Gallbladder schistosomiasis: rare but possible, a case report and review of the literature.

After Malaria, schistosomiasis remains the most important tropical disease in large parts of the world. It affects mainly the colon and the urinary tract. The hepatic involvement is significantly frequent, particularly by the mansoni species. Still one of the extremely rare locations is the gallbladder. Our case is about a 51 year old woman from Tunisia, which is no longer considered an endemic country, with no particular medical history, underwent surgery for symptomatic cholelithiasis. She had a laparoscopic cholecystectomy. Post operative period was uneventful. Histology of the gallbladder showed fibrosis in the mucosa and schistosomal ova in the wall. As a conclusion we can see that due to the lack of specific clinical and radiological signs, the diagnosis of gallbladder schistosomiasis is established only after the histological examination.

Unexpectedly High Prevalence of Cystoisospora belli Infection in Acalculous Gallbladders of Immunocompetent Patients.

Objectives: Indications for cholecystectomy have changed dramatically over the past three decades. Cystoisospora belli has been reported in cholecystectomy specimens of immunocompetent patients. The present study was designed to determine the prevalence and clinical association of C belli in the gallbladder. Methods: The study included retrospective review of cholecystectomy specimens (n = 401) removed for various indications, and a prospective cohort of cholecystectomy specimens (n = 22) entirely submitted for histologic evaluation. Correlations of presence of C belli with age, sex, clinical indication, and abnormalities of preoperative laboratory values were assessed by Fisher exact test. Results: C belli was identified in 39/401 (9.7%) of the retrospective cohort, and 6/22 (27.3%) of the entirely submitted specimens. The presence of C belli showed no correlation with age, sex, clinical indication, or laboratory abnormalities. Conclusions: C belli resides in a latent state in the gallbladder and may be best considered a commensal organism.

Differential diagnosis of gallbladder ascariasis debris: the added value of contrast enhanced ultrasound with high frequency transducer.

Ascariasis debris of the gallbladder is a very rare incidental or symptomatic presentation. Ascaris debris has a pseudotumorous appearance and may be confused with neoplasia. The aim of the current retrospective study is to investigate the value of contrast enhanced ultrasound (CEUS) for the differential diagnosis of ascariasis debris and neoplasia of the gallbladder. MATERIAL AND METHODS: Conventional B-mode ultrasound (BMUS) and CEUS were performed for solitary echo-rich gallbladder lesions. Analysis of the CEUS enhancement pattern of the lesions was conducted according to the current EFSUMB guidelines. Two radiologists assessed the CEUS enhancement patterns in consensus. The final gold standard was surgery with histological examination or imaging follow-up. RESULTS: A total of 9 patients with final diagnoses of gallbladder ascariasis debris were included. As a control group 26 solitary hyperechoic gallbladder lesions without shadowing were included as a control group. The typical zigzag morphology with multiple echogenic parallel lines without shadow were detected inside the lumen of the gallbladder in 6 patients. After injection of 2.4 ml ultrasound contrast agents, all hyperechoic gallbladder ascariasis debris lesions showed no enhancement. All patients in the control group with similar BMUS morphology showed contrast enhancement. CONCLUSIONS: Real time visualization of contrast enhancement without radiation exposure is one of the main advantages of CEUS over other diagnostic modalities to differentiate ascariasis debris in the gallbladder from enhancing neoplasia. Thus, surgery and other interventions and their complications could be avoided.

Epithelial Inclusions in Gallbladder Specimens Mimic Parasite Infection: Histologic and Molecular Examination of Reported Cystoisospora belli Infection in Gallbladders of Immunocompetent Patients.

