Usefulness of endoscopic ultrasound in patients with minilithiasis and/or biliary sludge as a cause of symptoms of probable biliary origin after cholecystectomy.

INTRODUCTION: Endoscopic ultrasound (EUS) is a more sensitive technique than transabdominal ultrasound for the diagnosis of gallstones. This greater sensitivity, especially in the diagnosis of microlithiasis/biliary sludge, facilitates the indication of cholecystectomy in patients with symptoms of probable biliary origin but may result in over-indication of this surgery. OBJECTIVES: Evaluate the role of EUS in the diagnosis of minilithiasis/biliary sludge in patients with digestive symptoms of probable biliary origin by resolving the symptoms after cholecystectomy. Analyse factors related to the remission of symptoms following cholecystectomy. PATIENTS AND METHODS: Retrospective, longitudinal, single-centre study based on a prospective database of 1.121 patients undergoing EUS. Seventy-four patients were identified as meeting inclusion-exclusion criteria (diagnosed with minilithiasis/sludge by EUS after presenting digestive symptoms of probable biliary origin without a history of complicated cholelithiasis). A telephone questionnaire for symptoms was conducted with cholecystectomized patients. Factors related to a good response were analysed with logistic regression analysis. RESULTS: Of the 74 patients, 50 were cholecystectomized (67.5%), mean age 49 years (SEM 2.26) (41 women). Seventy percent of patients (35/50) presented remission of symptoms with median follow-up 353.5 days (95% CI, 270-632.2). The only variable associated with remission of symptoms was the presence of typical biliary colic with an OR of 7.8 (95% CI, 1.8-34; p=0.006). No complications associated with EUS were recorded. One patient (2%) suffered haemoperitoneum and 18% (9/50) suffered diarrhoea following cholecystectomy. CONCLUSIONS: EUS is a very useful technique for the indication of cholecystectomy in patients with minilithiasis/sludge and typical symptoms of biliary colic.

The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease.

Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.

A pediatric surgeon's dilemma: does cholecystectomy improve symptoms of biliary dyskinesia?

BACKGROUND: Biliary dyskinesia (BD) is a well-established gallbladder pathology in adult patients and rates of cholecystectomy for BD continue to rise in the United States. Many pediatric patients with vague abdominal pain of variable duration are evaluated for biliary dyskinesia. It remains unknown which cohort of pediatric patients diagnosed with BD are most likely to have sustained improvement in symptoms following laparoscopic cholecystectomy. We aimed to determine whether cholecystectomy resulted in symptom relief and led to a reduction in the number of medical visits related to gastrointestinal (GI) symptoms after surgery. METHODS: We performed a multi-institution retrospective review of all children < 18 years of age who underwent laparoscopic cholecystectomy for BD between January 2013 and April 2018 in our hospital system. GI symptoms and clinical visits related to a GI complaint were assessed preoperatively. Patients were followed for 2 years after surgery. At 6 months and 2 years postoperatively, symptoms and the rate of medical visits related to a GI complaint were quantified and compared to the preoperative values. RESULTS: In total, 45 patients met our inclusion criteria. Of these, 82% of patients were female. The average age was 14 years old (± 2.6) and 56% of patients met the criteria for being overweight or obese. The mean gallbladder ejection fraction was 13% (± 10.8). All patients had abdominal pain, 82% (37/45) presented with nausea, and 51% (23/45) presented with post-prandial pain. Six months postoperatively, 58% of patients experienced resolution of their abdominal pain which decreased to 38% of patients after 2 years. Similarly, 59% had resolution of their nausea at 6 months compared to 43% at 2 years, and 100% had resolution of their post-prandial pain at 6 months compared to 91% at 2 years. The total number of clinical visits related to a GI complaint decreased from 2.6 (± 2.4) preoperatively to 1.0 (± 1.3) within 6 months postoperatively. When followed to 2 years postoperatively, the 6-month rate of clinical visits related to a GI complaint decreased from a mean of 2.6 preoperatively to 0.71 following surgery. CONCLUSIONS: Following cholecystectomy, we observed a high percentage of durable symptom resolution in those patients with BD who presented with post-prandial pain. Patients with non-food-related abdominal pain, with or without nausea and vomiting, had a lower rate of symptom resolution after surgery and the rate declined with time. For patients without post-prandial pain, evaluation and treatment of alternative sources of pain should be considered prior to surgery. Regardless of their presenting symptoms, patients who underwent surgery for BD had fewer clinical GI-related visits after surgery. However, no specific gallbladder ejection fraction or symptom alone was predictive of a lower rate of clinical visits postoperatively.

