This case report describes a 61-year-old male patient who presented with chronic abdominal pain and was found to have xanthogranulomatous cholecystitis (XGC), a rare inflammatory disease of the gallbladder, along with gallstones. Imaging studies revealed thickening of the gallbladder wall and a mass, concerning for possible gallbladder carcinoma. The patient underwent cholecystectomy and was found to have XGC pathology, characterized by lipid-laden macrophages and chronic inflammatory cells infiltrating the gallbladder wall. XGC is a benign condition that can be confused for gallbladder cancer. The patient's surgery and recovery were uncomplicated.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
In this presentation, I have shown how to do open anterior resection both high and low varieties in a step-by-step manner with clear pictures as if reading an atlas of operative surgery.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
Rupture of a Hydatid Cyst into the Bile Ductasclepiuspdfs
Cholestasis secondary to a cystobiliary communication is a rare complication associated with hepatic hydatidosis. The most established surgical procedure is the evacuation of the contents of the cyst (daughter cysts) without spills, sterilization of the cyst cavity with scolicide agents to prevent the dissemination of the hydatids to the peritoneal cavity, and cavity management (capitonnage) together with the closing of the communication.
Chronic diarrhea as a result of colonic fistulas -two case reports with different origin. When it comes to chronic diarrhea symptom, the first thing
one thinks of is never a surgical cause, but an infectious disease. The aim of this paper is to show 2 different cases of chronic diarrhea, resulting from
benign surgical causes - colonic fistula. The first case is a result of cholecystocolic fistula, while the second is the result of gastrojejunocolic fistula.
Colonic fistulas originate from different causes: malignancy, NSAID, diverticulosis of the colon, cholecystitis, pancreatitis, lymphoma, or after radiation
therapy. They can also result from a trauma, which can be post-surgical.
Introduction:
Cholecystocolic fistula occurs as a result of the inflammation of the gallbladder. It arises from existing adhesions. The incidence rate
is not high, but the complication is not a rarity per se. It is less frequent complication than cholecystoduodenal fistula. The main symptoms are secretory
diarrhea, vitamin K malabsorption and weight loss, and thus suspicion of malignancy is usual. The treatment is surgical removal of the gallbladder,
fistula and part of the colon en bloc.
Case report:
A 73-year old male patient was admitted to the department after 5 months of medical treatment. Laboratory tests, coproculture,
colonoscopy, abdominal ultrasonography, and gastroduodenoscopy were performed - the diagnosis was not established. The diagnosis was made by
means of irrigography and short and narrow cholecystocolic fistula was confirmed. The possibility of malignant disease was not completely excluded.
The patient underwent surgery after parental nutrition-adhesions, gallbladder, and the prepared fistula were removed as well as the longitudinal part
of the transverse colon, which was simultaneously repaired. Ex-tempore diagnosis-the surgical specimen originated from inflammation, not from
malignancy. The post-operative course was uneventful. The first post-operative stool was normal. The patient gained some weight after a few months.
Conclusion:
Along with the contemporary diagnostics methods, contrast examination plays an important diagnostic role. When infection is
excluded as the cause of chronic diarrhea, cholecystocolic fistula should be considered. Malignant disease should be excluded before the surgery, or it
may be diagnosed during the surgery, which would determine the course of the treatment. The treatment of benign cholecystocolic fistula is surgical
en bloc procedure.
In this presentation, I have shown how to do open anterior resection both high and low varieties in a step-by-step manner with clear pictures as if reading an atlas of operative surgery.
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
Rupture of a Hydatid Cyst into the Bile Ductasclepiuspdfs
Cholestasis secondary to a cystobiliary communication is a rare complication associated with hepatic hydatidosis. The most established surgical procedure is the evacuation of the contents of the cyst (daughter cysts) without spills, sterilization of the cyst cavity with scolicide agents to prevent the dissemination of the hydatids to the peritoneal cavity, and cavity management (capitonnage) together with the closing of the communication.
