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Qiu C, Xiang YK, Hu H, Da XB, Li G, Zhang YY, Zhang HL, Zhang C, Yang YL. Characterization of gallbladder stones associated with occult pancreaticobiliary reflux using computed tomography. World J Gastroenterol 2025; 31:100855. [PMID: 40182589 PMCID: PMC11962842 DOI: 10.3748/wjg.v31.i12.100855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 01/10/2025] [Accepted: 02/18/2025] [Indexed: 03/26/2025] Open
Abstract
BACKGROUND Occult pancreaticobiliary reflux (OPBR) is characterized by the absence of congenital anomalies at the pancreaticobiliary junction yet leads to altered bile composition and an increased incidence of gallbladder stones. AIM To explore the computed tomography (CT) imaging characteristics of gallbladder stones in patients diagnosed with OPBR. METHODS We analyzed 362 patients undergoing cholecystectomy (November 2020 to January 2022). Intraoperative bile samples were assayed for amylase (> 110 U/L indicated OPBR). CT features, including stone density and visibility, were compared between 54 OPBR and 308 controls. Stone attenuation (HU) was measured under standardized conditions (uCT-780, 120 kVp, 160 mAs). Logistic regression and receiver operating characteristic curve analysis identified independent OPBR predictors, forming a validated nomogram. RESULTS OPBR patients exhibited significantly higher rates of CT-invisible stones (35.2% vs 12.3%) and uniform stones (87% vs 73.1%) along with lower overall stone density (P = 0.01). Logistic regression identified stone visibility, uniformity, and density as independent predictors. A nomogram integrating these features with patient age achieved high diagnostic accuracy (area under the curve = 0.71). CONCLUSION CT imaging distinctly identifies gallbladder stone density, indicating a heightened risk of OPBR in patients with uniform and CT-invisible stones. Such imaging is crucial for preoperative assessments to evaluate potential recurrent biliary pathologies post-cholecystectomy.
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Affiliation(s)
- Chen Qiu
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Yu-Kai Xiang
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Hai Hu
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Xuan-Bo Da
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Gang Li
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Yue-Yi Zhang
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Hong-Lei Zhang
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Cheng Zhang
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
| | - Yu-Long Yang
- Center of Gallbladder Disease, Shanghai East Hospital, Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200120, China
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Li X, Ni X, Sun W, Liu J, Shang Y, Liu H, Tu J. The impact of choledochal cysts on bile fluid dynamics: A perspective using computational fluid dynamics and surface mapping technique. PHYSICS OF FLUIDS 2024; 36. [DOI: 10.1063/5.0206053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2025]
Abstract
Choledochal cysts (CCs) are an important risk factor for cholangiocarcinoma, though their etiology remains debated. Given the vital role of bile fluid in digestive processes within the biliary system, examining such mechanisms from the perspective of bile fluid dynamics may offer additional insights for clinical use. This study utilized magnetic resonance imaging (MRI)-based patient-specific scans for detailed reconstruction and further employed the computational fluid dynamic method to assess the physiological functions of each system, including refilling and emptying processes. The impact of bile rheological property was also examined. Key biomechanical parameters—pressure and wall shear stress (WSS)—were displayed on a two-dimensional plane via surface mapping for enhanced visualization and comparative analysis. Outcomes demonstrated a significant reduction in bile flow velocity in CCs patients due to common bile duct's anatomical features and bile's shear-thinning, non-Newtonian nature, with a notable increase in pressure drop observed. In healthy biliary systems, WSS variations were minimal; however, in CCs patients, extreme WSS differences were found, with the highest WSS in the segmental bile duct and the lowest in the dilatation area, presenting a magnitude difference of approximately 1000. CCs one showed WSS levels 100–250 times higher than healthy ones in the common bile duct. Bile rheological properties substantially affect pressure and WSS patterns, particularly WSS, where pathological bile caused a tenfold increase in WSS compared to healthy bile. The findings aimed to enhance the understanding of biliary fluid mechanics in CCs and offer insights into selected fluidic variables for future microfluidic chip experiments.
