- Email: [email protected]
Haemobilia and gallbladder carcinoma
DIGESTLIUERDIS 2002;34:681-2
CORRESPONOENCETOTHE EDITOR
Haemobilia
and gallbladder
carcinoma
Sir Gallbladder carcinoma (GBC) is an infrequent neoplasm, the clinical manifestations of which resemble those of cholecystitis. Pain at the right upper abdominal quadrant in up to 90% of cases, palpable mass (30%), weight loss (28%) jaundice, nausea and vomiting (20%) I. Less frequent clinical manifestations are: ascites, duodenal and/or colonic obstruction and haemobilia 2. A patient presenting with haematemesis and melena associated with gallbladder cancer is described. A 60-year-old female was referred on account of melena, haematemesis and abdominal pain. At admission, routine blood tests were normal but mild iron-deficiency anaemia was detected. Upper gastrointestinal (GI) endoscopy was normal except for duodenal blood debris. Ultrasonography (US) and computed tomography (CT) liver scan showed a distended gallbladder with heterogeneous changes (Fig. 1). Cholecystectomy was car-
_.
-
-.
CT scan that shows a distended gallbladder with heterogeneous changes..
ried out; at laparotomy, the patency of the biliary tree was confirmed after having removed blood clots. Pathology revealed the presence of an ulcerated moderately to poorly differentiated adenocarcinoma of the gallbladder with haemorrhagic necrosis infiltrating the muscular layer (Stage 11 by the modified Nevin staging system) (Fig. 2). The outcome was uneventful and the patient is still symptomless 24 months later without any evidence of recurrence. Haemobilia i.e., haemorrhage originating in the gallbladder or in a bile duct is uncommon and secondary to trauma, inflammatory changes, iatrogenic lesions, lithiasis or primary vascular alterations such as aneurysm. It has rarely been associated with bile duct malignancies. It is diffkult to establish a diagnosis of haemobilia since the classic triad represented by biliary colic, obstructive jaundice and GI bleeding appears in only 30% of cases 3. Clinical presentation can include haematemesis and melena, obstructive jaundice and/or pancreatitis. There is also the possibility of blood accumulating in the gallbladder, thereby increasing intraluminal pressure and appearing as acute cholecystitis. The possibility of haemobilia should be suspected in patients with haematemesis and melena in the absence of symptoms consistent with a disease of the biliary system. This possibility can be definitely demonstrated by US, CT scan endoscopic retro-cholangio-pancreatography (ERCP) or selective angiography (this latter procedure being preferred in the case of hepatic injury, due to the possibility of performing emergency therapeutic embolisation). Persistence of bleeding and radiological findings, in our patient, indicated the need for surgery which revealed a primary gallbladder neoplasm. Malignancies are responsible for haemobilia in about 7% of the reported cases. Of these, only 24% originated in the gallbladder and very few cases, reported in the literature, relate to this neoplasm. Manifestations of GBC are similar to those of a benign biliary disease, which might explain the possible delay in diagnosis, treatment selection as well as forecast of the patient. Usually, pre-operative diagnosis of GBC only occurs in less than 20% of the patients: the presence of GI bleeding, in our case, allowed us to diagnose the neoplasm at an earlier stage, and probably influenced the outcome. In conclusion, haemobilia is a very rare clinical manifestation in patients with gallbladder adenocarcinoma. It is related to the presence of ulceration within the tumour and needs patency of the cystic duct to become clinically evident. Improvement in diagnostic methods has led to a more frequent pre-operative diagnosis. In the case here reported, the early bleeding allowed a prompt diagnosis with a favourable effect on prognosis. _____. list of abbreviations 1 CT: computed tomography; ERCP: endoscopic retro cholanglo-pancreatography; GBC: gallbladder carcinoma; GI: gastrointestinal; US: ultrasonography.
E. Hernaindez-Castillo, AL Garduiio-Lipez, Il. MondraginSBnchez,R.Gernal-Maldonado, A.Mondragin-Sfinchezl Department of Gastroenterology, National Institute of Cancer, 1 Department of Surgery Hospital, 1’ the Octubre ISSSTE, Mexico, DF. Fax: +52-7-2153538.
