The gallbladder: uncommon gallbladder conditions and unusual presentations of the common gallbladder pathological processes

An institutional approach to thick wall gall bladder and our experience of 5450 gallstone disease

INTRODUCTION

Gallstone disease (GSD) has a high prevalence in India. GSD presentation varies from being asymptomatic to severe complications. Laparoscopic cholecystectomy (LC) is the procedure of choice. Histopathological varies from chronic cholecystitis to carcinoma gall bladder (CaGB). Thick wall gall bladder (TWGB) is grey zone. Various parameters of GSD especially TWGB were evaluated to develop an approach to reduce perioperative complications and histopathological surprises.

PATIENTS AND METHODS

This study was conducted at the Department of Surgical Gastroenterology, Dr. RMLIMS, Lucknow. Data of all patients undergoing cholecystectomy between January 2015 and March 2023 were analysed retrospectively. Demographic profile, clinical presentation, blood investigations, radiological findings, operative findings and histopathology report were examined. Clinical and radiological features of difficult cholecystectomies, incidence and type of bile duct injury (BDI), presentation and outcomes of TWGB, incidence of incidental CaGB and its outcome, were evaluated and analysed.

RESULTS

A total of 5450 patients underwent cholecystectomy during the study period. GSD is common in females and 4 th decade. The laparoscopic to open conversion rate was 1.2%, the most common cause was unclear anatomy. The incidence of BDI in our series was 0.11% ( n = 6). The most common histopathological outcome was chronic cholecystitis followed by xanthogranulomatous cholecystitis. Incidence of incidental carcinoma gall in our series was 0.3% ( n = 16) with an overall survival of 68.75% at a mean follow-up of 19.4 months. TWGB workup includes contrast-enhanced computed tomography, intraoperative most have difficult cholecystectomy and had a higher rate of conversion, injury and incidental CaGB.

CONCLUSION

Thorough pre-operative evaluation and using the suggested algorithm may decrease perioperative complications and histopathological surprises after LC.

Fetal "Phrygian Cap" Gallbladder: Malformation or Deformation?

A series of five fetuses with a Phrygian cap gallbladder, a condition infrequently reported in the antenatal period, is reported. In all cases, examination of the fetal gallbladder displayed the characteristic folding of the fundus over the body. No associated findings were detected. The gallbladder length was longer than normal in all cases, suggesting that this anomaly could represent a deformity rather than a primary malformation. This might be caused by excessive longitudinal growth of the gallbladder, eventually folding after the fundus reaches the anterior border of the liver and is then diverted laterally by the abdominal wall.

Imaging of hepato-pancreato-biliary emergencies in patients with cancer

Hepato-pancreato-biliary (HPB) emergencies in patients with cancer encompass an extensive array of various conditions, including primary malignancies that require prompt treatment, associated severe complications, and life-threatening consequences arising from treatment. In patients with cancer, the liver can be affected by chemotherapy-induced hepatotoxicity, veno-occlusive disease, Budd-Chiari syndrome, liver hemorrhage, and other complications arising from cancer therapy with all these complications requiring timely diagnosis and prompt treament. Cholecystitis induced by systemic anticancer therapies can result in severe conquences if not promptly identified and treated. The application of immunotherapy in cancer therapy is associated with cholangitis. Hemobilia, often caused by medical interventions, may require arterial embolization in patients with severe bleeding and hemodynamic instability. Malignant biliary obstruction in patients with biliary cancers may necessitate palliative strategies such as biliary stenting. In pancreatic cancer, patients often miss surgical treatment due to advanced disease stages or distant metastases, leading to potential emergencies at different treatment phases. This comprehensive review underscores the complexities of diagnostic and treatment roles of medical imaging in managing HPB emergencies in patients with cancer. It illustrates the crucial role of imaging techniques, including magnetic resonance imaging, computed tomography and ultrasound, in diagnosing and managing these conditions for timely intervention. It provides essential insights into the critical nature of early diagnosis and intervention in cancer-related HPB emergencies, ultimately impacting patient outcomes and survival rates.