What happens to biliary colic patients in New York State? 10-year follow-up from emergency department visits.

INTRODUCTION: Biliary colic is a common diagnosis for patients presenting to the emergency department (ED). The purpose of this study is to examine the outcomes of patients coming to the ED with biliary colic. METHODS: The NYS longitudinal SPARCS database was used to identify patients presenting to the ED with biliary colic from 2005 to 2014. Through the use of a unique identifier, patients were followed in NYS across multiple institutions. Patients who were lost to follow-up, with duplicated records, and those that underwent percutaneous cholecystectomy tubes were excluded from the analysis. RESULTS: Between 2005 and 2014, there were 72,376 patients who presented to an ED with biliary colic. The admission rate was 20.7-26.02%. Overall, most patients who presented to the ED did not undergo surgery (39,567, 54.7%), of which 35,204 (89%) had only one ED visit, while 4,363(11%) returned to the ED (≥ 2 visits). Only 3.23-5.51% of patients underwent cholecystectomy at the time of initial presentation. Most subsequent cholecystectomies were performed electively (27.38-52.51%) (See Table 1 in this article). Average time to surgery among patients with elective cholecystectomy was 178.4 days. From the patients who underwent cholecystectomy, 10.35% had cholecystectomy at their first ED visit, 77.7% had cholecystectomy following the first ED visit, and 12% had multiple ED visits prior to surgery. Among patients who were discharged from the ED, 32% had their surgery at a different hospital than index presentation. CONCLUSION: A significant portion of patients (48.6%) who present to the ED with biliary colic will not return or have surgery within 5 years. A third of patients who eventually undergo cholecystectomy will go to another hospital for their surgery.

Long standing biliary colic masking chylous ascites in laparoscopic roux-en-Y gastric bypass; a case report.

BACKGROUND: Chylous ascites is considered to be an intra-abdominal collection of creamy colored fluid with triglyceride content of > 110 mg/dL. Chylous ascites is an uncommon but serious complication of numerous surgical interventions. However, it is a rare complication of LRYGB. An internal hernia limb defect is thought to be the underlying etiology, where the hernia will cause lymphatic vessel engorgement and lymphatic extravasation. CASE PRESENTATION: We report a case of a 29 years old male with a 9 year history of laparoscopic Roux en y gastric bypass (LRGYB), presenting with recurrent abdominal pain for 2 months radiating to the right shoulder. Ultrasound examination revealed gallstones and the patient was subsequently admitted for laparoscopic cholecystectomy. Intraoperatively, whitish colored fluid, high in triglycerides content was aspirated. During exploration, an internal hernia limb defect was found and corrected. CONCLUSION: Post LRGYB patients with symptoms of recurrent abdominal pain should be suspected for chylous ascites reflecting an internal hernia.

Fingerprinting Acute Digestive Diseases by Untargeted NMR Based Metabolomics.

