RUQ Pain in 89F • Xray of the Week 2016 • Week #27
This 89 year old female presented to the Emergency Department with right upper quadrant abdominal pain. What is the differential diagnosis?
Fig. 1 CT: Diffuse gallbladder wall thickening with surrounding mesenteric infiltration and lymphadenopathy.
The patient underwent a cholecystectomy and the pathology was gallbladder carcinoma.
Fig. 2 CT: Diffuse gallbladder wall thickening with surrounding mesenteric infiltration (red arrow) and lymphadenopathy (blue arrow). The patient underwent a cholecystectomy and the pathology was gallbladder carcinoma.
Gallbladder carcinoma is an uncommon malignancy, which usually presents at an advanced stage. Greater than 90% of the histologic type is adenocarcinoma with squamous comprising most of the remainder. Most cases occur in the elderly population with F:M ratio of 4:1. At least 75% are associated with gallstones.
Fig. 3 Porcelain gallbladder. CT scan with dense calcification throughout the wall of the gallbladder.
Porcelain gallbladder (Fig. 3) is also highly correlated with gallbladder cancer as up to 25% of patients with diffuse calcification of the gallbladder wall go on to develop gallbladder cancer. Symptoms occur late in the disease and are usually related to local invasion resulting in biliary obstruction, gastric outlet obstruction or adjacent bowel obstruction. Prognosis is extremely poor with 5 year survival less than 5%.
Fig. 4 Left: Ultrasound with polypoid masses in the gallbladder. Right: Axial CT and MRI with contrast. Polypoid masses in the gallbladder.
Fig. 5 Axial CT with contrast. Large mass in the gallbladder fossa with direct extension and invasion of the adjacent liver. Case courtesy of Radswiki, a href=httpradiopaedia.orgRadiopaedia.orga. From the case a href=httpradiopaedia.orgcases11438rID 11438a
Imaging features on CT, MRI, and US include focal or diffuse gallbladder wall thickening or a polypoid mass in the gallbladder lumen. (Fig. 4) Due to late presentation, the majority of cases have a large mass replacing the gallbladder with direct extension to the liver and adjacent organs. (Fig.5) Biliary dilatation is present in close to half of cases. This case presented with diffuse gallbladder wall thickening (Fig.1), a nonspecific finding.
Differential diagnosis of diffuse gallbladder wall thickening includes acute and chronic cholecystitis, hepatic disease, hypoalbuminaemia, congestive heart failure, and adjacent inflammatory processes such as perforated duodenal ulcer or pancreatitis, diffuse adenomyomatosis of the gallbladder, and gallbladder carcinoma. In this case, the adjacent lymphadenopathy and mesenteric infiltration (Fig.2) are a clue to the diagnosis of gallbladder carcinoma.
1. Levy A, Murakata L, et-al. Gallbladder Carcinoma: Radiologic-Pathologic Correlation RadioGraphics 2001; 21:295–314
2. Furlan A, Ferris J, et-al. Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and Treatment Options. American Journal of Roentgenology. 2008;191: 1440-1447
3. Ralls PW, Quinn MF, Juttner HU et-al. Gallbladder wall thickening: patients without intrinsic gallbladder disease. AJR Am J Roentgenol. 1981;137 (1): 65-8.
4. Van breda vriesman AC, Engelbrecht MR, Smithuis RH et-al. Diffuse gallbladder wall thickening: differential diagnosis. AJR Am J Roentgenol. 2007;188 (2): 495-501.
Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and given as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice to launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field.
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