Gallbladder Mucocele Workup

  • Author: Vijayaraghavan Rajagopalan, MBBS, MS, FRCS(Edin); Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jun 30, 2011
 

Laboratory 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 patients 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.[1, 2, 3]
Next

Imaging Studies

Ultrasonography, although entirely operator dependent, is extremely sensitive in detecting stones in the gallbladder, as shown in the images below. 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. Ultrasonographic Murphy sign may be positive. The wall may be thickened, and a small amount of pericholecystic fluid may be present in patients 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.[1, 3, 8]

A 35-year-old woman presented with recurrent episoA 35-year-old woman presented with recurrent episodes of right upper quadrant 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 ultrasonographic 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. A stone in the neck of the gallbladder, with postaA 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. This ultrasonographic transverse scan of the gallbThis ultrasonographic 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. These ultrasonographic transverse scans of the galThese ultrasonographic transverse scans of the gallbladder show layering of the gallbladder wall; this suggests edema and indicates an acute cholecystitis. This ultrasonographic longitudinal scan shows layeThis ultrasonographic 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. This ultrasonographic scan shows a cluster of impaThis ultrasonographic 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. This ultrasonographic scan clearly shows a clusterThis ultrasonographic 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.

Plain radiography 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.

Computed tomography (CT) scanning may be indicated in cases in which the diagnosis is unclear or in which 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 this modality is increasingly being used in place of 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 anatomic details.

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

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

Vijayaraghavan Rajagopalan, MBBS, MS, FRCS(Edin) is a member of the following medical societies: International College of Surgeons and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Michael A Grosso, MD  Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

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

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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. [Medline].

  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. Rosai J. Rosai and Ackerman's Surgical Pathology. vol 1. 9th ed. New York, NY: Mosby; 2004:1039.

  7. 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].

  8. 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].

  9. Vijayaraghavan R, Belagavi CS. Double gallbladder with different disease entities: a case report. J Min Access Surg. 2006;2:23-6. [Full Text].

  10. Majeed AW, Reed MW, Stephenson TJ, Johnson AG. Chemical ablation of the gallbladder. Br J Surg. May 1997;84(5):638-41. [Medline].

  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. [Medline].

  12. Popkharitov AI. Laparoscopic cholecystectomy for acute cholecystitis. Langenbecks Arch Surg. Nov 2008;393(6):935-41. [Medline].

  13. [Best Evidence] Gurusamy KS, Samraj K, Fusai G, et al. Robot assistant for laparoscopic cholecystectomy. Cochrane Database Syst Rev. Jan 21 2009;CD006578. [Medline].

  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. [Medline].

 
Previous
Next
 
A 35-year-old woman presented with recurrent episodes of right upper quadrant 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 ultrasonographic 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.
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.
This ultrasonographic 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.
These ultrasonographic transverse scans of the gallbladder show layering of the gallbladder wall; this suggests edema and indicates an acute cholecystitis.
This ultrasonographic 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.
This ultrasonographic 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.
This ultrasonographic 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.
This perioperative photograph shows a distended gallbladder with evidence of adhesions on its wall. The irregular surface indicates recurrent attacks of cholecystitis.
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.
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
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.