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STRAWBERRY GALLBLADDER: A CASE REPORT

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Floret
Floret
Floret
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Balaji
Balaji
Balaji
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Alankrith Ramesh
Alankrith Ramesh
Alankrith Ramesh
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Abstract

BACKGROUND Cholesterolosis is an uncommon surgical condition characterized by abnormal and excessive deposition of cholesterol esters and triglycerides within the macrophages in gallbladder. Cholesterolosis is more common in females around 6th decade and relatively rare in young individuals. Cholesterolosis can occur due to increased uptake of cholesterol from supersaturated bile. Cholesterolosis need not necessarily show high levels of serum cholesterol levels or presence of cholesterol stones. This indicates that it is possible for a patient to develop cholesterolosis even in absence of risk factors presenting as acute cholecystitis, which warrants further need to understand this rare form of an uncommon disease. We present a young female who had complaints of only right hypochondrial pain first episode, she was diagnosed as cholecystitis clinically. Her ultrasound report showed multiple gallbladder polyps. She underwent elective laparoscopic cholecystectomy and postoperative recovery was uneventful. Her histopathological report revealed cholesterolosis with chronic calcific cholecystitis. Case presented for its occurrence at early age with no risk factor and it needs to be differentiated from gallbladder malignancy and other disorder of gallbladder where management differs.
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Jemds.com Case Report
J. Evolution Med. Dent. Sci./ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 05/ Issue 24/ Mar. 24, 2016 Page 1313
STRAWBERRY GALLBLADDER: A CASE REPORT
Floret Soundrapandian1, Balaji Durairaj2, Alankrith Ramesh Kashyap3, Reegan Jose4
1Professor, Department of General Surgery, SRM Medical College Hospital & Research Centre, Chennai.
2Assistant Professor, Department of General Surgery, SRM Medical College Hospital & Research Centre, Chennai.
3Post Graduate, Department of General Surgery, SRM Medical College Hospital & Research Centre, Chennai.
4Post Graduate, Department of General Surgery, SRM Medical College Hospital & Research Centre, Chennai.
ABSTRACT
BACKGROUND
Cholesterolosis is an uncommon surgical condition characterized by abnormal and excessive deposition of cholesterol esters and
triglycerides within the macrophages in gallbladder. Cholesterolosis is more common in females around 6 th decade and relatively
rare in young individuals. Cholesterolosis can occur due to increased uptake of cholesterol from supersaturated bile. Cholesterolosis
need not necessarily show high levels of serum cholesterol levels or presence of cholesterol stones. This indicates that it is possible
for a patient to develop cholesterolosis even in absence of risk factors presenting as acute cholecystitis, which warrants further need
to understand this rare form of an uncommon disease. We present a young female who had complaints of only right hypochondrial
pain first episode, she was diagnosed as cholecystitis clinically. Her ultrasound report showed multiple gal lbladder polyps. She
underwent elective laparoscopic cholecystectomy and postoperative recovery was uneventful. Her histopathological report revealed
cholesterolosis with chronic calcific cholecystitis. Case presented for its occurrence at early age with no risk factor and it needs to be
differentiated from gallbladder malignancy and other disorder of gallbladder where management differs.
KEYWORDS
Cholesterolosis, Strawberry Gallbladder, Cholecystitis.
HOW TO CITE THIS ARTICLE: Soundrapandian F, Durairaj B, Kashyap AR, et al. Strawberry gallbladder: a case report. J. Evolution
Med. Dent. Sci. 2016;5(24):1313-1314, DOI: 10.14260/jemds/2016/307
INTRODUCTION
CASE REPORT
A 20 yrs. old female was admitted with complaints of
intermittent right hypochondrial pain for 1 week. On
examination, tenderness in the right hypochondrium was
noted. She was afebrile and not icteric. No disturbances in
bowel and bladder habits. Vitals recorded were stable. Routine
blood investigations (Total Count: 7000 cells/cu.mm; Total
Bilirubin: 1 mg/dL; Indirect bilirubin: 0.2 mg/dL; Direct
bilirubin: 0.8 mg/dL; Total Protein: 8 g/dL; Albumin 5 g/dL)
and lipid profile (Total Cholesterol: 160 mg/dL; LDL: 90
mg/dL; HDL: 45 mg/dL) were within normal limits.
Her Ultrasound Abdomen Revealed
Multiple Gallbladder Polyps; Thickened Gallbladder Wall; No
Evidence of Calculi (Figure 1).
Fig. 1
Patient underwent elective laparoscopic cholecystectomy.