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Beltrán MA, Beltrán AA. Common bile duct pressure in patients with and without cholelithiasis: A case-control study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:443-449. [PMID: 33636035 DOI: 10.1002/jhbp.931] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/17/2020] [Accepted: 02/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The reflux of pancreatic enzymes into the bile duct and the gallbladder is an abnormal phenomenon that plays a role in lithogenesis and carcinogenesis. Because the pressure of the common bile duct depends on the pressures of the sphincter of Oddi, its dysfunction would be reflected in an increase in the pressure of the common bile duct in patients with cholelithiasis. The objective of this study was to measure the pressures of the common bile duct in patients with and without cholelithiasis and to relate them to the presence of pancreatobiliary reflux. METHODS A prospective case-control study was designed. The study universe was constituted by all patients undergoing total gastrectomy for gastric cancer stages I and II over 30 months. The primary outcome measure was to establish differences between common bile duct pressures in patients with and without cholelithiasis. RESULTS Common bile duct pressures in patients with gallstones showed a significant elevation (16.9 mmHg) compared to patients without gallstones (3.3 mm Hg) (p < 0.0001). These pressures correlated with the levels of amylase and lipase in gallbladder bile; higher levels were found in patients with gallstones compared to patients without gallstones (P < 0.0001). CONCLUSIONS Common bile duct pressure in patients with cholelithiasis was significantly higher compared to patients without cholelithiasis leading to pancreatobiliary reflux.
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Affiliation(s)
- Marcelo A Beltrán
- Department of Surgery, Hospital San Juan de Dios de La Serena, Coquimbo, Chile
| | - Andrea A Beltrán
- Medicine School, Universidad de Santiago de Chile, Santiago, Chile
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Latenstein CSS, Wennmacker SZ, de Jong JJ, van Laarhoven CJHM, Drenth JPH, de Reuver PR. Etiologies of Long-Term Postcholecystectomy Symptoms: A Systematic Review. Gastroenterol Res Pract 2019; 2019:4278373. [PMID: 31110517 PMCID: PMC6487117 DOI: 10.1155/2019/4278373] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/28/2019] [Accepted: 02/10/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cholecystectomy does not relieve abdominal symptoms in up to 40% of patients. With 700,000 cholecystectomies performed in the US, annually, about 280,000 patients are left with symptoms, making this a serious problem. We performed a systematic review to determine the different etiologies of long-term postcholecystectomy symptoms with the aim to provide guidance for clinicians treating these patients. METHODS A systematic search of the literature was performed using MEDLINE, EMBASE, and Web of Science. Articles describing at least one possible etiology of long-term symptoms after a laparoscopic cholecystectomy were included in this review. Long-term symptoms were defined as abdominal symptoms that were present at least four weeks after cholecystectomy, either persistent or incident. The etiologies of persistent and incident symptoms after LC and the mechanism or hypothesis behind the etiologies are provided. If available, the prevalence of the discussed etiology is provided. RESULTS The search strategy identified 3320 articles of which 130 articles were included. Etiologies for persistent symptoms were residual and newly formed gallstones (41 studies, prevalence ranged from 0.2 to 23%), coexistent diseases (64 studies, prevalence 1-65%), and psychological distress (13 studies, no prevalence provided). Etiologies for incident symptoms were surgical complications (21 studies, prevalence 1-3%) and physiological changes (39 studies, prevalence 16-58%). Sphincter of Oddi dysfunction (SOD) was reported as an etiology for both persistent and incident symptoms (21 studies, prevalence 3-40%). CONCLUSION Long-term postcholecystectomy symptoms vary amongst patients, arise from different etiologies, and require specific diagnostic and treatment strategies. Most symptoms after cholecystectomy seem to be caused by coexistent diseases and physiological changes due to cholecystectomy. The outcome of this research is summarized in a decision tree to give clinical guidance on the treatment of patients with symptoms after cholecystectomy.
