A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / It is estimated over 20 million people aged 20‐74 have gallbladder disease, with biliary colic being a common and painful symptom in these patients. Likely due to the relatively recent approval of intravenous ibuprofen use for fever and pain in adults, no assessment of its analgesic efficacy for biliary colic currently exists in the literature. In this double‐blind, randomized, controlled trial we aim to assess the analgesic efficacy of intravenous (IV) ibuprofen given in the emergency department (ED) for the treatment of biliary colic. Analgesic efficacy was evaluated using a visual analog scale (VAS) to assess for a decrease in pain scores. A VAS score decrease of 33% in relation to the VAS taken at the time of therapy drug administration was considered a minimum clinically important difference (MCID) in patient‐perceived pain. A VAS was administered in triage upon enrollment, at the time of therapy administration, at 15‐minute intervals during the first hour post‐administration, and 30‐minute intervals in the second hour. As the standard of care for suspected biliary colic at the study institution is administration of a one‐time dose of IV morphine, patients were not denied initial morphine analgesia and were permitted to receive “rescue” morphine analgesia at any point during their ED course. A total of 22 patients completed the study. 9 were randomized to the IV ibuprofen arm, 9 to placebo, and 4 were excluded for a diagnosis other than biliary colic. Mean VAS values at time 0 to time 120 decreased from 5.78 to 2.31 in the ibuprofen group, and from 5.89 to 2.67 in the control group. There was no statistically significant difference in treatment status of ibuprofen vs. placebo (p‐value (p.) 0.93), though there was a significant decrease in the measured VAS scores over time (0 minutes to 120 minutes, p.0.031) in both ibuprofen and placebo groups. A statistically significant and clinically important decrease in average VAS scores were seen in both placebo and ibuprofen groups (55% and 60%, respectively). There was no difference in time needed to achieve a clinically significant reduction in pain between groups. The sample size of this study may be inadequate to fully assess the analgesic efficacy of IV ibuprofen for biliary colic. In the analysis group (n=18) no significant difference in treatment status of ibuprofen vs. placebo was seen, however there was a statistically and clinically significant decrease in pain in both groups. Two potential confounding factors may have affected the trial’s results: administration of standard‐of‐care IV morphine following initial triage assessment, and the inherent episodic and self‐limited nature of biliary colic.

The present study evaluates the efficacy of self-hypnosis and its components--relaxation instructions and waking analgesia suggestions--for pain reduction in patients recovering from gallbladder surgery. Forty elective surgery patients were randomly assigned to one of the three experimental pain control procedures or to a standard treatment control group--preoperative teaching. The treatments were found to be equally credible and generated equivalent expectancies for success. Pain was assessed using multiple subjective and objective measures sampled across the postoperative period. Multivariate analysis of these data indicated that the experimental treatments were no more effective in diminishing postoperative pain than the control procedure. However, the analysis revealed several significant correlates and predictors of postoperative pain. These included trait anxiety, depression, stress coping style as well as interview and rating scale reports of cognitive coping strategies. Significant predictors of credibility--expectancy, treatment utilization and cognitive coping classifications were also found. Analysis of the pain measurement strategy indicated consistency among the subjective measures--the McGill Pain Questionnaire and visual analogue scales--which were relatively independent from the objective measures, which comprised electronically monitored gross motor activity and analgesic medication requirements. Possible interpretations and implications of these results as well as suggestions for future research are discussed.

Thesis (M.D.)--University of Adelaide, 1988. / Includes bibliographical references (leaves 171-211).

Thesis (M.S.)--University of Michigan, 1972.