Financial or Other, Competing Interest: None.
Submission 09-02-2016, Peer Review 04-03-2016,
Acceptance 11-03-2016, Published 24-03- 2016.
Corresponding Author:
Dr. Alankrith Ramesh Kashyap,
Room 308, PG Medical Gents Hostel,
SRM College Hospital & Research Centre,
SRM Nagar, Kattankulathur, Chennai-603203,
E-mail: koolchant@gmail.com
DOI: 10.14260/jemds/2016/307
Intraoperative Findings
Gallbladder was found to be inflamed. Cut section of the
specimen showed congested, thickened GB wall with yellowish
deposits with multiple concretions free and adherent to
mucosa (Figure 2, 3).
Fig. 2 Fig. 3
Histopathology
Columnar epithelium with basally placed nucleus showing
mucosal prolapse into the muscularis – Chronic Calculous
Cholecystitis with Cholesterolosis (Figure 4, 5).
Fig. 4 Fig. 5
Jemds.com Case Report
J. Evolution Med. Dent. Sci./ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 05/ Issue 24/ Mar. 24, 2016 Page 1314
DISCUSSION
The pathogenesis of cholesterolosis is not very clear and
remains questionable, though many theories and studies have
been documented, thus making it difficult to accurately
calculate the incidence.1,2 One study involving 1319 autopsy
cases showed an incidence of 12.5%.3 Cholesterol polyps and
cholesterolosis may infrequently occur together.4 An
incidental finding related to fatty steatosis-lipid laden
macrophages in lamina propria of gallbladder epithelium is
cholesterolosis.2,5 In literature the incidence varies from 2.7%
to 28.6%.6 Though the pathogenesis is still an enigma and
many mechanisms in literature for the same have been
proposed; cholesterolosis can occur due to increased uptake of
cholesterol from supersaturated bile.2,5 Excessive stimulation
of cholesterol acyltransferase by biliary cholesterol can lead to
increased deposition of esterified cholesterol in the
gallbladder mucosa.6 Venous and lymphatic stasis disturbing
the secretive and absorptive functions of gallbladder
epithelium together with muscularis (Lamina) propria
dysfunction: G proteins are not activated when
cholecystokinin binds to receptors on smooth muscle cells in
cholelithiasis also play a role.6
Though cholesterolosis may be associated with
cholesterol stones and high serum cholesterol levels, there are
situations where they may not be so.1,6,7 Cholesterolosis can be
considered as a rare manifestation of persistently raised
serum cholesterol levels more common in obese individuals
and unhealthy lifestyle, such as alcohol intake and smoking.2,6,8
Macroscopically lipid deposits appear as yellow flecks against
dark background, thus earning the moniker ‘Strawberry
Gallbladder.2’ The diffuse variety of cholesterolosis appears as
a carpet of fine yellow papules over mucosa surface, whereas
polypoid variety shows single or multiple polyps.4 Patient
presentation can vary from asymptomatic (Most often) to pain
in right hypochondrium similar to or superadded with chronic
cholecystitis, pain occurring due to hypercontraction of
gallbladder or free floating debris causing intermittent biliary
colic.3,4 Ultrasound may show gallbladder polyps with or
without gallstones and biliary sludge.4 Laparoscopic
cholecystectomy is safe with add-on benefits of early
discharge, return to normal activity and good cosmetic
results.6
CONCLUSION
Cholesterolosis though cited in many archives remains a
benign ambiguous entity due to its inconclusive epidemiology,
controversial association with variety of diseases, viz.
hypercholesterolaemia, alcohol and smoking, cholelithiasis,
cholecystitis and relatively asymptomatic course, but safe and
potentially treatable with cholecystectomy.
REFERENCES
1. Mark Feldman, Lawrence S Friedman, Lawrence J
Brandt. Sleisenger and fordtran's gastrointestinal and
liver disease: pathophysiology, diagnosis, management.
2015;10:1157.
2. Robert D Odze, John R Goldblum. Odze and goldblum
surgical pathology of the GI tract, liver, biliary tract and
pancreas. 2014;1010.
3. Richard M Gore, Marc S Levine. Textbook of
Gastrointestinal radiology. 2014;1379.
4. Ljubicic N, Zovak M, Doko M, et al. Management of
gallbladder polyps: an optimal strategy proposed. Acta
clin Croat 2001;40:57-60.
5. Kumar V, Abbas AK, Fausto N Robins, et al. Pathologic
basis of disease. Elsevier publication, 2004;7:37, 930.
