Gallbladder mass - infective

Case contributed by Dr Paul Simkin

Presentation

Right sided abdominal pain.

Patient Data

Age: 80 years
Gender: Female
CT
24 mm rounded hypodense lesion in the gallbladder neck with rim calcification consistent with a calculus. There is marked, irregular mural thickening of the gallbladder neck and distal body, and extensive pericholecystic fat stranding around the fundus. The intrahepatic bile ducts, and left and right hepatic ducts at the porta hepatis are dilated. Findings are suspicious for gallbladder body carcinoma complicated by acute cholecystitis, with the impression of a 2.4 cm obstructive calculus at the gallbladder neck.
Ultrasound
On precontrast scans calculi are seen in the fundus of the gallbladder as well as in the neck. The gallbladder has a somewhat hourglass configuration with marked mural thickening from the point of waisting in the mid body down through the body and neck. On contrast enhanced studies the wall of the gallbladder shows marked thickening from the mid body down to the neck. The differential diagnosis, in addition to cholecystitis, is gallbladder carcinoma, or possibly a marked form of adenomyomatosis, although I think the former (carcinoma) is more likely. There is no evidence on contrast enhanced scanning of direct liver tumor invasion.
MRI

Impacted stone at the gallbladder neck narrowing the extrahepatic bile duct. Further filling defect in the distal common bile duct. Extrahepatic bile duct measures up to 6 mm. No intrahepatic duct dilatation. Enhancing soft tissue with diffusion restriction within the mid-to-proximal gallbladder. The mass obstructs the fundus, which contains gallstones, and demonstrates adjacent fat stranding and pericholecystic fluid. Small adjacent enhancing collection. No convincing hepatic invasion but the post contrast images are markedly degraded by motion artifact. No suspicious lymph nodes. No suspicious liver lesion. Remainder of the imaged upper abdomen is unremarkable.

Conclusion: Findings remain suspicious for gallbladder carcinoma complicated by acute cholecystitis. Pericholecystic changes at the fundus are felt to relate to acute cholecystitis rather than tumor extension. No definite extracholecystic tumor extension or regional or distant tumor spread. Impacted gallbladder neck results in CBD narrowing (Mirrizi syndrome) - there is also slight compression of the main portal vein inferior surface in the porta hepatis. Choledocholithiasis in the distal CBD.

Case Discussion

The perforation at the fundus is favored to be infective rather than malignant.
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Case information

rID: 52908
Published: 8th Aug 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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