Orientador: Elizete Aparecida Lomazi da Costa Pinto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-07T13:04:46Z (GMT). No. of bitstreams: 1 VerasNeto_MagnoCardoso_M.pdf: 1277080 bytes, checksum: 79819f766291c884cad1299f8efb29ef (MD5) Previous issue date: 2006 / Resumo: A constipação intestinal é um problema freqüente na população pediátrica e sua apresentação clínica expressa grande heterogeneidade. Um grupo de pacientes constipados apresenta constipação refratária ao tratamento habitual e os conceitos fisiopatológicos clássicos pouco contribuíram para os avanços terapêuticos desejáveis a esses pacientes. O reconhecimento de distúrbios da motilidade gastrointestinal pode contribuir para o entendimento da fisiopatologia da constipação intestinal em crianças. Assim, o objetivo deste trabalho foi comparar os valores dos índices de contratilidade da vesícula biliar em crianças com constipação intestinal crônica funcional com aqueles de crianças sadias. Foi realizado estudo observacional, analítico e transversal, sendo selecionados como casos todos os pacientes com diagnóstico de constipação intestinal funcional, na faixa etária de 2 a 16 anos, em acompanhamento no ambulatório de Gastroenterologia Pediátrica do Hospital das Clínicas da UNICAMP no período de janeiro de 2004 a agosto de 2005. Os controles foram selecionados a partir de Unidades Básicas de Saúde de Campinas e região e pareados por sexo e idade. Casos e controles foram incluídos num protocolo de estudo e em seguida, foi realizado exame ultra-sonográfico pelo mesmo observador, mascarado e com registro dos índices de contratilidade. Foi considerado alterado o índice de contratilidade menor que 25%. Foram avaliados 132 casos e o mesmo número de controles. O índice de contratilidade da vesícula biliar apresentou diferença estatisticamente significativa entre os grupos, sendo menor nos pacientes constipados (31,5 ± 16,9 vs. 41,6 ± 12,7; p<0,001). Não houve diferença significativa no índice de contratilidade da vesícula biliar dos pacientes constipados de acordo com a idade de início da constipação, hábito intestinal, presença de escape fecal ou impactação, sintomas digestivos e uso de laxativos. Concluímos que, para o grupo de pacientes estudados, a contratilidade da vesícula biliar mostrou-se menor. Deste modo, a constipação intestinal pode representar um distúrbio mais amplo da motilidade do trato gastrintestinal / Abstract: Intestinal constipation is a frequent condition in pediatric population. Clinical presentation is heterogeneous. A group of children has a refractory outcome despite habitual therapy. Clinical picture in these children may result from physiopathologic mechanisms related to gastrointestinal motility disorders. Gastrointestinal motility investigation in children with functional constipation may add useful information for managing refractory patients. The objective of this study was to evaluate gallbladder motility in constipated children. An observational, cross-sectional study design was conducted. Research period included patients seen from January, 2004 to August, 2005 in a pediatric outclinic of a School Hospital. All patients with functional constipation assisted in the period were included (age range: 2 - 16 years). The control group was selected from Pediatrics Outclinics which usually sent patients to the School Hospital. The control group was matched for sex and age. Patients were interviewed for filling a study protocol. Gallbladder contractility index, calculated from fast and post-prandial area, was calculated in children with refractory functional constipation, using an ultrassonographic method. Data were compared with results obtained in healthy children. Ultrassonography studies were performed by the same physician in a blinded way. One-hundred-thirty-two constipated children and the same number of healthy children were included. Contractility index from constipated children was inferior than index from healthy children (31,5 ± 16,9 vs. 41,6 ± 12,7, p<0,001). There was no significant difference in contractility index from constipated children analyzed for constipation duration, evacuation frequency, and occurrence of soiling or fecal impaction, laxatives use and clinical symptoms. In a group of children with refractory intestinal constipation the gallbladder motility is reduced when compared with healthy children. This phenomenon may light up the understanding about functional constipation in children / Mestrado / Saude da Criança e do Adolescente / Mestre em Saude da Criança e do Adolescente