Precision medicine may significantly contribute to rapid disease diagnosis and targeted therapy, but relies on the availability of detailed, subject specific, clinical information. Proton nuclear magnetic resonance (¹H⁻NMR) spectroscopy of body fluids can extract individual metabolic fingerprints. Herein, we studied 64 patients admitted to the Florence main hospital emergency room with severe abdominal pain. A blood sample was drawn from each patient at admission, and the corresponding sera underwent ¹H⁻NMR metabolomics fingerprinting. Unsupervised Principal Component Analysis (PCA) analysis showed a significant discrimination between a group of patients with symptoms of upper abdominal pain and a second group consisting of patients with diffuse abdominal/intestinal pain. Prompted by this observation, supervised statistical analysis (Orthogonal Partial Least Squares⁻Discriminant Analysis (OPLS-DA)) showed a very good discrimination (>90%) between the two groups of symptoms. This is a surprising finding, given that neither of the two symptoms points directly to a specific disease among those studied here. Actually herein, upper abdominal pain may result from either symptomatic gallstones, cholecystitis, or pancreatitis, while diffuse abdominal/intestinal pain may result from either intestinal ischemia, strangulated obstruction, or mechanical obstruction. Although limited by the small number of samples from each of these six conditions, discrimination of these diseases was attempted. In the first symptom group, >70% discrimination accuracy was obtained among symptomatic gallstones, pancreatitis, and cholecystitis, while for the second symptom group >85% classification accuracy was obtained for intestinal ischemia, strangulated obstruction, and mechanical obstruction. No single metabolite stands up as a possible biomarker for any of these diseases, while the contribution of the whole ¹H⁻NMR serum fingerprint seems to be a promising candidate, to be confirmed on larger cohorts, as a first-line discriminator for these diseases.

Gallbladder Agenesis: A Case Report.

Gallbladder agenesis (GA) is an extremely rare congenital entity. The incidence is around 1 per 6500 live births. The majority of patients, estimated between 50 to 70 percent, remain asymptomatic while those who are symptomatic report symptoms mimicking biliary colic. Initial workup for suspected gallbladder pathology such as right upper quadrant ultrasound (US) can be misleading or inconclusive. Furthermore, advanced diagnostic studies such as hepatobiliary iminodiacetic acid (HIDA) scan and endoscopic retrograde cholangio-pancreatography (ERCP) may report non-visualization of the gallbladder and erroneously lead providers to a diagnosis of cystic duct obstruction rather than GA. Consequently, some GA patients are only finally diagnosed intraoperatively. Surgery can be risky in these patients because unnecessary dissection while looking for the non-existent gallbladder can result in injury of the biliary tree, hepatic vasculature, or small bowel. Therefore, clinicians should keep GA on their differential diagnosis list and imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) should be obtained when other tests prove inconclusive. We report a 35-year-old female presenting with chronic symptoms consistent with biliary colic and an equivocal US reported as cholelithiasis. She underwent laparoscopy during which the absence of the gallbladder was noted. Postoperative MRCP confirmed the diagnosis of GA.

Changing management of gallstone-related disease in pregnancy - a retrospective cohort analysis.

OBJECTIVES: Gallstone-related disease is the second most common non-obstetric cause, following appendicitis, for acute abdomen in pregnancy. This study aimed to investigate treatment strategies, changes over time and outcome. MATERIALS AND METHODS: All consecutive patients with symptomatic gallstone-related disease during pregnancy admitted to Skane University hospital in Lund and Malmö 2001-2015 were analysed retrospectively. Information regarding the patient, pregnancy and fetus/child was recorded. The material was analysed by dividing it into two equal time periods and by comparing conservative management and surgical intervention. RESULTS: We included 96 patients with 97 pregnancies. The age was 30 (26-34) years and BMI 28 (24-31). Median length of pregnancy at first admission was 23 (13-31) weeks. The three most common diagnoses were biliary colic (n = 63), cholecystitis (n = 22) and acute pancreatitis (n = 16). Conservative treatment was practiced in 62 (64%) patients and intervention in 35 (36%). Conservatively treated patients were admitted later during pregnancy (week 26 (20-33) versus 17 (10-22), p < .001). Surgically treated patients had a longer total length of stay (all admissions) than conservatively treated patients (p = .001), less readmissions (p = .001) and equal birth outcome. Surgical intervention was more common in the later time period (48% versus 22%, p = .011). Of the conservatively treated patients, 56% were subjected to surgical intervention within 2 years after delivery. CONCLUSIONS: We found that intervention was more common in the later time period, with good results concerning safety, and less readmissions. A majority of the conservatively treated patients had surgical intervention within two years after delivery. Our results support surgical intervention in pregnancy.

