[The effectiveness of the application of medicinal mineral water from the 'Omonkhona' source in the patients presenting with the diseases of the hepatobiliary system]. / Éffektivnost' primeneniia lechebnoi mineral'noi vody iz istochnika 'Omonkhona' u patsientov s zabolevaniiami gepatobiliarnoi sistemy.

BACKGROUND: Investigations into the medicinal properties of 'Omonkhona' mineral water used for the treatment of hepatobiliary pathology make up the entirely new field of balneological research in Uzbekistan. AIM: The objective of the present study was to identify the hepatoprotective and choleretic components of the 'Omonkhona' mineral water and elucidate their action in the patients presenting with the diseases of the hepatobiliary system. MATERIAL AND METHODS: A total of 77 patients suffering from the diseases of the hepatobiliary system were available for the examination including 38 patients with chronic hepatitis (CH), 17 with chronic cholecystitis (CC), and 22 patients with liver cirrhosis (Cr). All the patient were prescribed drinking the mineral water (from 1.0 to 3.0 liters per day) during consequtive 12-14 days. The clinical, biochemical, and instrumental studies were carried before and after the treatment. RESULTS: The treatment with 'Omonkhona' water resulted either in the complete elimination or the significant alleviation of pain in the right hypochondrium. The patients presenting with CH and CC experienced normalization of ESR even though it remained high in the Cr patients. All the patients exhibited a decrease of specific gravity of the urine, probably due to the diuretic effect of the mineral water. The biochemical studies of blood and bile showed that the initially slightly enhanced bilirubin levels, alanine aminotransferase and alkaline phosphatase activities in the CH and CC patients normalized after a course of the treatment with 'Omonkhona' mineral water (p<0.05). No such changes were documented in the patients with liver cirrhosis. The patients with CH and CC experienced the two-fold reduction in the intensity of inflammation whereas the bilirubin and bile acid levels increased although the relative cholesterol content decreased and the cholate-cholesterol coefficient increased (p<0.05). The Cr patients demonstrated only insignificant changes of these parameters. The ultrasound examination showed that the CC patients treated with 'Omonkhona' mineral water had a decrease in the swelling of the gallbladder walls, the improvement of its motor function and the disappearance of the stagnation phenomenon. In the CH patients, there was a significant decrease in the cranio-caudal size of the right lobe of the liver, the cranio-caudal size of the left lobe, and the anteroposterior size of the left lobe (p<0.05). A decrease in the acoustic conductivity was noted that can probably be attributed to the reduced swelling of the liver parenchyma. The Cr patients had no significant changes of these parameters following the treatment. CONCLUSIONS: The results of this study give evidence that the treatment of the diseases of the hepatobiliary system with 'Omonkhona' mineral water exerts the well apparent positive influence on the patients presenting with CC and CH even though its beneficial effect was less pronounced in the patients with livre cirrhosis.

PHARMACOECONOMIC ANALYSIS OF EFFICACY OF DIFFERENT MODES OF ANTIBIOTIC PROPHYLAXIS IN CHOLECYSTECTOMY.

Pharmacoeconomic assessment of efficacy of different modes of antibiotic prophylaxis was made in 27 patients with diagnosis of acute calculous cholecystitis using method of «cost-efficacy¼. Patients have taken ampicillin/sulbactam intravenously in the dose of 1,5 g or cephazolin intravenously in the dose 2,0 g. Medicine should be taken in 30 min. before the operation. The most expensive was antibiotic prophylaxis by cephazolin. The coefficient of «cost-efficacy¼ was 774,2 rubles on 1 unit of efficacy in case of cephazolin and it was 506,1 rubles on 1 unit of efficacy in other group with antibiotic prophylaxis by ampicillin/sulbactam. The authors noted the economical and clinical advantage of antibiotic prophylaxis by ampicillin /sulbactam.

Cholecystocolonic fistula following endoscopic ultrasound-guided gallbladder drainage for stump cholecystitis.

Cholecystocolonic fistulas are a rare sequela of gallstone disease. Presenting symptoms are variable but a triad of chronic diarrhea, vitamin K malabsorption, and pneumobilia has been proposed. If untreated, recurrent biliary sepsis can occur with substantial morbidity and mortality. Definitive management is surgical although endoscopic treatment has been described in nonsurgical patients. We present a case of a cholecystocolonic fistula following transgastric endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent for stump cholecystitis. The patient's presenting symptom was diarrhea. Upper endoscopy and cholecystoscopy 4 weeks following gallbladder drainage revealed a cholecystocolonic fistula. The cholecystogastric tract was closed through the scope clips. The patient had no episodes of cholangitis and had a patent biliary tree with a prior biliary sphincterotomy so clinical observation was chosen. Colonoscopy 1 month later confirmed the closure of the fistula and the patient had a resolution of diarrhea. Our case highlights a novel adverse event of endoscopic ultrasound-guided gallbladder drainage caused by direct pressure of the lumen apposing metal and double pigtail stents on an already inflamed gallbladder wall. Endoscopic therapies that aid in transcapillary biliary drainage are viable alternatives to surgery and can result in fistula closure.

