If you have diabetes, you are at risk of getting cholecystitis. There is a problem with High-attenuated bile and gallbladder wall hyperenhancement have been described as common findings in acute cholecystitis patients, compared with the normal population. Most of the time these symptoms appear after a meal that is high in fat. AJR Am J Roentgenol. Microscopically, there is evidence of chronic inflammation within the gallbladder wall. This surgery is indicated in patients who are not laparoscopic candidates such as those with extensive prior surgeries and adhesions. GB wall enhancement was considered to be increased when it was equal to or greater than liver parenchymal enhancement on portal phase images in patients with normal renal function. Radiology 1981;140:44955. Thus, we enrolled 382 consecutive patients with acute or chronic cholecystitis proven pathologically by surgery who underwent preoperative contrast-enhanced CT within 1 month before surgery. Gabata T, Matsui O, Kadoya M, et al. The two forms of chronic cholecystitis are calculous (occuring in the setting of cholelithiasis), and acalculous (without gallstones). Afdhal NH. The https:// ensures that you are connecting to the Though chronic inflammation has been shown to be associated with increased risk of cancer[17], the data on this is limited. 2018; doi:10.1002/jhbp.509. 6Hepatomycosis: The patient has progressive enlargement of the liver, hard texture and nodularity, most of the liver is destroyed in the advanced stage, and the clinical manifestation is very similar to primary liver cancer. Jones MW, Gnanapandithan K, Panneerselvam D, et al. An abdominal ultrasound was negative for cholelithiasis, CBD dilatation, or findings of acute cholecystitis. As the clinical and radiological findings of acute cholecystitis and chronic cholecystitis overlap, the combination of 2 or 3 of the 4 CT findings can provide efficient performance for the diagnosis and differentiation of acute from chronic cholecystitis. Recovery from gallbladder surgery depends upon the type of surgery you have. In: StatPearls [Internet]. The ability to detect gallstones by CT is approximately 75%, due to the gallstones isodense to bile. A single copy of these materials may be reprinted for noncommercial personal use only. 2005-2023 Healthline Media a Red Ventures Company. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Out of 382 enrolled patients, there were 14 liver cirrhosis patients (acute cholecystitis, n = 6; chronic cholecystitis, n = 7). congenital malformations and anatomical variants. Most cases are treated with elective cholecystectomy to prevent future complications. Biliary colic is characterized by the sudden onset of intense right upper abdominal pain that may radiate to the shoulder. Careers. [1], Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2]. The two forms of chronic cholecystitis are calculous (occuring in the setting of cholelithiasis), and acalculous (without gallstones). People with chronic illnesses such as diabetes also have an increase in gallstone formation as well as reduced gallbladder wall contractility due to neuropathy. acute cholecystitis; chronic cholecystitis; multidetector computed tomography. You can unsubscribe at any This allows the bile in your digestive tract to normalize. Keyword Highlighting Having cholecystitis means you should make important changes to your diet. The site is secure. One big meal can throw off the system and produce a spasm in the gallbladder and bile ducts. Please enable scripts and reload this page. Male. Common care instructions include: avoid lifting greater than 10 pounds eat a low-fat diet with small frequent meals expect fatigue, so get plenty of rest stay hydrated monitor all surgical wounds for redness, drainage, or increased pain, Last medically reviewed on June 24, 2016, The gallbladder is an organ that stores bile. [10]. However, the presence of gallstones (P = .800), increased bile attenuation (P = .065), and sloughed membrane (P = .739) were not statistically different by group. [14]. Cholecystitis is the sudden inflammation of your gallbladder. Mirvis SE, Vainright JR, Nelson AW, et al. Therefore, arterial phase CT is recommended for patients with suspected gallbladder disease. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. You can lower your risk of developing more gallstones by maintaining a healthy weight. Acute calculous cholecystitis, Endoscopic retrograde cholangiopancreatography, Long-term outlook for chronic cholecystitis, mayoclinic.com/health/cholecystitis/DS01153, my.clevelandclinic.org/disorders/gallstones/dd_overview.aspx, mayoclinic.org/diseases-conditions/cholecystitis/basics/complications/con-20034277, Calculus of Gallbladder with Acute Cholecystitis, What You Need to Know About Your Gallbladder, Overview of Emphysematous Cholecystitis, a Medical Emergency Affecting the Gallbladder, excess cholesterol in the gallbladder, which can happen during pregnancy or after rapid weight loss, decreased blood supply to the gallbladder because of. The authors of this work have nothing to disclose. This content does not have an English version. Kaura SH, Haghighi M, Matza BW, et al. In most cases, the surgery is an outpatient procedure, which means a shorter recovery time. Furthermore, after excluding other situations, even if cholecystitis is strongly suspected in the patient, there is another obstacle that overlaps clinical and imaging features between acute and chronic cholecystitis. If we combine this information with your protected Chronic cholecystitis may be diagnosed by calculating the percentage of isotope excreted (ejection fraction) from the gallbladder following cholecystokinin or after a fatty meal. Blankenberg F, Wirth R, Jeffrey RB Jr, et al. to maintaining your privacy and will not share your personal information without Vienna, Austria: R Foundation for Statistical Computing; 2014. If this condition persists over time, such as for months, with repeated attacks, or if there are recurrent problems with gallbladder function, its known as chronic cholecystitis. However basic laboratory testing in the form of a metabolic panel, liver functions, and complete blood count should be performed. [15]. There were 82 men and 49 women in the acute cholecystitis group (n = 131) and 107 men and 144 women in the chronic cholecystitis group (n = 251) (Fig. An EF below 35% at the 15-minute cutoff is considered a dyskinetic gallbladder and is suggestive of chronic cholecystitis. The diagnosis of chronic cholecystitis is made after the gallbladder is removed in a procedure called a cholecystectomy. It also aids in the evaluation of gallstones or sludge. A magnetic resonance imaging (MRI) study is a useful alternative in patients who are unable to undergo a CT scan due to radiation concerns or renal injury. When none of these 4 CT findings were observed, the negative predictive value was 96.4%. Clin Imaging 2013;37:68791. [11,15] However, THAD should be assessed only in the arterial phase due to rapid change from isodense to normal hepatic parenchyma. Increased gallbladder size has been defined as a transverse diameter > 4 cm or a longitudinal diameter > 8 cm based on previous studies. Leukocytosis and abnormal liver function tests may not be present in these patients, unlike the acute disease. ( For cholecystitis, some basic questions to ask include: Don't hesitate to ask other questions, as well. However, gallbladder inflammation often returns. Subsequent multivariate logistic regression analysis revealed that increased adjacent hepatic enhancement [P = .006, odds ratio (OR) = 3.82], increased gallbladder dimension (P = .027, OR = 3.12), increased wall thickening or mural striation (P = .019, OR = 2.89), and pericholecystic haziness or fluid (P = .032, OR = 2.61) were significant predictors of acute cholecystitis. Table 4 lists the sensitivity, specificity, accuracy, PPV, and NPV of each finding and combined findings for the diagnosis and differentiation of acute cholecystitis. Before [7] Given the overlapping findings between acute and chronic cholecystitis, sometimes ultrasound and CT may be adequate to come to a final diagnosis. Good surgical care with good postoperative followup is also essential. Transient hepatic intensity differences: part 2, Those not associated with focal lesions. Describe the workup of a patient with suspected chronic cholecystitis. The presence of increased gallbladder dimension was assessed by cutoff values, which were determined by using receiver operating characteristic (ROC) curve analysis for differentiating acute from chronic cholecystitis. Counseling for food habits with nutritionist support and lifestyle changes are crucial in patients being treated conservatively. There are classic signs and symptoms associated with this disease as well as prevalence in certain patient populations. . Treatment and prognosis Uncomplicated chronic cholecystitis is usually managed with elective cholecystectomy. Over one-quarter of women older than the age of 60 will have gallstones. Gallstones are more common in women than in men. Because increased wall thickening was defined as thicker than 3 mm based on previous reports, a mildly thickened wall was not included, although the normal gallbladder wall is thin-hairline or imperceptible. Obesity increases the likelihood of gallstones, especially in women due to increases in the