681
Correspondence to the Editor
References ’ Mondragdn-Shchez R, Saldivar MC, Castillero PCM, Ruiz MJM, Ofiate OL, Aiello CV Carcinoma primario de la vesicula biliar. Rev Gastroenterol Mex 1997;62: 189-93.
What
a coeliac
patient
must
* Kubota H, Kagoeka M, Twasaki H, Sugimoto K, Higuchi R, Honda S, et al. A patient with undifferentiated carcinoma of gallbladder presenting with hemobilia. J Gastroenterol 2000;35:63-8. 3 Yoshida J, Donahye PE, Nyhus LM. Hemobilia: review of recent experience with a worldwide problem. Am J Gastroenterol1987;82:448-53.
not eat
Sir Coeliac disease is caused in genetically predisposed individuals by ingestion of gluten ‘. Gluten is then presented to antigen-presenting cells triggering an inflammatory reaction with consequent damage in the mucosa of the small intestine *. Upon elimination of gluten from the diet the mucosa will recover. In 1985, Jackson et al. showed that lack of parental knowledge of coeliac disease and diet correlated with low dietary compliance 3. Parental perceptions and attitudes towards disease are also known to affect the behaviour of the physician and the future care of the child in non-gastrointestinal disorders “. The present letter focuses attention on an instrument that can be used to assess the knowledge of medical disorders in the general population. In the autumn of 199.5, 53,168 individuals (24,199 men, 28,969 women) took the Swedish Scholastic Aptitude Test (SweSAT) in order to qualify for university studies. 70% of those taking the test had 12-13 years of education. One exam question tested their knowledge on coeliac disease (translated from Swedish):
“Gluten intolerance is a lifelong disorder that often starts in childhood. In toddlers, there are cases of transient gluten intolerance. What type of food must a person with gluten intolerance avoid? a. Nuts and almonds; b. Wheat, rye and barley; c. Green vegetables; d. Fish and seafood”. (The Swedish word for coeliac disease/gluten intolerance used in the exam question has no resemblance to the Swedish words for wheat, rye or barley). Out of the 53,168 taking the test, 49,210 reported that coeliac patients must avoid wheat, rye and barley (92.6%) (Table I). Knowledge concerning the coeliac diet is not equivalent to knowledge of presenting symptoms in coeliac disease, nevertheless, it indicates a high degree of awareness of coeliac disease. This could help to explain the high prevalence of coeliac disease found in Sweden 5. Many parents in Sweden will ask physicians to test their child for coeliac disease (personal observation). This study highlights the high degree of awareness of coeliac disease in Sweden, but even more important the use of nonmedical databases as a means to evaluate knowledge of medical disorders in the general population.
k&b 1. Swedish Scholastic Aptitude Test. Knowledge of what coeliac patients must not eat. w.
cormGteaswer R 1%)
Total
53,166
49,210 [92,61
Sex (%I Male l45.51 Female C54.51
24,199 28,969
21,383 t88.41 27,827 (96,ll
N. subjech takJlt#twt
Age, years [%I* s20 E2.11 21-24 (23.71 25-29 Cl 2.81 30-39 (9.41 >40 l2.21
27,669 12,612 6702
4999 1166
25,126 11,746 6380 4623 1133
C90,71 c93.11 (95,21 [96,51 [97,21
Numbersindicate individualsthat answeredWheat, rye and barley”whenasked what typa of kmd e persnn with gluten intiemnce must avoid. * Due to munding off. the sum does not equal ~~~,o% in 8@?-tF/8tedpercsntages.
662
J.F.
Luduigsson
Paadiatric Department, tirebro University Hospital, Sweden. Fax: +46- 19-6023122. E-mail: [email protected]
References 1 Lundin KEA. Coeliac disease- all questions answered?Digest Liver Dis 2002;34:238-42. 2 Schuppan D. Current concepts of celiac disease pathogenesis. Gastroenterology 2000;119:234-42. 3 Jackson PT, Glasgow JF, Thorn R. Parents’understanding of coeliac disease and diet. Arch Dis Child 1985;60:672-4. 4 Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, Brook RH. The relationship between perceived parental expectations and prescribing behavior. Pediatrics pediatrician antimicrobial 1999;103:71l-8. 5 Carlsson AK, Axelsson IE, Borulf SK, Bredberg AC, Ivarsson SA. Serological screening for celiac disease in healthy 2.5-year-old children in Sweden. Pediatrics 2001;107:42-5.
