Rare Presentation of Gall Bladder Adenomyomatosis

Introduction: Adenomyomatosis is a benign alterations of gall bladder wall that can be found in 9% of patients. We present a case of gall bladder adenomyomatosis of young male presented with right upper quadrant pain. Case Report: A 22 year old male admitted with a history of pain over right upper quadrant for 8 months. The patient’s physical examination revealed tenderness over the right hypochondrium region. Contrast enhanced computed tomography showed - gall bladder wall appeared diffusely thickened with multiple small cystic areas noted. Conclusion: Symptomatic gall bladder adenomyomatosis is an indicator for cholecystectomy, which results in complete disappearance of symptoms. Asymptomatic cases are not an indication for surgery, but the radiological diagnosis must be beyond any doubt. If there is a any diagnostic doubt about the possibility of gall bladder cancer, a cholecystectomy is justified.

P-BN62 Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after acute biliary presentation

Background Laparoscopic cholecystectomy is introduced as a treatment option for symptomatic gall bladder disease in 1987 and it is now the gold standard treatment for symptomatic gall bladder disease. The rate of conversion from laparoscopic to open ranges between 5 and 10% .The step of paramount importance in cholecystectomy is the clear identification of the cystic duct and artery, which in some situations can be difficult especially in presence of dense adhesions or severely inflamed gall bladder, increasing the risk for common bile duct (CBD) injury. The traditional response to encountering a difficult laparoscopic cholecystectomy procedure is to perform conversion to an open procedure but the open conversion has its drawbacks; The subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure, thus reducing complications associated with the open cholecystectomy. Studies have also shown that this procedure decreases the bile duct injury rate . Subtotal cholecystectomy rates increased nationally over the past decade. The aim of our study is to identify factors which could predict the need for a subtotal cholecystectomy in the acute biliary admission group having delayed elective Laparoscopic cholecystectomy ,hence proper planning in terms on theatre timing, expertise and patients consenting Methods We conducted a retrospective analysis of patients who had delayed elective laparoscopic subtotal cholecystectomy after admission with Acute Biliary disease and managed conservatively in a tertiary London hospital, between 01/03/2019-29/02/2020 We collected data for all patients whose primary diagnosis was either Acute Cholecystitis, Cholelithiasis, Ascending Cholangitis, Choledocholithiasis and Gallstone Pancreatitis, and analysed these in terms of patient demographics, , duration of index admission, laboratory and radiological results during the acute admission and need to intervention during the acute phase either as a drain (cholecystostomy) or ERCP during initial management. Data were collected from electronic patient records, regarding age, gender, indication for surgery, operative notes, preoperative gall bladder wall thickness on US scan, laboratory results during acute admission. BMI, other interventions such as endoscopic retrograde cholangiopancreatography (ERCP) and cholecystostomy Odds ratios were calculated to assess the risk of patients having a subtotal cholecystectomy. Results 243 patients presented between 01/03/19-29/02/2020 which acute biliary pathology – 95 Male and 148 Female, 230 patients had delayed elective laparoscopic cholecystectomy at least 6 weeks post-acute admission Of 230 laparoscopic cholecystectomies, 22 (9.56%) cases had a subtotal cholecystectomy 13(59.9%) patients were male patients, median age 72 (54.5%) had BMI more than 30 No open conversion. The indication for cholecystectomy in the subtotal group was as follows: Acute cholecystitis 12 (54.54%), Ascending cholangitis 4 (18.18%), Choledocholithiasis 3(13.63%), gall stone pancreatitis 1(4.5%), Cholelithiasis 2 (9.09%)The subtotal cholecystectomy group had Gall bladder wall thickness during index admission documented 4 (18.18%)patients had Gall bladder wall thickness less than 4 or equal 4 mm, 18(81.81%) patients had Gall bladder wall thickness more 4 mm. Odds ratios were calculated to assess the correlation between several characteristics and the likelihood of having a subtotal cholecystectomy in the delayed elective cholecystectomy, we concluded that Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC > 15000 during acute admission, all increased the likelihood of having a subtotal cholecystectomy Conclusions Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC > 15000 during acute admission all increased the likelihood of having a subtotal cholecystectomy. We recommend all these information should be documented during planning for laparoscopic cholecystectomy to allow proper theatre time planning and patient consenting for the possibility of having a subtotal cholecystectomy.