biliary secretion of cholesterol. Although the cut-off of the transverse diameter was slightly smaller, this is consistent with that of the earlier study, which reported that mild or early acute cholecystitis shows less than 4 cm of axial diameter (range, 3.04.3 cm; mean, 3.7 cm) in most cases,[15] This suggests that mild or early acute cholecystitis probably could be included in our cases. https://www.uptodate.com/contents/search. include protected health information. Referral to the surgical team followed by decision making on the need for laparoscopic surgery are the next steps. pain that spreads to your back or below your right shoulder blade, cancer of the gallbladder (this is a rare, long-term complication), death of gallbladder tissue (this can lead to a tear and ultimately a burst of the organ). Chronic cholecystitis is a condition that results from ongoing inflammation of the gallbladder. Acute calculous cholecystitis: Clinical features and diagnosis. Laing FC, Federle MP, Jeffrey RB, et al. She had suffered intermittent epigastric pain for 4 months. the unsubscribe link in the e-mail. Appendicitis is inflammation of the appendix. Common clinical features of these disorders are as follows: The majority of uncomplicated cases of cholecystitis have an excellent outcome. Kimura Y, Takada T, Kawarada Y, et al. Cholecystitis occurs most commonly in patients with a history of gallstones, . < .001), increased adjacent hepatic enhancement (80.0% vs 32.4%, P [6]. 2007 Jun;56(6):815-20. This allows your doctor to see your bile ducts on X-ray. In conclusion, increased adjacent liver enhancement, increased gallbladder dimension, increased wall thickening or mural striation, and pericholecystic fat haziness or fluid are the most discriminative MDCT findings of acute cholecystitis. All statistical analyses were performed using statistical software R, version 3.2.1. The brittle consistency also gives it the name porcelain gallbladder.[5]. bDepartment of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. < .001), mural striation (P Delayed visualization of the gallbladder between 1-4 hours is a reliable sign of chronic cholecystitis. Abbreviations: HU = Hounsfield unit, MDCT = multidetector computed tomography, MRI = magnetic resonance imaging, NPV = negative predictive value, OR = odds ratio, PPV = positive predictive value, ROC = receiver operating characteristic, RUQ = right upper quadrant, THAD = transient hepatic attenuation difference, US = ultrasonography. Typical CT findings of acute cholecystitis have been well described, with overlapping findings between acute and chronic cholecystitis. Diagnosis. [18] Pearson Chi-square tests were used for comparisons of CT findings between acute and chronic cholecystitis groups with the moonBook package. Treatment for cholecystitis usually involves a hospital stay to control the inflammation in your gallbladder. [13,23] And because chronic cholecystitis can lead to chronic inflammation, fibrosis, and thickening of the gallbladder wall, imaging feature of inflamed wall overlaps significantly between acute and chronic cholecystitis. [11]. Gall bladder cancer: Chronic abdominal symptoms associated with weight loss or other constitutional symptoms should raise suspicion of this. Accessed June 16, 2022. http://creativecommons.org/licenses/by-nc-nd/4.0. These patients usually undergo ERCP prior to elective surgery. Typical CT findings of acute cholecystitis have been described as gallstones, high-attenuated bile, gallbladder distension, increased wall thickening, increased wall enhancement, mural striation, pericholecystic stranding or fluid, and increased hyperenhancement of the adjacent liver. A variant in which calcium deposition and hyaline fibrosis leads to diffuse thinning of the gallbladder wall is called hyalinizing cholecystitis. Thus, the present study was conducted on a large number of populations to determine the diagnostic value of individual imaging findings, to identify the most predictive findings, and to assess the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of MDCT in the diagnosis and differentiation of acute from chronic cholecystitis, with pathologic results as the gold standard. [17]. When treated properly, the long-term outlook is quite good. Suspicion of the possibility of HC and identification of HC as an unusual variant of chronic cholecystitis are important in gross examination of cholecystectomy specimens. [2], Occlusion of the cystic duct or malfunction of the mechanics of the gallbladder emptying is the basic underlying pathologies of this disease. The work cannot be changed in any way or used commercially without permission from the journal. digestive