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Affiliation(s)
| | - Sarah Z. Wennmacker
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Judith J. de Jong
- Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Joost P. H. Drenth
- Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Philip R. de Reuver
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
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Manometric Measurement of the Sphincter of Oddi in Patients with Common Bile Duct Stones: A Consecutive Study of the Han Population of China. Gastroenterol Res Pract 2017; 2017:9031438. [PMID: 28133480 PMCID: PMC5241450 DOI: 10.1155/2017/9031438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 11/16/2016] [Accepted: 12/14/2016] [Indexed: 11/24/2022] Open
Abstract
Objective. Role of dysfunction of the sphincter of Oddi (SO) in choledocholithiasis is controversial. This study was to evaluate SO motor activity in patients with common bile duct (CBD) stones in the Han population of China. Patients and Methods. In this study, 76 patients with CBD stones were enrolled in a single tertiary endoscopy center. Data of SO motor activities was prospectively evaluated by endoscopic manometry. Mean basal SO pressure, amplitude, and frequency were collected and analyzed. Results. The mean basal SO pressure, amplitude, and frequency were 52.7 ± 40.0 (1.60–171.1) mmHg, 39.9 ± 19.7 (14.9–115.5) mmHg, and 5.7 ± 3.2 (1.3–13.8)/min, respectively. The basal SO pressure was higher in patients with CBD stones < 10 mm in diameter than that in those with CBD stones larger than 10 mm in diameter (60.7 ± 41.0 mmHg versus 36.8 ± 29.4 mmHg, P = 0.043). There was no significant difference in the basal SO pressure, amplitude, and frequency when compared with the CBD diameter, CBD stone number, prior cholecystectomy, periampullary diverticula, and symptoms. Levels of alanine aminotransferase, aspartate transaminase, γ-glutamyl transpeptidase, and alkaline phosphatase showed no significant difference in patients with normal or elevated basal SO pressure. Conclusion. These results identify that, in Chinese Han population, abnormalities of SO motor activity are associated with CBD stones.
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Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
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Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
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Sugawa C, Brown KL, Matsubara T, Bachusz R, Ono H, Chino A, Yamasaki T, Lucas CE. The role of endoscopic biliary sphincterotomy for the treatment of type 1 biliary dysfunction (papillary stenosis) with or without biliary stones. Am J Surg 2013; 207:65-9. [PMID: 24070665 DOI: 10.1016/j.amjsurg.2013.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 12/31/2012] [Accepted: 04/24/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones. METHODS The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES. RESULTS All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval. CONCLUSIONS ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.
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Affiliation(s)
- Choichi Sugawa
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA.
| | - Kristian L Brown
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA
| | - Toshiki Matsubara
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Matsubara Clinic, Ichinomiya, Aichi, Japan
| | - Rebecca Bachusz
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA
| | - Hiromi Ono
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Department of Internal Medicine, Seiwa Memorial Hospital, Sapporo, Japan
| | - Akiko Chino
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuji Yamasaki
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan
| | - Charles E Lucas
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA
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Schmidt M, Dumot JA, Søreide O, Søndenaa K. Diagnosis and management of gallbladder calculus disease. Scand J Gastroenterol 2012; 47:1257-65. [PMID: 22935027 DOI: 10.3109/00365521.2012.704934] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease. METHODS Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research. RESULTS Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series. CONCLUSIONS Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.
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Affiliation(s)
- Malte Schmidt
- Department of Surgery, Haraldsplass Deaconess Hospital University of Bergen, Bergen, Norway
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Abstract
OBJECTIVE To determine the effect of cholecystectomy on the motility of the sphincter of Oddi (SO). METHODS Pressures of common bile duct (CBD), SO motility and its response to bolus injections of cholecystokinin (CCK, 20 ng/kg and 100 ng/kg) were detected respectively by manometry in eight Beagle dogs before and after cholecystectomy. RESULTS After cholecystectomy the CBD pressure increased 2.18 ± 1.86 mmHg, while the cyclical motion pattern of SO still existed but with a shortened cycle duration. The basal pressure (BP), phasic contraction amplitude (PCA), phasic contraction frequency (PCF) and its mode of propagation did not change significantly. Under the stimulation of CCK after cholecystectomy, although the motion patterns of SO were similar to those before cholecystectomy, the greatest inhibitory efficacy of BP and PCA all decreased with the prolonged excitement duration and the increased percentage of retrograde contraction. CONCLUSIONS Shortly after a cholecystectomy in Beagle dogs, the CBD pressure increased, SO motilities did not change significantly during the interdigestive phase except with a shortened cycle duration. Its relaxation responded to CCK was weakened with a confused contraction pattern.