Chronic diarrhea as a result of colonic fistulas -two case reports with different origin. When it comes to chronic diarrhea symptom, the first thing
one thinks of is never a surgical cause, but an infectious disease. The aim of this paper is to show 2 different cases of chronic diarrhea, resulting from
benign surgical causes - colonic fistula. The first case is a result of cholecystocolic fistula, while the second is the result of gastrojejunocolic fistula.
Colonic fistulas originate from different causes: malignancy, NSAID, diverticulosis of the colon, cholecystitis, pancreatitis, lymphoma, or after radiation
therapy. They can also result from a trauma, which can be post-surgical.
Introduction:
Cholecystocolic fistula occurs as a result of the inflammation of the gallbladder. It arises from existing adhesions. The incidence rate
is not high, but the complication is not a rarity per se. It is less frequent complication than cholecystoduodenal fistula. The main symptoms are secretory
diarrhea, vitamin K malabsorption and weight loss, and thus suspicion of malignancy is usual. The treatment is surgical removal of the gallbladder,
fistula and part of the colon en bloc.
Case report:
A 73-year old male patient was admitted to the department after 5 months of medical treatment. Laboratory tests, coproculture,
colonoscopy, abdominal ultrasonography, and gastroduodenoscopy were performed - the diagnosis was not established. The diagnosis was made by
means of irrigography and short and narrow cholecystocolic fistula was confirmed. The possibility of malignant disease was not completely excluded.
The patient underwent surgery after parental nutrition-adhesions, gallbladder, and the prepared fistula were removed as well as the longitudinal part
of the transverse colon, which was simultaneously repaired. Ex-tempore diagnosis-the surgical specimen originated from inflammation, not from
malignancy. The post-operative course was uneventful. The first post-operative stool was normal. The patient gained some weight after a few months.
Conclusion:
Along with the contemporary diagnostics methods, contrast examination plays an important diagnostic role. When infection is
excluded as the cause of chronic diarrhea, cholecystocolic fistula should be considered. Malignant disease should be excluded before the surgery, or it
may be diagnosed during the surgery, which would determine the course of the treatment. The treatment of benign cholecystocolic fistula is surgical
en bloc procedure.
AbstractIntestinal cystic pneumatosis is a rare condition characterized by the presence of gaseous cysts in the intestinal wall.We report the observation of a 51-year-old patient with dyspepsia syndrome and recurrent episodes of abdominal pain who had a three-day cessation of materials and gas for three days.
AbstractIntestinal cystic pneumatosis is a rare condition characterized by the presence of gaseous cysts in the intestinal wall.We report the observation of a 51-year-old patient with dyspepsia syndrome and recurrent episodes of abdominal pain who had a three-day cessation of materials and gas for three days
AbstractIntestinal cystic pneumatosis is a rare condition characterized by the presence of gaseous cysts in the intestinal wall.We report the observation of a 51-year-old patient with dyspepsia syndrome and recurrent episodes of abdominal pain who had a three-day cessation of materials and gas for three days. The clinical ex-...
AbstractIntestinal cystic pneumatosis is a rare condition characterized by the presence of gaseous cysts in the intestinal wall.We report the observation of a 51-year-old patient with dyspepsia syndrome and recurrent episodes of abdominal pain who had a three-day cessation of materials and gas for three days. The clinical ex-...
We report the observation of a 51-year-old patient with dyspepsia syndrome and recurrent episodes
of abdominal pain who had a three-day cessation of materials and gas for three days. The clinical examination on admission showed a slightly distended abdomen, an empty rectal bulb with digital rectal
examination. The biological assessment was without abnormality, the radiography of the abdomen
without preparation showed central hydro-aeric levels of the hail-like type with a gaseous crescent
inter hepato-diaphragmatic. The abdominal CT objectified a pneumoperitoneum with aerobilia, an
upper digestive distension with probable proximal digestive volvulus. The patient was admitted to
the block and an exploratory laparotomy was performed which revealed the presence of a gas cyst in
several places in the small intestine with distension of the latter upstream of a large mass of benign
appearance. Taking a segment of the jejunum. We carried out an anastomosis resection of the small
intestine carrying out the mass which we sent to the pathological anatomy laboratory and the result
of which returned in favor of intestinal cystic pneumatosis. The postoperative suites were simple with
good evolution and resumption of transit at end of the third day
Introduction: Diffuse Large B Cell Lymphoma (DLBCL), as a set of heterogeneous aggressive lymphoma, most commonly originated in the germinal center B lymphocytes. Rare cases were from peripheral blood B cell (outside germinal center) or from the inert lymphoma development and transformation. And such tumor with originality outside germinal center was seldom seen in the literature. Even the tumor in combination with chronic gastritis has not been reported before.