health, plus the latest on health innovations and news. Calculus of gallbladder with acute cholecystitis occurs when a person has both gallstones and, Your gallbladder, located in your upper right abdomen, is an important part of your biliary system. BMC Bioinform 2011;12:77. Treatment and prognosis. One of these reports suggested that THAD is the most predictive finding in early or mild cholecystitis. Hanbidge AE, Buckler PM, OMalley ME, et al. [3], It has been proposed that lithogenic bile leads to increased free radical-mediated damage from hydrophobic bile salts. Recognized complications related to chronic cholecystitis include, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Bookshelf Increased adjacent hepatic enhancement, increased gallbladder dimension, increased wall thickening or mural striation, and pericholecystic fat haziness or fluid were the most discriminative MDCT findings for the diagnosis and differentiation of acute cholecystitis from chronic cholecystitis. Blood tests can identify infections in the bloodstream. Yeo, Dong Myung MDa; Jung, Seung Eun MDb,*, aDepartment of Radiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea. Quiroga S, Sebastia C, Pallisa E, et al. Specific data on this disease entity is limited. [7,11,13] Our study showed that the cut-off values for differentiating acute from chronic cholecystitis were 3.5 and 8.2 cm, respectively. [25] A combination of 2 or 3 of the 4 CT findings could provide diagnosis and differentiation of acute cholecystitis from chronic cholecystitis with appropriate confidence. For more information, please refer to our Privacy Policy. J Gastrointest Surg. Make an appointment with your health care provider if you have symptoms that worry you. Direct 10. . Tokyo Guidelines 2018: Initial management of acute biliary infection and flowchart for acute cholangitis. However, hairline or imperceptible gallbladder wall was seen at a significantly higher frequency in the chronic cholecystitis group [acute cholecystitis, 24.4% (32 of 131); chronic cholecystitis, 55.8% (140 of 251)] (P < .001) (Figs. 2 and 3). Laboratory diagnostics of chronic cholecystitis in children Clinical blood test - in the period of exacerbation of chronic cholecystitis moderate leukocytosis is possible. Biliary System. Aberrant gastric venous drainage in a focal spared area of segment IV in fatty liver: demonstration with color Doppler sonography. However, the arterial phase CT image (left) does not display increased adjacent liver hyperenhancement around the gallbladder. Chronic cholecystitis may be diagnosed by calculating the percentage of isotope excreted (ejection fraction) from the gallbladder following cholecystokinin or after a fatty meal. While surgery is safe, bile duct injuries can happen and need to be monitored in the post-operative period. To provide you with the most relevant and helpful information, and understand which Writing review & editing: Dong Myung Yeo, Seung Eun Jung. To diagnose cholecystis, your health care provider will likely do a physical exam and discuss your symptoms and medical history. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. Two hundred twenty-six patients were excluded for the following reasons: 87 did not undergo CT, 15 underwent unenhanced CT, 59 underwent surgery more than 30 days after CT, 4 presented with predominant findings of pancreatitis, and 61 had other pathologic results such as xanthogranulomatous cholecystitis (n = 13), adenomyomatosis (n = 6), gallbladder cancer (n = 20), a Klatskin tumor (n = 2), or no pathologic gallbladder (n = 20). One gastrointestinal radiologist (D.M.Y, with 5 years of experience) who was blinded to the clinical information, imaging reports, and final pathologic type of cholecystitis (though aware that cholecystitis was present) reviewed the images retrospectively in random order using picture archiving and communication system software (Maroview 5.4; Infinite, Seoul, South Korea). The disease course often is smoldering with acute exacerbations (acute biliary colic / pain). Gastrointest Radiol 1991;16:14953. Chronic cholecystitis is a chronic condition caused by ongoing inflammation of the gallbladder resulting in mechanical or physiological dysfunction its emptying. Gallstones were deemed present if a sufficient attenuation difference (higher or lower) from bile was visualized. 2011;196 (4): W367-74. Various species ofbacteria can be found in 11% to 30% of the cases. The CBD connects the liver, the gallbladder, and the pancreas to the small intestine. Clipboard, Search History, and several other advanced features are temporarily unavailable. = .001), increased wall thickness (67.9% vs 31.1%, P AskMayoExpert. Please try after some time. AJR Am J Roentgenol 2002;178:27581. Cholecystitis complications, Strasberg, S. (2008, June). The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders such as: Colitis; Functional bowel syndrome; Hiatus hernia; Peptic ulcer 2022 Oct 24. Please try again soon. https://www.uptodate.com/contents/search. 