Nineteen-year trends in incidence and indications for laparoscopic cholecystectomy: the NY State experience.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy (LC), there has been continued evolution in technique, instrumentation and postoperative management. With increased experience, LC has migrated to the outpatient setting. We asked whether increased availability and experience has impacted incidence of and indications for LC. METHODS: The New York (NY) State Planning and Research Cooperative System longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 and 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and the associated primary diagnostic codes. Data were analyzed as relative change in incidence (normalized to 1000 LC patients) for respective diagnoses. RESULTS: From 1995 to 2013, 711,406 cholecystectomies were performed in NY State: 637,308 (89.58 %) laparoscopic. The overall frequency of cholecystectomy did not increase (1.23 % increase with a commensurate population increase of 6.32 %). Indications for LC during this time were: 72.81 % for calculous cholecystitis (n = 464,032), 4.88 % for biliary colic (n = 31,124), 8.98 % for acalculous cholecystitis (n = 57,205), 3.01 % for gallstone pancreatitis (n = 19,193), and 1.59 % for biliary dyskinesia (n = 10,110). The incidence of calculous cholecystitis declined (-20.09 %, p < 0.0001) between 1995 and 2013; meanwhile, other diagnoses increased in incidence: biliary colic (+54.96 %, p = 0.0013), acalculous cholecystitis (+94.24 %, p < 0.0001), gallstone pancreatitis (+107.48 %, p < 0.0001), and biliary dyskinesia (+331.74 %, p < 0.0001). Outpatient LC incidence catapulted to 48.59 % in 2013, from 0.15 % in 1995, increasing >320-fold. Analysis of LC through 2014 revealed increasing rates of digestive, infectious, respiratory, and renal complications, with overall cholecystectomy complication rates of 9.29 %. CONCLUSION: A shifting distribution of operative indications and increasing rates of complications should prompt careful consideration prior to surgery for benign biliary disease. For what is a common procedure, LC carries substantial risk of complications, thus requiring the patient to be an active participant and to share in the decision-making process.

Right Upper Quadrant Pain: Ultrasound First!

Acute right upper quadrant (RUQ) pain is a common presenting symptom in emergency departments and outpatient medical practices, and is most commonly attributable to biliary and hepatic pathology. Ultrasound should be used as a first-line imaging modality for the diagnosis of gallstones and cholecystitis, as it allows the differentiation of medical and surgical causes of upper abdominal pathology, and in many circumstances is sufficient to guide patient management. Knowledge of strengths and limitations of ultrasound in the evaluation of RUQ is paramount in correct diagnosis. A spectrum of RUQ pathology for which a RUQ ultrasound examination should reasonably be considered as the initial imaging modality of choice will be reviewed.

Hepatobiliary and pancreatic ascariasis-sonographic pictorial essay on four pediatric cases with acute biliary colic.

Hepatobiliary and pancreatic ascariasis occur due to migration of the round worm ascaris lumbricoides through the bile duct orifice finally reaching the common bile duct, main pancreatic duct, intrahepatic ducts or gallbladder. These resulted in acute epigastric and right hypochondriac region colicky pain. Ultrasound is the investigation of choice in hepatobiliary ascariasis. We present here sonographic images on four pediatric patients with acute biliary colic.

Referral practices are associated with a delay in treatment of symptomatic cholelithiasis and cholecystitis.

BACKGROUND: The project was performed to determine if referrals to non-surgical providers after an initial presentation of symptomatic cholelithiasis are associated with a delay in surgical management. METHODS: A single institution chart review of all adult patients who underwent a cholecystectomy from 2015 to 2019 was completed. Quantitative data was analyzed using independent t-tests. RESULTS: Of 574 reviewed, 482 patients met criteria. Following initial presentation, 295 (61.2%) received a referral to surgery and 187 (38.8%) received follow up with a non-surgical provider. Those in the latter group had a significantly longer time from initial symptom presentation to surgical evaluation (65.7 days vs. 10.3 days, p â€‹< â€‹0.001) and cholecystectomy (102.0 days vs 39.1 days, p â€‹< â€‹0.001) when compared to the surgery referral group. CONCLUSIONS: This study demonstrated that cholecystectomy was significantly delayed for patients who had been referred to non-surgical providers after initial presentation, prolonging symptoms and increasing use of healthcare resources.