Treatment considerations for recurrent MRSA bacteremia leading to cholecystitis.

We present an end-stage renal disease patient with acute cholecystitis caused by a recurrence of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Timely antibiotic therapy with vancomycin did not eradicate the patient's infection. In this patient, the minimum inhibitory concentration (MIC) of the organism for vancomycin was at the upper limit of susceptibility. The ability to thoroughly understand and interpret mean inhibitory concentrations is crucial in antibiotic selection. For high-risk patients with Staphylococcus aureus infection with reduced susceptibility to vancomycin as demonstrated by an MIC of 2 mg/L or greater, we suggest further investigation into linezolid as an alternative antibiotic to vancomycin therapy. Compared to vancomycin, linezolid has similar effectiveness in patients with MRSA bacteremia as well as improved penetration, particularly in bile.

Antibiotic stewardship in UK surgical departments: challenges and possible solutions.

Antibiotics are one of the most widely used classes of drugs within hospitals in the UK. They have a wide range of uses within all surgical specialties, both as preoperative prophylaxis and for treatment of acute surgical conditions. Antimicrobial resistance has increasingly been seen as a major issue, as the production of new antibiotics has decreased and overall use worldwide has increased. With the COVID-19 pandemic increasing concerns about antimicrobial resistance, there is an ever-increasing need for action. This article examines the particular challenges of antibiotic stewardship in surgical departments within the UK, and outlines possible solutions for improving adherence and reducing the risk of antimicrobial resistance in the future.

Disseminated Coccidioidomycosis to the Gallbladder.

Coccidioidomycosis is an infection caused by inhalation of arthroconidia produced by dimorphic fungi in the genus Coccidioides. Forty percent of patients will develop an influenza-like illness with symptoms suggestive of a mild and self-limited respiratory infection; however, 5% of these individuals will develop extrapulmonary disseminated disease. An immunocompromised patient presented with right upper quadrant pain, ultrasound with pericholecystic fluid, in which a percutaneous cholecystostomy contained biliary fluid that grew the fungus Coccidioides immitis. Patient was initiated on intravenous amphotericin therapy and was followed closely with postoperative bile drainage with eventual laparoscopic cholecystectomy. We present a very rare case of disseminated coccidioidomycosis to the gallbladder.

Methamphetamine consumption and life-threatening abdominal complications: A case report.

RATIONALE: Methamphetamine (METH) abuse is increasing rapidly all over the world and becoming a significant public health concern in China. However, abdominal complications secondary to METH abuse are usually overlooked. We describe an unusual case of gangrenous cholecystitis and small intestinal ischemia due to METH abuse. PATIENT CONCERNS: In this report, a 44-year-old male patient with abdominal pain and hematochezia has a history of crystal meth abuse. DIAGNOSIS: The patient was diagnosed as septic shock, paralytic ileus, gangrenous cholecystitis, and small intestinal ischemia due to METH abuse based on computed tomography (CT) scan, endoscopy examination, laparotomy, and pathology. INTERVENTIONS: Antishock treatment, broad-spectrum antibiotics, and exploratory laparotomy were given. OUTCOMES: The patient survived. Six months later, he tolerated oral intake and stopped using crystal METH. LESSONS: Visceral ischemia should be considered if an adult patient with a history of METH abuse is accompanied by abdominal pain and hematochezia.

Cystic artery pseudoaneurysm following acute necrotising pancreatitis.

Cystic artery pseudoaneurysm is a rare pathology. Of the 20 cases reported so far, chronic cholecystitis and iatrogenic biliary injury form the majority of causes. Currently, there is no published report of such pseudoaneurysms caused secondary to pancreatitis, hence the management in such a scenario is unclear. We hereby present the first such report of cystic artery pseudoaneurysm occurring as a sequel of acute necrotising pancreatitis. A 33-year-old man who recovered from a recent attack of acute pancreatitis was readmitted for melena and fever. Computed tomography of abdomen revealed blood in the gall bladder with pericholecystic blush and resolving pancreatic necrosis. Percutaneous transarterial embolisation of the cystic artery was done. This stabilised the patient but persistent sepsis and clinical deterioration warranted a surgical exploration and cholecystostomy. Hence, transarterial embolisation followed by surgery in selected cases can be an ideal management protocol.

Bilothorax as a complication of percutaneous transhepatic biliary drainage.

