Gallbladder and Pancreas in Henoch-Schönlein Purpura: Review of the Literature

OBJECTIVE Involvement of the pancreato-biliary system has been occasionally noted in Henoch-Schönlein purpura. Furthermore, cases of this vasculitis syndrome sometimes develop in the context of a viral hepatitis or after hepatitis vaccination. METHODS We completed a review of the literature. RESULTS Fifty reports published between 1977 and 2015 were retained for the analysis. A pancreato-biliary involvement was recognized in 34 individually well-described patients (♂:♀ = 19:15) with severe abdominal pain: pancreatitis (N = 20), acalculous cholecystitis (N = 11), both pancreatitis and cholecystitis (N = 3). In all of the pancreatitis patients, full recovery occurred (within ≤3 weeks in three-fourths of the patients). Cholecystectomy was performed in 8 cholecystitis patients. Seventeen Henoch-Schönlein patients (♂:♀ = 9:8) were associated with a viral liver disease and 4 (♂:♀ = 1:3) with a hepatitis vaccination. The vasculitis syndrome rapidly remitted in the 7 patients accompanying hepatitis A or E, in 2 patients of hepatitis B, and in the 4 patients preceded by a vaccination. Henoch-Schönlein purpura seemed to be serious in 5 patients with chronic hepatitis B and in 3 with chronic hepatitis C. CONCLUSIONS This analysis indicates that pancreato-biliary involvement is unusual in Henoch-Schönlein purpura. This complication deserves consideration in patients with especially severe abdominal pain. Finally, viral hepatitides and hepatitis vaccinations seem to be rare triggers of Henoch-Schönlein purpura.

Atención quirúrgica en hombres y mujeres ¿Diferente o desigual?

Explorar la posible existencia de sesgos de género en procedimientos quirúrgicos (PQ) frecuentes y en sus estancias medias (EM) postquirúrgicas es objetivo del presente trabajo, mediante su comparación entre sexos en el Servicio de Cirugía General y Digestiva del Hospital General de Alicante (2000-2004). Se intervienen más hombres que mujeres en 4 de los 7 PQ estudiados, apuntando posibles sesgos de género en el patrón quirúrgico, como por apendicectomías agudas (1,36 Hombres/1 Mujer) y complicadas (1,79/1). La estancia postapendicectomías, a igual edad y comorbilidad, es de 2 días más en hombres (9,49) que en mujeres (7,5). No detectar diferencias por sexo en colecistectomías por colecistitis (más frecuentes en mujeres), puede indicar colelitiasis evolucionadas por no sospecha diagnóstica en hombres.

Ultrasonography of gallbladder abnormalities due to schistosomiasis

After malaria, schistosomiasis remains the most important tropical parasitic disease in large parts of the world. Schistosomiasis has recently re-emerged in Southern Europe. Intestinal schistosomiasis is caused by most Schistosoma (S.) spp. pathogenic to humans and leads to chronic inflammation and fibrosis of the colon as well as to liver fibrosis. Gallbladder abnormalities usually occur in patients with advanced hepatic portal fibrosis due to Schistosoma mansoni infection. Occasionally, gallbladder abnormalities have been seen also in children and occurring without associated overt liver abnormalities.The specific S. mansoni-induced gallbladder abnormalities detectable by ultrasound include typical hyperechogenic wall thickening with external gallbladder wall protuberances. The luminal wall surface is smooth. The condition is usually clinically silent although some cases of symptomatic cholecystitis have been described. The ultrasonographic Murphy response is negative. Gallbladder contractility is impaired but sludge and calculi occur rarely. Contrary to other trematodes such as liver flukes, S. mansoni does not obstruct the biliary tract. Advanced gallbladder fibrosis is unlikely to reverse after therapy.

Miscellany. Lane collections pamphlets.

Binder's title.

