Chronic cholecystitis as polypoidal lesion on imaging.

Case contribution: Dr Radhiana Hassan

Clinical:

  • A 51 years old lady
  • Underlying hypertension and chronic rheumatic heart disease
  • Presented with abdominal pain for one month
  • Associated with post prandial vomiting
  • No fever. No jaundice.
Abdominal radiograph AP supine view
Enlarged annotated image from the abdominal radiograph

Radiographic findings:

  • Small stippled faint calcifications (red arrows) are observed at the lower edge of the liver, likely representing multiple gall stones.
  • The largest of these stones is measured at 0.5 cm.
  • Otherwise no other pathological calcification is detected.
  • The bowel gas pattern is non-specific and unremarkable.
  • There is no evidence of free intraperitoneal air or soft tissue mass.
Ultrasound of hepatobiliary system

Ultrasound findings:

  • Gallbladder is well distended.┬áThere is an irregular hypoechoic lesion seen arising from the anterior wall measuring about 1.3 cm x 1.8 cm. No intra-lesion vascularity detected on colour Doppler examination. This lesion does not move on patient manoeuvre.
  • There are also multiple tiny calculi within the gallbladder.
  • Gallbladder wall is regular and not thickened.
  • No pericholecystic fluid observed. No ascites.
  • No focal liver lesion is seen.
CT scan abdomen in axial plane soft tissue window; non-contrast (upper row) and contast-enhanced (lower row).

CT scan findings:

  • There is a solitary polypoidal lesion seen arising from the wall of gall bladder, measuring 1.3 x 0.8 x 1.0cm (AP x W x CC). The polyp demonstrates about similar degree of enhancement with the gall bladder wall (white arrows).
  • The gall bladder wall demonstrates smooth morphology, with no other polypoid lesion seen. No focal or diffuse thickening of the gall bladder wall seen.
  • Numerous tiny calculi can be seen layering within the dependent aspect of the gall bladder (yellow arrows).
  • No peri-cholecystic fluid detected.

HPE findings:

  • Macroscopy: specimen labelled as gallbladder consists of a surgically cut opened gallbladder measuring about 78x35x15 mm. Cut section shows multiple small blackish stone within the lumen measuring 1-2 mm in widest dimension. The gall bladder wall measures 2-7 mm in thickness. No malignancy or mass seen. Representative sections are submitted: neck, body, fundus and thickened gall bladder wall.
  • Microscopy: sections of gallbladder show mainly of devoid epithelial lining and replaced by granulation tissue formation with mild lymphoplasmacytic cells infiltrate. The muscular layer are hypertrophic with present of Rokitansky-Aschoff sinuses. The serosa layer is fibrotic. Negative for malignancy.
  • Interpretation: chronic cholecystitis.

Diagnosis: Chronic cholecystitis.

Discussion:

  • Chronic cholecystitis is prolong inflammatory condition that affects the gallbladder.
  • It is almost always seen in the setting of cholelithiasis (95%) caused by intermittent obstruction of the cystic duct or infundibulum or dysmotility.
  • The most commonly observed cross-sectional imaging finding are cholelithiasis and gall bladder wall thickening. The gall bladder may appear contracted or distended and pericholecystic inflammation is usually absent.
  • Polyoidal appearance is not a common feature of chronic cholecystitis.
Author: radhianahassan