A case of mucinous cystic neoplasm of the gallbladder

The patient was a 70-year-old woman in whom examination revealed a high level of carbohydrate antigen 19-9. Abdominal ultrasonography and computed tomography (CT) revealed a multilocular cystic lesion compressing the gallbladder. CT indicated the presence of a multilocular cystic tumor (67?×?68?×?72 mm) in contact with the right hepatic lobe. Intraoperative findings indicated that the cyst diameter was 8.5?×?6.0 cm, and the cyst was continuous with the gallbladder. The gallbladder was resected along with the cyst. The cyst was multilocular and originated from the cystic duct and gallbladder wall. The cyst wall contained cuboidal to columnar mucin-producing epithelial cells and ovarian-like stroma (OS). The final diagnosis was mucinous cystic neoplasm (MCN) of the gallbladder with low-grade dysplasia. In the 2010 WHO classification of tumors of the digestive system, MCN have been newly defined as a type of hepatobiliary tract epithelial neoplasms. MCN of the gallbladder with OS is extremely rare. Only three cases have been published in the literature. The presence of OS is necessary for diagnosis of MCN.     

Post-cholecystectomy amputation neuroma of the common bile duct with obstructive jaundice

Amputation neuroma of the common bile duct after surgery is a rare and mostly asymptomatic lesion. A 60-year old patient presented with obstructive jaundice three months after a cholecystectomy for symptomatic gallstones. Imaging investigations showed common extrahepatic bile duct stenosis. Surgical resection of the stricture with biliodigestive anastomosis was performed. Histological examination of the surgical specimen revealed an amputation neuroma. Despite its rarity, amputation neuroma of the common bile duct should be considered in patients with post-cholecystectomy syndrome following liver or extrahepatic bile duct surgical procedures.     

Gallbladder carcinoma associated with occult pancreatobiliary reflux in the absence of pancreaticobiliary maljunction

We herein report a case of gallbladder carcinoma associated with occult pancreatobiliary reflux (PR) in the absence of pancreatobiliary maljunction. A 67‐year‐old woman was referred to our hospital for the evaluation and treatment of a gallbladder tumor. Ultrasonography and computed tomography showed a nodular lesion in the fundus of the gallbladder, indicating the possibility of a gallbladder carcinoma. Endoscopic ultrasonography showed the nodular tumor and thickness of the surrounding epithelium. Endoscopic retrograde cholangiopancreatography revealed a normal pancreaticobiliary junction without the common channel and a slight dilatation of the common bile duct (15 mm in diameter). An open cholecystectomy and partial resection of the liver bed of the gallbladder with regional lymphadenectomy was performed. A C‐tube was inserted from the cut end of the cystic duct into the common bile duct to prevent bile stasis. Biliary amylase and lipase levels sampled in the gallbladder were 2604 IU/l and 775 IU/l, respectively. Biliary amylase level in the bile collected from the C‐tube in the common bile duct was 119 550 IU/l on postoperative day (POD) 6 and 22 265 IU/l on POD 12. These observations suggested that PR was present in this patient. The histopathological findings of the resected specimen showed a well‐differentiated adenocarcinoma of the gallbladder with invasion to the muscle layer and no metastasis of the resected lymph nodes. A high index of nuclear staining for MIB‐I in the cancer cells (about 10%) was exhibited, and a few cells in the normal epithelium also stained positive.     

Definitive diagnosis of a duplicate gallbladder can only be made intraoperatively: report of a case

Duplicated gallbladders are rare congenital anomalies that are important in clinical practice as they may cause clinical, surgical, and diagnostic problems. Here, we describe the case of a 79-year-old female patient who presented with acute cholangitis. Abdominal ultrasonography, endoscopic ultrasonography, computed tomography, and magnetic resonance imaging revealed an intrahepatic cystic lesion, suggesting communication with the intrahepatic bile duct; no evidence of a polypoid lesion within the cystic lesion was observed. Based on these findings, intrahepatic cholangiectasis, intrahepatic bile duct cystadenoma, and the presence of a duplicated gallbladder were suspected, and surgery was performed. During surgery, a tube inserted into the common bile duct from a cystic duct facilitated intraoperative cholangiography, which indicated the presence of a duplicated gallbladder. Thus, we believe that a duplicated gallbladder should be an additional consideration when typical gallbladder disease symptoms are present under certain circumstances. A multimodal imaging approach can help to establish the diagnosis preoperatively or intraoperatively.     

Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.     

Primary sclerosing cholangitis successfully treated by resection of the confluence of the hepatic duct

Primary sclerosing cholangitis (PSC) is a cholestatic disease characterized by chronic inflammatory fibrosis of the extra- and intrahepatic bile ducts. Although the prognosis of patients with PSC was believed to be poor, some patients have not experienced the expected rapid clinical progression. A 51-year-old man with PSC was initially hospitalized for jaundice. Laboratory data showed low levels of the complement components C3, C4, and CH50. Percutaneous transhepatic biliary drainage was performed. Cholangiography revealed complete obstruction of the common bile duct below the confluence of the cystic duct. The confluence of the hepatic duct was resected and it was reconstructed by hepaticojejunostomy for palliation of the obstructive jaundice. Increased thickness of the walls of the common bile duct, right hepatic bile duct, and gallbladder was observed. Histopathological examination of the resected specimen revealed periductal fibrosis, with an onion-skin-like appearance. The patient is currently doing well, approximately 7 years after the surgery, without any signs of PSC recurrence. In this extraordinary patient, the laboratory data for C3, C4, and CH50 showed a complete return to normal levels. The positive results in this patient suggest that resection of the confluence of the hepatic duct may be an effective surgical treatment for noncirrhotic PSC patients who have dominant extrahepatic strictures.     

Cystic lymphangioma of the gall-bladder: A case report

Intra-abdominal cystic lymphangiomas are rare lesions that can be difficult to diagnose. We present a report of a patient with a giant multilocular cystic lesion in the abdomen. Ultrasonography and computed tomography scans of the abdomen revealed that the cyst had originated in the gallbladder fossa. There was some calcification and thickening of the cyst wall. Endoscopic retrograde cholangiopancreatography demonstrated a medially deviated common bile duct, an elongated cystic duct and an inferior compressed gallbladder. There was no apparent communication between the cyst and the biliary tract; however, an abdominal angiogram revealed that the lesion was supplied by a branch of the cystic artery. Histological findings obtained intra-operatively were consistent with a cystic lymphangioma. Its characteristic histology was observed in the subserous layer of the gall-bladder. This case is a rare instance of a cystic lymphangioma originating in the gall-bladder.     

Eosinophilic cholangitis: a case of 'malignant masquerade'

BackgroundA variety of causes of inflammatory bile duct stricture can masquerade as hilar cholangiocarcinoma. Eosinophilic cholangitis is a further example.Case outlineA 50-year-old woman with epigastric pain and deranged liver function was found to have a stricture of the common hepatic duct on ERCP with an associated mass on MRl.The lesion was excised with reconstruction of the right and left hepatic ducts, and the patient recovered well. Histopathological examination of the resected gallbladder and bile duct showed diffuse inflammation with a predominant eosinophil infiltrate.The presence of Candida albicans in the bile duct lumen can probably be attributed to the preoperative biliary stent.There was a modest postoperative rise in peripheral eosinophil count.DiscussionA literature search reveals only six previous cases of eosinophilic cholangitis, but similar infiltrates have also been seen in occasional cholecystectomy specimens. As the present patient did not have gallstones, the aetiology remains unclear. Peripheral eosinophilia is an unreliable clue to the diagnosis, which is usually likely to escape detection until the biliary stricture has been resected.     

