Presentation
Th patient first presented with pain in the abdomen. An ultrasound done at that time revealed only mild wall thickening. The patient was managed conservatively. He then presented with a repeated episode of acute abdomen after 25 days. However, besides pain and a positive Murphy sign, no abdominal guarding or any signs of sepsis were present. No fever. Lab work revealed only mildly raised CRP with normal TLC. The images below are corresponding to this later presentation.
Patient Data
The gallbladder shows normal distention. There is irregular thickening of the GB wall involving the posterior wall in the fundal region of the GB. This thickening shows a mass-like appearance and measures approximately 31 mm x 25 mm. The omentum adheres to the gallbladder in this region and there is loss of interface between the adjacent fat planes and the thickened wall of the GB. Minimal sludge is noted in the GB lumen; however, there is no evidence of any detectable calculus within the gallbladder lumen. The rest of the GB wall appears to be relatively normal. A very thin rim of pericholecystic fluid is evident. The hepatic flexure of the colon also appears to be adhered to the omentum and to the fundus of the gall bladder. There also appears to be adhesions between the gallbladder fundus and the inferior border of the liver, however, the interface between the liver and the gallbladder is maintained. Mildly increased vascularity is noted in this region.
The CBD is normal in caliber. There is no intrahepatic biliary dilatation. No obvious calculus/shadowing echogenic lesion detected in the pericholecystic region to suggest expelled gallbladder calculus. No obvious free fluid noted in the Morison's pouch or perisplenic area.
GALLBLADDER: The gallbladder is not distended. There is evidence of irregular thickening of the GB wall involving the posterior wall in the fundal region of GB. This thickening shows mass like appearance and measures approximately 31 mm x 25 mm. The omentum is adherent to the gallbladder in this region and there is loss of interface between the adjacent fat planes and the thickened wall of the GB. Minimal sludge is noted in the GB lumen; however, there is no evidence of any detectable calculus within the gall bladder lumen. The rest of the GB wall appears to be relatively normal. A very thin rim of pericholecystic fluid is evident. The hepatic flexure of the colon also appears to be adhered to the omentum and to the fundus of the gall bladder. There also appears to be adhesions between the gallbladder fundus and the inferior border of the liver, however, the interface between the liver and the gallbladder is maintained. Mildly increased vascularity noted in this region. CBD is normal in caliber. There is no intrahepatic biliary dilatation. No obvious calculus/shadowing echogenic lesion detected in the pericholecystic region to suggest expelled gallbladder calculus. No obvious free fluid noted in the Morison's pouch or perisplenic area.
Case Discussion
The imaging features were strongly suggestive of neoplastic etiology for the gallbladder wall thickening. However, the clinical presentation went against the possibility of malignancy.
The patient underwent laproscoopy which confirmed the imaging findings with involvement of the hepatic flexure of the colon, gallbladder fundus, and omentum. No gallbladder calculus was found. Pathology revealed xanthogranulomatous cholecystitis.