Ultrasonographic Appearance of Gallbladder Neoplasia in 14 Dogs and 1 Cat

Ultrasonography is the most commonly used diagnostic imaging tool for gallbladder disease in veterinary medicine. Primary gallbladder neoplasia is an uncommon finding with variable prognosis for which no studies have been published describing their ultrasonographic appearance and diagnosis. This retrospective, multicenter, case series study examines the ultrasonographic appearance of gallbladder neoplasia with histologically or cytologically confirmed diagnoses. A total of 14 dogs and 1 cat were analyzed. All discrete masses were sessile in shape and varied in size, echogenicity, location, and gallbladder wall thickening. All studies with images showing Doppler interrogation exhibited vascularity. Cholecystoliths were an uncommon finding, being present in only one case in this study, unlike in humans. The final diagnosis of the gallbladder neoplasia was neuroendocrine carcinoma (8), leiomyoma (3), lymphoma (1), gastrointestinal stromal tumor (1), extrahepatic cholangiocellular carcinoma (1), and adenoma (1). Findings from this study indicate that primary gallbladder neoplasms have variable sonographic appearances and cytologic and histologic diagnoses.

Diagnostic and Therapeutic Radiology of the GI Tract, Liver, and Pancreas in Patients with COVID

Coronavirus disease 2019 (COVID-19) pulmonary involvement has been extensively reported in the literature. Current data highlight how COVID-19 is a systemic disease, affecting many other organs, including the gastrointestinal, hepatobiliary, and pancreatic organs. Recently, these organs have been investigated using imaging modalities of ultrasound and particularly computed tomography. Radiological findings of the gastrointestinal, hepatic, and pancreatic involvement in patients with COVID-19 are generally nonspecific but are nonetheless helpful to evaluate and manage COVID-19 patients with involvement of these organs.

What's new in the hot gallbladder: the evolving radiologic diagnosis and management of acute cholecystitis

Acute cholecystitis (AC) is a common condition and its incidence is rising. New technologies have advanced the imaging diagnosis of AC, providing more structural and functional information as well as allowing the radiologist to distinguish AC from mimics and identify complications from both the disease and its management. Dual energy CT aids in detecting gallstones and gallbladder wall enhancement, which helps to diagnose AC and identify its complications. Similarly, contrast-enhanced and non-contrast perfusion ultrasound techniques improve detection of abnormal gallbladder wall enhancement. Advances in MR imaging including hepatobiliary contrast agents aid in characterizing post-cholecystectomy complications such as bile leaks. Newer interventional techniques have also expanded the suite of options for minimally invasive management. Lumen apposing metal stents provide more options for conservative treatment in non-surgical candidates and are compared to a standard percutaneous cholecystostomy. Radiologists should be familiar with these advanced imaging methods and intervention techniques and the value they can bring to the diagnosis and management of AC.

Precordial pain caused by a hemocholecyst due to gallbladder cancer: A case report

INTRODUCTION AND IMPORTANCE

A hemocholecyst refers to hemorrhage originating from and confined to the gallbladder. Intraluminal hemorrhage of the gallbladder is a rare symptom of gallbladder cancer (GBC), which can cause hemorrhagic cholecystitis. The symptoms of hemorrhagic cholecystitis are similar to those of classic acute cholecystitis where precordial pain is atypical. Here, we report a case of a precordial pain-inducing hemocholecyst due to GBC.

CASE PRESENTATION

An 86-year-old woman was admitted to the emergency department due to persistent, sudden-onset precordial pain. Electrocardiogram (ECG) findings and cardiac enzyme levels were normal; however, severe anemia (hemoglobin 6.4 g/dL) was noted. Computed tomography (CT) showed a tense gallbladder with a heterogeneous, high-density area. Contrast-enhanced CT did not reveal contrast extravasation or obvious mass lesions. Considering the risk of hemorrhagic cholecystitis, we performed laparoscopic cholecystectomy. Operative findings were normal, however, the gallbladder lumen was filled with blood clots, while the gallbladder body had a papillary, infiltrating-type lesion.

CLINICAL DISCUSSION

Histopathological examination confirmed the diagnosis of moderately differentiated gallbladder adenocarcinoma. The precordial pain disappeared postoperatively. Due to the patient's age and general condition, no additional gallbladder bed resection or S4/5 hepatic bisegmentectomy and lymphadenectomy were performed.

CONCLUSION

A hemocholecyst can cause precordial pain; therefore, abdominal imaging may be useful for diagnosing patients with nonspecific precordial pain. In addition, GBC should be considered as a potential cause of hemocholecysts. Early diagnosis and urgent cholecystectomy should be performed to prevent gallbladder perforation in patients with hemocholecysts.

