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Although oral cholecystography is a highly accurate investigation for the diagnosis of gallbladder disease, false normal examinations do occur. In other patients, the presence of jaundice, nausea, or vomiting may preclude oral cholecystography. When there is clinical suspicion of gallbladder disease with a normal or equivocal oral cholecystogram, ultrasound examination is a highly accurate alternative imaging procedure. We describe in this article three patients with apparently normal oral cholecystography who were found to have obvious gallstones on ultrasound examination and at surgery. The relative accuracy of these diagnostic procedures is reviewed and their place in the diagnosis of biliary tract disease is discussed.
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PMID:Ultrasound and false normal oral cholecystogram. 67 99

Dyspepsia, defined as chronic or recurrent upper abdominal pain or nausea, is a common occurrence. Dyspepsia without an ulcer (non-ulcer dyspepsia) is diagnosed in patients at least twice as often as peptic ulceration. Diseases that may present with similar symptoms include gastroesophageal reflux, biliary tract disease, chronic pancreatitis, and irritable bowel syndrome. A careful history and physical examination, supplemented by selected tests, usually lead to a correct diagnosis. The pathogenesis of non-ulcer dyspepsia remains unknown. Gastric acid secretion, duodenogastric reflux, psychological factors, environmental exposures, and heredity probably do not play a major role. Some patients may have motility disturbances, but whether these disturbances cause dyspepsia is unknown. Campylobacter pylori infection and associated gastritis are common in non-ulcer dyspepsia, but their etiologic role is controversial, as is the importance of chronic duodenitis. By recognizing the heterogeneity of patients who present with non-ulcer dyspepsia, more rational management may be possible. Although an empiric trial of antacids or H2 blockers has been recommended to treat dyspepsia, most controlled trials show that although these substances reduce severity of symptoms, they are no more effective than placebos in non-ulcer dyspepsia.
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PMID:Non-ulcer dyspepsia: potential causes and pathophysiology. 328 48

To determine the frequency of pancreatitis and to define risk factors for pancreatitis in patients with AIDS, we compared patients with pancreatitis to patients without pancreatitis in an urban infectious disease practice. Pancreatitis was defined as at least one clinical sign or symptom (nausea, vomiting, abdominal pain, or tenderness) accompanied by elevation of serum amylase or lipase. Twenty-four (22%) of 105 patients with AIDS, 2 (4%) of 46 patients with AIDS-related complex, 1 (3%) of 39 asymptomatic patients infected with HIV-1, and none of 9 uninfected patients at risk for HIV-1 developed pancreatitis as defined above. Fourteen patients experienced multiple episodes and three were symptomatic for more than 2 months. Pancreatitis was more likely to have occurred in patients with AIDS (P < .001), biliary tract disease (P = .013), and hypertriglyceridemia (P = .032). After matching for these factors and duration of current HIV disease, cryptosporidiosis, intravenous pentamidine, and isoniazid were each associated independently with pancreatitis (P < .05). Before didanosine (ddl) became available, 22% of the patients with AIDS in this practice had pancreatitis. Cryptosporidiosis, isoniazid, and intravenous pentamidine should be considered among the potential etiologies.
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PMID:Pancreatitis associated with human immunodeficiency virus infection: a matched case-control study. 882 75

Thirty-one patients with biliary enteric fistula who were operated on over a 19-year period (1976-1994) with an incidence of 0.74% in all biliary tract operations were reviewed retrospectively to identify etiologic factors, types of fistulas, signs and symptoms, methods of diagnosis, management and prognosis of the cases. Most common symptoms were abdominal pain, nausea, vomiting and jaundice. Two patients had gallstone ileus. The majority of the patients had severe concomitant medical illnesses. The exact preoperative diagnosis of a biliary enteric fistula was established in only five (16%) patients. In 81% of the cases fistula was secondary to chronic calculous biliary tract disease. Postoperative complications included wound infection in six (19%), biliary fistula in two (6%) and erosive gastritis in one (3%) patient. Two patients died of intra-abdominal sepsis and two of cardiac failure, with an operative mortality of 13%. Early elective cholecystectomy is recommended to avoid complications of chronic calculous cholecystitis such as bilioenteric fistulas and their increased mortality and morbidity.
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PMID:Biliary enteric fistulas. 937 75