Chilean red chili peppers contaminated with aflatoxins were reported in a previous study. If the development of gallbladder cancer (GBC) in Chile is associated with a high level of consumption of aflatoxin-contaminated red chili peppers, such peppers from other countries having a high GBC incidence rate may also be contaminated with aflatoxins. We aimed to determine whether this might be the case for red chili peppers from Bolivia and Peru. A total of 7 samples (3 from Bolivia, 4 from Peru) and 3 controls (2 from China, 1 from Japan) were evaluated. Aflatoxins were extracted with acetonitrile:water (9:1, v/v) and eluted through an immuno-affinity column. The concentrations of aflatoxins B1, B2, G1, and G2 were measured using high-performance liquid chromatography (HPLC), and then the detected aflatoxins were identified using HPLC-mass spectrometry. In some but not all of the samples from Bolivia and Peru, aflatoxin B1 or aflatoxins B1 and B2 were detected. In particular, aflatoxin B1 or total aflatoxin concentrations in a Bolivian samples were above the maximum levels for aflatoxins in spices proposed by the European Commission. Red chili peppers from Bolivia and Peru consumed by populations having high GBC incidence rates would appear to be contaminated with aflatoxins. These data suggest the possibility that a high level of consumption of aflatoxin-contaminated red chili peppers is related to the development of GBC, and the association between the two should be confirmed by a case-control study.

This investigation illustrates the topography, gross anatomy, histology and ultrastructure of the liver and gallbladder of the Nile crocodile in order to fill the gap that exists in the literature regarding this important crocodilian. For the topographical and macroscopical descriptions the livers and gallbladders were obtained from the carcasses of slaughtered juvenile Nile crocodiles. Perfusion and immersion fixation of tissues for histology and transmission electron microscopy were performed on juvenile Nile crocodiles donated to the university. Published descriptions of other vertebrates were inevitably relied upon for comparison due to the lack of information on these two organs of the Nile crocodile. The liver was located in its own coelomic cavity with the post-pulmonary and the post-hepatic membranes intimately associated with the cranial and caudal surfaces of the bi-lobed liver respectively. The right lobe was larger than the left lobe and they were located at the level of the third to seventh intercostal spaces with their extremities extending to the ninth intercostal space. The triangular shaped liver lobes were joined dorso-medially by a narrow isthmus consisting of liver tissue. The liver was covered by Glisson’s capsule. Central veins, sinusoids and portal tracts were distributed haphazardly with no visible lobulation. The parenchymal component occupied the largest part of the liver and was formed by anastomosing and branching cell cords consisting of two-cell-thick plates in the longitudinal sectional plane and at least five hepatocytes in the cross-sectional plane. Central bile canaliculi contained microvilli originating from apical hepatocyte surfaces and were sealed off by junctional complexes. Hemosiderin granules, bile pigments, melanin pigments, lipid droplets, cholesterol ester slits and glycogen granules were observed in addition to the normal hepatic cytoplasmic organelles. Non-parenchymal cells consisted of endothelial cells, Kupffer cells, stellate cells and pit cells localized in and around the angular sinusoids. The space of Disse existed between endothelial cells and the base of the hepatocytes which was lined by microvilli. Endothelial cells were flat cells with long fenestrated cytoplasmic extensions that lined the sinusoidal wall and contained numerous endocytotic vesicles and many lysosomes. Pleomorphic Kupffer cells were located in the sinusoidal lumen, in the space of Disse and within groups of hepatocytes. They were often situated between groups of hepatocytes, connecting two adjacent sinusoids. Large phagosomes were present in the Kupffer cells and contained a combination of melanin and hemosiderin granules as well as ceroid. Phagocytosis of apoptotic and dying cells was evident. Conspicuous groups of membrane-bound tubular organelles with a filamentous or crystalline interior were present in the Kupffer cells. Stellate cells occupied a subendothelial position in the space of Disse and contained prominent lipid droplets that indented the nuclei. A solitary cilium was infrequently found projecting into the space of Disse. Myofibroblastic cells were found in the same region as stellate cells. Pit cells with indented eccentric nuclei were found in the sinusoidal lumen and in close contact with endothelial and Kupffer cells. Numerous small electron-dense membrane-bound cytoplasmic granules were present. Occasional intercalated cells resembling lymphocytes were seen in the space of Disse and forming part of the groups of hepatocytes. Glisson’s capsule extended collagenous trabeculae into the parenchymal interior and variably sized trabeculae randomly traversed the liver tissue. Portal tracts were enmeshed by a collagenous network that contained fibroblasts, lymphocytes, plasma cells and phagocytes. Portal triads consisted of branches of the portal vein, hepatic artery and bile duct with lymphatic vessels sometimes in accompaniment. Reticular fibres were positioned around hepatocyte tubules and a basal lamina supported the hepatocytes adjacent to Glisson’s capsule. Occasional unmyelinated nerve axons were present. The isthmus contained liver tissue with similar parenchymal and a non-parenchymal components. Three anatomical zones were identified in the pouch-like gallbladder that was attached caudally to the right liver lobe in the dorso-medial region. The gallbladder wall consisted of pseudostratified columnar epithelium, a lamina propria, a muscularis externa and a serosal layer. The accumulation of apical secretory granules, apical bulging, exocytosis of mucous granules and the desquamation of the apical portions of the epithelial cells into the lumen indicated different stages of the mucus secretory cycle. Copyright / Dissertation (MSc)--University of Pretoria, 2012. / Anatomy and Physiology / Unrestricted