6. Khairy Gamal A, Guraya Salman Y, Murshid Khalid R.
Cholesterolosis. Incidence, correlation with serum
cholesterol level and role of laparoscopic
cholecysytectomy. Saudi Med J 2004;25(9):1226-8.
7. Méndez-Sánchez N, Tanimoto MA, Cobos E, et al.
Cholesterolosis is not associated with high cholesterol
levels in patients with and without gallstone disease. J
Clin Gastroenterol 1997;25(3):518-21.
8. Sandri L, Colecchia A, Larocca A, et al. Gallbladder
cholesterol polyps and cholesterolosis. Minerva
Gastroenterol Dietol 2003;49(3):217-24.
ResearchGate has not been able to resolve any citations for this publication.
Management of Gallbladder Polyps: An Optimal Strategy Proposed
Article
Full-text available
  • Mar 2001
  • ACTA CLIN CROAT
Polypoid lesions of the gallbladder can be divided into benign and malignant lesions. Benign polypoid lesions of the gallbladder are divided into tumors and pseudotumors. Pseudotumors make up the majority of polypoid lesions of the gallbladder. They can occur in the form of polyps, hyperplasia or other miscellaneous lesions. Adenomas are the most common benign neoplasms of the gallbladder. Ultrasound has been demonstrated to be significantly better in detecting polypoid lesions of the gallbladder as compared with computed tomography and cholecystography. Recommendations for an optimal strategy in the management of gallbladder polyps are presented. Generally, no treatment is required in a young patient with very small gallbladder polyps, who is completely free from symptoms. In patients with unequivocal recurrent biliary colic, elective cholecystotomy is warranted, especially in case of coexistence of stones and polyps. Cholecystectomy is also indicated in patients with gallbladder polyps greater than 10 mm, irrespective of symptomatology. In patients with gallbladder polypoid lesions smaller than 10 mm, cholecystectomy is only indicated if complicating factors are present, e.g., age ³ 50 and coexistence of gallstones. If a gallbladder polyp is smaller than 10 mm and if complicating factors are absent, the “watch-and-wait” strategy seems to be recommendable.
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Cholesterolosis Incidence correlation with serum cholesterol level and the role of laparoscopic cholecystectomy
Article
Full-text available
  • Sep 2004
To report the incidence of cholesterolosis in the surgically removed gallbladders, its association with serum cholesterol level and to review the role of laparoscopic cholecystectomy in the treatment. This retrospective study included all patients who had consecutive cholecystectomies for various gallbladder disorders, performed by 2 consultants during a 5-year period from January 1997 through to December 2002, in the College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. The clinical records of those found to have cholesterolosis on histopathological examination were reviewed, and the data were analyzed for their age, sex, fasting serum cholesterol level and the final outcome of cholecystectomy. The study group was comprised of 549 patients and out of which, 74 (13.4%) had cholesterolosis of the gallbladder. There were 59 (79.9%) female and 15 (20.1%) male patients. Age ranged from 18-64-years with a mean of 35.7-years. Sixty-three (85.1%) cases were reported to have abnormally high fasting serum cholesterol levels (>=5.5 mmol/L), whereas 11 (14.9%) had normal serum cholesterol level. Cholesterolosis with coexistent gallstones was documented in 47 (63.3%) patients while 27 (36.5%) subjects showed acalculous cholesterolosis. Laparoscopic cholecystectomy was performed in 71 (95.9%) individuals, whereas 3 patients ended up with open cholecystectomy (conversion rate of 4.2%). There were no postoperative complications. Cholesterolosis of the gallbladder is a distinct pathologic entity and carries a positive correlation with high serum cholesterol level. Laparoscopic cholecystectomy is effective, safe and a feasible treatment modality for cholesterolosis.