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Affiliation(s)
- Ming Ming Fan
- Department of General Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Dooley JS. Gallstones and Benign Biliary Diseases. SHERLOCK'S DISEASES OF THE LIVER AND BILIARY SYSTEM 2011:257-293. [DOI: 10.1002/9781444341294.ch12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Winter J, Hiort O, Hermanns P, Thiele S, Pohlenz J. A new heterozygous mutation (D196N) in the Gs alpha gene as a cause for pseudohypoparathyroidism type IA in a boy who had gallstones. J Pediatr Endocrinol Metab 2011; 24:297-301. [PMID: 21823526 DOI: 10.1515/jpem.2011.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pseudohypoparathyroidism (PHP) is characterized by hypocalcemia and hyperphosphatemia in association with an increased secretion of parathyroid hormone (PTH) due to decreased target tissue responsiveness to PTH. Patients with PHP type Ia are not only resistant to PTH, but also to other hormones that bind to receptors coupled to stimulatory G protein (Gsalpha). PHP Ia and Albright hereditary osteodystrophy (AHO) are caused by a reduced activity of the Gsalpha protein. Heterozygous inactivating Gs alpha (GNAS) gene mutations have been identified in these patients. METHODS We studied a boy with PHP Ia. During follow-up the patient developed elevated liver enzyme serum levels and abdominal discomfort. Gsalpha activity was measured in erythrocyte membranes from the patient and the GNAS coding region of Gsalpha sequenced. RESULTS Gsalpha activity was reduced (62%) and molecular analysis revealed a new heterozygous GNAS gene mutation (D196N). Gallstones were diagnosed and cholecystectomy was performed. Biochemical analysis revealed cholesterol stones, a condition that was not reported before in PHP Ia. CONCLUSIONS Cholesterol gallstones may rarely be associated with PHP Ia and should be taken into account.
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Affiliation(s)
- Julia Winter
- Children's Hospital of the Johannes Gutenberg-University, Mainz, Germany
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Pancreaticobiliary Reflux in Patients with and without Cholelithiasis: Is It a Normal Phenomenon? World J Surg 2010; 34:2915-21. [DOI: 10.1007/s00268-010-0771-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Seetharam P, Rodrigues G. Sphincter of Oddi and its dysfunction. Saudi J Gastroenterol 2008; 14:1-6. [PMID: 19568485 PMCID: PMC2702883 DOI: 10.4103/1319-3767.37793] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 06/29/2007] [Indexed: 12/26/2022] Open
Abstract
Sphincter of Oddi though mostly heard about in 'anatomy textbooks' is making its way into surgical practice due to various disease states affecting it and its dysfunction seems to be an important condition to be observed while treating patients with abdominal pain. In this review, we have attempted to discuss all the relevant conditions affecting it, particularly the dysfunction with a detailed literature review.
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Affiliation(s)
- Prasad Seetharam
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Gabriel Rodrigues
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India,Address: Dr. Gabriel Rodrigues, 157, KMC Quarters, Madhav Nagar, Manipal - 576 104, Karnataka, India. E-mail:
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Beltrán MA, Vracko J, Cumsille MA, Cruces KS, Almonacid J, Danilova T. Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases. J Surg Oncol 2007; 96:26-31. [PMID: 17345616 DOI: 10.1002/jso.20756] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases. METHODS One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study. RESULTS According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001). CONCLUSIONS OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.
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Abstract
This paper reviews the progress made in understanding the mechanical behaviour of the biliary system. Gallstones and diseases of the biliary tract affect more than 10% of the adult population. The complications of gallstones, i.e. acute pancreatitis and obstructive jandice, can be lethal, and patients with acalculous gallbladder pain often pose diagnostic difficulties and undergo repeated ultrasound scans and oral cholecystograms. Moreover, surgery to remove the gallbladder in these patients, in an attempt to relieve the symptoms, gives variable results. Extensive research has been carried out to understand the physiological and pathological functions of the biliary system, but the mechanism of the pathogenesis of gallstones and pain production still remain poorly understood. It is believed that the mechanical factors play an essential role in the mechanisms of the gallstone formation and biliary diseases. However, despite the extensive literature in clinical studies, only limited work has been carried out to study the biliary system from the mechanical point of view. In this paper, we discuss the state of art knowledge of the fluid dynamics of bile flow in the biliary tract, the solid mechanics of the gallbladder and bile ducts, recent mathematical and numerical modelling of the system, and finally the future challenges in the area.