No description available.

Biliary diseases are uncommon, potentially fatal causes of acute abdomen in dogs. Little information is present comparing the performance of computed tomography (CT) to ultrasound in identifying canine biliary pathology. Thirty-five client-owned dogs presenting for acute abdomen signs received an abdominal ultrasound and contrast-enhanced abdominal CT. Two authors reviewed the randomized, anonymized CT and ultrasound studies. Twenty-eight dogs had biliary pathology and seven dogs serving as controls had no evidence of biliary disease. The final diagnoses of patients with biliary pathology included cholelithiasis, gallbladder mucoceles, cholangiohepatitis/cholangitis, extrahepatic biliary obstruction, gallbladder wall edema, gallbladder wall mass, and cystic mucosal hyperplasia. Computed tomography was more accurate in identifying cholelithiasis than ultrasound. No statistical difference in the odds to identify other biliary pathology was identified between ultrasound and CT. Findings from this study suggest CT may be used in place of ultrasound in canine patients presenting for acute abdominal signs of biliary origin.

INTRODUÇÃO: O câncer da vesícula biliar é a lesão maligna mais comum da árvore biliar e pouco se sabe sobre a sua carcinogênese. O possível caráter pré-neoplásico das alterações histológicas da vesícula biliar vem sendo estudado recentemente. O objetivo deste estudo foi identificar e quantificar as alterações histológicas da vesícula biliar no nosso meio e correlacioná-las com dados clínicos, e correlacionar as alterações metaplásicas, em separado, com as demais alterações encontradas. MÉTODOS: Neste estudo retrospectivo realizado entre novembro de 1999 a dezembro de 2006, foram avaliados 1.689 prontuários de doentes submetidos a colecistectomia laparoscópica por colecistolitíase. Os doentes foram divididos em relação à idade em doentes com até 60 anos e com mais de 60 anos. Em relação ao tempo de sintomas antes da cirurgia foram agrupados em doentes sem sintomas, doentes com sintomas até 1 ano, e doentes com sintomas por mais de 1 ano antes da cirurgia. Em relação ao tamanho e número dos cálculos foram agrupados em doentes com cálculos de até 10 mm, e aqueles com cálculos maiores que 10 mm, e em doentes com cálculos únicos ou múltiplos. RESULTADOS: Eram mulheres 1.238 doentes (73,3%) e 451 eram homens (26,7%). Apresentaram idade de até 60 anos 1.192 doentes (70,6%) e 497 (29,4%) apresentaram mais de 60 anos. Apresentaram cálculos menores que 10 mm 1.319 doentes (78,1%) e 370 doentes (21,9%) apresentaram cálculos maiores que 10 mm. Foi observado inflamação aguda em 174 doentes (10,3%), gangrena em 23 (1,4%), abscesso em 8 (0,4%), colesterolose em 305 (18,1%), adenomiomatose em 40 (2,4%), colecistite xantogranulomatosa em 29 (1,7%), fibrose em 12 (0,7%), escleroatrofia em 20 (1,2%), pólipo hiperplásico em 3 (0,2%), pólipo de colesterol em 17 (1,0%), metaplasia pilórica em 72 (4,3%), metaplasia intestinal em 18 (1,1%), displasia em 4 (0,2%), câncer em 2 (0,1%). Não foram observados pólipos adenomatosos. CONCLUSÕES: O sexo masculino apresenta maior freqüência de complicações inflamatórias que o feminino. Não há relação entre o tempo de sintomas e uma maior ocorrência das alterações histológicas estudadas, excetuando-se a colecistite xantogranulomatosa. Nos doentes idosos há maior ocorrência de adenomiomatose, gangrena e abscesso. Há aumento