WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *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.* 00:21.739 --> 00:24.250 A United States Army Medical Department Continuing 00:24.260 --> 00:25.510 Education program. 00:26.870 --> 00:29.600 The following program was recorded at the fifth annual 00:29.610 --> 00:32.200 William Beaumont gastrointestinal symposium 00:32.250 --> 00:33.909 17 through 19 March, 00:33.919 --> 00:36.840 1976 held at William Beaumont Army 00:36.849 --> 00:38.919 Medical Center in El Paso Texas, 00:40.799 --> 00:43.200 acute non calculus cholecystitis, 00:43.490 --> 00:46.119 an unusual complication of ERC in a 00:46.130 --> 00:48.409 radiologically normal biliary system 00:49.470 --> 00:51.220 with major James L stammer. 00:51.229 --> 00:54.130 MD Brook Army Medical Center for Sam 00:54.139 --> 00:54.560 Houston, 00:54.569 --> 00:55.159 Texas. 00:56.009 --> 00:58.759 Uh I'd like to present a brief case report of a 00:58.770 --> 01:00.979 uh not quite so rare 01:01.250 --> 01:04.000 phenomenon we observed at Brooke within the past 01:04.010 --> 01:04.699 six months. 01:05.900 --> 01:08.510 And for those 13 minute clan geographers 01:10.080 --> 01:13.050 assuming a reasonable standard deviation 01:13.059 --> 01:14.870 and anatomical advantage. 01:16.230 --> 01:18.720 I submit this case report for your interest. 01:18.800 --> 01:21.699 The results of the A S G E survey 01:21.709 --> 01:24.120 of August 1975 01:25.379 --> 01:26.260 and more recently, 01:26.269 --> 01:28.940 the University of Oregon survey in a 01:28.949 --> 01:31.769 recent gastro of the complications of 01:31.779 --> 01:34.650 er C P reported colitis 01:34.660 --> 01:36.970 as the second most common complication. 01:37.639 --> 01:40.480 All cases of colitis had some degree 01:40.489 --> 01:42.529 of mild duct obstruction. 01:43.349 --> 01:46.099 There were no reports of colitis or 01:46.110 --> 01:48.580 other biliary tract complications occurring in a 01:48.589 --> 01:50.959 radiologically normal biliary tree. 01:51.790 --> 01:54.449 Similar results have been reported by Zimin at 01:54.650 --> 01:57.610 all in an analysis of the complications of, 01:57.620 --> 02:00.440 er C P and 300 consecutive 02:00.449 --> 02:03.110 cases in the absence of extra 02:03.389 --> 02:04.339 paic obstruction. 02:04.779 --> 02:07.040 Zimin performed cola geography without 02:07.050 --> 02:09.440 complication in 85 cases. 02:09.449 --> 02:12.330 25 of which had intense intra paic choli 02:12.490 --> 02:13.029 stasis. 02:13.639 --> 02:16.449 We are unaware of a previous report of 02:16.460 --> 02:19.210 acute cholecystitis following er, 02:19.220 --> 02:20.830 c in a 02:21.669 --> 02:24.279 normal or abnormal biliary system. 02:24.979 --> 02:25.149 Now, 02:25.160 --> 02:26.389 the first line please, 02:28.250 --> 02:30.619 a 52 year old caucasian male chronic 02:30.630 --> 02:33.429 alcoholic was admitted with a 10 day history of jar 02:33.639 --> 02:34.610 and peritus. 02:34.910 --> 02:37.520 He had stopped drinking 10 days prior to admission, 02:37.529 --> 02:38.630 he denied nausea, 02:38.830 --> 02:39.539 vomiting, 02:39.550 --> 02:40.419 abdominal pain, 02:40.429 --> 02:41.679 fever or chills. 02:41.979 --> 02:44.970 He had had viral hepatitis in 1952 02:44.979 --> 02:47.460 without sequel and a liver biopsy in 02:47.470 --> 02:50.050 1963 which revealed fatty 02:50.059 --> 02:50.839 change. 02:51.029 --> 02:53.500 He underwent a bill Roth one and a Vigo in 02:53.509 --> 02:55.839 1962 for intractable dual 02:56.289 --> 02:57.240 ulcer disease. 03:01.229 --> 03:04.169 Physical exam was normal except for marked iris, 03:04.179 --> 03:06.220 spider angiomata and tender HEPA. 03:07.320 --> 03:09.839 There was no a petal or asterixis 03:12.649 --> 03:13.580 on admission. 03:14.119 --> 03:16.539 Laboratory data included a white blood count of 03:16.550 --> 03:19.399 14,500 with a mild shift to the 03:19.410 --> 03:22.309 left S G O T of 211 al 03:22.770 --> 03:25.610 phosphor 2.5 times the upper limit of normal 03:25.699 --> 03:28.690 total billy Rubin of 24 a half and a cholesterol of 03:28.699 --> 03:29.800 350. 