The Clinical Significance of Hemorrhagic Cholecystitis

Background

Hemorrhagic cholecystitis (HC) is a rare complication of acute cholecystitis. HC is difficult to diagnose pre-operatively and previous case reports suggest a strong association with anticoagulation and an increased morbidity. The purpose of the study is to determine the clinical presentation and outcomes of patients with HC in a large cohort of patients.

Method

A retrospective review of HC patients diagnosed following review of the clinical and pathological database between January 1, 2000 - June 30, 2021 at two hospitals. A search of the histopathology database, patient medical records, laboratory results, and imaging was conducted.

Results

Thirty-five patients were diagnosed on the histopathology report from approximately 6458 patients who had cholecystectomies. Thirty-one had emergency presentation and four patients (11.4%) had elective surgery. Twenty-one patients (60%) were female and 15 patients (40%) were male. The median age was 51 years. All patients had laparoscopic cholecystectomy, four patients were converted to open and five patients required postoperative endoscopic retrograde cholangiopancreatography. Two patients (5.7%) were on anticoagulation therapy. Twenty-three (65.7%) had ultrasound, 12 patients (34.2%) had computed tomography, three patients (8.5%) had magnetic resonance cholangiopancreatography, and one patient with a pre-operative diagnosis of HC.

Conclusion

HC is a rare form of acute cholecystitis. Anticoagulation only accounts for a small fraction of these patients. Pre-operative diagnosis of HC is not often made. Patients were treated with cholecystectomies and made a full recovery with no complications. Our study seems to show HC is a histological diagnosis with no clinical consequences for the patients.

Ectopic gallbladder with congenital biliary dilatation: a pediatric case report

Background

An ectopic gallbladder is a rare anomaly and can result in the misinterpretation of imaging findings and clinical confusion. Knowledge of such anomalies facilitates accurate diagnoses and prompt management. We report a pediatric case of an ectopic gallbladder concomitant with congenital biliary dilatation (CBD).

Case presentation

A 9-year-old girl was referred to our hospital for elevated liver enzyme levels. Following physical examination and a review of medical imaging findings, she was diagnosed with Todani type IV-A CBD. We could not visualize the gallbladder by abdominal ultrasonography, CT, and MRI scans; therefore, we suspected gallbladder agenesis. A laparoscopic excision of the extrahepatic bile duct was performed to treat the CBD. Neither a gallbladder nor a cystic duct were revealed on the liver undersurface. Therefore, gallbladder agenesis was considered as a diagnosis based on preoperative imaging and intraoperative findings. However, during dissection of the hepatic hilum, a cyst-like structure was found on the ventral side of the common hepatic duct, slightly to the right, and a small additional duct that originated from the cystic structure was found. Upon incision, a small amount of bile was drained from the small duct. Thus, the cystic structure was diagnosed as an ectopic gallbladder with hypoplasia. Following the removal of the ectopic gallbladder, the extrahepatic bile duct was excised. Subsequently, laparoscopic Roux-en-Y hepaticojejunostomy was performed without any complications. Postoperative histopathological evaluations of the resected specimen revealed Rokitansky–Aschoff sinuses in the resected cystic lesion. The pathological investigations confirmed the diagnosis of an ectopic gallbladder. Following an uneventful postoperative course, the patient was discharged on day nine.

Conclusions

To our knowledge, this is the first pediatric case report describing an ectopic gallbladder concomitant with CBD. If the gallbladder cannot be detected in a preoperative imaging examination, it is important to consider the possibility of an ectopic gallbladder.

Emergency laparoscopic cholecystectomy for hemorrhagic cholecystitis: A case report

Introduction

Hemorrhagic cholecystitis (HC) is a rare but specific complication of acute cholecystitis. HC progression often leads to fatal and severe outcomes.

Presentation of case

We describe the case of a 64-year-old man who was diagnosed with HC. Intraoperatively, the gallbladder surface was congested. The resected specimen had no gallstones and showed basophilic degenerate material toward the mucosal surface. In addition, vascular congestion and red cell extravasation were noted at the bottom of the layer. The patient's postoperative course was good, and he was discharged with remission 4 days following the operation.

Discussion

Diagnosis and treatment during early stages are the most critical aspects of HC management and may lead to improved outcomes.

We successfully performed timely laparoscopic cholecystectomy for the treatment of HC.

Conclusion

In cases where HC occurs, appropriate treatment should be chosen by experiential judgment and consideration of the current literature.

