Gallbladder Mucocele

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Practice Essentials

The term gallbladder mucocele refers to an overdistended gallbladder filled with mucoid or clear and watery content. Usually noninflammatory, it results from outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct.

Signs and symptoms

Symptoms of a gallbladder mucocele include the following:

The following suggest other conditions:

Physical findings include the following:

See Presentation for more detail.

Diagnosis

Laboratory studies that may be helpful include the following:

Imaging modalities that may be considered include the following:

See Workup for more detail.

Management

Surgery is definitive treatment for gallbladder obstruction, and no absolute contraindication to such treatment exists. However, the following factors may be considered:

Surgical options include the following:

See Treatment for more detail.

Image library


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Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.

Background

Mucocele (hydrops) of the gallbladder is a term denoting an overdistended gallbladder filled with mucoid or clear and watery content. The condition can result from gallstone disease, the most common affliction of the biliary system. Gallstone disease affects 15-20% of the US population, with nearly 1 million new cases reported annually.[1, 2, 3]

The gallbladder mucocele distention, which is usually noninflammatory, 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.[1, 2, 4, 5]

No single laboratory test is diagnostic of a gallbladder mucocele. However, laboratory workup should include all tests performed for acute cholecystitis. Ultrasonography is extremely sensitive in detecting stones in the gallbladder; other imaging modalities may be helpful in certain circumstances (see Workup).

Cholecystectomy is the definitive treatment for an obstructed gallbladder. Medical approaches may be considered in specific circumstances (see Treatment).

For patient education resources, see the Digestive Disorders Center and the Cholesterol Center, as well as Gallstones.

Pathophysiology

Long-standing obstruction to the gallbladder’s outflow results in overdistention of the gallbladder; occasionally, the gallbladder assumes massive proportions, and its volume may reach 1.5 L. 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 gallbladder wall may be of normal thickness, though in long-standing cases, the mucosa atrophies and the wall becomes thin, sometimes even transparent. Wall thickening can occur with recurrent attacks of cholecystitis (see the image below). The contents are usually sterile, and any bacterial contamination ends in empyema of the gallbladder.


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Distended gallbladder with evidence of adhesions on its wall. Irregular surface indicates recurrent attacks of cholecystitis.

Gross overdistention may result in gangrene 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.[1, 2, 4]

Etiology

Causes of gallbladder mucoceles include the following:

In infants and children, acute, acalculous, noninflammatory hydrops of the gallbladder may be associated with the following:

Epidemiology

About 3% of all pathologic gallbladders in adults are mucoceles. Because different authors use varying criteria to define the condition, the true prevalence of gallbladder mucocele may be higher.[1, 2, 7] Some reports indicate that an association could exist between mucoceles and solitary stones of the gallbladder.[8]

Prognosis

The prognosis is excellent if the diagnosis is correct and no complications have ensued.

Complications may develop when progressive inflammation leads to acute cholecystitis and all its attendant manifestations.

In addition, bacterial contamination of the bile can lead to empyema of the gallbladder, in which case the patient will usually have a toxic and ill appearance. Gas-producing organisms may lead to an emphysematous gallbladder; air bubbles in the wall of the gallbladder can be visualized by means of plain radiography, ultrasonography, or computed tomography (CT).

Another potential complication is perforation of the gallbladder (see the first image below) with ensuing pericholecystic abscess or fluid collection and peritonitis (see the second image below); the diagnosis is usually strongly suspected on clinical grounds. Pseudomyxoma peritonei may result from the rupture of a true mucocele of the gallbladder.


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Subserosal perforation of acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. Patient presented with features suggestive of ....


View Image

Yellowish aspirate from gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. Slightly yellowish fluid w....

Perforation of the gallbladder into the intestinal tract results in a cholecystenteric 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 ultrasonograms. If the stone is large, this may result in obstruction of the distal small bowel, leading to gallstone ileus.

Large gallbladders may compress the pylorus or duodenum, causing gastric outlet obstruction.[1, 9]

History and Physical Examination

Typical symptoms of a gallbladder mucocele include the following:

Continuance of pain or persistence of tenderness for 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 when there is coexisting obstruction of the common bile duct (CBD), either by stones or by extrinsic compression (Mirizzi syndrome).

Typically, minimal acute inflammatory signs are present. A large, palpable, somewhat (albeit usually minimally) tender mass is usual; at times, the gallbladder may even be felt down in the pelvis.[1, 2, 3, 8, 9]

Laboratory Studies

No single laboratory test is diagnostic of a mucocele. However, laboratory workup should include all tests performed for acute cholecystitis. Typical findings include the following:

Ultrasonography

Ultrasonography, though entirely operator-dependent, is extremely sensitive in detecting stones in the gallbladder. A grossly distended, thin-walled gallbladder measuring more than 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 (see the images below). The ultrasonographic Murphy sign may be positive.


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Stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder suggest mucocele.


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Transverse scan shows stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder are also visible.


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Cluster of impacted calculi in neck of gallbladder, minimal wall thickening, and clear content; this indicates mucocele of gallbladder.