CORRESPONOENCETOTHE EDITOR
Haemobilia
and gallbladder
carcinoma
Sir Gallbladder carcinoma (GBC) is an infrequent neoplasm, the clinical manifestations of which resemble those of cholecystitis. Pain at the right upper abdominal quadrant in up to 90% of cases, palpable mass (30%), weight loss (28%) jaundice, nausea and vomiting (20%) I. Less frequent clinical manifestations are: ascites, duodenal and/or colonic obstruction and haemobilia 2. A patient presenting with haematemesis and melena associated with gallbladder cancer is described. A 60-year-old female was referred on account of melena, haematemesis and abdominal pain. At admission, routine blood tests were normal but mild iron-deficiency anaemia was detected. Upper gastrointestinal (GI) endoscopy was normal except for duodenal blood debris. Ultrasonography (US) and computed tomography (CT) liver scan showed a distended gallbladder with heterogeneous changes (Fig. 1). Cholecystectomy was car-
_.
-
-.
CT scan that shows a distended gallbladder with heterogeneous changes..
ried out; at laparotomy, the patency of the biliary tree was confirmed after having removed blood clots. Pathology revealed the presence of an ulcerated moderately to poorly differentiated adenocarcinoma of the gallbladder with haemorrhagic necrosis infiltrating the muscular layer (Stage 11 by the modified Nevin staging system) (Fig. 2). The outcome was uneventful and the patient is still symptomless 24 months later without any evidence of recurrence. Haemobilia i.e., haemorrhage originating in the gallbladder or in a bile duct is uncommon and secondary to trauma, inflammatory changes, iatrogenic lesions, lithiasis or primary vascular alterations such as aneurysm. It has rarely been associated with bile duct malignancies. It is diffkult to establish a diagnosis of haemobilia since the classic triad represented by biliary colic, obstructive jaundice and GI bleeding appears in only 30% of cases 3. Clinical presentation can include haematemesis and melena, obstructive jaundice and/or pancreatitis. There is also the possibility of blood accumulating in the gallbladder, thereby increasing intraluminal pressure and appearing as acute cholecystitis. The possibility of haemobilia should be suspected in patients with haematemesis and melena in the absence of symptoms consistent with a disease of the biliary system. This possibility can be definitely demonstrated by US, CT scan endoscopic retro-cholangio-pancreatography (ERCP) or selective angiography (this latter procedure being preferred in the case of hepatic injury, due to the possibility of performing emergency therapeutic embolisation). Persistence of bleeding and radiological findings, in our patient, indicated the need for surgery which revealed a primary gallbladder neoplasm. Malignancies are responsible for haemobilia in about 7% of the reported cases. Of these, only 24% originated in the gallbladder and very few cases, reported in the literature, relate to this neoplasm. Manifestations of GBC are similar to those of a benign biliary disease, which might explain the possible delay in diagnosis, treatment selection as well as forecast of the patient. Usually, pre-operative diagnosis of GBC only occurs in less than 20% of the patients: the presence of GI bleeding, in our case, allowed us to diagnose the neoplasm at an earlier stage, and probably influenced the outcome. In conclusion, haemobilia is a very rare clinical manifestation in patients with gallbladder adenocarcinoma. It is related to the presence of ulceration within the tumour and needs patency of the cystic duct to become clinically evident. Improvement in diagnostic methods has led to a more frequent pre-operative diagnosis. In the case here reported, the early bleeding allowed a prompt diagnosis with a favourable effect on prognosis. _____. list of abbreviations 1 CT: computed tomography; ERCP: endoscopic retro cholanglo-pancreatography; GBC: gallbladder carcinoma; GI: gastrointestinal; US: ultrasonography.
E. Hernaindez-Castillo, AL Garduiio-Lipez, Il. MondraginSBnchez,R.Gernal-Maldonado, A.Mondragin-Sfinchezl Department of Gastroenterology, National Institute of Cancer, 1 Department of Surgery Hospital, 1’ the Octubre ISSSTE, Mexico, DF. Fax: +52-7-2153538.
681
Correspondence to the Editor
References ’ Mondragdn-Shchez R, Saldivar MC, Castillero PCM, Ruiz MJM, Ofiate OL, Aiello CV Carcinoma primario de la vesicula biliar. Rev Gastroenterol Mex 1997;62: 189-93.