A Rare Case of Biliobiliary Fistula

Abstract: Biliobiliary fistula is a rare clinical entity. The case of a 72 year old female, who presented with epigastric pain and jaundice, is detailed herein. Endoscopic retrograde cholangiopancreatography (ERCP) revealed two stones, one each in the common bile duct and the gallbladder. Continuous endoscopic nasobiliary drainage (ENBD) was performed to relieve obstructive jaundice. Further study with contrast medium administered via the ENBD tube revealed a fistula between the neck of the gallbladder and the common bile duct. The cystic duct was intact. A stone was considered to have migrated into the common bile duct through the fistula. A diagnosis of biliobiliary fistula, Corlette type I was made. However, in this particular case, a biliobiliary fistula was noted at a site below the junction of the cystic duct and common bile duct. Removal of the gallbladder stones was followed by cholecystectomy. The common bile duct was then repaired by utilizing a T-tube. No evidence of malignancy was recognized in the resected gallbladder specimen. In the one year to date since surgery, the patient has been asymptomatic and without signs of biliary disease.     

Triple carcinomas of the biliary tract associated with congenital choledochal dilatation and pancreaticobiliary maljunction

We report a rare case of triple carcinomas of the biliary tract associated with congenital choledochal dilatation (CCD) and pancreaticobiliary maljunction (PBM). The patient was a 58-year-old Japanese man who complained of epigastralgia. Ultrasonography and computed tomography revealed an elevated lesion inside the markedly dilated extrahepatic bile duct, thickening of the gallbladder wall, and small polypoid lesions in the gallbladder. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed CCD and PBM. With a diagnosis of carcinoma of the bile duct and cholesterol polyps in the gallbladder, pylorus-preserving pancreaticoduodenectomy was performed. The resected specimen showed two elevated lesions in the dilated bile duct, cholesterol polyps, and an area of irregular mucosa in the gallbladder. Histopathological examination showed two carcinomas in the bile duct, an adenosquamous cell carcinoma, and a moderately differentiated tubular adenocarcinoma, and a well differentiated tubular adenocarcinoma of the gallbladder. Two years and 6 months after the operation, a solitary metastatic liver tumor was detected. Left hepatic lobectomy was performed. At present, 7 months after the second operation, the patient is doing well with no signs of recurrence. Multiple carcinomas in the biliary tract associated with CCD and PBM, including the details in the present patient, were reviewed. Received: March 31, 1999 / Accepted: October 22, 1999     

Recurrent carcinoma of cystic duct remnant with subcutaneous implantation in abdominal wall

A case of recurrent carcinoma of the cystic duct remnant invading the common bile duct and portal vein with subcutaneous implantation of the abdominal wall is presented. The patient was a 55-year-old woman with an abdominal wall tumor at the site of the surgical scar of a cholecystectomy, performed at a local hospital 5 years ago for symptomatic cholelithiasis. The diagnosis was made by incisional biopsy of the tumor, computed tomography, percutaneous transhepatic cholangiography, and angiography. She underwent extended right hepatic lobectomy with en bloc resection of the caudate lobe, extrahepatic bile duct, and portal vein. The abdominal wall tumor was resected concomitantly. Histological examination showed that both the recurrent carcinoma of the cystic duct remnant and the abdominal wall implantation were moderately differentiated adenocarcinoma. This recurrence probably could have been prevented if both the macroscopic and microscopic examinations of the resected specimen had been precisely carried out after the previous cholecystectomy and the primary carcinoma identified and treated at that time.     

Severe dysplasia of the gallbladder associated with occult pancreatobiliary reflux

Pancreatobiliary reflux usually occurs in patients with pancreaticobiliary maljunction and can be associated with the occurrence of gallbladder carcinoma. We present the case of a patient with pancreatobiliary reflux despite having a normal pancreatobiliary junction (occult pancreatobiliary reflux; OPBR), in whom the resected gallbladder presented severe dysplasia. The patient, a 61-year-old woman, showed thickness of the gallbladder wall, detected by ultrasonography and computed temography (CT). Her biliary amylase level in the common bile duct was 103 000 IU/l, and in the gallbladder it was 153 500 IU/l, although endoscopic retrograde cholangiopancreatography revealed a normal pancreaticobiliary junction. Immunohistochemical staining showed many p53-positive nuclei in the dysplastic lesion, and about 50% of the dysplastic cells exhibited diffuse nuclear staining for Ki-67. In the present patient, early diagnosis of occult pancreatobiliary reflux led to early detection of a precancerous lesion of the gallbladder mucosa.     