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We observed that the surface of the gallbladder was congested and we diagnosed the hemorrhagic cholecystitis

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We successfully performed timely laparoscopic cholecystectomy for the treatment of hemorrhagic cholecystitis as an emergency operation.

Complications of cholecystitis: a comprehensive contemporary imaging review

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Key Imaging Findings for the Prospective Diagnosis of Rare Diseases of the Gallbladder and Cystic Duct

There are various diseases of the gallbladder and cystic duct, and imaging diagnosis is challenging for the rare among them. However, some rare diseases show characteristic imaging findings or patient history; therefore, familiarity with the imaging presentation of rare diseases may improve diagnostic accuracy and patient management. The purpose of this article is to describe the imaging findings of rare diseases of the gallbladder and cystic duct and identify their pathological correlations with these diseases.

Porcelain gallbladder and its relationship to cancer

Background

Porcelain gallbladder (PGB) is defined as calcium deposits encrusting the internal visceral layer, which becomes hard, brittle, and bluish. Porcelain gallbladder is rare and has been found in less than 1% of routine cholecystectomy specimens. Several studies report an incidence of gallbladder carcinoma (GBC) associated with gallbladder calcification varying between 12.5 and 61%, data which have been known for 60 years. There is a lack of information concerning PGB and its association with GBC, and the aim of this study is to better define this relationship.

Methods

A total of 10 patients were found to have PGB in 1050 consecutive routine surgical cholecystectomies. Clinical and laboratory findings, gallbladder histologic examination, bile culture, and bile pH were related to stone composition analysis performed by X‑ray diffraction using Perkin–Elmer (Perkin Elmer Corp. Norwalk, CT, US) 1625 FTIR.

Results

Among the 10 patients with PGB, complete calcification of the entire gallbladder wall was present in six cases, while four patients had partial calcification. Gallstones were present in all cases of PGB, multiple stones in nine cases and a single stone in one case. Bile culture was performed in all patients of the series. Among the 10 cases with PGB, culture was positive in two cases.

Conclusion

PGB is a disease as rare as it is subtle. Moreover, the chronic stimulation by stones can generate an initial dysplasia that will subsequently turn into a neoplasm: the cancerization risk is probably no different from long-standing cholesterol or combined stones, but as risk factor for cancer it requires early cholecystectomy.

Pictorial Summary of Congenital Gallbladder and Biliary Duct Anomalies Presentation on HIDA Imaging

Hepatobiliary iminodiacetic acid (HIDA) scan is one of the principal imaging modalities for the evaluation of the gallbladder and biliary tree. Congenital biliary anomalies are rare and can be difficult to recognize on HIDA scan. They may also mimic other biliary pathology. The purpose of this article is to review the spectrum of congenital gallbladder and biliary anomalies and describe their imaging appearance on HIDA scan. In addition, the diagnostic utility of functional imaging with HIDA when evaluating biliary tract anomalies is described.

Gallbladder Carcinoma and Its Differential Diagnosis at MRI: What Radiologists Should Know

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response. ^©RSNA, 2020.

Clinical Significance of CBS and CCL21 in Gallbladder Adenocarcinomas and Squamous Cell/Adenosquamous Carcinomas

Gallbladder cancer (GBC) is a rare disease with high mortality. However, no biomarkers for the carcinogenesis, progression, prognosis, and early diagnosis are clinically available. This study investigated the expressions of cystathionine-β-synthase (CBS) and C-C chemokine receptor 7 (CCR7) protein and their clinical and pathologic significances in gallbladder squamous cell/adenosquamous carcinomas (SC/ASC) and adenocarcinomas (AC). CBS and chemokine ligand 21 (CCL21) expression was measured using immunohistochemistry in 69 SC/ASCs and 146 ACs. A significantly high percentage of patients with an age above 45 years, lymph node metastasis, and invasion was observed in the SCs/ASCs compared with ACs (P<0.05). Both AC and SC/ASC patients with positive CBS and CCL21 expression exhibited a high tumor-lymph node-metastasis stage, lymph node metastasis, and invasion compared with patients with negative CBS and CCL21 expression (P<0.05 or P<0.01). SC/ASC patients with positive CBS expression was prone to have a larger tumor size than those with negative expression (P<0.05). Positive CBS and CCL21 expression correlated with poor differentiation and larger tumor size in AC patients. Positive CBS and CCL21 are closely associated with a decreased overall survival in SC/ASC and AC patients (P<0.05 or P<0.01) and were independent factors for a poor-prognosis. Both CBS and CCL21 showed a good overall diagnostic performance for SC/ASC (AUC=0.742 and AUC=0.764, respectively) and AC (AUC=0.734 and AUC=0.718, respectively). In conclusion, positive CBS and CCL21 expression are closely associated with the clinical severity and poor prognosis in GBC, and can be a marker for the diagnosis of AC and SC/ASC type of GBC.

Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations

Infection with severe acute respiratory syndrome coronavirus 2 results in coronavirus disease 2019 (COVID-19), which was declared an official pandemic by the World Health Organization on March 11, 2020. COVID-19 has been reported in most countries, and as of August 15, 2020, there have been over 21 million cases of COVID-19 reported worldwide, with over 800 000 COVID-19-associated deaths. Although COVID-19 predominantly affects the respiratory system, it has become apparent that many other organ systems can also be involved. Imaging plays an essential role in the diagnosis of all manifestations of the disease and its related complications, and proper utilization and interpretation of imaging examinations is crucial. A comprehensive understanding of the diagnostic imaging hallmarks, imaging features, multisystem involvement, and evolution of imaging findings is essential for effective patient management and treatment. In part 1 of this article, the authors described the viral pathogenesis, diagnostic imaging hallmarks, and manifestations of the pulmonary and peripheral and central vascular systems of COVID-19. In part 2 of this article, the authors focus on the key imaging features of the varied pathologic manifestations of COVID-19, involving the cardiac, neurologic, abdominal, dermatologic and ocular, and musculoskeletal systems, as well as the pediatric and pregnancy-related manifestations of the virus. Online supplemental material is available for this article. ©RSNA, 2020.

Safety and Efficacy of Percutaneous Cholecystostomy for Emphysematous Cholecystitis

Objective:

The objective of the study was to evaluate the safety and efficacy of percutaneous cholecystostomy (PC) in treating critically ill patients with emphysematous cholecystitis who were deemed poor surgical candidates.

Materials and Methods:

The Institutional Review Board exemption was obtained for this retrospective study. Patients with emphysematous cholecystitis who were deemed to be poor operative candidates by the treating surgeon and underwent PC placement between May 2008 and April 2017 at a single institution were identified through a medical records search. Demographics, laboratory values, imaging data, procedural technique, complications, hospitalization course, clinical outcome, and survival data were obtained.

Results:

Ten consecutive patients were included, with a mean age of 75.0 ± 12.2 years, including six men and four women. The most common comorbidity was diabetes (60%, 6/10) followed by hypertension (40%, 4/10). Intraluminal or intramural gas as well as gallbladder wall thickening were noted in all patients. Procedure technical success rate was 100%. There was a complete resolution of symptoms in 90% (9/10) of patients at a mean of 2.9 ± 1.4 days post-procedure. Thirty-day survival rate was 90% (9/10); one patient died on the 6^th post- procedure day from sepsis. Two more deaths occurred within a year after PC from unrelated causes. About 50% (5/10) of patients underwent elective cholecystectomy at a median interval of 69 days post-procedure. In 40% (4/10) of patients, cholecystostomy was the definitive treatment, with tube removal at a median of 140 days post- procedure.

Conclusion:

PC appears to be a safe and generally effective alternative management option in patients with emphysematous cholecystitis that is considered very high risk for surgery.

Multimodality Imaging of Congenital Variants in the Gallbladder: Pictorial Essay

Congenital variants of the gallbladder development are infrequent and sometimes represent an asymptomatic imaging finding. In this case series, we want to present multimodality imaging findings that permit the diagnosis. Ultrasound, multidetector computed tomography, and magnetic resonance images are included.The proper recognition of these infrequent congenital benign entities avoids unnecessary complementary examinations and misdiagnosis. Although ultrasound represents the most commonly used initial diagnostic tool, the increased use of magnetic resonance imaging and the wide use of multidetector computed tomography make it crucial to know how these entities are seen.A retrospective review of cases of congenital variants of gallbladder through different imaging modalities was performed in our computer archives. Representative images were selected. Agenesis, hypoplasia, septated, duplicated, intrahepatic, and left-sided gallbladder are described.Better understanding and recognition of congenital anomalies in gallbladder images will avoid misdiagnosis.

Hemorrhagic shock secondary to cholecystoduodenal fistula with gallbladder pseudoaneurysm: A case report

BACKGROUND

Hemorrhagic shock secondary to cholecystoduodenal fistula (CDF) with gallbladder pseudoaneurysm is very rare.