Recent publications have described epithelial cytoplasmic vacuoles and inclusions incidentally noted within gallbladder epithelium and concluded that they represent coccidian parasite infection, in particular, Cystoisospora belli. We identified 8 gallbladder specimens from our institution in the past 3 years in which this diagnosis was suggested or in which similar epithelial alterations were prominent. Molecular analysis was performed on the 8 gallbladder specimens and on 3 positive control specimens: small bowel biopsies from acquired immunodeficiency syndrome patients with diarrhea. Polymerase chain reaction using primers designed to amplify an internal transcribed spacer (ITS2) in the C. belli ribosomal gene cluster was performed on the DNA samples. All 8 gallbladder specimens were negative for amplification, while a product consistent with C. belli was amplified from all 3 positive controls. Histologically, the gallbladder cytoplasmic inclusions stained diffusely positive for Grocott-Gomori's methenamine silver and Periodic acid-Schiff with diastase. In contrast, sections from a positive control small bowel biopsy demonstrated organisms that were negative for Grocott-Gomori's methenamine silver and showed a distinct capsular and punctate internal staining on Periodic acid-Schiff with diastase in various parasite forms. Together, the lack of molecular evidence of C. belli and the distinct morphologic and special staining patterns in these gallbladders compared with positive control small bowel suggest that these epithelial changes do not represent true C. belli infection. Our results suggest that gallbladders of immunocompetent patients may occasionally show epithelial changes that can morphologically mimic C. belli infection. Pathologists should be aware of this histologic variant to minimize unnecessary treatment, testing, and patient anxiety.

Biliary ascariasis presenting with gangrenous perforation of the gall bladder: report of a case and brief review of literature.

The most common cause of gallbladder perforation is calculous cholecystitis. Rarer causes include trauma, iatrogenic injuries, biliary stasis and gall bladder ischemia. We report a case of gall bladder gangrene with perforation, secondary to extensive ascariasis. A 45-year-old woman presented with acute intestinal obstruction and jaundice. She had abdominal distension and right hypochondrial tenderness. Abdominal radiography showed dilated bowel loops and ultrasonogram showed worms in the small intestine and biliary tree. On exploration, a bolus of worms 2 feet proximal to the ileocaecal junction was found causing obstruction. Worms were also present in the bile duct and gallbladder causing gangrene and perforation. She underwent cholecystectomy, bile-duct exploration and enterotomy. However, she died on the third postoperative day of overwhelming sepsis. Enteric complications of ascaris leading to bowel obstruction are well-known. Hepatobiliary complications such as cholangitis and obstructive jaundice are rare. However, such an extreme degree of infestation leading to gangrene and perforation of the gall bladder is extremely rare.

Prevalence of Platynosomum fastosum infection in free roaming cats in northeastern Brazil: Fluke burden and grading of lesions.

The objective of this paper was to investigate prevalence and parasite load of the trematode Platynosomum fastosum infection and the risk of developing cholangitis/cholangiohepatitis among infected domestic cats in a city of northeastern Brazil, and to characterize the influence of fluke burden in the formation of lesions in liver and gallbladder. A total of 141 cats was necropsied and examined for the presence of P. fastosum. The observed prevalence was 42.6% (60/141, 95% CI=34.2-50.9). Parasite load varied from 1 to 219 flukes per animal. Adult cats were more frequently infected than kittens (p<0.01). Risk of cholangitis was about three times higher in infected animals (RR=3.23, 95% CI=2.01-5.07, p<0.01). Centrolobular congestion, portal cholangitis and cholestasis was significantly more common in infected as compared to non-infected cats (p<0.01). Similarly, fibrosis, cholangitis and mucous gland hyperplasia were significantly more prevalent in the bile duct of infected animals (p<0.01). Mild fibrosis and cholecystitis were observed principally in infected cats. Hyperplastic precursor lesions of cholangiocarcinoma were observed, but no solid tumor was diagnosed. These results reveal high prevalence of P. fastosum in free roaming cats in northeastern Brazil, with increased risk of liver disease.

Cystoisospora belli Infection of the Gallbladder in Immunocompetent Patients: A Clinicopathologic Review of 18 Cases.

