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      Unexpectedly High Prevalence of Cystoisospora belli Infection in Acalculous Gallbladders of Immunocompetent Patients

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          Abstract

          Objectives

          Indications for cholecystectomy have changed dramatically over the past three decades. Cystoisospora belli has been reported in cholecystectomy specimens of immunocompetent patients. The present study was designed to determine the prevalence and clinical association of C belli in the gallbladder.

          Methods

          The study included retrospective review of cholecystectomy specimens (n = 401) removed for various indications, and a prospective cohort of cholecystectomy specimens (n = 22) entirely submitted for histologic evaluation. Correlations of presence of C belli with age, sex, clinical indication, and abnormalities of preoperative laboratory values were assessed by Fisher exact test.

          Results

          C belli was identified in 39/401 (9.7%) of the retrospective cohort, and 6/22 (27.3%) of the entirely submitted specimens. The presence of C belli showed no correlation with age, sex, clinical indication, or laboratory abnormalities.

          Conclusions

          C belli resides in a latent state in the gallbladder and may be best considered a commensal organism.

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          Most cited references 35

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          A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club.

          The Southern Surgeons Club conducted a prospective study of 1518 patients who underwent laparoscopic cholecystectomy for treatment of gallbladder disease in order to evaluate the safety of this procedure. Seven hundred fifty-eight operations (49.9 percent) were performed at academic hospitals, and 760 (50.1 percent) at private hospitals. In 72 patients (4.7 percent) the operation was converted to conventional open cholecystectomy; the most common reason for the change was the inability to identify the anatomy of the gallbladder as a result of inflammation in the region of this organ. A total of 82 complications occurred in 78 (5.1 percent) of the patients; this is comparable with the rates of 6 to 21 percent that have been reported for conventional cholecystectomy. Overall, the most common complication was superficial infection of the site of insertion of the umbilical trocar. A total of seven injuries to the common bile duct or the hepatic duct occurred during the operation, for a rate of 0.5 percent. Four of the seven injuries were simple lacerations, which were repaired after conversion to conventional cholecystectomy. The incidence of bile-duct injury in the first 13 patients operated on by each surgical group was 2.2 percent, as compared with 0.1 percent for subsequent patients. No complications were attributed directly to either cautery or laser-surgical technique, and similar numbers of complications occurred in academic and private hospitals. The mean hospital stay for the entire group was 1.2 days (range, 6 hours to 30 days). The results of laparoscopic cholecystectomy compare favorably with those of conventional cholecystectomy with respect to mortality, complications, and length of hospital stay. A slightly higher incidence of biliary injury with the laparoscopic procedure is probably offset by the low incidence of other complications.
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            Biology of Isospora spp. from humans, nonhuman primates, and domestic animals.

            Coccidial parasites of the genus Isospora cause intestinal disease in several mammalian host species. These protozoal parasites have asexual and sexual stages within intestinal cells of their hosts and produce an environmentally resistant cyst stage, the oocyst. Infections are acquired by the ingestion of infective (sporulated) oocysts in contaminated food or water. Some species of mammalian Isospora have evolved the ability to use paratenic (transport) hosts. In these cases, infections can be acquired by ingestion of an infected paratenic host. Human intestinal isosporiasis is caused by Isospora belli. Symptoms of I. belli infection in immunocompetent patients include diarrhea, steatorrhea, headache, fever, malaise, abdominal pain, vomiting, dehydration, and weight loss, blood is not usually present in the feces. The disease is often chronic, with parasites present in the feces or biopsy specimens for several months to years. Recurrences are common, Symptoms are more severe in AIDS patients, with the diarrhea being more watery. Extraintestinal stages of I. belli have been observed in AIDS patients but not immunocompetent patients. Treatment of I. belli infection with trimethoprim-sulfamethoxazole usually results in a rapid clinical response. Maintenance treatment with trimethoprim-sulfamethoxazole is needed because relapses often occur once treatment is stopped.
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              Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment.

               L. Stewart,  L W Way (1995)
              To analyze the treatment of bile duct injuries during laparoscopic cholecystectomy to discern the factors affecting outcome. An analysis of the treatment of 88 patients with laparoscopic bile duct injuries. A university hospital. Eighty-eight patients with major bile duct injuries following laparoscopic cholecystectomy. Success of treatment, morbidity rate, mortality rate, and length of illness. Operations to repair bile duct injuries were unsuccessful in 27 (96%) of 28 procedures when cholangiograms were not obtained preoperatively, and they were unsuccessful in 69% when cholangiographic data were incomplete. In some cases, lack of complete cholangiographic information led to an inappropriate and harmful operation. When cholangiographic data were complete, the first repair was successful in 16 (84%) of 19 patients. A primary end-to-end repair over a T tube (13 patients) was unsuccessful in every case in which the duct had been divided. Direct closure of a partial defect in the duct was successful in four of seven patients. Fifty-four (63%) of 84 Roux-en-Y hepaticojejunostomies were successful. Factors responsible for the unsuccessful outcomes were the following: incomplete excision of the scarred duct, use of nonabsorbable suture material, use of two-layer anastomosis, and failure to eradicate subhepatic infection before the attempted repair. Dilatation and stenting was uniformly unsuccessful as primary treatment (three patients) and was unsuccessful in only seven of 26 patients following a previous operative repair. Patients first treated by the primary surgeon had an average length of illness of 222 days (P < .01). Only 17% of primary repair attempts and no secondary repair attempts performed by the laparoscopic surgeon were successful. Patients whose first repair was performed by tertiary care biliary surgeons had a length of illness of 78 days (P < .01), and 45 (94%) of 48 repairs by tertiary care biliary surgeons were successful. Surgeons who specialize in the repair of bile duct injuries achieve much better results than those with less experience. The worse results of other surgeons could be attributed in many instances to specific correctable errors. Nonsurgical treatment was usually unsuccessful and substantially increased the duration of disability.
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                Author and article information

                Journal
                Am J Clin Pathol
                Am. J. Clin. Pathol
                ajcp
                American Journal of Clinical Pathology
                Oxford University Press (US )
                0002-9173
                1943-7722
                January 2019
                04 October 2018
                04 October 2018
                : 151
                : 1
                : 100-107
                Affiliations
                [1 ]Department of Pathology, University of Rochester Medical Center, Rochester, NY
                [2 ]Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
                [3 ]Department of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY
                [4 ]Department of Pathology, University of Michigan, Ann Arbor
                Author notes
                Corresponding author: Michael G. Drage MD, PhD; Michael_Drage@ 123456URMC.rochester.edu .

                H.D.N. and K.S. are undergraduate students from other institutions who performed their contribution to the project while participating in the PathIT program at University of Rochester Medical Center.

                Article
                aqy122
                10.1093/ajcp/aqy122
                6287653
                30285068
                © American Society for Clinical Pathology, 2018.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Page count
                Pages: 8
                Product
                Funding
                Funded by: University of Rochester Medical Center 10.13039/100009750
                Categories
                Original Articles

                cystoisospora belli, gallbladder, cholecystectomy

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