CASE SUMMARY

A middle-aged man presented with uncontrolled hemorrhage of the upper gastrointestinal tract. A subsequent diagnosis of rupture of gallbladder pseudoaneurysm secondary to cholecystoduodenal fistula was made. After active treatment, the patient was rescued successfully.

CONCLUSION

Most of CDF cases are caused by cholelithiasis and difficult to diagnose early. The joint application of B-mode ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, gastroscopy, and endoscopic retrograde cholangio-pancreatography could improve early diagnosis rate, and digital subtraction angiography can be used in the treatment of CDF with active bleeding. The therapeutic principle of CDF is cholecystectomy, removing calculus, and cutting off and repairing fistula.

Uncommon Intraluminal Tumors of the Gallbladder and Biliary Tract: Spectrum of Imaging Appearances

Intraluminal pathologic conditions of the bile ducts and gallbladder are common, most frequently consisting of calculi and adenocarcinoma. In recent years, intraductal papillary neoplasm of the bile ducts (IPN-B), which is analogous to intraductal papillary mucinous neoplasm of the pancreas, has been recognized as a distinct pathologic entity and a precursor lesion to adenocarcinoma of the bile ducts. Intraductal tubulopapillary neoplasm (ITPN) of the bile duct was subsequently described as a distinct pathologic entity. With increased awareness and advances in imaging techniques, these lesions are diagnosed with increased frequency at preoperative imaging. A similar neoplasm in the gallbladder is referred to as intracholecystic papillary neoplasm. These lesions are often diagnosed at a preinvasive stage and have a better prognosis than invasive cholangiocarcinoma when treated with curative resection, underscoring the importance of an accurate imaging diagnosis. The most common causes of polypoid lesions of the gallbladder are cholesterol polyps and adenomyomatosis. These lesions need to be differentiated from the less common but clinically important adenocarcinoma of the gallbladder. Imaging is crucial to identify polyps that are at high risk for malignancy so that the appropriate management choice between imaging follow-up and cholecystectomy can be made by the treating physicians. Other less common gallbladder tumors, such as gallbladder adenomas, lymphoma, and metastases to the gallbladder, can manifest as intraluminal tumors; and awareness of these lesions is also important. In this article, the recent literature is reviewed; and the imaging appearances, histopathologic findings, and management of uncommon intraluminal tumors of the bile ducts and gallbladder and their mimics are discussed. ^©RSNA, 2019.

Porcelain gallbladder: A case report

Porcelain gallbladder is an extremely rare variant of chronic cholecystitis. Previous studies have shown that the incidence of gallbladder cancer has reached 60% in patients with porcelain gallbladder, but in more recent studies, this incidence has been proven to be around 6%. Therefore, surgical intervention is not recommended for every patient. Although laparoscopic surgery is the preferred method of treatment, It is recommended that open surgery should be preferred in some publications because of high complication rates and technical difficulties of laparoscopic approach.

Spontaneous Hepatic Hemorrhage Caused by Emphysematous Cholecystitis: A Case Report and Literature Review

BACKGROUND

Emphysematous cholecystitis and spontaneous hepatic hemorrhage are uncommon and serious conditions with non-specific presentations that can lead to a poor clinical outcome. We report a case of spontaneous hepatic hemorrhage of emphysematous cholecystitis. A 49-year-old male presented to the emergency department with fever, chills, right upper quadrant pain, vomiting, and diarrhea of four days' duration. He had a history of diabetes mellitus, hypertension, and uarthritis. Computed tomography (CT) revealed an enlarged gallbladder with intra-luminal, intra-mural, and peri-cholecystic air; subcapsular high-density fluid collection; and an intra-hepatic mass with gas and liquid in the right lobe of the liver. After receiving prompt administration of appropriate antibiotic agents, drainage, and an alternative operation the patient recovered well.

CONCLUSION

Emphysematous cholecystitis is potentially fatal because of its serious complications. It needs to be diagnosed promptly, not only based on the effervescent gallbladder sign but also on the inflammatory presentations. Furthermore, for patients with spontaneous hepatic hemorrhage, attention should be paid to the underlying cause. Treatment should be individualized to improve diagnosis and cure as early as possible, thereby improving prognosis.