Spontaneous Gall Bladder Perforation: A rare clinical entity, a diagnostic an...Crimsonpublisherssmoaj
Gallbladder perforation requiring an emergent treatment is usually a complication of cholecystitis [1]. Acute cholecystitis develops in up to 2% of patients affected by asymptomatic cholelithiasis. Gallbladder perforation occurs in 2 to 11% of acute cholecystitis cases. Due to the high mortality that can be caused by a delay in the correct diagnosis and following adequate surgical treatment, gallbladder perforation represents a special diagnostic and surgical challenge [2].
https://crimsonpublishers.com/smoaj/fulltext/SMOAJ.000505.php
For more Open access journals in Crimson Publishers
Please click on: https://crimsonpublishers.com/
For more articles in Open access journal of Innovation in Surgical Medicine Open Access Journal Please click on: https://crimsonpublishers.com/smoaj/index.php
Management of Perforated Duodenal Diverticulum: Case Reportasclepiuspdfs
It has been reported that duodenal diverticula are common but perforated duodenal diverticulum is a rare entity. At this time, there is no standardized management for perforated duodenal diverticulum. In these cases, patients usually complain of vague abdominal pain and computed tomography scan is mostly ordered used as an important diagnostic method. Diagnosis and the severity of the disease need to be assessed before any intervention. Essentially, the perforated small bowel is treated with surgical intervention. However, conservative treatment with broad-spectrum antibiotics and strict nil per os has been offered in the past for stable patients. Below, we report one case of perforated duodenal diverticulum that we managed with conservative treatment.
Incisional Hernia Occurring after Ventriculoperitoneal Shunt Fixationsemualkaira
Ventriculo-peritoneal shunt is the procedure of choice for hydrocephalus. Various complications of ventriculoperitoneal shunts
were reported. Abdominal complications involving the distal tip
of the catheter make the majority of the complications. In this case
report we present a case of incisional hernia occurring in a patient
who underwent fixation of ventriculoperitoneal shunt followed by
revision of the shunt after a while.
Incisional Hernia Occurring after Ventriculoperitoneal Shunt Fixationsemualkaira
Ventriculo-peritoneal shunt is the procedure of choice for hydrocephalus. Various complications of ventriculoperitoneal shunts
were reported. Abdominal complications involving the distal tip
of the catheter make the majority of the complications. In this case
report we present a case of incisional hernia occurring in a patient
who underwent fixation of ventriculoperitoneal shunt followed by
revision of the shunt after a while.
Abdominal Splenosiscausing Hydronephrosis- A Case Reportsemualkaira
Splenosis is anuncommenprocess ofintra abdominal or extra abdominal splenic tissue seeding, mostly post traumatic.The issueof splenosismostly comesupinpatientspresentingwith suspicious nodules inthe abdominal or chest cavity. It is exactly these patients with a history of blunt abdominal trauma who should be considered as candidates for having splenosis and should be screened with a proper medical history and with the use of novel non invasive imaging modalities thus sparing the patients unnecessary and potentially dangerous procedures.