Histological analysis of gallbladder diseases in relation to opisthorchiasis in endemic areas of Thailand

Chronic gallbladder disease frequently accompanies infection with the liver fluke, Opisthorchis viverrini, in Northeast Thailand. However, the pathology and pathogenesis of the gallbladder disease have not been described. Accordingly, gallbladder specimens from 187 consecutive patients who had undergone cholecystectomy at a referral hospital in an endemic area in Thailand were histologically characterized in relation to O. viverrini infection. The infection was assessed by the presence of parasite eggs in the bile and/or antibody response to the liver fluke. The average level of parasite-specific IgG was significantly higher in patients with Opisthorchis eggs in the bile than those without (P < 0.001). The main histopathologic features of the gallbladder included inflammation, mucosal atrophy/or hyperplasia, goblet cell metaplasia, mucous gland hyperplasia, Rokitansky-Aschoff sinus formation, dysplasia and fibrosis. The fibrosis was strongly associated with elevated levels of Opisthorchis-specific antibody (P < 0.001) but not with the presence of parasite eggs. Other pathologic features did not vary in frequency or severity with parasitological status. Our results show that severe fibrosis of the gallbladder is a more common histologic feature of cholecystitis among those with O. viverrini infection compared to those without infection. The close relationship between parasite-specific IgG and severe fibrosis suggests that specific immune response to the parasite play an important role in the pathogenesis of the fibrotic change. (C) 2003 Elsevier B.V. All rights reserved.

Increased rate of cholecystectomies performed with doubtful or no indications after laparoscopy introduction: a single center experience

Background During recent years laparoscopic cholecystectomy has dramatically increased, sometimes resulting in overtreatment. Aim of this work was to retrospectively analyze all laparoscopic cholecystectomies performed in a single center in order to find the percentage of patients whose surgical treatment may be explained with this general trend, and to speculate about the possible causes. Methods 831 patients who underwent a laparoscopic cholecystectomy from 1999 to 2008 were retrospectively analyzed. Results At discharge, 43.08% of patients were operated on because of at least one previous episode of biliary colic before the one at admission; 14.08% of patients presented with acute lithiasic cholecystitis; 14.68% were operated on because of an increase in bilirubin level; 1.56% were operated on because of a previous episode of jaundice with normal bilirubin at admission; 0.72% had gallbladder adenomas, 0.72% had cholangitis, 0.36% had biliodigestive fistula and one patient (0.12%) had acalculous cholecystitis. By excluding all these patients, 21.18% were operated on without indications. Conclusions The broadening of indications for laparoscopic cholecystectomy is undisputed and can be considered a consequence of new technologies that have been introduced, increased demand from patients, and the need for practice by inexperienced surgeons. If not prevented, this trend could continue indefinitely.

Cholecystectomy by single incision laparoscopic surgery (SILS): early experience and technique standardization

Single Incision Laparoscopic Surgery (SILS) is a recent surgical technique, first described in the 1990s. Its aim is to optimize the esthetic result offered by laparoscopy by minimizing the number of abdominal incisions. Various preliminary studies have been carried out on the application of SILS, especially in cholecystectomy and appendectomy. This study evaluates the preliminary results of cholecystectomy by SILS (SILS™ Port) conducted between October 2009 and February 2011 on 21 patients (4 men and 17 women) with a mean age of 49.9 years and a mean Body Mass Index (BMI) of 22.8. All patients were treated by the same team, which had previously undergone six months’ simulator training. There were two main selection criteria, both evaluated intraoperatively: absence of adhesions and of significant inflammatory sequelae from previous cholecystitis; and suitable distance between gallbladder and SILS access port. Conversion to traditional laparoscopy was necessary in just two cases, while an accessory trocar was introduced in another two cases. Conversion to open surgery was not necessary in any case. One case of SILS cholecystectomy was complicated by postoperative bile leakage, which was treated conservatively, as the fistula had a low output. The mean duration of hospitalization was 3.6 days. This preliminary experience led us to conclude that SILS is safe and highly satisfactory in the postoperative phase, thanks to the reduced need for painkillers and the improved esthetic result.

Laparoscopic approach in abdominal emergencies: a 5-year experience at a single center

Background. Laparoscopy is ever more common in both elective and emergency surgery. In fact, in abdominal emergencies it enables the resolution of preoperative diagnostic doubts as well as treatment of the underlying disease. We present a retrospective study of the results of a 5-year experience at a single center. Patients and methods. Between September 2006 and August 2011, 961 patients were treated via laparoscopy, including 486 emergency cases (15 gastroduodenal perforation; 165 acute cholecystitis; 255 acute appendicitis; 15 pelvic inflammatory disease and non-specific abdominal pain [NSAP]; 36 small bowel obstruction). All procedures were conducted by a team trained in laparoscopic surgery. Results. The conversion rate was 22/486 patients (4.53%). A definitive laparoscopic diagnosis was possible in over 96% of cases, and definitive treatment via laparoscopy was possible in most of these. Conclusions Our own experience confirms the literature evidence that laparoscopy is a valid option in the surgical treatment of abdominal emergencies. In any case, it must be performed by a dedicated and highly experienced team. Correct patient selection is also important, to enable the most suitable approach for each given situation.