The development of laparoscopic cholecystectomy has allowed the introduction of outpatient surgery for biliary tract disease. However, there appears to be a wide variation of the interpretation of "outpatient surgery," ranging from discharge the same day to keeping patients for overnight observation. We prospectively reviewed the last 50 chole-cystectomies performed at Spartanburg Regional Medical Center, a private teaching institution, and Upstate Carolina Medical Center, a private nonteaching hospital. All cholecystectomies were performed by board certified surgeons or surgical residents under the supervision of board certified surgeons. Spartanburg Regional Medical Center's standard was 23-hour observation with 9 patients (18%) being discharged home the day of surgery. Upstate Carolina Medical Center's standard was discharge home (usually 4-8 hours after completion of the procedure) with 39 patients (78%) discharged the same day. No patient discharged the same day presented back with any significant complication. Comorbid disease, biliary pancreatitis, ascending cholangitis, gangrenous gallbladder, extreme age and living conditions and conversion to open were factors considered for admission. Intra-operative difficulty such as oozing, excessive adhesiolysis, postoperative nausea, vomiting or pain control were also indications for overnight admissions. The extra 15 to 19 hours for routine observation did not change any treatment for any of the 41 patients and resulted in additional cost to the hospital of approximately $15,000. We conclude that same day, outpatient laparoscopic cholecystectomy can be done safely with discharge home 4 to 8 hours postoperative without significant morbidity in selective patients.
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PMID:Comparison of outpatient laparoscopic cholecystectomy in a private nonteaching hospital versus a private teaching community hospital. 987 47

Right-sided colonic diverticulitis is an uncommon disorder that most frequently mimics appendicitis. During pregnancy, displacement of the diseased cecum and ascending colon into the right upper quadrant may result in symptomatology that mimics cholecystitis. A 37-year-old white woman with a history of previous benign incidental appendectomy presented at 20 weeks' gestation with right upper abdominal pain and nausea for 2 days. Significant findings included local rebound tenderness and palpable fullness over the gallbladder, leukocytosis, and low-grade fever, but otherwise unremarkable routine serum laboratory test results and sonographic evidence of biliary tract disease. Cholescintigraphy was rejected by the patient. Persistence of symptoms for 3 hospital days despite administration of broad-spectrum parenteral antibiotics prompted surgical intervention. Laparoscopy demonstrated a normal-appearing gall-bladder and an acutely infected, solitary diverticulum of the midascending colon with adhesions to the omentum and to the parietal peritoneum near the gallbladder. Adhesiolysis, omental biopsy, and peritoneal drainage were performed endoscopically. The patient recovered uneventfully and delivered vaginally at term without fetal or maternal complications. Right-sided colonic diverticulitis may present during pregnancy and may mimic symptoms of acute cholecystitis. Laparoscopic treatment of a solitary, acutely infected colonic diverticulum is feasible in this setting.
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PMID:Right-sided colonic diverticulitis mimicking acute cholecystitis in pregnancy: case report and laparoscopic treatment. 995 Jan 33

Since Helicobacter pylori (Hp) was first isolated in 1983, much work has been carried out on the pathogenic effects of this organism. Hp infection is common in humans and currently is the most important etiologic agent in the development of chronic active gastritis, gastric and duodenal ulcers, carcinoma and Malt-lymphoma of the stomach. Moreover Hp infection has also been associated with various extradigestive diseases. At present, a role of Hp infection in dyspepsia is discussed. Dyspepsia is defined by persistence of pain, burning or discomfort localised to the upper abdomen; some authors include in dyspepsia symptoms such as belching, bloating, alitosis, nausea, postprandial repletion, vomiting and regurgitation. In absence of any underlying pathologies, such as peptic ulcer, gastroesophageal reflux, pancreatitis, biliary tract disease or others, dyspepsia is defined as functional or idiopathic dyspepsia. Functional dyspepsia may be distinct in ulcer, reflux or dysmotility-like dyspepsia and unspecified dyspepsia. Hp infection is common in dyspeptic patients and a role of this bacterium has been postulated mostly in ulcer-like dyspepsia. Mechanisms by when Hp induces dyspeptic symptoms are uncertain; bacterial cytotoxins, phlogosis mediators, activity of chronic gastritis Helicobacter-related and host immune response probably play an important role in pathogenesis of functional dyspepsia. However, dyspepsia is not present only in infected patients; therefore other pathogenic factors may be implicated in expression of dyspeptic symptoms in uninfected subjects, such as gastric dysmotility, modifications of gastric output or altered visceral sensibility, psychological factors, gastroesophageal reflux and irritable bowel.
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PMID:[Dyspepsia and Helicobacter pylori]. 1036 46