*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* A United States Army Medical Department Continuing Education program. The following program was recorded at the fifth annual William Beaumont gastrointestinal symposium 17 through 19 March, 1976 held at William Beaumont Army Medical Center in El Paso Texas, acute non calculus cholecystitis, an unusual complication of ERC in a radiologically normal biliary system with major James L stammer. MD Brook Army Medical Center for Sam Houston, Texas. Uh I'd like to present a brief case report of a uh not quite so rare phenomenon we observed at Brooke within the past six months. And for those 13 minute clan geographers assuming a reasonable standard deviation and anatomical advantage. I submit this case report for your interest. The results of the A S G E survey of August 1975 and more recently, the University of Oregon survey in a recent gastro of the complications of er C P reported colitis as the second most common complication. All cases of colitis had some degree of mild duct obstruction. There were no reports of colitis or other biliary tract complications occurring in a radiologically normal biliary tree. Similar results have been reported by Zimin at all in an analysis of the complications of, er C P and 300 consecutive cases in the absence of extra paic obstruction. Zimin performed cola geography without complication in 85 cases. 25 of which had intense intra paic choli stasis. We are unaware of a previous report of acute cholecystitis following er, c in a normal or abnormal biliary system. Now, the first line please, a 52 year old caucasian male chronic alcoholic was admitted with a 10 day history of jar and peritus. He had stopped drinking 10 days prior to admission, he denied nausea, vomiting, abdominal pain, fever or chills. He had had viral hepatitis in 1952 without sequel and a liver biopsy in 1963 which revealed fatty change. He underwent a bill Roth one and a Vigo in 1962 for intractable dual ulcer disease. Physical exam was normal except for marked iris, spider angiomata and tender HEPA. There was no a petal or asterixis on admission. Laboratory data included a white blood count of 14,500 with a mild shift to the left S G O T of 211 al phosphor 2.5 times the upper limit of normal total billy Rubin of 24 a half and a cholesterol of 350. Additionally, the patient had glucose b un prothrombin time and serum amylase all within normal limits. Jaundice with peritus became more intense during the first week of hospitalization with his billy Ruben rising to 38 liver scan revealed diffused. The pato cellular disease. A four centimeter core biopsy. The liver revealed fatty change mark collis, stasis and moderate portal fibrosis, percutaneous transat. Ay was unsuccessful on the 13th hospital day, endoscopic retrograde gland geography was done on day 20 using 20 mg of Valium and one mg of glucagon. During the procedure, the entire procedure including spot films and overheads required 20 minutes. The paella had two ductal orifices and the more cephalad one was cannulated. 50 ccs of 30% ren grain were injected. The pancreatic duct was not can is an overhead view demonstrating rapid emptying of previously filled intra pado ducts. The gallbladder, bifurcation of the common duct and the common duct were the normal limits without an obvious obstructing lesion films of the intra bill. Radicals were within the normal range here. And on the next slide, delayed films after the initial overheads were not taken nor was fatty meal stimulation carried out 24 hours post procedure. The patient was released on pass. He returned 12 hours later complaining of severe right upper quadrant pain. He was a febrile, a palpable markedly tender gallbladder was found on physical exam at K U B at this time, revealed no residual contrast in the gallbladder or biliary trait at surgery. The gallbladder was Ademi red and distended. The gallbladder mucosa was hemorrhagic and appeared to be fluffing part of the contents of the gallbladder is shown here. Next next to the gallbladder. The common bile duct was normal to palpation at surgery. Histopathology of the gallbladder revealed striking inflammation of the mucosa and areas of focal ulceration. High powered view demonstrates marked inflammatory infiltrate that one area gallbladder, koza, the contents of the gallbladder contain mostly debris and blood diffusely infiltrated with acute inflammatory cells and islands of gallbladder. Epithelium. No calculi were found aerobic and non aerobic cultures of the bile revealed no growth, blood and gallbladder wall cultures were not obtained slide off the temporal occurrence of acute non calculus cholecystitis following er C with improving collis, stasis clinically suggests a cause and effect relationship. Acute cholecystitis has not been reported as a complication of er R C. The most frequent complication of die injection in er C is chole occurring in approximately 6 to 7% of patients with common mild duct obstruction chole or other inflammatory diseases of the biliary tract have not been reported in patients with a normal biliary tree and gallbladder. Found at the time of retrograde gland geography. In this regard, the lack of any obstruction of the common bile duct or cystic duct in our patient is of particular interest. A calculus cholecystitis has been associated with anatomical anomalies and bacterial infection of the gallbladder. Other postulated ecological factors include pancreatitis, diabetes, melati collagen vascular diseases, dehydration trauma and severe burns. None of these factors were present in this case. A possible exception is infection of the gallbladder. Cultures of the biel were negative. However, the patient had received ampicillin just prior to surgery. Ampicillin has been reported not to reach effective blood levels. Therapeutic levels in the bile of obstructed gallbladders. And therefore, the cultures done here may be a reliable indicator of the sterility of the bile. The mechanism of cholecystitis experienced by this patient following er, c remains obscure the contribution of previous vagotomy to stasis of gallbladder contents or hypo chloris is secondary to collis. Stasis cannot be determined if operative, they could potentially augment any damaging effects of ren grain on the gallbladder. Mucosa ren grain induced hemorrhagic cholecystitis and acute obstruction of the cystic duct by debris clot or sluff gallbladder. Epithelium could result in biliary colic and a tender palpable gallbladder. The next slide please. This unusual complication of er C is reported to alert the gastroenterologist to the possibility, albeit rare of acute nonn calculus cholecystitis in patients with radiologically normal biliary tracts. Contrary to published observations, a radiologically normal biliary system does not preclude the development of inflammatory disease. Thank you. This program has been produced through the mobile facilities of the television branch, Health Sciences, media division, the Academy of Health Sciences of the US Army, Fort Sam Houston, Texas.