Abdominal Splenosiscausing Hydronephrosis- A Case Reportsuppubs1pubs1
Splenosis is anuncommenprocess ofintra abdominal or extra abdominal splenic tissue seeding, mostly post traumatic.The issueof splenosismostly comesupinpatientspresentingwith suspicious nodules inthe abdominal or chest cavity. It is exactly these patients with a history of blunt abdominal trauma who should be considered as candidates for having splenosis and should be screened with a proper medical history and with the use of novel non invasive imaging modalities thus sparing the patients unnecessary and potentially dangerous procedures.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
1. Case Reports in Surgery 2014-15
Chronic Xanthogranulomatous Cholecystitis
with associated Focal Adenomyosis:
Case Report and Literature review
Dr. Iyad Anabtawi1
, Dr. Ali Beaila1
, Dr. Damodhar.M.V 1
, Dr. Mohammed Galal 2
, Dr. Ahmad Shalaby 3
1. Department of Surgery, Security Forces Hospital Dammam
2. Department of Radiology, Security Forces Hospital Dammam,
3. Department of Pathology, Security Forces Hospital Dammam
Correspondence should be addressed to Dr. Iyad Anabatwi, email: ianabtawi@SFHD.med.sa
Prepared for publication 25 January 2015
ABSTRACT:
Xanthogranulomatous Cholecystitis is a rare inflammatory disease of the
gallbladder characterized by a focal or diffuse destructive inflammatory process, with
accumulation of lipid laden macrophages, fibrous tissue, and acute and chronic
inflammatory cells. Its importance lies in the fact that it is a benign condition that may be
confused with carcinoma of the gallbladder, which is associated with a poor prognosis. It
was initially described as a variant of chronic Cholecystitis it is has an active destructive
process that can lead to significant morbidity as the inflammatory process usually extends
into the gallbladder wall and adjacent structures [1].
INDEXED KEYWORDS:
Gall Bladder, Acute, Cholecystitis, Chronic, Xanthogranulomatous
INTRODUCTION:
Xanthogranulomatous cholecystitis (XGC) It is a benign condition that may be confused
with carcinoma of the gallbladder, which is associated with a poor prognosis. Gallstones
may have an important role in the pathogenesis, since they appear to be present in most
patients. The clinical and laboratory findings of cases are similar to those of acute or
chronic Cholecystitis. Patients are frequently misdiagnosed with imaging studies and
even during the operation as having carcinoma of the gallbladder. [2]We would like to
share a case of xanthogranulomatous Cholecystitis that was associated with focal
adenomyosis which was presented to our clinic which is also an unusual presentation.
2. CASE:
A 61-year-old male presented with chronic abdominal pain patient was admitted
previously one month back for the same complaints. Pain was associated with nausea but
no vomiting. Patient is allergic to egg and is a known smoker. Patient had previously
undergone lateral sphinterotomy or rectopexy many years back which he faintly
remembers. Patient had normal vital signs. Abdominal examination revealed midline
incisional hernia which is reducible, tenderness in right hypochondrium and epigastric
region, without any palpable lump.
Laboratory tests revealed: Hemoglobin 13.5 g/dL, leucocytic count counts 12600,
Bilirubin Total/Direct 3.68/3.35 mg/dl, AST 230 IU/L, ALT 216 IU/L and Alkaline
Phosphatase 272 IU/L.
Abdominal Ultrasonography showed contracted gall bladder, containing multiple small
stones, heterogeneous mass like lesion measured about 2.7x2.6cms at the fundus of the
gall bladder, no pericholecysitic fluid with dilated common bile duct measuring about
11mm. Figure-1
Figure-1 Abdominal Ultrasonography showing the gall bladder mass.
CT scan of the abdomen with IV contrast showed mild increase in wall thickness of the
gallbladder with lobulated mass like lesion at the fundus of gall bladder, this mass shows
peripheral contrast enhancement with central hypodensity. This picture goes with
differential diagnosis of gallbladder carcinoma versus focal chronic cholecysitis.
In addition to dilatation of both cystic and CBD duct associated with recurrent para-
umbilical hernia. Figure-2
Figure-2 Arrow showing the increase in gall bladder wall thickness.
3. Magnetic Resonance Cholangiopancreatography(MRCP) showed mild dilatation of
intrahepatic biliary radicles, dilated tortuous cystic duct and dilated CBD with two small
stones at its distal part measured about 6x6 and 3x2 mm. Figure 3
Figure-3 Arrow pointing to the stones in the common bile duct.