Mucin-producing bile duct carcinoma originating at the hepatic hilus

We describe a mucin-producing bile duct carcinoma that was resected and analyzed pathologically. Endoscopic retrograde cholangiography disclosed amorphous filling defects in the dilated extrahepatic bile duct, suggesting that a large amount of mucin was excreted from the tumor. An intraductal amorphous filling defect showed shape change at different examination times. Pathology examination revealed a papillary tumor which showed mucus production, in the right hepatic duct. The cut section of the resected specimen showed a protuberant papillary lesion, measuring 14×14mm in diameter, forming a cystic mucous lake within the duct wall. Many cancer cells were also found in the mucous lake, the contents of which were strongly positive for mucin stain. The mucous lake developed laterally and communicated with the peribiliary glands, suggesting that the tumor had originated in these glands.     

An alternative surgical approach to a difficult case of Mirizzi syndrome： A case report and review of the literature

INTRODUCTION Mirizzi syndrome (MS) is a rare complication of long- standing cholelithiasis, which results from impaction of a large calculus or multiple small stones in the cystic duct or in the neck of the gallbladder causing extrinsic narrowing of the c…     

Gallbladder lymphangioma： A case report and review of the literature

Lymphangiomas are rare, benign tumors of the lymphatic system, usually present in children aged 5 years and younger. Because they are asymptomatic until the mass enlarges to cause symptoms, most lymphangiomas are diagnosed at adulthood incidentally. We experienced a case of a 60-year-old man diagnosed with a cystic lymphangioma of the gallbladder, which was successfully resected without any complication.Magnetic resonance imaging and magnetic resonance cholangiopancreatography were very helpful for the diagnosis of the cystic lesion around the gallbladder as were ultrasonography and computed tomography scan. These showed a multi-lobulated cystic mass with intact cystic duct and bile duct in the gallbladder fossa. The patient underwent an open cholecystectomy and the histological findings were consistent with a cystic lymphangioma of the gallbladder. We here report the case of cystic lymphangioma of the gallbladder with a review of the literature.     

An extrahepatic bile duct metastasis from a gallbladder cancer mimicking Mirizzi's syndrome

We report a case of an extrahepatic bile duct metastasis from a gallbladder cancer that mimicked Mirizzi's syndrome on cholangiography. A 67-yr-old woman was admitted to our hospital with a diagnosis of acute calculous cholecystitis. As obstructive jaundice developed after the admission, percutaneous transhepatic biliary drainage was performed to ameliorate the jaundice and to evaluate the biliary system. Tube cholangiography revealed bile duct obstruction at the hepatic hilus, and extrinsic compression of the lateral aspect of the common hepatic duct, with nonvisualization of the gallbladder. No impacted cystic duct stone was visualized on CT or ultrasonography. Laparotomy revealed a gallbladder tumor as well as an extrahepatic bile duct tumor. We diagnosed that the latter was a metastasis from the gallbladder cancer, based on the histopathological features. This case is unique in that the extrahepatic bile duct metastasis obstructed both the common hepatic duct and the cystic duct, giving the appearance of Mirizzi's syndrome on cholangiography. Metastatic bile duct tumors that mimic Mirizzi's syndrome have not been previously reported. The presence of this condition should be suspected in patients with the cholangiographic features of Mirizzi's syndrome, when the CT or ultrasonographic findings fail to demonstrate an impacted cystic duct stone.     