We report two cases of bilothorax that occurred as a complication of percutaneous transhepatic biliary drainage. In an 86-year-old woman who had undergone percutaneous transhepatic biliary drainage for obstructive jaundice, bilothorax occurred after accidental removal of the tube. She recovered with chest drainage only. An 83-year-old man who had undergone percutaneous transhepatic biliary drainage for cholecystitis developed bilothorax with infection. He recovered with thoracoscopic curettage. Although bilothorax is a rare complication of percutaneous transhepatic biliary drainage, appropriate diagnosis and prompt treatment is important, especially when bilothorax is accompanied by infection.

Acute acalculous cholecystitis. A reminder that this condition may appear in a primary care practice.

Acute acalculous cholecystitis carries high morbidity and mortality rates, but if it is detected early, the prognosis for recovery is good. Detection requires diligence, because signs and symptoms may be nonspecific or atypical. Because their sensitivity and specificity are limited, the various imaging techniques available serve only as adjuncts to history taking and physical examination. Prompt initiation of treatment is essential to reduce complications. Options range from conservative medical therapy to aggressive surgical intervention. Recently, ultrasound-guided percutaneous cholecystostomy has become a favored approach. Best treatment varies, depending on underlying disease and the patient's condition.

[Gallbladder puncture and drainage as therapy of acute cholecystitis]. / Gallenblasenpunktion und -drainage als Therapie der akuten Cholezystitis.

PATIENTS AND METHODS: An ultrasound-guided, percutaneous puncture (n = 30) and cholecystostomy (n = 10) was performed on 40 high-risk patients aged between 38 and 99 (mean age 78 years old) suffering from acute lithogenic cholecystitis or acalculous stress cholecystitis on account of general inoperability. Two catheter dislocations and in 3 cases a slight bile leakage were observed as complications. RESULTS: The puncture and drainage led to a dramatic alleviation of pain for all patients, the involution of a paralytic subileus and improvement of the general condition. Eighteen patients underwent a laparoscopic or open interval cholecystectomy in a stabilised condition. There was no recurrence of inflammation in 22 patients over a follow-up period of up to 5 years, so that one can assume a cicatrised healing of the acute choleycstitis. CONCLUSIONS: Ultrasound-guided, percutaneous puncture and cholecystostomy are effective, low-risk, and only slightly invasive procedures which can be employed for risk patients with acute cholecystitis as a life-saving, and in some cases definitive treatment. On account of pathogenic considerations, they should be included in the diagnostic and therapeutic concept at an early stage, particularly for acute, acalculous stress cholecystitis.

Treatment of extrahepatic bile duct disease in infancy and early childhood.

Extrahepatic bile duct disease is a rare finding in infancy and early childhood. However, there is an increasing number of patients operated at this age reported in the literature. This increase may have multifactorial reasons, e.g. real increase, better ability of detection as a result of better diagnostic techniques and knowledge of predisposing factors of extrahepatic bile duct disease in childhood, especially in early childhood and infancy. The following report describes three cases of extrahepatic bile duct disease in infancy and early childhood treated at the Department of Surgery of the University of Technology in Aachen, Germany. From 1986 to 1998 28 Patients below 18 years were operated at our Department of Surgery. There was a recognizable increase of patients in 1996, 1997 and 1998. Whereas from 1986 to 1995 an average of 1.5 Cholecystectomies in pediatric patients were done, the years from 1996 to 1998 show an average of 5,33 patients operated per year. Every patient obtained a Cholecystectomy -- 15 conventional open Cholecystectomies and 13 Laparoscopies, which were primarily performed in children in our clinic in 1991. Besides cholecystectomy in one case a Hepaticoenterostomy was necessary and in another case surgical treatment of the Papilla of Vater and the Common Bile Duct was performed. In 22 patients symptomatic Cholelithiasis was the indication for a Cholecystectomy. Another Patient had a gallbladder polyp consisting of heterotopic Duodenal glands, two patients showed a shock gallbladder following trauma and cardiac operation and three patients had chronic Cholecystitis without gallstones. Clinical data was collected and retrospectively reviewed. Additionally, we created a personal questionnaire to carry through a follow-up. Three Patients were less than 3 1/2 years old. The youngest patient was only 5 months old and presented with Cholelithiasis and Choledocholithiasis. Another male patient, aged 2 years received a Cholecystectomy and a Hepaticoenterostomy because of a Choledochal Cyst Type Ib (Todani-Classification). And a 3-year-old-girl had a shock gallbladder caused by thromboembolism following cardiac operation nine days before.

[Prevention of lithogenesis in cholecystitis]. / Profilaktika kamneobrazovaniia pri kholetsistite.

