused by Echinococcus granulosus. Here, it develops in liver, lung, brain or other organs but liver is the most commonly affected organ. Intensity of morbidity depends upon location, expansion and activity of cyst. In modern medicine, surgery is still the treatment of choice but the chance of relapse and other complications is always there. Homoeopathy provides a better response in such conditions. One such case report is presented below. A young female patient attended outdoor patient department chiefly for complaints of jaundice, vomiting and right hypochondriac pain for the last 1 month and her diagnosis was hydatid cyst in right lobe of liver sized 11 × 15mm (by ultrasonography). She was successfully treated with the single and individualised homoeopathic medicine Crotalus horridus in 50 millesimal potencies in respect of both symptomatically and pathologically as evident by ultrasonography reports. Possible causal attribution of changes was explicitly depicted by Modified Naranjo Criteria. It shows positive role of homoeopathic treatment in regression of hydatid cyst in a young female.

A case of elevated carbohydrate antigen 19-9 with a benign cause

Serum carbohydrate antigen 19-9 (CA 19-9), a marker of malignant tumors, is generally slightly elevated in benign conditions. We report a case of cholecystitis with perforated gall bladder with significantly elevated level of serum CA 19-9 based on abdomen computed tomography and intra operative findings. A 70 years diabetic and hypertensive female presented with right hypochondriac pain associated with occasional itching and nausea without vomiting with markedly raised CA 19-9 (1554 U/ml) with CECT abdomen suggestive of perforated gall bladder with cholecystitis. Patient electively operated for open cholecystectomy and per operative findings were distended gall bladder with multiple calculi within with edematous gall bladder wall and adhesions between gall bladder and omentum and colon. Gall bladder removed and biopsy suggestive of chronic calculus cholecystitis. On post-operative day 5th and 7th CA 19-9 was repeated twice and drastic fall to 5 U/ml and 12 U/ml respectively. Chronic calculus cholecystitis with high elevation of CA 19-9 is rare.

A comparative study of Accuracy, Sensitivity, and Specificity of MR Cholangiopancreatography versus Ultrasonography for diagnosis of hepatobiliary and pancreatic pathologies

Background: The diagnosis of abdominal pathologies is a challenge and radiology is a very important tool in diagnosis. Various methods are often used for the diagnosis of such conditions. We in the present study tried to compare the efficacy of magnetic resonance cholangiopancreatography and ultrasonography in evaluating biliary duct diseases. Methods: The present study was conducted in the Department of Radiodiagnosis, Prathima Institute of Medical Sciences, Naganur, Karimnagar. All patients presenting with recurrent pancreatitis, hypochondriac pain, jaundice presenting to the radiology department are included in the present study. Patients with metallic implants, claustrophobia are excluded from the present study. Ultrasonography was performed using a Philips HD 15 and Philips affinity 70 machine. Both curvilinear and linear probes were used in the study. Images of the biliary tree were recorded for later review. MRI-MRCP was performed on Philips ACHIEVA 1.5 Tesla MRI Scanner. Results : In this study, n=13 subjects were clinically suspected to have cholelithiasis (n=7), choledocholithiasis (n=2), and both Cholelithiasis with choledocholithiasis (n=4). Ultrasonography was able to diagnose Cholelithiasis correctly in n=5 cases, choledocholithiasis in n=1 case, Cholelithiasis with choledocholithiasis in n=4 cases and rule out Cholelithiasis in n=2 cases, but failed to identify distal CBD calculus in n=1 case (choledocholithiasis) hence having a diagnostic accuracy of 92.31% for the cholelithiasis-choledocholithiasis group. Conclusion: MR Cholangiopancreatography is very accurate in demonstrating calculi at the distal end of CBD as an area of the signal void, also in demonstrating strictures as the cause of dilatation of biliary radicals. It showed the length of the stricture segment very well and differentiated stricture as malignant and benign.