Cystoisospora belli, previously known as Isospora belli, is an obligate intracellular coccidian parasite that is most often associated with gastrointestinal disease in immunocompromised patients. In this study, we detail the clinicopathologic features of 18 cases of Cystoisospora infection affecting the gallbladder in immunocompetent individuals and compare them with a control group. Each case was reviewed for cholecystitis (none, acute, chronic), epithelial disarray, presence of intraepithelial lymphocytes (none, rare [≤5 per 20 epithelial cells], present [>5 per 20 epithelial cells]), architectural distortion, intramucosal eosinophilia, and mural thickening/serositis. The mean age of patients with Cystoisospora infection was 33 years and the male to female ratio 1:4.3. Cholecystectomy was performed for biliary dyskinesia (n=7), abdominal pain (n=7), suspected cholelithiasis (n=5), and cholecystitis (n=3). In 2 cases, Cystoisospora was found in donor gallbladders resected at the time of liver transplantation. Each case was characterized by eosinophilic, oval or banana-shaped intraepithelial parasites within perinuclear parasitophorous vacuoles. Most cases showed epithelial disarray and minimal intraepithelial lymphocytosis. Of the 11 cases with an average follow-up of 15 months, none had evidence of disease related to Cystoisospora infection within the biliary tract or elsewhere in the gastrointestinal tract. We present the largest series of gallbladder cystoisosporiasis in immunocompetent patients to date. Cystoisospora infection is underrecognized in the gallbladders of immunocompetent patients, in part due to the subtle findings in routine cholecystectomy specimens. On the basis of the clinical follow-up, gallbladder cystoisosporiasis in immunocompetent individuals appears to be a self-limited infection.

Live worm in gallbladder: a case report.

Ascariasis, the most common helminthic infection is caused by ascaris lumbricoides. Usually the adult worm lives in the small intestine. Rarely it migrates through the papilla of vater and may enter the common bile duct. We are reporting a case of live worm in gall bladder. Presence of Ascaris lumbricoides in gallbladder is rare entity as it is difficult to reach there due to narrow and tortuous cystic duct.

Ascariasis vesicular: reporte de un caso / Gallbladder ascariasis: case report

We report a case of a young patient who was admitted for study and management of severe hypocalcemia. During evolution of the condition the patient presents abdominal pain (biliary colic) related to the presence of Ascaris lumbricoides in the gallbladder, responding to conservative medical therapy.

Reportamos un caso de un paciente joven que ingresó para estudio y manejo de una hipocalcemia grave. Durante su evolución el paciente presentó dolor abdominal (cólico vesicular) relacionado con la presencia de un ejemplar de Ascaris lumbricoides en la vesícula biliar, que respondió a terapia médica conservadora.

Gallbladder ascariasis with uneventful worm migration back to the duodenum: A case report.

Ascariasis, a worldwide parasitic disease, is regarded by some authorities as the most common parasitic infection in humans. The causative organism is Ascaris lumbricoides, which normally lives in the lumen of the small intestine. From the intestine, the worm can invade the bile duct or pancreatic duct, but invasion into the gallbladder is quite rare because of the anatomical features of the cystic duct, which is narrow and tortuous. Once it enters the gallbladder, it is exceedingly rare for the worm to migrate back to the intestine. We report a case of gallbladder ascariasis with worm migration back into the intestine, in view of its rare presentation.

Gallbladder ascariasis.

BACKGROUND/AIMS: Gallbladder ascariasis is rarely encountered. The causative agent is Ascaris lumbricoides. Presence of ascaris inside the gallbladder can incite acalculous cholecystitis. We aimed in this report to study gallbladder ascariasis. METHODS: This is a case study of 28 patients with a diagnosis of gallbladder ascariasis from 2005 to 2010 who were seen in the Department of General Surgery, SMHS Hospital. RESULTS: Three patients with gallbladder ascariasis had associated worms in the common bile duct. On abdominal sonography, all patients showed worms as linear echogenic shadows or the worms showed 'belly dance' of worms when actively moving. Acute acalculous cholecystitis was present in 21 patients, and 7 had biliary colic. Dead worms in the gallbladder were seen in 4 patients, of which, one was fragmented and another had calcified form of parasite. Twenty-two patients had spontaneous exit of worms from the gallbladder with a time interval ranging from 1 hour to 144 hours from the time of a diagnosis. Six patients had cholecystectomy. Two patients were subjected to emergency cholecystectomy due to multiple impacted worms not exiting from the gallbladder after conservative treatment. CONCLUSIONS: Based on our experience, ultrasound diagnosis is advocated as a highly sensitive and noninvasive technique for suspected gallbladder ascariasis and it can be repeated frequently to monitor movement of worms in the gallbladder and common bile ducts.