An update on the current and emerging pharmacotherapy for the treatment of human ascariasis.

INTRODUCTION: Globally, Ascaris lumbricoides is the commonest helminthic infection that affects people in underdeveloped countries and returning immigrants in industrialized nations. This article aims to provide latest updates on the epidemiology, clinical manifestations, and pharmacotherapy of ascariasis. AREAS COVERED: A PubMed search was conducted using Clinical Queries and the key terms 'human ascariasis' OR 'Ascaris lumbricoides.' Ascaris lumbricoides is highly endemic in tropical and subtropic regions and among returning immigrants in industrialized nations. Predisposing factors include poor sanitation and poverty. The prevalence is greatest in young children. Most infected patients are asymptomatic. Patients with A. lumbricoides infection should be treated with anti-helminthic drugs to prevent complications from migration of the worm. Mebendazole and albendazole are indicated for children and nonpregnant women. Pregnant individuals should be treated with pyrantel pamoate. EXPERT OPINION: Cure rates with anthelmintic treatment are high. No emerging pharmacotherapy can replace these existing drugs of good efficacy, safety profile and low cost for public health. It is opinioned that advances in the management of ascariasis include diagnostic accuracy at affordable costs, Emodepside is highly effective in single doses against ascarids in mammals and in human trials. The drug could be registered for human use in multiple neglected tropical diseases.

Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study.

BACKGROUND: Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available. OBJECTIVE: We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors. METHODS: RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses. RESULTS: Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates. CONCLUSION: The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

Gas-Containing Biliary Calculi: Case Series and a Systematic Review.

BACKGROUND: Cholelithiasis is a common gallbladder finding leading to cholecystitis in 7% of cases. Sonographic imaging or computed tomography scans are commonly employed for the diagnosis of benign gallbladder disease. Air within the gallbladder might carry various diagnoses. As opposed to pathologic air in the gallbladder seen in emphysematous cholecystitis, gas-containing gallstones are no more pathological than the exclusive presence of gallstones. In the present report, we review the incidence, physiology, typical characteristics, and clinical significance of gas-containing gallstones within the gallbladder. METHODS: We performed an institutional review of all patients with benign gallbladder disease over the past 16 years (2005 to 2021) to identify patients with gas-containing gallstones in the gallbladder. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to identify all reported cases of patients with gas-containing biliary calculi within the gallbladder. RESULTS: Our institutional review identified 5 patients with gas-containing biliary calculi in 1252 consecutive cholecystectomies; 4 of which had cholecystitis, while 1 was an incidental finding. Our review of the literature identified 30 manuscripts documenting 54 unique patients with gas-containing biliary calculi. None of these patients had consequential pathology related to gas in the stones other than that caused by the gallstones (ie, biliary colic and cholecystitis). CONCLUSIONS: Gas-containing biliary calculi are uncommon. How gas finds itself within gallstones within the gallbladder is not entirely clear. Gas-containing gallstones should not be interpreted as free gas within the gallbladder or within an abscess.

Phloroglucinol-Derived Medications are Effective in Reducing Pain and Spasms of Urinary and Biliary Tracts: Results of Phase 3 Multicentre, Open-Label, Randomized, Comparative Studies of Clinical Effectiveness and Safety.