Follicular cholecystitis with cholelithiasis – A diagnostic pitfall

Follicular Cholecystitis (FC) is an extremely rare subtype of Chronic Cholecystitis (CC). It is characterized by hyperplastic lymphoid follicles along with prominent germinal centers. It constitutes about 2% of routine cholecystectomies. In this article, we report a case of FC in a 69 years lady. She had abdominal pain, clinically diagnosed as Calculus cholecystitis and managed by laparoscopic cholecystectomy. Grossly, thickening of the gall bladder wall was noted. Histopathological examination revealed gall bladder wall infiltrated by dense lymphoid infiltrate forming lymphoid follicles with prominent germinal centres. Hence, we rendered a diagnosis of FC. The purpose of presenting this case is to make pathologists aware about this entity. One should not mistake this lesion for lymphoma. A careful histopathological examination is diagnostic and Immunohistochemistry may be helpful in difficult cases.Follicular Cholecystitis is extremely rare variant of Chronic cholecystitis. It is characterized by at least 3 Lymphoid Follicles per cm of Gall Bladder tissue with inflammatory infiltrate composed almost exclusively of scattered well-formed Lymphoid Follicles. Pathologist must be familiar with this entity to avoid misdiagnosis of lymphoma.

An observational study to assess male gender as an isolated risk factor in the laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the procedure of choice for majority of patients with gall bladder disease. The aim of the study was to investigate the role of male gender as an isolated risk factor responsible for the increased peri-operative morbidity of laparoscopic cholecystectomy by excluding associated risk factors.Methods: This was a prospective observational descriptive study 60 cases of elective laparoscopic cholecystectomy admitted to the S. M. S. Hospital from July 2019 to May 2020 were included.Results: The most common age group in male was 41-50 years and in female was 51-60 years. Impacted stones and gall bladder wall thickness >4 mm was causes of difficult cholecystectomy and evenly distributed in both sexes. Operative time (p value=0.268), visual analogue score on day 1 (p value=0.307) and hospital stay (p value=0.376) was more in male group but not statistically significant.Conclusions: Impacted stone and gall bladder wall thickness >4 mm were only factors associated with difficult laparoscopic cholecystectomy and excludes male gender as an isolated risk factor for difficult cholecystectomy however large-scale studies may provide different results.

Gall Bladder Wall Thickness as a Predictor for Laparoscopic Cholecystectomy Difficulties in Gadarif, Eastern Sudan

Background: Laparoscopic cholecystectomy is a revolutionary change in the treatment of patients with gallbladder stones. Multiple studies have identified factors that are predictive of surgical difficulties including preoperative ultra-sonographic findings. Objective: To determine the effectiveness of sonographic measurement of gall bladder wall thickness as a predictive factor for laparoscopic cholecystectomy difficulties in Gadarif Teaching Hospital, Sudan. Patients and methods: This are a prospective, observational, analytical cross-sectional hospital-based study in which all patients who underwent laparoscopic cholecystectomy for gall stones disease and had a pre-operative sonographic measurement for GBWT in GTH in the year 2019 were included. Results: 110 cases were studied. The male to female ratio was 0.2: 1, the mean age was 35±3.8 years. Past history of the acute attack reported in 54 (48.2%) of the patients, history of ERCP was reported in 2 (1.8%) and the majority of patients 71 (64.5%) has no associated medical condition. Abdominal examination was normal in 69 (62.7%) of the patients, 35 (31.8%) patients showed positive Murphy's sign or other signs. Gall bladder thickening, as a predictor of difficulty, was normal of ≤ 3 mm in 69 (62.7%), mild (4-5 mm) in 34 (30.9%), moderate (6-7 mm) in 5 (4.5%), and severe > 7 in 2 (1.8%) of the patients. A significant association was found between GBWT and: duration of symptoms, the number of attacks, operative time and hospital stay, postoperative complication, and conversion to open cholecystectomy. Operative time was found to be associated with the experience of the operator (P-value < 0.05). Conclusion: Pre-operative sonographic increasing gall bladder wall thickness is associated with difficult laparoscopic cholecystectomy in terms of postoperative complications, prolonged operative time, and conversion to open cholecystectomy even in expert hands.

LABORATORY PROFILE OF CHILDREN WITH DENGUE INFECTION: DESCRIPTIVE CLINICAL STUDY

INTRODUCTION: Dengue virus type-2 and Dengue virus type-3(DENV-3) are commonly associated with DHF, however, but no consistent correlation between a particular DENV serotype and genotype is ever established. In general, Asian genotypes appear to be more virulent than American and South Pacic genotypes. Informed consent was taken from METHODOLOGY: parents before enrolling in study. A clinical history, physical examination and relevant baseline investigations were done for all the cases. A prestructured proforma was used to record the clinical data and laboratory parameters from individual case selected for the study. Among RESULTS: the laboratory predictive markers, the sensitivities of thrombocytopenia, leucopenia and elevated AST were 74%, 73%, and 74.5%, while the specicities for above features were 85%, 63.75% and 61.25%, respectively. Prolonged PT, Hypoa CONCLUSION: lbuminemia, Elevated ALT and radiological features gall bladder wall edema and pleural effusion though had a high speccities however had low sensitivity