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Gallbladder Mucocele
Article Last Updated: Nov 8, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Rajagopalan Vijayaraghavan, MBBS, MS, FRCS(Edin), MMed, FICS, Consulting Surgeon, Department of Surgery, RMV Hospital, India
Rajagopalan Vijayaraghavan is a member of the following medical societies: International College of Surgeons and Royal College of Surgeons of Edinburgh
Editors: Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
hydrops of the gallbladder, gallstone disease, overdistended gallbladder filled with mucoid or clear and watery content, outlet obstruction of the gallbladder, cholecystitis, Mirizzi syndrome, common bile duct obstruction, cholangitis
Gallstone disease is the most common affliction of the biliary system, affecting 15-20% of the US population, with nearly 1 million new cases reported annually.
Problem
Mucocele or hydrops of the gallbladder describes an overdistended gallbladder filled with mucoid or clear and watery content. This usually noninflammatory distension results from an outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct.
Frequency
About 3% of all pathologic gallbladders in adults are mucoceles. The true prevalence may be higher because of the varying criteria used by different authors to define the condition.
Reports indicate that an association could exist between mucoceles and solitary stones of the gallbladder.
Etiology
Causes include the following: - Impacted stone in the gallbladder neck or cystic duct
- Spontaneously resolved acute cholecystitis
- Tumors - Polyps or malignancy of the gallbladder
- Extrinsic compression of the neck or cystic duct by lymph nodes or inflammatory fibrosis or adjacent malignancies in the liver, duodenum, or colon
- Prolonged total parenteral nutrition or ceftriaxone therapy
- Congenital narrowing of the cystic duct
- Parasites such as Ascaris (occasionally)
- In infants and children, acute, acalculous, noninflammatory hydrops of the gallbladder may be associated with the following:
- Kawasaki syndrome (mucocutaneous lymph node syndrome)
- Streptococcal pharyngitis
- Mesenteric adenitis
- Typhoid
- Leptospirosis
- Hepatitis
- Familial Mediterranean fever
- Nephrotic syndrome
- Fibrocystic disease
Other problems to be considered include the following: - Hepatomegaly, choledochal cyst
- Courvoisier gallbladder due to simultaneous obstruction of the gallbladder and common bile duct
- Pseudocyst of the pancreas
- Renal mass
- Right suprarenal gland mass
- Mesenteric cysts
- Parasitic cysts - Hydatid cyst
- Ascending colon mass
Pathophysiology
Long-standing obstruction to the outflow from the gallbladder results in overdistension of the gallbladder; occasionally, the gallbladder assumes massive proportions and the volume may be as much as 1.5 liters. The bile or bile pigment is slowly resorbed, and continuing secretion from the mucosa of the gallbladder results in clear and watery or mucoid content (white bile). The wall may be of normal thickness, or, in long-standing cases, the mucosa atrophies and the wall becomes thin, sometimes even transparent. Wall thickening can occur with recurrent attacks of cholecystitis. The contents are usually sterile, and any bacterial contamination ends in empyema of the gallbladder. Gross overdistension may result in gangrene and/or perforation of the gallbladder, with ensuing pericholecystic collection or peritonitis. The severity of the inflammatory episode dictates the clinical presentation.
Microscopic examination reveals a flattened mucosa lined by low columnar or cuboidal cells; the increased intraluminal pressure results in plentiful Rokitansky-Aschoff sinuses. Inflammatory cells may be present either in small numbers or in abundance.
Clinical
Symptomatology includes right upper quadrant (RUQ) pain or epigastric pain and discomfort, nausea, and vomiting. Continuance of pain or persistence of tenderness longer than 6 hours indicates possible acute cholecystitis. Fever and chills suggest infected bile, with a possible empyema of the gallbladder. Jaundice is unusual except in coexisting obstruction of the common bile duct either by stones or by extrinsic compression (Mirizzi syndrome). A palpable, somewhat tender mass is usual; the gallbladder at times may even be felt down in the pelvis. Diagnostic criteria The diagnosis of a mucocele should be considered in the following: - Minimal acute inflammatory signs are present.
- A large, palpable, minimally tender gallbladder is found on clinical examination.
- Laboratory test results are normal or just within the upper limit of reference range values.
- Plain radiograph of the abdomen shows a soft tissue density globular shadow in the subhepatic region.
- Ultrasonography of the RUQ shows evidence of minimal wall thickening, an impacted stone in the neck, or infundibulum of an enlarged gallbladder and clear content.