03:30.130 --> 03:30.800 Additionally, 03:30.809 --> 03:33.610 the patient had glucose b un prothrombin 03:33.929 --> 03:36.649 time and serum amylase all within normal 03:36.660 --> 03:37.139 limits. 03:37.610 --> 03:40.479 Jaundice with peritus became more intense 03:40.869 --> 03:43.660 during the first week of hospitalization with his billy Ruben 03:43.669 --> 03:45.429 rising to 38 03:46.460 --> 03:48.529 liver scan revealed diffused. 03:48.559 --> 03:50.270 The pato cellular disease. 03:50.479 --> 03:52.179 A four centimeter core biopsy. 03:52.190 --> 03:54.619 The liver revealed fatty 03:54.630 --> 03:56.580 change mark collis, 03:56.600 --> 03:59.199 stasis and moderate portal fibrosis, 03:59.399 --> 04:00.820 percutaneous transat. 04:01.639 --> 04:04.220 Ay was unsuccessful on the 13th hospital 04:04.229 --> 04:04.679 day, 04:05.449 --> 04:08.339 endoscopic retrograde gland geography was done on day 04:08.350 --> 04:11.149 20 using 20 mg of Valium 04:11.250 --> 04:12.669 and one mg of glucagon. 04:12.750 --> 04:13.830 During the procedure, 04:14.089 --> 04:16.769 the entire procedure including spot films and overheads 04:16.779 --> 04:18.079 required 20 minutes. 04:18.500 --> 04:21.399 The paella had two ductal orifices and the 04:21.410 --> 04:23.540 more cephalad one was cannulated. 04:23.630 --> 04:26.380 50 ccs of 30% ren grain 04:26.589 --> 04:27.579 were injected. 04:27.589 --> 04:29.570 The pancreatic duct was not can 04:33.570 --> 04:36.369 is an overhead view demonstrating 04:36.380 --> 04:39.230 rapid emptying of previously filled 04:39.239 --> 04:40.510 intra pado ducts. 04:43.459 --> 04:44.500 The gallbladder, 04:45.209 --> 04:47.950 bifurcation of the common duct and the 04:47.959 --> 04:50.920 common duct were the normal limits without an obvious 04:50.929 --> 04:51.940 obstructing lesion 04:53.899 --> 04:56.140 films of the intra bill. 04:56.200 --> 04:58.510 Radicals were within the normal range here. 04:58.559 --> 04:59.619 And on the next slide, 05:02.850 --> 05:05.420 delayed films after the initial overheads were not 05:05.429 --> 05:08.079 taken nor was fatty meal stimulation carried 05:08.089 --> 05:10.739 out 24 hours post 05:10.750 --> 05:11.339 procedure. 05:11.350 --> 05:13.100 The patient was released on pass. 05:13.109 --> 05:15.690 He returned 12 hours later complaining of 05:15.700 --> 05:18.130 severe right upper quadrant pain. 05:18.279 --> 05:19.630 He was a febrile, 05:19.799 --> 05:22.619 a palpable markedly tender gallbladder was found on 05:22.630 --> 05:25.609 physical exam at K U B at this 05:25.619 --> 05:25.910 time, 05:25.920 --> 05:28.829 revealed no residual contrast in the gallbladder or biliary 05:29.029 --> 05:29.549 trait 05:32.959 --> 05:33.720 at surgery. 05:33.730 --> 05:36.299 The gallbladder was Ademi red and 05:36.309 --> 05:36.959 distended. 05:38.459 --> 05:41.149 The gallbladder mucosa was hemorrhagic and 05:41.160 --> 05:43.679 appeared to be fluffing part of the 05:43.690 --> 05:45.730 contents of the gallbladder is shown here. 05:45.739 --> 05:47.799 Next next to the gallbladder. 05:48.559 --> 05:51.420 The common bile duct was normal to palpation at 05:51.429 --> 05:52.140 surgery. 05:52.510 --> 05:55.410 Histopathology of the gallbladder revealed 05:56.070 --> 05:58.920 striking inflammation of the mucosa and 05:58.929 --> 06:01.119 areas of focal ulceration. 06:03.019 --> 06:06.010 High powered view demonstrates marked inflammatory 06:06.019 --> 06:08.190 infiltrate that one area 06:08.440 --> 06:09.059 gallbladder, 06:09.309 --> 06:09.529 koza, 06:11.859 --> 06:13.630 the contents of the gallbladder 06:14.350 --> 06:16.950 contain mostly debris and blood diffusely 06:16.959 --> 06:19.589 infiltrated with acute 06:19.600 --> 06:21.929 inflammatory cells and islands of 06:21.940 --> 06:22.640 gallbladder. 06:22.649 --> 06:23.359 Epithelium. 06:24.959 --> 06:26.910 No calculi were found 06:27.690 --> 06:30.480 aerobic and non aerobic cultures of the bile 06:30.820 --> 06:32.299 revealed no growth, 06:32.309 --> 06:35.299 blood and gallbladder wall cultures were not obtained 06:35.760 --> 06:38.380 slide off the 06:38.390 --> 06:41.369 temporal occurrence of acute non calculus cholecystitis 06:41.380 --> 06:43.440 following er C with improving collis, 06:43.609 --> 06:46.320 stasis clinically suggests a cause and 06:46.329 --> 06:47.510 effect relationship. 