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Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas
Book
  • Jan 2009
This one-of-a-kind reference provides a comprehensive and practical guide to help you interpret endoscopic biopsies and resection specimens of all organs related to the digestive system. Plus, thanks to Expert Consult, you'll be able to access the entire contents of this title online and download all images, from anywhere there's an internet connection. The more than 2250 high quality illustrations, 30% more than in the first edition, help you recognize and diagnose any tissue sample under the microscope. Five new chapters, additional expert authors, expanded tables, and coverage of the current clinical approach to management and treatment options, particularly screening and surveillance recommendations for preneoplastic disorders, round out this unique reference. Acts as a one-stop resource for the entire gastrointestinal system, liver, biliary tract, and pancreas. Incorporates over 2250 high quality color illustrations so you can recognize and diagnose any tissue sample under the microscope. Provides all the necessary tools to make a comprehensive diagnostic workup including data from ancillary techniques and molecular findings whenever appropriate. Simplifies complex topics and streamlines decision-making using extensive tables, graphs, and flowcharts. Helps you avoid diagnostic errors thanks to practical advice on pitfalls in differential diagnosis. Uses a new "road map" at the beginning of each chapter, as well as a new, more clinical focus to help you navigate through the book more quickly. Reflects the latest classification and staging systems available so you can provide the clinician with the most accurate and up-to-date diagnostic and prognostic indicators, including key molecular aspects of tumor pathology. Includes access to the entire contents online, from anywhere there's an internet connection. Adds five new chapters including "Screening and Surveillance of the GI Tract", "Congenital and Developmental Disorders of the GI Tract", "Pediatric Enteropathies of the GI Tract", "Vascular Disorders of the GI Tract", and "Fatty Liver Disease". Expands appropriate chapters with new coverage of the normal histology of the GI tract, liver, biliary tract and pancreas. Uses expanded tables to outline specific differential diagnostic points helpful for surgical pathologists. Discusses the key molecular aspects of tumor progression and risk assessment in all chapters that cover neoplastic disorders. Helps you evaluate diagnostically challenging cases using diagnostic algorithms. Increases the number of high quality photographs by at least 30% to include even more normal and abnormal tissue samples. Updates all chapters to include the latest references, concepts, data, and controversies. Incorporates expanded coverage of the pancreas and liver, eliminating the need for a separate text. Your purchase entitles you to access the web site until the next edition is published, or until the current edition is no longer offered for sale by Elsevier, whichever occurs first. If the next edition is published less than one year after your purchase, you will be entitled to online access for one year from your date of purchase. Elsevier reserves the right to offer a suitable replacement product (such as a downloadable or CD-ROM-based electronic version) should access to the web site be discontinued.
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Cholesterolosis Is Not Associated With High Cholesterol Levels in Patients With and Without Gallstone Disease
Article
  • Oct 1997
High levels of cholesterol have been associated with certain gallbladder disorders such as cholesterolosis and gallstone disease. Furthermore, obesity is considered the main risk factor for cholesterol gallstone disease. We investigated the incidence of cholesterolosis in patients with and patients without gallbladder stones (GS). We reviewed the clinical records of patients with gallstone disease and other gallbladder disorders who had consecutive cholecystectomy during a 5-year period. We recorded demographic data, sex, age, serum cholesterol levels, and body mass index. The diagnosis of cholesterolosis was made macroscopically and microscopically. A total of 636 patients were included in this study: 446 with and 190 without GS. Cholesterolosis was more frequent in patients without GS (p < 0.01). However, hypercholesterolemia occurred more frequently in patients with GS (p < 0.001). Obese patients with GS had higher percentages of cholesterolosis and hypercholesterolemia than did eutrophic patients (p < 0.01 and p < 0.05, respectively). We suggest that cholesterolosis in the human gallbladder is not necessarily associated with gallstone disease and high plasma cholesterol levels.
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Gallbladder cholesterol polyps and cholesterolosis
Article
  • Oct 2003
Cholesterolosis of the gallbladder consists in an accumulation of cholesterol esters and triglycerides in the macrophages at gallbladder wall level and may be either diffuse or polypoid in form. A prevalence of 4-8% has been reported, particularly in the male sex; results concerning a relationship between cholesterolosis and lifestyle are controversial (alcohol intake, smoking habit), as well as the clinical and laboratory parameters, such as serum cholesterol and body mass index. Even more controversial is the relationship with gallstones which has been associated with the presence of cholesterol polyps only in a few surgical series. An increase in the activity of the cholesterol ester enzyme has been observed, in cholesterolosis patients, at gallbladder mucosa level which has led to the hypothesis of an increase in cholesterol ester deposit at this level; the hypothesis of an alteration in bile composition, in these patients, still remains to be elucidated. Ultrasonography is a sensitive tool in the diagnosis of cholesterolosis even if the use of echoendoscopy is becoming increasingly important in the differential diagnosis between benign and malignant polypoid lesions. Even if, in a few series, patients with polyps present a clinical pattern characterized by specific biliary symptoms, both in our experience and in that of others, symptoms are aspecific, the frequency of dyspeptic symptoms being comparable to that in the general population. The natural history of this lesion is, in general, benign and for polyps with size ranging from 6 mm to 10 mm a yearly follow-up with ultrasonography is advisable.
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