Introduction
Mucocele, or hydrops, of the gallbladder describes an overdistended gallbladder filled with mucoid or clear and watery content, as shown in the image below. 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
This perioperative photograph shows a distended gallbladder with evidence of adhesions on its wall. The irregular surface indicates recurrent attacks of cholecystitis.
Problem
The gallbladder mucocele distension, 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, as illustrated in the images below.1,2,4,5
Laparoscopic view of a distended gallbladder in a woman aged 70 years with sudden onset of severe right upper abdominal pain
Note the stone being extracted out of the cystic duct through a small ductotomy. This was the cause of the mucocele in the gallbladder shown in the previous photograph
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.1,2,6
Reports indicate that an association could exist between mucoceles and solitary stones of the gallbladder.7
Etiology
Causes of gallbladder mucocele 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 by 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)8
- 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 gallbladder's outflow 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 gallbladder wall may be of normal thickness, although 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, as illustrated in the images below.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.
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.
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
Presentation
Symptomatology of a gallbladder mucocele 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.1,2,3,7,9
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 and 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.
Indications
See Surgical Therapy.
Relevant Anatomy
See Pathophysiology.
Contraindications
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.1,2,3,10
More on Gallbladder Mucocele |
 Overview: Gallbladder Mucocele |
| Workup: Gallbladder Mucocele |
| Treatment: Gallbladder Mucocele |
| Follow-up: Gallbladder Mucocele |
| Multimedia: Gallbladder Mucocele |
| References |
| Further Reading |
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References
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. [Medline].
Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver disease. 6th ed. Philadelphia, Pa: WB Saunders Company; 1998.
Rosen P, Barkin R. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book Inc; 1998.
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.
Wight DGD, Symmers WS, eds. Systemic pathology. In: The Liver, Biliary Tract and Exocrine Pancreas. vol 11. 3rd ed. Philadelphia, Pa: Churchill Livingstone; 1994.
Rosai J. Rosai and Ackerman's Surgical Pathology. vol 1. 9th ed. New York, NY: Mosby; 2004:1039.
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. [Medline].
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. [Medline].
Vijayaraghavan R, Belagavi CS. Double gallbladder with different disease entities: a case report. J Min Access Surg. 2006;2:23-6. [Full Text].
Majeed AW, Reed MW, Stephenson TJ, Johnson AG. Chemical ablation of the gallbladder. Br J Surg. May 1997;84(5):638-41. [Medline].
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. [Medline].
Popkharitov AI. Laparoscopic cholecystectomy for acute cholecystitis. Langenbecks Arch Surg. Nov 2008;393(6):935-41. [Medline].
[Best Evidence] Gurusamy KS, Samraj K, Fusai G, et al. Robot assistant for laparoscopic cholecystectomy. Cochrane Database Syst Rev. Jan 21 2009;CD006578. [Medline].
[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. [Medline].
Further Reading
Related eMedicine topics:
Bedside Ultrasonography, Gallbladder Disease
Cholecystitis [Gastroenterology]
Cholecystitis [Pediatrics: General Medicine]
Cholecystitis, Acalculous
Cholecystitis, Acute
Cholecystitis and Biliary Colic
Cholelithiasis [Emergency Medicine]
Cholelithiasis [Gastroenterology]
Cholelithiasis [Pediatrics: General Medicine]
Cholelithiasis [Radiology]
Emphysematous Cholecystitis
Empyema, Gallbladder
Gallbladder Disease
Mirizzi Syndrome
Postcholecystectomy Syndrome
Clinical guidelines:
ACR Appropriateness Criteria® right upper quadrant pain
ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas
Clinical trials:
Minimally Invasive Surgery: Using Natural Orifices (NOTES)
Minimally Invasive Surgery: Using Natural Orifice Translumenal Endoscopic Surgery (NOTES)
NOTES-Assisted Laparoscopic Cholecystectomy Surgery
Study of Pain Perception Between Males and Females Following Laparoscopic Cholecystectomy
Keywords
gallbladder mucocele, gallbladder, gallstones, gallstone, cholecystectomy, cholecystitis, gall stones, gallbladder disease, gallbladder surgery, gallbladder removal, cholelithiasis, gall bladder surgery, gall stone, HIDA scan, cystic duct, gallbladder hydrops, hydrops of the gallbladder, gallstone disease, overdistended gallbladder filled with mucoid or clear and watery content, outlet obstruction of the gallbladder