To treat and prevent cholelithiasis is one of the pressing problems facing modern medicine. A Vega MPT-705 apparatus was used to treat 52 patients with different forms of cholecystitis. Matrix regenerating therapy that had effects at cellular and subcellular levels was found to arrest an acute inflammation in the gallbladder wall, to normalize the physicochemical parameters of bile. It was concluded that the Vega MPT-705 apparatus could treat acute cholecystitis and hence prevent cholelithiasis.

[Gallbladder ascariasis with acute hepatitis. Conservative treatment]. / Ascaridiasis vesicular asociada a hepatitis aguda. Manejo conservador.

We report two cases of gallbladder ascaridiasis associated with acute hepatitis, its clinical evolution with conservative treatment, making diagnosis by both laboratory and ultrasono-graphic studies. Case 1: was a male in his early forties who experienced symptoms of acute hepatitis and cholecystitis within a time lapse of 72 h of evolution. When laboratory tests and ultrasound (US) were done, an ascaris inside gallbladder was corroborated. There were also alterations compatible with acute non-viral hepatitis. Conservative treatment was done with observations within an 8-day period that hepatic examinations were normal as well as absence of helminthus inside gallbladder. Case 2: A 10-year-old female, who expelled worms 8 months previously had 11 days evidence of acute cholecystitis and hepatitis. An ultrasound of liver and biliary tract was done, with evidence of Ascaris lumbricoides inside gallbladder, with alterations in hepatic tests. This was medically treated, achieving expulsion of the Ascaris lumbricoides from inside the gallbladder and normalization of liver function tests. Gallbladder ascaridiasis management may be conservative. Patient general condition must be evaluated, as well or medical evolution and associated pathologies that may interfere in certain ways in surgery. Follow-up of these patients must be strict, with medical evaluation and laboratory controls.

[Results of various treatment modalities in the calculous cholecystitis]. / Rezultaty primeneniia razlichnykh metodov lecheniia kalkulëznogo kholetsistita.

Two alternative methods for the treatment of calculous cholecystitis are evaluated: extracorporeal lithotripsy was performed in 284 patients, laparoscopic cholecystectomy--in 130 patients. Even in strict selection of patients, lithotripsy was ineffective in 32 of them and they were subjected to an operation; in another group of patients elimination of the fragments from the gallbladder was incomplete. Therefore, extracorporeal lithotripsy may be used in no more than 10% of patients with cholelithiasis. Laparoscopic cholecystectomy was conducted in 130 patients. In 6 (4.5%) of them the operation had to be completed by laparotomy because complications occurred during the laparoscopic intervention. Laparoscopic cholecystectomy has some obvious advantages over open cholecystectomy: easier postoperative period, early activation of the patients, a good cosmetic effect. However, to determine the boundaries and possibilities of this method accumulation of experience is needed.

Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation.

BACKGROUND: Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis. DATA SOURCES: We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field. REVIEW METHODS: Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions. RESULTS: Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model. CONCLUSIONS: The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed. STUDY REGISTRATION: The study was registered as PROSPERO CRD42012002817. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Exceptional, potentially fatal combination of emphysematous pancreatitis and gas-forming cholecystitis: successful multidisciplinary conservative treatment supported by repeated CT-staging.

Usually considered as a life-threatening disease, emphysematous pancreatitis requires early diagnosis and aggressive multidisciplinary treatment including the Departments of Gastroenterology, Intensive Care Medicine, Interventional Radiology and even Surgery. The prognosis for emphysematous cholecystitis is also quite poor. It requires surgery even if a percutaneous cholecystostomy can contribute to a temporary stabilization of the patient. Computed tomography is the imaging modality of choice to detect emphysematous pancreatitis and gas-forming cholecystitis. It enables their grading and helps identify their complications. Moreover, it proves essential in the follow-up of the lesions.

Acute cholecystitis: delayed surgery or observation. A randomized clinical trial.

BACKGROUND: The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients randomly allocated to delayed operation or conservative treatment. METHODS: One-hundred-and-eighty patients were considered for participation in the study; 71 were excluded according to predefined criteria and 45 did not join for other reasons. The remaining 64 patients were randomized to cholecystectomy (n = 31) or observation (n = 33). Randomized patients were contacted regularly and followed up for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. RESULTS: Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group (19%; 95% CI 5%-33%) and in 12 patients (36%; 9% CI 20%-53%) in the observation group. Twenty-seven of 31 patients randomized to cholecystectomy had a cholecystectomy at a median of 3.6 months after randomization, and, of these, 3 (11%; 95% CI 0%-23%) suffered a major and 7 (26%; 95% CI 9%-42%) a minor complication. Ten patients randomized to observation later had their gallbladders removed, 1 (10%; 95% CI 0%-29%) patient had a major and 1 (10%; 95% CI 0%-29%) a minor complication. We found no mortality after cholecystectomy. CONCLUSIONS: We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis, but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis.