Gallbladder Mucocele Treatment & Management
- Author: Vijayaraghavan Rajagopalan, MBBS, MS, FRCS(Edin); Chief Editor: John Geibel, MD, DSc, MA more...
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 for an obstructed gallbladder. Laparoscopic cholecystectomy 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 RUQ pain and a positive HIDA scan, symptom relief is more likely to occur following cholecystectomy than it is after medical treatment.[14] )
Open cholecystectomy may be performed in patients with a very large gallbladder, with greatly thickened gallbladder walls, and with an obliterated Calot triangle, in whom laparoscopic dissection could be difficult and time-consuming.
In some patients, percutaneous (ultrasonographically 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.[1]
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.
Complications
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 (see the image below); air bubbles in the wall of the gallbladder are visualized using plain radiography, ultrasonography, or CT scanning.
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. 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 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]
Outcome and Prognosis
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.
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