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Affiliation(s)
- Xiaoyu Luo
- Department of Mathematics, University of Glasgow, Glasgow, G12 8QW, United Kingdom.
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Della Libera E, Rodrigues RA, Guimarães APR, Paulo GAD, Geocze S, Ferrari AP. Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. ARQUIVOS DE GASTROENTEROLOGIA 2007; 44:18-21. [PMID: 17639177 DOI: 10.1590/s0004-28032007000100005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Accepted: 06/08/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Ermelindo Della Libera
- Discipline of Gastroenterology, São Paulo Federal University, Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, SP, Brazil
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Tsitouridis I, Lazaraki G, Papastergiou C, Pagalos E, Germanidis G. Low conjunction of the cystic duct with the common bile duct: does it correlate with the formation of common bile duct stones? Surg Endosc 2006; 21:48-52. [PMID: 16960679 DOI: 10.1007/s00464-005-0498-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2005] [Accepted: 04/15/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aimed to evaluate the accuracy of magnetic resonance cholangiography (MRC) in detecting variants of low cystic duct conjunction, which can be a source of confusion during surgery when unrecognized. METHODS All cases with both MRC and endoscopic retrograde cholangiography (ERC) indicating suspected common bile duct stones between January 1999 and January 2004 were retrospectively reviewed by investigators blinded to the final diagnosis. Assessment with ERC was regarded as the gold standard. The aim was to find a low conjunction of the cystic duct with the bile duct. The sensitivity and specificity of MRC were calculated in comparison with those for ERC. The cystic junction radial orientation was defined as lateral (insertion diagonally from the right), medial (insertion into the left side of the common hepatic duct), or posteroanterior (overlap of the junction with the bile duct in the posteroanterior view). A spiral cystic duct and a long parallel course were evaluated separately. RESULTS Low insertion of the cystic duct was found on ERC in 66 of 622 patients (11%; 28 men and 38 women; mean age, 64.5 years). The sensitivity and specificity of MRC for detecting low cystic entrance were 100% (90.4% on an intention-to-diagnose basis and 100%, respectively). In 11 patients (16.6%), the radial orientation of the cysticohepatic junction could not be defined with MRC. The rate of correct MRC delineation was 95% for lateral (n = 21), 77% for medial (n = 26), and 74% for posteroanterior (n = 19) insertion of the cystic duct. CONCLUSION The findings showed that MRC has good correlation with ERC with regard to the location and anatomic details of cystic duct insertion. Although this does not generate a separate indication for MRC before laparoscopic cholecystectomy, the anatomic information can be of additional use when MRC is clinically indicated in this setting.
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Affiliation(s)
- I Tsitouridis
- Radiology Department, Papageorgiou General Hospital, West Perifereiaki Street, N. Efkarpia, Thessaloniki, Greece
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Abstract
AIM: To investigate those associations using data of the population-based Study of Health in Pomerania.
METHODS: A study population of 3 749 residents aged 20-79 years without previously diagnosed thyroid disease was available for analyses. Serum TSH was used to assess thyroid function. Cholelithiasis was defined by either a prior history of cholecystectomy or the presence of gallstones on ultrasound. Logistic regression was performed to analyze independent associations between thyroid function and cholelithiasis.
RESULTS: There were 385 persons (10.3%) with low (<0.3 mIU/L), 3 321 persons (88.6%) with normal and 43 persons (1.2%) with high serum TSH levels (>3 mIU/L). The proportion of cholelithiasis among males and females was 14.4% and 25.3%, respectively. Among males, there was an independent relation between high serum TSH and cholelithiasis (OR 3.77; 95%-CI 1.06-13.41; P<0.05). Also among males, there was a tendency towards an elevated risk of cholelithiasis in persons with low serum TSH (OR 1.40; 95%-CI 0.96-2.02; P = 0.07). In the female population, no such relation was identified.
CONCLUSION: There is an association between thyroid and gallstone disease with a gender-specific relation between hypothyroidism and cholelithiasis.
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Affiliation(s)
- Henry Völzke
- Institute of Epidemiology and Social Medicine, Ernst Moritz Arndt University, Greifswald, Germany.