- Intraoperatively, the aspirate from the gallbladder is clear and watery or mucoid (white bile).
- The gallbladder on opening shows a white wall; clear, watery, or mucoid content; a stone or stones impacted in the neck or cystic duct; a narrowed cystic duct; or a tumor and/or polyp causing obstruction of the neck of the gallbladder.
See Surgical therapy.
See Pathophysiology.
The contraindications to surgical treatment of mucocele of the gallbladder would obviously include any associated medical conditions or illnesses that preclude surgery. No absolute contraindication exists. Laboratory research has indicated that chemical ablation of the gallbladder mucosa might be an alternative in patients who are medically unfit, elderly, or critically ill. A combination of ethanol, sodium tetradecyl sulfate, and mucosal exfoliant has been successfully tried in rats.
Lab Studies
- No single laboratory test is diagnostic of a mucocele. However, laboratory workup should include all tests performed for acute cholecystitis.
- A mild leukocytosis with a shift to the left is common. Higher counts indicate the possibility of acute cholecystitis or infected bile. Bilirubin levels are usually within the reference range or may be mildly raised in cases of Mirizzi syndrome or in those with associated common bile duct (CBD) obstruction or cholangitis. Liver enzymes are usually within the reference range, although a mild rise in alkaline phosphatase may be present. Any gross rise should raise the suspicion of an obstructed CBD. Serum amylase levels are generally within the reference range; any gross rise suggests the possibility of acute pancreatitis due to an obstruction close to the ampulla of Vater.
Imaging Studies
- Ultrasonography, although entirely operator dependent, is extremely sensitive in detecting stones in the gallbladder. A grossly distended thin-walled gallbladder measuring over 5 cm across anteroposteriorly, an impacted stone in the infundibulum or neck of the gallbladder or in the cystic duct, and clear fluid content indicate a possible mucocele. Sonographic Murphy sign may be positive. The wall may be thickened, and a small amount of pericholecystic fluid may be present in cases with acute cholecystitis. Gross wall thickening and murky, thick fluid with sediments and a pericholecystic collection suggest an empyema or pyocele of the gallbladder. Ultrasonography is also useful in identifying ductal obstruction and is extremely sensitive in identifying intrahepatic biliary tree dilatation.
- Plain radiograph of the abdomen may show a soft tissue density shadow with an intraluminal calcific shadow in the subhepatic region. This finding alone is nonspecific and should only be used as a guideline in differential diagnosis.
- Scintigraphy (hepato-iminodiacetic acid [HIDA] scan) may be indicated in obscure cases, although it can only offer indirect evidence. Nonvisualization of the gallbladder indicates an obstructed gallbladder and possible acute cholecystitis; nonvisualization in the small intestine indicates CBD obstruction.
- CT scan may be indicated in cases where the diagnosis is unclear or where other associated conditions and/or complications must be assessed. The gallbladder is well visualized, and the wall and contents can be assessed; however, stones may be difficult to identify. Associated hepatic conditions, pancreatitis, and complications such as an abscess formation and perforation of the gallbladder may be better assessed with a CT scan.
- Magnetic resonance cholangiopancreatography (MRCP) clearly shows the biliary-pancreatic tree, and it is being used increasingly instead of a diagnostic endoscopic retrograde choledochopancreatography (ERCP) to assess the biliary tree; cholecystokinin (CCK)-enhanced studies are more specific.
- Occasionally, percutaneous injection of contrast into the mass may be carried out to identify anatomical details.
Medical therapy
Do not consider a medical line of management with oral dissolution therapy in obstructed gallbladders. In acalculous hydrops observed in children as a part of a wider spectrum, expectant management may be considered.
Surgical therapy
Cholecystectomy is the definitive treatment of an obstructed gallbladder. Laparoscopic cholecystectomy is the criterion standard procedure. Open cholecystectomy may be performed in patients with very large gallbladders, those with greatly thickened walls, and those with an obliterated Calot triangle in whom laparoscopic dissection could be difficult and time consuming. In some patients, percutaneous (ultrasound-guided) or open cholecystostomy may be used as a temporary measure; cholecystostomy is usually performed in patients who are very sick or when the dissection is technically very difficult. A subsequent completion cholecystectomy may be carried out once the initial condition improves.