Comportamiento de la patología biliar aguda y su manejo en el servicio de trauma y emergencia del Hospital "Vicente Corral Moscoso" Cuenca. Enero a junio de 2014

La patología biliar afecta a un gran porcentaje de la población adulta, motivo por el cual su tratamiento en la actualidad ha cambiado hacia un nuevo paradigma de cuidado bajo el concepto de “Acute Care Surgery” (ACS) 1 el cual se caracteriza por priorizar la valoración integral del paciente e intervención precoz de la patología. En el Hospital Vicente Corral Moscoso (HVCM) bajo este modelo ACS, y mediante la utilización de protocolos estandarizados se ha logrado dar un giro importante en el tratamiento oportuno de la patología biliar mediante la utilización de herramientas habituales como pruebas de laboratorio, imagenología y si es el caso, la resolución quirúrgica mediante técnica mínimamente invasiva o por vía convencional. OBJETIVO: Describir el comportamiento de la patología biliar y su manejo en el servicio de Trauma y Emergencias del Hospital “Vicente Corral Moscoso”, durante el período de enero a junio de 2014, bajo el modelo ACS. MÉTODOS: Estudio descriptivo transversal, que analizó los casos de colecistitis aguda litiásica (CAL), coledocolitiasis, pancreatitis aguda biliar (PAB) y su manejo, registrado en la base de datos digital del servicio de Emergencias del Hospital Vicente Corral Moscoso, bajo criterios clínicos, de laboratorio e imagenológicos, durante el periodo de enero a junio del 2014. RESULTADOS: El estudio contó con un total de 240 pacientes atendidos en el servicio de Trauma y Emergencia del HVCM, durante el periodo de enero a junio de 2014. La patología en orden de frecuencia fue: en un 47%, la Coledocolitiasis; 35% colecistitis aguda y, pancreatitis aguda biliar 18%. La prevalencia fue mayor en el sexo femenino en un 85%, 67%, y 81% respectivamente y el tratamiento se adaptó a cada patología. 1 Acute Care Surgery” (ACS): si bien no existe una definición literal hace referencia a una disciplina tripartita que engloba la cirugía de trauma, general en emergencias y cuidados críticos quirúrgicos, y que prioriza la identificación y manejo de las patologías potencialmente letales y de alta morbilidad. En nuestro medio lo más próximo a la definición seria Cirugía de Trauma y Emergencias. El manejo de la pancreatitis aguda biliar (PAB) bajo el concepto de cuidado agudo de pacientes quirúrgicos o “Acute Care Surgery” hace indispensable una intervención oportuna y temprana, utilizando todos los recursos disponibles para un manejo integral. CONCLUSIONES: La implementación del modelo de Cirugía de Trauma y Emergencias en nuestra institución ha logrado un manejo integral de colecistitis aguda litiásica, pancreatitis aguda biliar y coledocolitiasis, disminuyendo las complicaciones asociadas y evitando las recidivas de cuadros de mayor gravedad.

First case reported of Bouveret's syndrome associated to duodenal and biliary perforation to retroperitoneum

We present the case of a 69 year old woman with a history of cholecystitis, who consulted for severe abdominal pain, nausea and vomiting. Abdominal CT showed duodenal obstruction caused by a gallstone, cholecystoduodenal fistula and pneumobilia, what is known as Bouveret's syndrome, a rare form of gallstone ileus. Additionally, she presented free duodenal and vesicular perforation to retroperitoneum at the same level of the cholecystoduodenal transit point. The patient underwent a difficult cholecystectomy, enterolithotomy, repair of the duodenal defect, extensive washing and drainage of the retroperitoneum. The postoperative course was uneventful except for a laparotomy infection.

Desenlaces en pacientes embarazadas con patología quirúrgica abdominal 2011-2014

Estudio transversal realizado entre 2011 y 2014 en la Clínica de la Mujer con el fin de describir el comportamiento de la salud el binomio madre hijo en gestantes que requirieron manejo quirúrgico de patologías quirúrgicas abdominales no ginecobstétricas.