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Cluster of calculi with postacoustic shadowing in neck of gallbladder, normal wall, and clear content; this indicates mucocele of gallbladder.

The wall may be thickened, and a small amount of pericholecystic fluid may be present in patients with acute cholecystitis (see first and second images below). Gross wall thickening and murky, thick fluid with sediments and a pericholecystic collection suggest an empyema or pyocele of the gallbladder (see third image below). Ultrasonography is also useful in identifying ductal obstruction and is extremely sensitive in identifying intrahepatic biliary tree dilatation.[1, 3, 6]


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Image is from a 35-year-old woman who presented with recurrent episodes of right upper quadrant colic; most recent attack was 3 days before. Gross wal....


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Transverse scans show layering of gallbladder wall; this suggests edema and indicates acute cholecystitis.


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Longitudinal scan shows layering, with fluid in wall of gallbladder and impacted stone in neck of gallbladder. Intraluminal shadowing indicates sedime....

Other Imaging Studies

Plain radiography of the abdomen may show a soft-tissue–density shadow with an intraluminal calcific shadow in the subhepatic region. By itself, this finding is nonspecific; it should be used only as a guideline in the differential diagnosis.

Scintigraphy (hepato-iminodiacetic acid [HIDA] scanning) may be indicated in obscure cases, though it can offer only indirect evidence. Nonvisualization of the gallbladder indicates an obstructed gallbladder and possible acute cholecystitis; nonvisualization in the small intestine indicates CBD obstruction.

Computed tomography (CT) may be indicated in cases where the diagnosis is unclear or where there are other associated conditions or complications that must be assessed. The gallbladder is well visualized on CT scanning, and the wall and contents are readily assessed; however, stones may be difficult to identify. The best use of CT may lie in the evaluation of associated hepatic conditions, pancreatitis, and complications such as abscess formation or perforation of the gallbladder.

Magnetic resonance cholangiopancreatography (MRCP) clearly shows the biliary-pancreatic tree, and it is increasingly being used in place of diagnostic endoscopic retrograde cholangiopancreatography (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 anatomic details.

Approach Considerations

Contraindications to surgical treatment of gallbladder mucocele would obviously include any associated medical conditions or illnesses that preclude surgery. No absolute contraindication to surgical treatment exists.

Laboratory research suggests that chemical ablation of the gallbladder mucosa may 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.[1, 2, 3, 10]

A medical line of management with oral dissolution therapy should not be considered in patients with obstructed gallbladders. In acalculous hydrops observed in children as a part of a wider spectrum, expectant management may be considered.

Cholecystectomy and Cholecystostomy

Cholecystectomy is the definitive treatment for an obstructed gallbladder. Laparoscopic cholecystectomy (see the images below) is the criterion standard procedure.[11, 12, 13] A 2009 study derived from database information and a literature review found evidence that even when gallstones are absent in patients with right upper quadrant (RUQ) pain and a positive hepato-iminodiacetic acid (HIDA) scan, symptom relief is more likely to occur after cholecystectomy than it is after medical treatment.[14]


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Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.


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Stone being extracted from cystic duct through small ductotomy.

Open cholecystectomy may be performed in patients who have a very large gallbladder, greatly thickened gallbladder walls, or an obliterated triangle of Calot. In such cases, laparoscopic dissection may be difficult and time-consuming.

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 during the same admission.

Intraoperative aspiration of the large gallbladder helps facilitate grasping the gallbladder for dissection. The aspirate is clear and watery or mucoid (white bile). Intraoperative cholangiography may be indicated, depending on clinical and investigative features that may suggest obstruction of the common bile duct.

Upon being opened, the gallbladder shows a white wall, clear and watery or mucoid content, a stone or stones impacted in the neck or cystic duct, a narrowed cystic duct, or a tumor or polyp causing obstruction of the neck of the gallbladder.

In some patients, percutaneous (ultrasonographically guided) or open cholecystostomy may be used as a temporary measure. Cholecystostomy is usually performed in cases where the patient is very sick or the dissection is technically very difficult; in such instances if the surgeon is an expert, laparoscopic subtotal cholecystectomy also can be performed. A subsequent completion cholecystectomy may be carried out once the patient’s initial condition improves.[1]

Author

R Vijayaraghavan, MBBS, MS, FRCS(Edin), Consultant General and Laparoscopic Surgeon, Department of Surgery, RMV Hospital, India