Patient on the second day underwent Endoscopic Retrograde
Cholangiopancreatography (ERCP), sphintertomy was done and two stones were
retrieved from CBD. Two weeks later after patients discharge, laboratory tests were
normalized and patient was admitted and underwent Open Cholecystectomy removing
part of the liver bed surrounding the gall bladder as local invasion was observed
intraoperatively. Mesh repair for the incisional hernia was done. The patient course post
operatively went smooth with no significant morbidities.
On gross examination Gall bladder received open measures 4x1.5x0.5 cm. with
attached piece of liver tissue measuring about 2.5*2*3 cm. Microscopic examination
reveals a thickened gall bladder wall with massive infiltration of all wall layers by mixed
inflammatory cells mainly plasma cells, lymphocytes histiocytes, neutrophils and
myofibroblasts. The glandular epithelium is found insinuated deeply in the wall; some of
which is partially destroyed by inflammatory cellular reaction which is also present
around nerve trunks Many foamy histiocytes were present forming sheets of cells with
focal multinucleate cell non-caseating granuloma formation. Some glands show Moderate
dysplasia. The liver tissue show mild focal compression changes with fibro-inflammatory
adhesions.
Figure 4 Xanthogranulomatous Cholecystitis- Note Numberous Vaculated macrophages
and cholesterol clefts.
Figure 5 Inflammatory pseudo tumors.
4. Figure 4 Figure 5
Patient was discharged on 5th post-operative day in a satisfactory condition. Patient is
currently being followed up regularly in the General Surgery clinic, Patient has no new
complaints.
DISCUSSION:
INTRODUCTION — it is an uncommon inflammatory disease of the gallbladder which
appears in 0.7% of population in the United States of America.
PATHOGENESIS — The pathogenesis is thought to be related to extravasation of bile
into the gallbladder wall from rupture of Rokitansky-Aschoff sinuses or by mucosal
ulceration [2]. This event incites an inflammatory reaction in the interstitial tissue,
whereby fibroblasts and macrophages phagocyte the biliary lipids in bile such as
cholesterol and phospholipids leading to the formation of xanthoma cells.
Gallstones may have an important role in the pathogenesis, since they appear to be
present in all patients [3].
PATHOLOGY — on gross examination, the gallbladder is thickened and the serosa is
covered with dense fibrous adhesions the mucosal surface is ulcerated and cross sections
through the wall reveals Xanthogranulomatous foci, which appear as yellow nodules or
plaques. These yellowish foci extended into adjacent structures, such as the liver,
duodenum, transverse colon, and omentum [3].
Microscopically, the xanthogranulomatous foci are composed of abundant lipid laden
macrophages, fibroblasts, and inflammatory cells. The lipid laden macrophages are of
two morphological types: rounded foamy macrophages and spindle-shaped cells with
more granular cytoplasm and elongated nuclei. [4].
CLINICAL FEATURES Clinical findings on physical examination and the results of
laboratory tests do not appear to be of use in differentiating this gallbladder disorder from
other more frequent types [5]. The vomiting, upper right quadrant pain, positive Murphy's
sign on sonography, and leukocytosis observed in our patients are similar to the findings
described in other types of cholecystitis. A history of repeated episodes of biliary colic or
pancreatitis is also fairly common. Physical examination is usually unremarkable except
5. possibly for a positive Murphy's sign when acute Cholecystitis is present. A right
hypochondriac mass may be more common in Xanthogranulomatous Cholecystitis than
in acute Cholecystitis, mimicking carcinoma of the gallbladder [6].
COMPLICATIONS — there is a fairly high incidence of complications in
Xanthogranulomatous Cholecystitis, amounting to more than 30 percent in one report [6].
Local complications in the gallbladder include perforation and the development of
strictures. Prolonged cystic duct obstruction and gallbladder distension under pressure
during the acute inflammatory phase can lead to extension of the Xanthogranulomatous
inflammation beyond the gallbladder with formation of hepatic abscesses and fistulas into
adjacent structures.