LAPAROSCOPIC CHOLECYSTECTOMY IN SITUS INVERSUS TOTALIS – A CASE REPORT

Background: Situs inverses totalis is a rare congenital anomaly with transposition of major organs to opposite side of the body. Due to atypical clinical presentation and due to contra lateral presence of the gall bladder, it causes clinical challenge to operate with complete reorientation of anatomy. Visual motor skills are particularly tested when it comes to lapararoscopy. Case: A 25 year, lady presented with left hypochondriac pain and diagnosed as calculus cholecystitis with situs inverses total is. After ruling out associated anamolies patient underwent elective laparoscopic cholecystectomy. Discussion: Around 60 cases of situs inverses total is with cholecystectomy have been reported till date. These cases cause technical and visuo-motor difficulty due to contra lateral deposition of gall bladder in left hypochondrium during laparoscopic cholecystectomy. Consumption of extra time also been reported during calot’s dissection, as it’s like operating on a mirror image. Conclusion: Laparoscopic cholecystectomy, the gold standard treatment for cholelithiasis, is a feasible option even in cases with SIT; in the hands of good experienced, ambidextrous laparoscopic surgeons.

Case Report: Biloma gastrostomy after failed sonogram-guided percutaneous aspiration, pigtail catheter insertion and surgical drainage

Bilomas are rare abnormal extrabiliary accumulation of bile. This can be either intrahepatic or extrahepatic following traumatic or spontaneous rupture of the biliary tree. The commonest causes of biloma are surgery, percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, transcatheter arterial embolization and abdominal trauma. We report here a 15 year old patient whom we followed for over 10 years. His chief complaints were right hypochondriac pain, loss of appetite and vomiting. Initial clinical presentation, sonographic as well as laboratory findings suggested a liver abscess, which was drained, but the definitive diagnosis of biloma was entertained after sonographically guided percutaneous aspirations and percutaneous transhepatic cholangiography 7 years later. We also discuss the role of imaging and surgical challenges encountered that culminated into bilomo-gastrostomy. The patient is now enjoying a peaceful life.

Duplication of the Gallbladder: A Rare Congenital Anomaly

ABSTRACTBiliary tract shows a large number of anatomic variations and duplication of the gallbladder (GB) is a rare congenital anomaly. Although it is very often detected incidentally, it may present with complications due to gall stone disease. Careful identification of this anomaly on imaging is important to prevent any serious surgical complications. We here report a case of duplicated GB in a 26-year-old male, who presented with right hypochondriac pain and detected to have two GB on magnetic resonance imaging (MRI).

Clinicopathological study and management of biliary stones

Background: Biliary calculi are one of the most common problems affecting the digestive tract. Need for the study is to evaluate age, sex, incidence, most common etiopathological factors for the formation of biliary calculi and to illustrate varying clinical presentation with various modes of management adopted in the institution as well as to analyse biochemical types of stones prevalent in the region.Methods: A prospective study of 50 patients with clinical diagnosis of biliary colic was conducted in a tertiary center for a period of one year. Clinical presentation, etiology, and management of biliary calculi were studied.Results: Biliary calculi affect most commonly in fourth to the fifth decade with a higher preponderance in females (72%). Right hypochondriac pain is the commonest presentation (84%). Ultrasonography is sensitive and specific, and hence considered the investigation of choice. Open surgical procedures such as cholecystectomy, choledochotomy with T-tube drainage, choledochoduodenostomy were done in these subjects. Postoperative complications such as wound infection noted in 8% of the subjects. Most of the histopathological specimens (90%) revealed chronic cholecystitis.Conclusions: Biliary calculus disease is multifactorial in origin with slight female preponderance. The most common presentation is a right hypochondriac pain. This can be diagnosed accurately with the aid of ultrasonography and Endoscopic Retrograde Cholangio-pancreatography. Biliary calculus is managed according to the location of the calculus, whether intrahepatic or extrahepatic. Most of the patients presented with chronic cholecystitis.