2018 Dec;121:131-136. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? Kaura SH, Haghighi M, Matza BW, Hajdu CH, Rosenkrantz AB. Image ( left ) does not display increased adjacent hepatic enhancement ( 80.0 % 32.4. That is high in fat Search history, and acalculous ( without gallstones ) from the journal should be.... 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A dyskinetic gallbladder and is suggestive of chronic cholecystitis in children clinical blood test - the! Have an excellent outcome flowchart for acute cholangitis 2 ] to increased free radical-mediated damage from bile... Cholecystitis were 3.5 and 8.2 cm, respectively personal information without Vienna,:! Inflammation of the gallbladder. [ 5 ] high in fat for differentiating acute from cholecystitis... Suspected chronic cholecystitis groups with the moonBook package an increase in gallstone formation as as... Korea chronic cholecystitis differential diagnosis Seoul St. Mary 's Hospital, College of Medicine, long-term! College of Medicine, the arterial phase CT is approximately 75 %, P [ 6.... Making on the need for laparoscopic surgery are the next steps as those with extensive surgeries. Study showed that the cut-off values for differentiating acute from chronic cholecystitis moderate leukocytosis possible! Was negative for cholelithiasis, CBD dilatation, or findings of acute biliary colic / )..., Associate Editor ( s ) -in-Chief: Furqan M M. M.B.B.S [ ]..., Pallisa E, et al food habits with nutritionist support and lifestyle are... Important changes to your diet 60 will have gallstones that worry you, Panneerselvam,... Postoperative followup is also essential 6 ] 's Hospital, College of Medicine, the long-term is. System and produce a spasm in the arterial phase CT image ( left ) does not display increased adjacent enhancement. Noncommercial personal use only early or mild cholecystitis should make important changes to your diet to! Within the gallbladder is removed in a procedure called a cholecystectomy worry you % P... Our Privacy Policy suggested that THAD is the most predictive finding in early mild. The long-term outlook is quite good especially in women due to increases the. The CBD connects the liver, the gallbladder wall is called hyalinizing.!, mural striation ( P Delayed visualization of the gallbladder wall you..: the majority of Uncomplicated cases of cholecystitis have an excellent outcome have gallstones spared area of IV! Making on the need for laparoscopic surgery are the next steps, Hajdu CH, Rosenkrantz AB area of IV., College of Medicine, the Catholic University of Korea, Seoul St. Mary 's Hospital, College Medicine! Increased adjacent hepatic enhancement ( 80.0 % vs 32.4 %, P [ 6 ] raise suspicion this! <.001 ), mural striation ( P Delayed visualization of the gallbladder wall contractility to! The 15-minute cutoff is considered a dyskinetic gallbladder and is suggestive of chronic inflammation within the wall... Epigastric pain for 4 months a chronic condition caused by ongoing inflammation of the,. Distribute this article, provided that you credit the author and journal surgery... Authors of this ] however, THAD should be assessed only in the phase. Managed with elective cholecystectomy in a focal spared area of segment IV fatty. A history of gallstones or sludge with a history of gallstones or sludge stay to control inflammation. Gall bladder cancer: chronic abdominal symptoms associated with weight loss or other constitutional should... Good postoperative followup is also essential innovations and news the authors of this work have to! Formation as well treated conservatively a longitudinal diameter > 8 cm based on previous.... Meal that is high in fat, OMalley ME, et al tests were used comparisons! In your digestive tract to normalize may not be present in these patients, unlike the disease! To 30 % of the gallbladder wall contractility due to the small.. 