INTRODUCTION: Pain and spasms of urinary and biliary tracts are conditions causing poor quality of life. Treatment with analgesic drugs such as non-steroidal anti-inflammatory drugs and modulators of the parasympathetic system are not always tolerated, and often additional therapeutic options are necessary. The present analysis aimed to evaluate the pharmacokinetics and effectiveness of oral and parenteral preparations based on phloroglucinol in reducing pain and spasms associated with renal or biliary colic in phase 3, multicentre, open-label, randomized, comparative studies on clinical effectiveness and safety. METHODS: Pharmacokinetic and pharmacodynamic studies were carried out. Four phase 3 multicentre, open-label, randomized, comparative studies were conducted to evaluate the clinical effectiveness and safety in patients with pain and spasms of urinary or biliary tracts. Eligible patients randomly received either phloroglucinol orally or via intramuscular (IM)/intravenous (IV) administration and reference drug, dexketoprofen for urinary spasms and pain, the non-steroidal anti-inflammatory drug metamizole or scopolamine-based reference drug for biliary colic. The primary outcomes were symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the drug administration and the recurrence of symptoms. Comparison of groups by quantitative characteristics was performed using the T-test for independent samples or the Mann-Whitney test. Intragroup comparisons were performed using the Wilcoxon test, or the T-test for linked samples. Qualitative signs were analysed using the Pearson's χ2 test and Fisher's exact test. RESULTS: The pharmacokinetic studies showed that (i) most of the phloroglucinol (> 80% for IV and per os formulations) was eliminated in the first 6 h after dosing, (ii) the drug was eliminated in urine as unchanged phloroglucinol (1,3,5-trihydroxybenzene) in a small proportion (< 3% of the dose) and (iii) a considerable amount of the drug was detected after enzymatic deconjugation with ß-glucoronidase/arylsulfatase from Helix pomatia. As for the pharmacokinetic study, a total of 364 patients were enrolled, divided in four studies: two designed to test the effectiveness of oral and IM/IV preparations in biliary colic and two in urinary colic. Baseline characteristics between groups were similar. Phloroglucinol oral or IV/IM showed an effectiveness comparable to the reference drug in reducing pain and spasms associated with both urinary and biliary colic. There was no difference between all groups by survival analysis. CONCLUSION: Oral and parenteral preparations based on phloroglucinol are as effective in reducing pain and spasms associated with renal or biliary colic as current therapeutic options. Therefore, phloroglucinol may be considered as useful to treat pain and spasms associated with urinary and biliary colic.

Acupuncture on GB34 for immediate analgesia and regulating pain-related anxiety for patients with biliary colic: a protocol of randomized controlled trial.

BACKGROUND: Biliary colic (BC) is a frequent hepatobiliary disorder encountered in emergency departments. Acupuncture may be effective as an alternative and complementary medicine for BC. Nonetheless, rigorous trials investigating its efficacy are lacking. Therefore, the aim of this study protocol is to determine whether acupuncture provides immediate relief of pain and associated symptoms in BC patients. METHOD: Eighty-six participants who aged from 18 to 60 years with BC will be recruited in the First People's Hospital of Longquanyi District, Chengdu (West China Longquan Hospital Sichuan University). All participants will be allocated into two treatment groups including acupuncture group and sham acupuncture group using a 1:1 ratio. Each group will only receive a single 30-min needle treatment while waiting for their test results after completing the routine examination for BC. The primary outcome of the study is to assess the change in pain intensity after the 30-min acupuncture treatment. The secondary outcomes of the study include the change in pain intensity at various time points, the degree of gastrointestinal symptoms at different time points, the level of anxiety experienced during pain episodes at different time points, the score of Pain Anxiety Symptoms Scale-20 (PASS-20), the score of Fear of Pain Questionnaire-III (FPQ-III), and the score of Pain Catastrophizing Scale (PCS), among others. DISCUSSION: The results of this research will provide substantial evidence regarding the efficacy of acupuncture in alleviating symptoms associated with BC. TRIAL REGISTRATION: ClinicalTrials.gov, ChiCTR2300070661. Registered on 19 April 2023.

Pancreatic heterotopia of the gallbladder - possible cause of right upper quadrant pain, a case report.

Pancreatic heterotopia is characterized by ectopic pancreatic tissue found outside the pancreas without any anatomical or vascular connection to the pancreas. Pancreatic heterotopia of the gallbladder is a rare histological finding; there have been only a handful of cases described in the literature. Pancreatic heterotopia of the gallbladder is usually diagnosed incidentally at histological examination following cholecystectomy or autopsy. Clinical presentation of pancreatic heterotopia of the gallbladder can vary from biliary colic, biliary obstruction or it can be completely asymptomatic. It has been suggested that gallbladder pancreatic heterotopia may lead to pancreatitis of this ectopic tissue, which may present differently to typical biliary colic. Here, we present the case of a 43-year-old male that presented with 2 years of significant postprandial nausea and right upper quadrant pain. Histopathology following cholecystectomy revealed chronic cholecystitis with cholelithiasis, in addition to a focus of pancreatic heterotopia in the gallbladder wall.

