Presentation
Ongoing chronic epigastric and right hypochondrial pain. Previous diagnosis of gallstones.
Patient Data
A distended gallbladder with mucinous fluid and sludge. Echogenic gallstones with posterior echogenic shadowing are identified. The wall is of normal thickness, there is no pericholecystic fluid and the cystic duct is collapsed.
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The liver is of normal size and normal signal intensity with multiple simple intrahepatic cysts. There are no dilated intrahepatic ducts and no suspicious intrahepatic mass lesions.
The gallbladder is moderately distended. There is a normal wall thickness, no pericholecystic fluid, with a collapsed cystic duct. There is moderate sludge/mucin forming a circumscribed pseudo mass within which are the calcified gallstones. This extends to the gallbladder neck and appears occlusive.
The common bile duct is normal with no choledocholithiasis. The pancreas and pancreatic duct are normal.
There are multiple simple renal cysts bilaterally. There is a right adrenal adenoma, identified on CT imaging.
A moderately distended gallbladder is present. There is calcific cholelithiasis and no features of acute cholecystitis. There is a poor appreciation of the sludge/mucin identified on ultrasound. There is no biliary obstruction and a normal pancreas and pancreatic duct. There is no hepatomegaly, with incidental simple non suspicious intrahepatic cysts.
There are multiple simple renal cysts of varying sizes, a right adrenal adenoma, severe prostatomegaly and features suggestive of chronic bladder outlet obstruction.
No other significant findings present.
Case Discussion
Features suggestive of gallbladder hydrops ( gallbladder mucocele). The gallbladder remained moderately distended over multiple visits and multiple imaging studies. There is likely cystic duct obstruction due to sludge/ mucin accumulation with the calcified gallstones2. There was ongoing biliary colic and epigastric pain over a period of 4 months. The patient underwent laparoscopic cholecystectomy due to poor response to conservative management and the onset of deteriorating inflammatory markers and liver function tests. Histology confirmed acute on chronic cholecystitis.
Intrinsic obstruction of the cystic duct (gallstone/ tumor/ polyps ) or extrinsic compression (tumor/ lymph nodes/ other ) represent the causes of gallbladder hydrops2,3,4.
Kawasaki disease (a medium vessel vasculitis) with periportal inflammation spreads to involve the cystic duct and represents an unusual cause of gallbladder hydrops in infants and children mostly under 4 years of age 3,4.
Case assistance: Dr K.Govender.