progressivo de idade para a ocorrência de metaplasia pilórica, metaplasia intestinal, displasia e câncer. O tamanho dos cálculos não guarda relação com a ocorrência das alterações estudadas, exceto para colecistite aguda que se associou com cálculos pequenos e múltiplos. Há associação entre a ocorrência de metaplasia pilórica e adenomiomatose, metaplasia pilórica e displasia, metaplasia pilórica e câncer. Há também associação entre a ocorrência de metaplasia intestinal e metaplasia pilórica, metaplasia intestinal e adenomiomatose, metaplasia intestinal e displasia, metaplasia intestinal e câncer. / INTRODUCTION: Gallbladder cancer is the most common malignant lesion of the biliary tree; yet, little is known about its carcinogenesis. The possible preneoplastic character of histological gallbladder alterations has been studied in recent medical literature. The purpose of this study was to identify and quantify histological gallbladder alterations in our population, to correlate them with clinical data, and to correlate the metaplastic alterations, separately, with the other histological alterations found. METHODS: In this retrospective study conducted between November,1999 and December, 2006, the medical records of 1.689 patients who were submitted to laparoscopic cholecystectomy by cholecystolithiasis were analyzed. The patients were classified according to age: 60 years or younger, and older than 60. In relation to the duration of symptoms before the surgery, they were grouped according to: patients without symptoms, patients with symptoms for 1 year or less, and patients with symptoms for over 1 year before the surgery. In relation to the size and number of the gallstones, they were grouped according to: patients with gallstones of 10 mm or less, and those with gallstones over 10 mm, and those with single or multiple gallstones. RESULTS: There were 1,238 (73.3%) female and 451 (26.7%) male patients. In relation to age, 1,192 patients were 60 or younger (70.6%) and 497 (29.4%) were older than 60. There were 1.319 (78.1%) patients with gallstones smaller than 10 mm and 370 patients (21.9%) with gallstones larger than 10mm. Acute choelcystitis was observed in 174 patients (10.3%), gangrene in 23 (1.4%), abscess in 8 (0.4%), cholesterolosis in 305 (18.1%), adenomyomatosis in 40 (2.4%), xanthogranulomatous cholecystitis in 29 (1.7%), fibrosis in 12 (0.7%), sclero-atrophic gallbladder in 20 (1.2%), hyperplasic polyp in 3 (0.2%), cholesterol polyp in 17 (1.0%), pyloric metaplasia in 72 (4.3%), intestinal metaplasia in 18 (1.1%), dysplasia in 4 (0.2%), and cancer in 2 (0.1%). No adenomatous polyp was found. CONCLUSIONS: Male patients have more inflammatory complications than females. With the exception of xanthogranulomatous cholecystitis, there is no correlation between symptom duration and an increased occurrence of the histological alterations studied. In the elderly patients, the occurrence of adenomyomatosis, gangrene and abscess is more frequent. The size of gallstones has no relationship with the occurrence of the histological alterations studied, except for acute cholecystitis, which is associated with small and multiple gallstones. There is an association between pyloric metaplasia and the following: adenomyomatosis, dysplasia, and cancer. There is also an association between intestinal metaplasia and the following: pyloric metaplasia, adenomyomatosis, dysplasia, and cancer.