Preoperative details
In patients with systemic signs and symptoms, preoperative management should include correction of hydration, nasogastric drainage (if necessary), and appropriate broad-spectrum antibiotic therapy. Preferably, cholecystectomy is carried out in the same admission.
Intraoperative details
Intraoperative aspiration of the large gallbladder helps to facilitate grasping the gallbladder for dissection.
Intraoperative cholangiography is indicated, depending on clinical and investigative features that may suggest CBD obstruction.
- Progressive inflammation leads to acute cholecystitis and all its attendant manifestations.
- Bacterial contamination of the bile leads to an empyema of the gallbladder; the patient usually has a toxic and ill appearance. Gas-producing organisms may lead to an emphysematous gallbladder; air bubbles in the wall of the gallbladder are visualized on plain radiograph, ultrasound, or CT scan.
- Perforation of the gallbladder with ensuing pericholecystic abscess or fluid collection and peritonitis is another complication; the diagnosis is usually strongly suspected on clinical grounds. Pseudomyxoma peritonei may result from the rupture of a true mucocele of the gallbladder.
- Perforation of the gallbladder into the duodenum results in a cholecystoenteric fistula. This occurs when the stone erodes into adjacent bowel, usually the duodenum. Gas in the biliary tree may be evident on plain radiographs of the abdomen or on ultrasonography. If the stone is large, this may result in obstruction of the distal small bowel, leading to gallstone ileus.
- Large gallbladders may compress on the pylorus or duodenum, causing gastric outlet obstruction.
The prognosis is excellent if the diagnosis is correct and no complications have ensued. For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education article Gallstones.
| Media file 1:
Gallbladder mucocele. A 35-year-old woman presented with recurrent episodes of right upper quadrant (RUQ) colic. Her most recent attack was 3 days ago. Note the gross wall thickening; this is usually measured on the anterior wall of the gallbladder on ultrasound examination. Also note the clear content, the stone in the neck of the gallbladder, and the absence of pericholecystic fluid. All favor a diagnosis of acute cholecystitis. |
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Media type: CT
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| Media file 2:
Gallbladder mucocele. A stone in the neck of the gallbladder, with postacoustic shadowing, is clearly shown. Also, the minimal wall thickening and a dilated gallbladder suggest a mucocele. |
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Media type: CT
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| Media file 3:
Gallbladder mucocele. This transverse scan of the gallbladder shows a stone in the neck of the gallbladder, with postacoustic shadowing. Also, minimal wall thickening and a dilated gallbladder are visible (see Media file 2). |
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| Media file 4:
Gallbladder mucocele. These transverse scans of the gallbladder show layering of the gallbladder wall; this suggests edema and indicates an acute cholecystitis. |
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| Media file 5:
Gallbladder mucocele. This longitudinal scan shows layering with fluid in the wall of the gallbladder and an impacted stone in the neck of the gallbladder. The intraluminal shadowing indicates sediments in the fluid; this image indicates acute cholecystitis with a possible pyocele of the gallbladder. |
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Media type: CT
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| Media file 6:
This scan shows a cluster of impacted calculi in the neck of the gallbladder, minimal wall thickening, and clear content. This is indicative of a mucocele of the gallbladder. |
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Media type: CT
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| Media file 7:
This scan clearly shows a cluster of calculi with postacoustic shadowing in the neck of the gallbladder, normal wall, and clear content; this indicates a mucocele of the gallbladder. |
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Media type: CT
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| Media file 8:
Gallbladder mucocele. This perioperative photograph of a gallbladder shows a distended gallbladder with evidence of adhesions on the wall of the gallbladder. The irregular surface indicates recurrent attacks of cholecystitis. |
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| Media file 9:
Gallbladder mucocele. This intraoperative photograph shows a subserosal perforation of an acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. He presented with features suggestive of ileus. He had a high intrathoracic liver (and gallbladder), and clinical signs were atypical. The green color is unusual. |
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| Media file 10:
Gallbladder mucocele. This perioperative photograph of a gallbladder shows the inflamed mucosa in a gallbladder; note the stones. |
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| Media file 11:
Gallbladder mucocele. This perioperative photograph of a gallbladder in a patient with acute cholecystitis shows an inflamed, edematous gallbladder with areas of erythema and congestion. |
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| Media file 12:
Gallbladder mucocele. This intraoperative photograph shows a yellowish aspirate from the gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. The slightly yellowish fluid was sterile and was rich in cholesterol. |
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Gallbladder Mucocele excerpt Article Last Updated: Nov 8, 2007
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