06:47.890 --> 06:50.600 Acute cholecystitis has not been reported as a 06:50.609 --> 06:52.250 complication of er R C. 06:52.579 --> 06:55.559 The most frequent complication of die injection in 06:55.570 --> 06:58.369 er C is chole occurring in approximately 06:58.380 --> 07:01.109 6 to 7% of patients with common 07:01.119 --> 07:03.679 mild duct obstruction chole 07:04.290 --> 07:07.109 or other inflammatory diseases of the biliary tract have not been 07:07.119 --> 07:09.600 reported in patients with a normal biliary 07:09.790 --> 07:11.220 tree and gallbladder. 07:11.260 --> 07:13.859 Found at the time of retrograde gland 07:13.970 --> 07:14.660 geography. 07:14.670 --> 07:15.489 In this regard, 07:15.500 --> 07:18.399 the lack of any obstruction of the common bile duct or cystic 07:18.410 --> 07:21.190 duct in our patient is of particular interest. 07:22.470 --> 07:25.290 A calculus cholecystitis has been associated 07:25.299 --> 07:28.160 with anatomical anomalies and bacterial 07:28.170 --> 07:29.570 infection of the gallbladder. 07:29.760 --> 07:32.549 Other postulated ecological factors include 07:32.559 --> 07:33.630 pancreatitis, 07:33.790 --> 07:34.510 diabetes, 07:34.519 --> 07:36.519 melati collagen vascular diseases, 07:36.529 --> 07:38.910 dehydration trauma and severe 07:38.920 --> 07:39.619 burns. 07:40.130 --> 07:42.519 None of these factors were present in this case. 07:44.399 --> 07:47.070 A possible exception is infection of the gallbladder. 07:47.250 --> 07:49.369 Cultures of the biel were negative. 07:49.380 --> 07:49.790 However, 07:49.799 --> 07:52.160 the patient had received ampicillin just prior to 07:52.170 --> 07:52.869 surgery. 07:53.200 --> 07:55.980 Ampicillin has been reported not to reach 07:55.989 --> 07:57.230 effective blood levels. 07:57.239 --> 07:59.600 Therapeutic levels in the bile of obstructed 07:59.609 --> 08:00.640 gallbladders. 08:00.649 --> 08:01.290 And therefore, 08:01.299 --> 08:03.980 the cultures done here may be a reliable 08:03.989 --> 08:06.290 indicator of the sterility of the bile. 08:07.019 --> 08:10.000 The mechanism of cholecystitis experienced by this 08:10.010 --> 08:11.839 patient following er, 08:11.850 --> 08:14.790 c remains obscure the contribution 08:14.799 --> 08:17.279 of previous vagotomy to stasis of gallbladder 08:17.290 --> 08:20.100 contents or hypo chloris is secondary to collis. 08:20.269 --> 08:22.799 Stasis cannot be determined if 08:22.809 --> 08:23.309 operative, 08:23.320 --> 08:25.989 they could potentially augment any damaging 08:26.000 --> 08:27.940 effects of ren grain on the gallbladder. 08:27.950 --> 08:30.760 Mucosa ren grain induced hemorrhagic 08:30.769 --> 08:33.690 cholecystitis and acute obstruction of the cystic duct 08:33.700 --> 08:36.690 by debris clot or sluff gallbladder. 08:36.700 --> 08:38.820 Epithelium could result in biliary 08:39.059 --> 08:42.039 colic and a tender palpable gallbladder. 08:42.479 --> 08:43.859 The next slide please. 08:45.390 --> 08:48.359 This unusual complication of er C is reported 08:48.369 --> 08:51.210 to alert the gastroenterologist to the possibility, 08:51.609 --> 08:54.070 albeit rare of acute nonn calculus 08:54.080 --> 08:57.049 cholecystitis in patients with radiologically normal 08:57.059 --> 08:58.130 biliary tracts. 08:58.659 --> 09:00.700 Contrary to published observations, 09:00.710 --> 09:03.559 a radiologically normal biliary system does not 09:03.570 --> 09:06.210 preclude the development of inflammatory disease. 09:06.369 --> 09:06.880 Thank you. 09:11.460 --> 09:14.320 This program has been produced through the mobile facilities of the 09:14.330 --> 09:15.309 television branch, 09:15.530 --> 09:16.369 Health Sciences, 09:16.380 --> 09:17.229 media division, 09:17.390 --> 09:19.780 the Academy of Health Sciences of the US Army, 09:19.789 --> 09:20.690 Fort Sam Houston, 09:20.700 --> 09:21.270 Texas.