Haemorrhagic cholecystitis: a rare entity not to be forgotten

Haemorrhagic cholecystitis is a rare entity of acute cholecystitis that carries a high morbidity and mortality rate if management is delayed. Its clinical course can mirror that of acute cholecystitis. Characteristic findings on ultrasound or CT scan are useful clues to early diagnosis. Urgent cholecystectomy is required prior to progressing to perforation of gallbladder. Most of the literature are case reports with causes associated with anticoagulation. Herein, we described a morbidly obese patient with poorly controlled diabetes presenting with non-specific right upper quadrant pain and was subsequently diagnosed with haemorrhagic cholecystitis. A review of the literature was also performed to summarise the potential clinical presentations, distinctive imaging findings and management options available for this rare condition.

Gallbladder duplication and cholecystitis

Cholecystitis is a common gallbladder pathology characterized by abdominal pain, positive Murphy sign and elevated white blood count. Abdominal ultrasound usually gives a definite diagnosis. Duplication of the gallbladder is a rare congenital anomaly that can either be asymptomatic or and can present with symptoms associated with cholelithiasis, cholecystitis, cholangitis or pancreatitis. Clinically indistinguishable from regular gallbladder pathologies. The management of duplicated gallbladder is similar to that of other gallbladder diseases, if one or both gallbladders cause symptoms, cholecystectomy should be done for both gallbladders. We present a case of a 50-year-old female patient, she presented to the emergency room with abdominal pain and tenderness. Ultrasound detected a gallbladder duplication with cholecystitis in one of them and magnetic resonance cholangiopancreatography confirmed this diagnosis. Surgery was decided and the patient underwent full recovery. Y-shaped gallbladder duplication with cholecystitis due to cholelithiasis in one of them was the final diagnosis.

Sonographic Findings of Gallbladder Perforation With Hepatic Abscesses

Gallbladder perforation is a complication of gallbladder disease. There are high morbidity and mortality rates, and it is believed that this is due to the delay in diagnosis and when the condition is managed conservatively. Sonography combined with computed tomography can be used to identify gallbladder perforation and the presence of hepatic abscesses. Sonographic findings for gallbladder perforation may include the presence of a stone outside of the gallbladder, an obvious defect in the gallbladder wall, and other signs such as distended gallbladder, thickened gallbladder wall, striated appearance of the gallbladder wall, gallstones, debris/sludge, and adjacent abscesses. It is important for a sonographer to recognize these signs so that prompt treatment can be initiated. This case presents the sonographic and computed tomography findings of a type II perforated gallbladder as a result of a large stone that eroded into the liver with the subsequent development of two hepatic abscesses.

Perfoation of the gallbladder: 'bait' for the unsuspecting laparoscopic surgeon

INTRODUCTION Cholecystectomy is one of the most common elective procedures carried out by general surgeons. Most patients present with typical biliary anatomy and simple gallstone disease. Intraoperative and postoperative courses are frequently predictable and uncomplicated. Nevertheless, a small but significant number of patients experience complicated disease with rare presentations and complex biliary anatomy. Unfortunately, consensus on appropriate care for such patients is lacking. CASE HISTORY We describe three patients who presented with complex manifestations of gallbladder perforation: acute perforation of the gallbladder; a spontaneous cholecystocutaneous fistula; a cholecystoduodenal fistula. The initial presentation, preoperative investigations, and selected surgical strategy for each case are described. CONCLUSIONS The case studies described here illustrate the need for a low index of suspicion for gallbladder perforation. Caution should be exercised in preoperative and intraoperative phases in this patient population.

Gallbladder perforation: a rare complication of postoperative chemotherapy of gastric cancer

A middle-aged man presented 1 day after being discharged from hospital with completing the first course of postoperative chemotherapy. He suffered a sudden persistent high fever and chills. It was noted that he had a history of a total gastrectomy (with D2 lymphadenectomy) 1 month ago. His admission bloods revealed total bilirubin was 142.2umol/L , indirect bilirubin of 107.6umol/L and white cell count of 20.05×10⁹/L. A color doppler ultrasound scan confirmed fluid and gas around liver and hilus lienis while the gallbladder cannot be detected. During Computed Tomography (CT) guided puncture positioning technology and setting a three-channel tube, about 400 ml of foul smell hazel turbid liquid was drained out. He was diagnosed as gallbladder perforation and he was underwent conservative treatment consist of drainage, banning diet, total parenteral nutrition and intravenous antibiotics. Then he recovered well within the subsequent 10 days and was discharged.