Heterotopic pancreatic tissue in the gallbladder. Two case reports and brief review of the literature.

Heterotopic pancreas tissue in the gallbladder is a rare benign condition with no clinical relevance and found incidentally in most cases. Only 28 cases of heterotopic pancreas are reported until 2007 in the worldwide literature. The preoperative diagnosis is very hard, so that it could be considered in differential diagnosis with other benign and malignant disease of gallbladder and biliary tree. The surgical approach for the excision of a undefined lesion and the histological identification is a correct procedure in suspect case. We report 2 cases of heterotopic pancreatic tissue of the gallbladder.

Rare gallbladder parasitosis mimicking cholelithiasis: Dicrocoelium dendriticum.

Cholelithiasis is increasingly diagnosed in childhood and infancy. Biliary parasites are the rarest cause of cholelithiasis in all age groups. We present a twelve-year-old girl with non-hemolytic gallbladder stone and discuss the clinical features and differential diagnosis of Dicrocoelium dendriticum (DD) invasion that causes and/or mimics cholelithiasis in children.

Ultrastructural review of Choleoeimeria spp., a coccidium infecting the gall-bladder epithelium of reptiles.

Choleoeimeria Paperna and Landsberg, 1989 is a reptile coccidium with unique features. Its endogenous development occurs in the cells of the bile epithelium. Its host cell while becoming hypertrophic emerges above the epithelial surface. The following species studied by electron microscopy: C. alloagamae Paperna, 2007 from Agama sp. West Africa; C. allogehyrae Paperna, 2007 from Gehyra australis and C. heteronotis Paperna, 2007 from Heteronotia binoei, from Australia, and C. pachydactyli Paperna and Landsberg, 1989 from Pachydactylus capensis from South Africa. The fine structure of the respective endogenous stages is fairly uniform. The host-cell hypertrophy coincides with a drastic depletion of the microvilli, their junction zone with the underlying cell extends into numerous long and fine membranal out-folds. The PV of all infected cells is filled with typical round granular particles. Young meronts undergo binary fission. The differentiating microgamont develops an expanded multilobed body. Macrogamont's organelles include type 1 and type 2 wall forming bodies, canaliculi and granular bodies, suspected to be the precursors of the sporozoites refractile bodies. The oocyst wall forms from 4 wall-membranes consolidating over the zygote plasmalemma.

Primary hydatid disease in a retroplaced gallbladder.

A 60-year-old man with abdominal distension, fever, vomiting and pain on the right upper quadrant of the abdomen was admitted to our hospital. US revealed a well circumscribed lesion of mixed echogenicity. CT revealed hypoplasia of the right liver lobe, and a cystic mass with solid components replacing a retroplaced gallbladder. On T1-weighted MR images the lesion had low signal intensity and presented mild peripheral post-contrast enhancement, while on T2-weighted images the periphery was of moderately high signal intensity and the centre of fluid-like, high signal intensity. Adjacent liver parenchyma had relatively high signal intensity on T2-weighted images. The patient underwent exploratory laparotomy, and a hydatid cyst of the gallbladder that was inflamed was evidenced.

Primary hydatid disease of the gallbladder: a rare clinical entity.

Hydatid disease is endemic in Greece, and has been known from Hippocrates' time to cause cysts in the liver. We report here three very rare cases of primary gallbladder hydatid disease without prior history or evidence of concurrent disease activity in any other location. To our knowledge, only two previous reports exist, each of one patient suffering from primary gallbladder hydatid disease. Unlike the insidious hydatid cysts of the liver, gallbladder hydatidosis in our patients was associated with early diagnosis, due to gallbladder dysfunction symptoms presenting early in its course. Moreover, the size of gallbladder cysts compared to liver cysts at diagnosis was small (maximal diameter, <5 cm), making total cyst excision along with cholecystectomy feasible for all of our patients. During long-term follow up of the patients (up to 10 years), no disease recurrences were noted. We provide supporting evidence that primary gallbladder hydatidosis presents a different pathophysiological and clinical course, having better prognosis, when compared with the usual liver disease.