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

Additional Contributors

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

  1. Agrawal S, Jonnalagadda S. Gallstones, from gallbladder to gut. Management options for diverse complications. Postgrad Med. Sep 1 2000;108(3):143-6, 149-53. [View Abstract]
  2. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver disease. 6th ed. Philadelphia, Pa: WB Saunders Company; 1998.
  3. Rosen P, Barkin R. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book Inc; 1998.
  4. Damjanov I, Linder J. Diseases of the digestive system: gallbladder and extrahepatic ducts. In: Anderson's Pathology. vol 2. 10th ed. St. Louis, Mo: Mosby-Year Book; 1996.
  5. Wight DGD, Symmers WS, eds. Systemic pathology. In: The Liver, Biliary Tract and Exocrine Pancreas. vol 11. 3rd ed. Philadelphia, Pa: Churchill Livingstone; 1994.
  6. Maurer K, Unsinn KM, Waltner-Romen M, et al. Segmental bowel-wall thickening on abdominal ultrasonography: an additional diagnostic sign in Kawasaki disease. Pediatr Radiol. Sep 2008;38(9):1013-6. [View Abstract]
  7. Rosai J. Rosai and Ackerman's Surgical Pathology. vol 1. 9th ed. New York, NY: Mosby; 2004:1039.
  8. Mofti AB, Al-Momen A, Suleiman SI, et al. The single gallbladder stone - is it innocent?. Ann Saudi Med. Nov 1994;14(6):471-3. [View Abstract]
  9. Vijayaraghavan R, Belagavi CS. Double gallbladder with different disease entities: a case report. J Min Access Surg. 2006;2:23-6.
  10. Majeed AW, Reed MW, Stephenson TJ, Johnson AG. Chemical ablation of the gallbladder. Br J Surg. May 1997;84(5):638-41. [View Abstract]
  11. Georgiades CP, Mavromatis TN, Kourlaba GC, et al. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy?. Surg Endosc. Sep 2008;22(9):1959-64. [View Abstract]
  12. Popkharitov AI. Laparoscopic cholecystectomy for acute cholecystitis. Langenbecks Arch Surg. Nov 2008;393(6):935-41. [View Abstract]
  13. [Best Evidence] Gurusamy KS, Samraj K, Fusai G, et al. Robot assistant for laparoscopic cholecystectomy. Cochrane Database Syst Rev. Jan 21 2009;CD006578. [View Abstract]
  14. [Best Evidence] Mahid SS, Jafri NS, Brangers BC, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. Feb 2009;144(2):180-7. [View Abstract]

Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.

Distended gallbladder with evidence of adhesions on its wall. Irregular surface indicates recurrent attacks of cholecystitis.

Subserosal perforation of acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. Patient presented with features suggestive of ileus. He had high intrathoracic liver (and gallbladder), and clinical signs were atypical. Green color is unusual.

Yellowish aspirate from gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. Slightly yellowish fluid was sterile and was rich in cholesterol.

Stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder suggest mucocele.

Transverse scan shows stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder are also visible.

Cluster of impacted calculi in neck of gallbladder, minimal wall thickening, and clear content; this indicates mucocele of gallbladder.

Cluster of calculi with postacoustic shadowing in neck of gallbladder, normal wall, and clear content; this indicates mucocele of gallbladder.

Image is from a 35-year-old woman who presented with recurrent episodes of right upper quadrant colic; most recent attack was 3 days before. Gross wall thickening is apparent; this is usually measured on anterior wall of gallbladder. Also apparent are clear content, stone in neck of gallbladder, and absence of pericholecystic fluid. All favor diagnosis of acute cholecystitis.

Transverse scans show layering of gallbladder wall; this suggests edema and indicates acute cholecystitis.

Longitudinal scan shows layering, with fluid in wall of gallbladder and impacted stone in neck of gallbladder. Intraluminal shadowing indicates sediments in fluid; image indicates acute cholecystitis with possible pyocele of gallbladder.

Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.

Stone being extracted from cystic duct through small ductotomy.

Image is from a 35-year-old woman who presented with recurrent episodes of right upper quadrant colic; most recent attack was 3 days before. Gross wall thickening is apparent; this is usually measured on anterior wall of gallbladder. Also apparent are clear content, stone in neck of gallbladder, and absence of pericholecystic fluid. All favor diagnosis of acute cholecystitis.

Stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder suggest mucocele.

Transverse scan shows stone in neck of gallbladder, with postacoustic shadowing. Minimal wall thickening and dilated gallbladder are also visible.

Transverse scans show layering of gallbladder wall; this suggests edema and indicates acute cholecystitis.

Longitudinal scan shows layering, with fluid in wall of gallbladder and impacted stone in neck of gallbladder. Intraluminal shadowing indicates sediments in fluid; image indicates acute cholecystitis with possible pyocele of gallbladder.

Cluster of impacted calculi in neck of gallbladder, minimal wall thickening, and clear content; this indicates mucocele of gallbladder.

Cluster of calculi with postacoustic shadowing in neck of gallbladder, normal wall, and clear content; this indicates mucocele of gallbladder.

Distended gallbladder with evidence of adhesions on its wall. Irregular surface indicates recurrent attacks of cholecystitis.

Yellowish aspirate from gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. Slightly yellowish fluid was sterile and was rich in cholesterol.

Subserosal perforation of acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. Patient presented with features suggestive of ileus. He had high intrathoracic liver (and gallbladder), and clinical signs were atypical. Green color is unusual.

Laparoscopic view of distended gallbladder in woman aged 70 years with sudden onset of severe right upper abdominal pain.

Stone being extracted from cystic duct through small ductotomy.