Recurrent liver tumor with intrabiliary ductal growth after hepatectomy for metastatic rectal cancer: Case report

A case of recurrent tumor with intrabiliary ductal growth after hepatic resection for liver metastasis from rectal cancer is presented. The patient, a 55-year-old female, underwent subsegmentectomy of the anteroinferior and posteroinferior areas of the liver for metastatic liver cancer on August 29, 1988. Computed tomography in February 1990 showed dilatation of the intrahepatic bile duct in the right anterosuperior subsegment (B8), in which a filling defect was detected by cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter. Percutaneous transhepatic cholangioscopy (PTCS) revealed a protruding lesion without tumor vessels. Cholangioscopic biopsy revealed dysplasia, but not adenocarcinoma. However, recurrent tumor originating in the resected margin of the remnant liver was suspected, and resection of the right lobe of the liver and partial resection of the duodenum were therefore performed. The resected specimen showed a tumor, 4 cm in diameter, in the previous resected margin, forming a protruding lesion with a rough surface (measuring 10×20 mm) in the B8 bile duct. This case suggested the possibility of cancer recurrence in the resected margin of the liver after hepatectomy for metastatic colorectal cancer, with intrabiliary ductal tumor growth showing segmental biliary dilatation.     

Multiple carcinoid tumors of the gallbladder and cystic duct

A very rare case of multiple carcinoid tumors of the gallbladder and cystic duct is reported in a 77-year-old woman. Cholecystectomy and resection of the common bile duct, with regional lymph node dissection, were performed. The tumors consisted of a large mass (30×20×15mm) in the neck of the gallbladder and three small lesions in the cystic duct. Histologically, the tumor cells were arranged in solid nests, and showed many mitoses. Histochemical studies revealed argyrophilic and argentaffinic staining. Immunohistochemically, the tumor cells were positive for serotonin, chromogranin A, Leu 7, synaptophysin, and neuron-specific enolase. Thus, the present case was diagnosed as midguttype carcinoids.     

A case of triple synchronous cancers occurring in the gallbladder,common bile duct,and pancreas

We report a 74-year-old man with triple synchronous cancers occurring in the gallbladder, common bile duct, and pancreas. The patient had consulted a nearby physician because of epigastralgia and icterus. On September 30, 1997, the patient was admitted to our department for further evaluation and treatment. Abdominal computed tomography (CT) showed dilatation of the common bile duct, cystic duct, and intrahepatic bile duct, and swelling of the gallbladder. On CT, the wall of the distal common bile duct was thick and a low-density mass was detected on the left side. Cholangiography, performed via percutaneous transhepatic cholangiodrainage (PTCD), revealed stenosis of the distal common bile duct. Endoscopic retrograde pancreatography (ERP) showed marked dilatation of the main pancreatic duct. On October 17, 1997, pancreatoduodenectomy was performed under the diagnosis of carcinoma of common bile duct and pancreas. Histopathological examination revealed poorly differentiated tubular adenocarcinoma of the common bile duct, well-differentiated tubular adenocarcinoma of the gallbladder, and mucinous cystadenocarcinoma of the pancreas. These three tumors were histopathologically different. Moreover, p53-positive nuclei were recognized only in the pancreas tumor. These findings suggested that the oncogenic mechanisms of multiple synchronous cancers were not the result of only abnormal DNA reparative mechanisms. Received: March 15, 2001 / Accepted: December 14, 2001 Reprint requests to: K. Sato     

A case of gallbladder adenomyomatosis with pancreaticobiliary maljunction and an anomaly of the cystic duct joined the common channel

A 46-yr-old woman was admitted to our hospital with mild epigastric pain. Ultrasonography and computed tomography revealed an extremely thickened gallbladder wall. Endoscopic retrograde cholangiopancreatography demonstrated that the main pancreatic duct joined the nondilated common bile duct at the outer point of the duodenal wall (P-C type of pancreaticobiliary maljunction), and the cystic duct joined the common channel directly. The intraoperative amylase levels of the bile juices both in the common bile duct and the cystic duct were high. A cholecystectomy was performed. The wall of the gallbladder was markedly thick, yellowish, elastic, and soft. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen. The diagnosis was a generalized type of adenomyomatosis. The pathogenesis of the adenomyomatosis was believed to result from chronic stimulation as a result of pancreatic juice reflux. The etiology of this unusual type of junction was considered to be the result of the combination of pancreaticobiliary maljunction and an anomaly of lower junction of the cystic duct.