DIAGNOSIS — The diagnosis is usually made by histological examination of the
resected gallbladder. The possibility of Xanthogranulomatous Cholecystitis should be
considered in any patient presenting with a right upper quadrant mass and/or a biliary
fistula. There are no consistent trends in biochemical or hematological findings that aid in
the diagnosis. Imaging studies and fine needle aspiration cytology may be suggestive, but
no reports on their utility exist. Confirmatory diagnosis is made only at surgery,
sometimes requiring a frozen section.
Ultrasonography often shows a thickened gallbladder wall (which may be focal or
diffuse) with gallstones. Other findings on ultrasonography include a gallbladder mass,
subhepatic fluid collection, obscure border between the gallbladder and liver, intramural
hypoechoic nodules, and rarely, gas in the biliary tree in patients with a biliary fistula [6].
As with sonography, thickening of the gallbladder wall was also the most frequent
CT finding. Two patients presented with a hypoattenuated band around the gallbladder
similar to that described by Chun et al. [7], and homogeneous uptake of contrast material
by the gallbladder mucosa. In these patients, CT was performed during an acute episode
of cholecystitis. The most specific CT finding in a review of 26 patients was a hypodense
band in the gallbladder wall, which was seen in 33 percent of patients.
Magnetic resonance imaging (MRI) — Data on the accuracy of MRI in
diagnosing xanthogranulomatous cholecystitis are limited, the addition of diffusion-
weighted MRI enabled better differentiation of xanthogranulomatous cholecystitis from
gallbladder cancer.
Fine-needle aspiration biopsy has been used in several cases with good results.
TREATMENT — the only definitive treatment for xanthogranulomatous cholecystitis is
surgery. The general principles for the management of acute cholecystitis should be
followed in patients who present with acute cholecystitis.
Because of the inflammatory and invasive nature of xanthogranulomatous cholecystitis, a
complete resection of adjacent xanthogranulomatous tissue should be attempted, even if
this includes resection into the hepatic bed [6].
Open cholecystectomy is the preferred surgical technique in most patients due to dense
fibrosis, extensive local inflammation, and concerns of possible coexistent malignancy
[8].
6. REFERENCES:
1. Dixit VK1, Prakash A, Gupta A, Pandey M, Gautam A, Kumar M, Shukla VK.,
Xanthogranulomatous cholecystitis.,Dig Dis Sci. 1998 May;43(5):940-2.
2. D Belekar, R Verma. An Unusual Case of Acute-on-Chronic Xanthogranulomatous
Cholecystitis. The Internet Journal of Surgery. 2008 Volume 19 Number 2.
3. Mehmet Yildirim1 , Ozgur Oztekin2 , Fatih Akdamar1 , Savas Yakan1 , Hakan Postaci.,
Xanthogranulomatous cholecystitis remains a challenge in medical practice: experience
in 24 cases Radiol Oncol 2009; 43(2): 76-83, doi:10.2478/v10019-009-0018-8
4. Krishna RP, Kumar A, Singh RK, et al. Xanthogranulomatous inflammatory strictures of
extrahepatic biliary tract: presentation and surgical management. J Gastrointest Surg
2008; 12:836.
5. 1. Houston JP, Collins MC, Cameron I, et al. Xanthogranulomatous cholecystitis. Br J
Surg 1994; 81:1030-1032 .
6. Srinivas GN, Sinha S, Ryley N, Houghton PW. Perfidious gallbladders - a diagnostic
dilemma with xanthogranulomatous cholecystitis. Ann R Coll Surg Engl 2007; 89:168.
7. . Chun KAC, Ha HK, Yu ES, et al. Xanthogranulomatous cholecystitis: CT features with
emphasis on differentiation from gallbladder carcinoma. Radiology 1997; 203:93-97
8. Reed A, Ryan C, Schwartz SI. Xanthogranulomatous cholecystitis. J Am Coll Surg
1994; 179:249.