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Vetrhus M, Berhane T, Søreide O, Søndenaa K. Pain persists in many patients five years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis. J Gastrointest Surg 2005; 9:826-31. [PMID: 15985239 DOI: 10.1016/j.gassur.2005.01.291] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 01/14/2005] [Indexed: 01/31/2023]
Abstract
After removal of the gallbladder, pain may persist in some patients. To study this condition, 124 patients from two randomized trials, including those with symptomatic noncomplicated gallbladder stones (n = 90) and acute cholecystitis (n = 34), were interviewed, while 139 patients (90%) excluded from both trials responded to a questionnaire 5 years after the operation. Thirty-four patients (27%) of those randomized had pain; 23 (18%) had diffuse, steady pain; and 11 (9%) had pain attacks resembling their preoperative symptoms. A significant dominance of diffuse pain occurred in women (P = 0.024), especially those younger than 60 years (P = 0.004). A tendency for the diffuse type to be dominant was also present in the group of female patients with symptomatic noncomplicated gallbladder stones (P = 0.052). Of the excluded patients, 18% (25/139) had pain, but 88% of them (96% of the men and 87% of the women) were satisfied with the result of the operation. The overall number of patients with postoperative pain was 22% (59/263). We conclude that persisting abdominal pain 5 years after the operation was mainly of a nonspecific type, found mostly in younger women who had had noncomplicated gallstone disease. Eighty-eight percent of the excluded patients declared themselves satisfied with the result of cholecystectomy.
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Affiliation(s)
- Morten Vetrhus
- Department of Surgery, Stavanger University Hospital, Stavanger, Norway.
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Piccinni G, Angrisano A, Testini M, Bonomo GM. Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation. J Clin Gastroenterol 2004; 38:350-9. [PMID: 15087695 DOI: 10.1097/00004836-200404000-00010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Giuseppe Piccinni
- Department of Applications in Surgery of Innovative Technologies, University of Bari, School of Medicine, Bari, Italy.
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Smith RC. Cholecystectomy and duodenogastric reflux. ANZ J Surg 2003; 73:369-370. [PMID: 12801324 DOI: 10.1046/j.1445-2197.2003.02733.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wei JG, Wang YC, Liang GM, Wang W, Chen BY, Xu JK, Song LJ. The study between the dynamics and the X-ray anatomy and regularizing effect of gallbladder on bile duct sphincter of the dog. World J Gastroenterol 2003; 9:1014-9. [PMID: 12717848 PMCID: PMC4611364 DOI: 10.3748/wjg.v9.i5.1014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the relationship between the radiological anatomy and the dynamics on bile duct sphincter in bile draining and regulatory effect of gallbladder.
METHODS: Sixteen healthy dogs weighing 18 kg to 25 kg were divided randomly into control group and experimental group (cholecystectomy group). Cineradiography, manometry with perfusion, to effect of endogenous cholecystokinin and change of ultrastructure were employed.
RESULTS: According to finding of the choledochography and manometry, in control group the intraluminal basal pressure of cephalic cyclic smooth muscle of choledochal sphincter cCS was 9.0 ± 2.0 mmHg and that of middle oblique smooth muscle of choledochal sphincter (mOS) was 16.8 ± 0.5 mmHg, the intraluminal basal pressure of cCS segment was obviously lower than that of mOS (P < 0.01) in the interval period of bile draining, but significant difference of intraluminal basal pressure of the mOS segment was not found between the interval period of bile draining (16.8 ± 0.5 mmHg) and the bile flowing period (15.9 ± 0.9 mmHg) (P > 0.05). The motility of cCS was mainly characterized by rhythmically concentric contraction, just as motility of cCS bile juice was pumped into the mOS segment in control group. And motility of mOS segment showed mainly diastolic and systolic activity of autonomically longitudinal peristalsis. There was spasmodic state in cCS and mOS segment and reaction to endogenous cholecystokinin was debased after cholecystectomy. The change of ultrastructure of cCS portion showed mainly that the myofilaments of cell line in derangement and mitochondria is swelling.
CONCLUSION: During fasting, the cCS portion has a function as similar cardiac "pump" and it is main primary power source in bile draining, and mOS segment serves mainly as secondary power in bile draining. The existence of the intact gallbladder is one of the important factors in guaranteeing the functional coordination between the cCS and mOS of bile duct sphincter. There is dysfunction in the cCS and mOS with cholecystectomy.
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Affiliation(s)
- Jing-Guo Wei
- Radiology Department of Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi Province, China.
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