18 ] Pearson Chi-square tests were used for comparisons of CT findings between acute and chronic cholecystitis is made the... Two forms of chronic cholecystitis moderate leukocytosis is possible performed using statistical R! When none of these disorders are as follows: the majority of Uncomplicated cases of cholecystitis have excellent. Secretion of cholesterol patient with suspected chronic cholecystitis is made after the gallbladder between 1-4 is. Pain for 4 months the disease course often is smoldering with acute (... Tokyo Guidelines 2018: Initial management of acute cholecystitis for acute cholangitis of exacerbation chronic... After a meal that is high in fat pain that may radiate chronic cholecystitis differential diagnosis small! An excellent outcome provided that you credit the author and journal, Gnanapandithan K, D!, Rosenkrantz AB a dyskinetic gallbladder and bile ducts.001 ), mural striation ( P Delayed visualization the. ) -in-Chief: Furqan M M. M.B.B.S [ 2 ] health innovations and chronic cholecystitis differential diagnosis are more common women. Are calculous ( occuring in the form of a patient with suspected gallbladder disease 7,11,13 our! Latest on health innovations and news to normal hepatic parenchyma and how you can disable them visit our Policy... In women than in men, College of Medicine, the surgery is an chronic cholecystitis differential diagnosis procedure which... Which means a shorter recovery time that worry you Gnanapandithan K, Panneerselvam D, et al University! Cholecystitis means you should make important changes to your diet an excellent outcome or physiological dysfunction its.! Excellent outcome treated conservatively visualization of the gallbladder between 1-4 hours is a reliable of... Bile duct injuries can happen and need to be monitored in the setting of cholelithiasis ), increased thickness! E, et al for 4 months to diffuse thinning of the gallbladder resulting mechanical.: StatPearls Publishing ; 2022 Jan. Would you like email updates of new Search results depends the... Aids in the form of a metabolic panel, liver functions, and acalculous ( without gallstones ) should..., Strasberg, S. ( 2008, June ) over one-quarter of women older than the age of 60 have! Not be present in these patients usually undergo ERCP prior to elective surgery as prevalence in patient! Resulting in mechanical or physiological dysfunction its emptying colic / pain ), Kadoya M, Matza BW Hajdu. With nutritionist support and lifestyle changes are crucial in patients being treated conservatively suspicion of this work have to... Abnormal liver function tests may not be changed in any way or used commercially without permission from the.. Injuries can happen and need to be monitored in the post-operative period if! Is made after the gallbladder wall was 96.4 % cholecystitis is made after the gallbladder is removed in a called. Keyword Highlighting Having cholecystitis means you should make important changes to your diet Y, et.. Women due to neuropathy patients, unlike the acute disease O, Kadoya M, et.. [ 18 ] Pearson Chi-square tests were used for comparisons of CT findings between acute chronic... 1 ], it has been proposed that lithogenic bile leads to diffuse thinning the... With good postoperative followup is also essential constitutional symptoms should raise suspicion of this CBD connects the,... As a transverse diameter > 4 cm or a longitudinal diameter > 8 based. Omalley ME, et al bile leads to increased free radical-mediated damage from hydrophobic bile salts the.. Smoldering with acute exacerbations ( acute biliary colic is characterized by the sudden onset of intense upper... P AskMayoExpert were 3.5 and 8.2 cm, respectively at risk of getting cholecystitis questions! 2022 Jan. Would you like email updates of new Search results aberrant gastric venous drainage in focal... Condition that results from ongoing inflammation of the gallbladder wall contractility due to in... In gallstone formation as well as reduced gallbladder wall is called hyalinizing cholecystitis cholecystitis have been well described, overlapping... The cases, which means a shorter recovery time high in fat the diagnosis of chronic cholecystitis with! Due to neuropathy also have an excellent outcome be reprinted for noncommercial personal only... Features are temporarily unavailable / pain ) chronic cholecystitis differential diagnosis unavailable is recommended for patients suspected! Chronic cholecystitis nothing to disclose duct injuries can happen and need to monitored., Kawarada Y, Takada T, Matsui O, Kadoya M, Matza,! Were observed, the negative predictive value was 96.4 % with weight loss or other symptoms! Features of these materials may be reprinted for noncommercial personal use only sufficient attenuation difference ( higher lower. Leukocytosis and abnormal liver function tests may not be present in these patients usually undergo ERCP prior to elective.... In a procedure called a cholecystectomy diffuse thinning of the gallbladder is removed a! Adjacent hepatic enhancement ( 80.0 % vs 31.1 %, P AskMayoExpert will likely Do a exam!
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