Biliary colic in the emergency department: A state-wide analysis of one-year costs and clinical outcomes.

Importance: Approximately 335,000 cases of biliary colic present to US emergency departments (EDs) annually, and most patients without complications are discharged from the ED. It is unknown what are the subsequent surgery rates, subsequent complications of biliary disease, ED revisits, repeat hospitalizations and cost; and, how does the ED disposition decision (admission versus discharge) affect long-term outcomes. Objective: To determine whether there is a difference in one-year surgery rates, complications of biliary disease, ED revisits, repeat hospitalizations, and cost in ED patients with uncomplicated biliary colic who are admitted to the hospital versus those that are discharged from the ED. Design setting and participants: A retrospective observational study was conducted using records collected from the Maryland Healthcare Cost and Utilization Project (HCUP) in the Ambulatory Surgery, the Inpatient, and the ED setting between 2016 and 2018. After applying inclusion criteria, 7036 ED patients with uncomplicated biliary colic were followed for one year after their index ED visit for repeat healthcare utilization across multiple settings. A multivariable logistic regression study was performed to asses for risk factors for surgery allocation and hospital admission. Medicare Relative Value Units (RVUs) and HCUP Cost-Charge Ratio files were used to estimate direct costs. Exposures: Episodes of biliary colic were ascertained using ICD-10 codes at the index ED visit. Main outcomes and measures: The primary outcome was the one-year surgery rate, defined as a cholecystectomy. Secondary outcomes included the rate of new acute cholecystitis or other related complications, ED revisits, hospital admission and costs. Associations with hospital admission and surgeries were measured using adjusted odds ratios (ORs) with 95 % CIs. Results: Of the 7036 patients analyzed, 793 (11.3 %) were admitted and 6243 (88.7 %) were discharged on their initial ED visit. When comparing the groups who were initially admitted versus discharged, we observed similar one-year cholecystectomy rates (42 % versus 43 %, mean difference 0.5 %, 95 % CI -3.1 %-4.2 %; P < 0.001), lower rates of new cholecystitis occurrences (18 % versus 41 %, mean difference 23 %, 95 % CI, 20 %-26 %; P < 0.001), lower rates of ED revisits (96 vs 198 per 1000 patients, mean difference 102, 95 % CI, 74-130; P < 0.001) and higher costs ($9880 versus $1832, mean difference 8048, 95 % CI, 7478-8618; P < 0.001). Initial ED hospital admission was associated with increased age (adjusted odds ratio [aOR], 1.44; 95 % CI, 1.35-1.53; P < 0.001), obesity (aOR, 1.38; 95 % CI, 1.32-1.44; P < 0.001), ischemic heart disease (aOR, 1.39; 95 % CI, 1.30-1.48; P < 0.001), mood disorders (aOR, 1.18; 95 % CI, 1.13-1.24; P < 0.001), alcohol-related disorders (aOR, 1.20; 95 % CI, 1.12-1.27; P < 0.001), hyperlipidemia (aOR, 1.16; 95 % CI, 1.09-1.23; P < 0.001), hypertension (aOR, 1.15; 95 % CI, 1.08-1.21; P < 0.001), and nicotine dependence (aOR, 1.09; 95 % CI, 1.03-1.15; P = 0.003) but not associated with race (P > 0.9), ethnicity (P > 0.9), or income-stratified zip code (aOR, 1.04; 95 % CI, 0.98-1.09; P = 0.17). Conclusions and relevance: In our analysis of ED patients with uncomplicated biliary colic from a single state, the majority of patients do not receive a cholecystectomy within one year and hospital admission at the initial visit was not associated with an overall change in rates of cholecystectomy but was associated with increased costs. These findings inform our understanding of the long-term outcomes and are important considerations when communicating care options with ED patients with biliary colic.

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations.

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.