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Case 252

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A 23-year-old male, asymptomatic, performed routine exams for control after bariatric surgery (vertical gastrectomy) performed one year ago, indicated by morbid obesity (BMI = 53) and metabolic syndrome. Currently, he is healthy, without complaints and with BMI = 29. In the follow-up propaedeutic, total abdominal ultrasonography (US) was requested.

Based on the clinical history and images provided, what is the probable diagnosis?

a) Cholecystolithiasis

25%

b) Hemangioma

25%

c) Gallbladder polyp

25%

d) Choledocholithiasis

25%
   

Image analysis

Image 1: Upper abdominal ultrasonography, longitudinal sections, showing liver with moderately pronounced dimensions, regular contours, homogeneous structure and echogenicity of slightly enlarged parenchyma (steatosis).

 

Image 2: Abdominal ultrasound, oblique longitudinal cut, right hypochondrium level. Gallbladder with normal parietal dimensions and thickness. Presence of echogenic formation (yellow arrow) conditioner of posterior acoustic shadow (red dash).

 

Image 3: Abdominal ultrasound, oblique longitudinal cut, right hypochondrium level. Hepatocoledoco (red arrow) and portal vein (yellow arrow) with calibers within the limits of normality. Presence of gas in the gastrointestinal tract, conditioning posterior acoustic shade (green arrow).

Highlights

- Cholecystolithiasis is the presence of one or more calculi within the gallbladder translated by hyperechogenic formation (s) and acoustic shade (s) to the US;

- Biliary lithiasis follows from the imbalance between the constituents of bile, stasis and possible bacterial proliferation;

- Biliary lithiasis has a prevalence of 10 to 18% in the population and is considered a multifactorial disease;

- The main predisposing factors are demographic / genetic, obesity, female sex hormones, increased age and rapid and marked weight loss;

- Most patients with cholecystolithiasis are asymptomatic;

- US is the procedure of choice for accurate identification of cholecystolithiasis;

- Surgical treatment (gallbladder removal) is indicated in specific cases (Table 1);

- Prophylactic cholecystectomy is of limited indication.

References

- Lehmann ALF, Valezi AC, Brito EM, Marson AC, Souza JCL. Correlação entre hipomotilidade da vesícula biliar e desenvolvimento de colecistolitíase após operação bariátrica. Rev. Col. Bras. Cir. 2006, vol.33, n.5, pp.285-288.

- Chen MYM, Pope TL, Ott DJ. Radiologia Básica. Porto Alegre, RS: AMGH Ed., 2012.

- Saad RJR, Maia AM, Salles RARV. Tratado de Cirurgia do CBC. ATHENEU EDITORA, 2009.

- Townsend, Beauchamp, Evens, Mattox. SABISTON Tratado de Cirurgia, 18a edição, 2009, Saunders Elsevier.

- Federação Brasileira de Gastroenterologia [Internet]. São Paulo [Acesso em 05/07/16]. Disponível em: www.fbg.org.br

- Nunes D. Patient selection for the nonsurgical treatment of gallstone disease. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012.

Authors

Luísa Bernardino Valério, 5th year medical student at UFMG.

E-mail: luisabernardino[arroba]gmail.com

Supervisor

Dr. Renato Gomes Campanati, Resident Physician of General Surgery, Hospital das Clínicas, UFMG.

E-mail: renatogcampanati[arroba]gmail.com

Reviewers

Fábio M. Satake, Laio Bastos, Daniela Braga, Carla Faraco, Professor José Nelson Mendes Vieira and Professor Viviane Parisotto.

Translated by

Daniele Araújo Pires, 6th year medical student at UFMG.

E-mail: daniarpires[arroba]gmail.com

 

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