What
a coeliac
patient
must
* Kubota H, Kagoeka M, Twasaki H, Sugimoto K, Higuchi R, Honda S, et al. A patient with undifferentiated carcinoma of gallbladder presenting with hemobilia. J Gastroenterol 2000;35:63-8. 3 Yoshida J, Donahye PE, Nyhus LM. Hemobilia: review of recent experience with a worldwide problem. Am J Gastroenterol1987;82:448-53.
not eat
Sir Coeliac disease is caused in genetically predisposed individuals by ingestion of gluten ‘. Gluten is then presented to antigen-presenting cells triggering an inflammatory reaction with consequent damage in the mucosa of the small intestine *. Upon elimination of gluten from the diet the mucosa will recover. In 1985, Jackson et al. showed that lack of parental knowledge of coeliac disease and diet correlated with low dietary compliance 3. Parental perceptions and attitudes towards disease are also known to affect the behaviour of the physician and the future care of the child in non-gastrointestinal disorders “. The present letter focuses attention on an instrument that can be used to assess the knowledge of medical disorders in the general population. In the autumn of 199.5, 53,168 individuals (24,199 men, 28,969 women) took the Swedish Scholastic Aptitude Test (SweSAT) in order to qualify for university studies. 70% of those taking the test had 12-13 years of education. One exam question tested their knowledge on coeliac disease (translated from Swedish):
“Gluten intolerance is a lifelong disorder that often starts in childhood. In toddlers, there are cases of transient gluten intolerance. What type of food must a person with gluten intolerance avoid? a. Nuts and almonds; b. Wheat, rye and barley; c. Green vegetables; d. Fish and seafood”. (The Swedish word for coeliac disease/gluten intolerance used in the exam question has no resemblance to the Swedish words for wheat, rye or barley). Out of the 53,168 taking the test, 49,210 reported that coeliac patients must avoid wheat, rye and barley (92.6%) (Table I). Knowledge concerning the coeliac diet is not equivalent to knowledge of presenting symptoms in coeliac disease, nevertheless, it indicates a high degree of awareness of coeliac disease. This could help to explain the high prevalence of coeliac disease found in Sweden 5. Many parents in Sweden will ask physicians to test their child for coeliac disease (personal observation). This study highlights the high degree of awareness of coeliac disease in Sweden, but even more important the use of nonmedical databases as a means to evaluate knowledge of medical disorders in the general population.
k&b 1. Swedish Scholastic Aptitude Test. Knowledge of what coeliac patients must not eat. w.
cormGteaswer R 1%)
Total
53,166
49,210 [92,61
Sex (%I Male l45.51 Female C54.51
24,199 28,969
21,383 t88.41 27,827 (96,ll
N. subjech takJlt#twt
Age, years [%I* s20 E2.11 21-24 (23.71 25-29 Cl 2.81 30-39 (9.41 >40 l2.21
27,669 12,612 6702
4999 1166
25,126 11,746 6380 4623 1133
C90,71 c93.11 (95,21 [96,51 [97,21
Numbersindicate individualsthat answeredWheat, rye and barley”whenasked what typa of kmd e persnn with gluten intiemnce must avoid. * Due to munding off. the sum does not equal ~~~,o% in 8@?-tF/8tedpercsntages.
662
J.F.
Luduigsson
Paadiatric Department, tirebro University Hospital, Sweden. Fax: +46- 19-6023122. E-mail: [email protected]
References 1 Lundin KEA. Coeliac disease- all questions answered?Digest Liver Dis 2002;34:238-42. 2 Schuppan D. Current concepts of celiac disease pathogenesis. Gastroenterology 2000;119:234-42. 3 Jackson PT, Glasgow JF, Thorn R. Parents’understanding of coeliac disease and diet. Arch Dis Child 1985;60:672-4. 4 Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, Brook RH. The relationship between perceived parental expectations and prescribing behavior. Pediatrics pediatrician antimicrobial 1999;103:71l-8. 5 Carlsson AK, Axelsson IE, Borulf SK, Bredberg AC, Ivarsson SA. Serological screening for celiac disease in healthy 2.5-year-old children in Sweden. Pediatrics 2001;107:42-5.