Article Search
검색
검색 팝업 닫기

Metrics

Help

  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

  • 2. Editorial Board

    Editor-in-Chief + MORE

    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
  • 3. Editorial Office
  • 4. Articles
  • 5. Instructions for Authors
  • 6. File Download (PDF version)
  • 7. Ethical Standards
  • 8. Peer Review

    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
    The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.

    The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.

Search

Search

Year

to

Article Type

Case Report

Split Viewer

Gallbladder Pseudodiverticulosis Mimicking a Multiseptate Gallbladder with Stones

Tae Hoon Lee, Sang-Heum Park*, Ji-Young Park, Chang-Kyun Lee, Il-Kwun Chung, Hong Soo Kim, and Sun-Joo Kim

Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Cheonan Hospital, Cheonan, Korea.

Correspondence to: Sang-Heum Park. Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, 23-20, Bongmyeong-dong, Cheonan 330-721, Korea. Tel: +82-41-570-3676, Fax: +82-41-574-5762, pparksh@sch.ac.kr

Received: February 13, 2009; Accepted: March 19, 2009

Gut Liver 2009;3(2):134-136

Published online June 30, 2009, Published Date June 30, 2009 https://doi.org/10.5009/gnl.2009.3.2.134

Copyright © Gut and Liver.

Gallbladder diverticula have the appearance of hernia-like protrusions of the gallbladder wall. This disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases. Gallbladder pseudodiverticula have an acquired cause, multiple fundal lesions, an association with gallstones, internal saccular lesions without external hernia-like protrusions, and little to no smooth muscle in the gallbladder wall. We report a unique anomaly of multiple pseudodiverticula presenting with calculous cholecystitis, which was pathologically different from true diverticula and had a unique shape similar to a bunch of grapes and a septation infilling pattern on endoscopic retrograde cholangiography.

Keywords: Gallbladder, Pseudodiverticulum

Diverticular diseases of the gallbladder are unusual congenital or acquired diseases occurring only in 0.1% to 0.2% of cases in previous studies of resected gallbladder specimens.1-3 These diseases are divided into congenital (true) diverticula and acquired pseudodiverticula according to different developmental, clinical, and pathological features.4,5

We describe a unique imaging case of pseudodiverticulosis of the gallbladder mimicking multiseptate gallbladder accompanied with multiple stones, as confirmed by surgical operation.

A 70-year-old woman presented with right upper quadrant abdominal pain radiating to the right lower abdomen; the pain had begun to aggravate the subject 8 to 9 hours earlier. Her medical history contained no significant events or diseases. Clinical examination revealed mild tenderness in the right upper quadrant of the abdomen. Laboratory tests revealed the followings: white blood cell count, 8.900×109/L; hemoglobin, 13.4 g/dL; amylase, 36 IU/L; aspartate aminotransferase, 42 U/L; alanine aminotransferase, 50 U/L; and alkaline phosphatase, 162 IU/L. Abdominal ultrasonography revealed multiple hyperechoic lesions in the gallbladder and linear septum-like structures in the fundus of the gallbladder. Subsequently, endoscopic retrograde cholangiography (ERC) was performed to evaluate the lesion; it showed multiple linear septated radiolucent defects and a diffusely scattered bunch of grape-like saccular filling defects in the elongated gallbladder (Fig. 1). Operative findings showed a normal outer surface of the elongated gallbladder without any protruding lesions fixed on the gallbladder fossa of the liver (Fig. 2). Grossly, multiple black stones and a round saccular lesion with an intervening septum-like structure were noted on the dissected gallbladder specimen (Fig. 3). Microscopic findings showed mucosal gland structures downsloping into a thin muscle layer (characteristically, the muscle layer is not thickened), which was different from adenomyomatosis (Fig. 4).

Gallbladder anomalies are diversely classified according to the shape and position of the Phrygian cap, multiseptation, and diverticula. ERC can be helpful in making a diagnosis and in the differentiation of these anomalous diseases. One septum or fold of the gallbladder between the fundus and the body is called the "Phrygian cap;" whereas, multiseptate gallbladders are characterized by multiple internal septa of various sizes, and a faintly bosselated external surface.6-8 Gallbladder diverticulum is an unusual congenital disease, which has the appearance of a hernia-like protrusion of the normal gallbladder wall. This disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases.1-3 Gallbladder pseudodiverticulum is a different type of adenomyomatosis pathologically, and can be differentiated from other similar anomalies based on some important factors. Pseudodiverticula have an acquired cause, multiple fundal lesions, an association with gallstones, internal saccular lesions without external hernia-like protrusions, and little to no smooth muscle in the gallbladder wall (Table 1).7,8

In our case, ERC revealed a unique shape similar to a bunch of grapes and a septation infilling pattern, contrasting with the fundus of a lengthened gallbladder. We found a multiseptate gallbladder; it was characterized by a "honeycomb" multicystic pattern and further characterized by multiple fixed lucent defects within an opacified gallbladder. However, operative findings showed a grossly normal gallbladder without any outpouches of the wall or inflammatory changes, and we could see multiple saccular outpouches internally with multiple gallstones when the gallbladder was opened. Histopathologic examination revealed multiple pseudodiverticula, which were characterized by multiple downslopings of the mucosal gland to a thin muscle layer of fundus. This lesion was different from the fundal type of lesion that is typical of adenomyomatosis or true diverticula, in terms of the definitive muscle thinness.

In summary, we diagnosed a unique, acquired anomaly of multiple pseudodiverticula presenting with calculous cholecystitis, which was pathologically different from true diverticula, adenomyomatosis, or multiseptate gallbladders.

Fig. 1.Endoscopic retrograde cholangiography showing multiple linear septated radiolucent defects and multiple variable-sized saccular filling defects in the gallbladder lumen.
Fig. 2.Operative finding of a dilated gallbladder with a normal outer surface and no outpouching lesions.
Fig. 3.Gross findings of a dissected specimen of gallbladder revealing multiple black stones and round saccular lesions with an intervening septum-like structure.
Fig. 4.Microscopic findings: (A) the muscular layer was not thickened (H&E stain, orig. mag. ×10), and (B) mucosal gland structures downsloping into the thin muscle layer were also evident (H&E stain, orig. mag. ×100).


Differential Diagnosis of Gallbladder Pseudodiverticulosis, Congenital Diverticula, and Adenomyomatosis


  1. Gross, RE. Congenital anomalies of the gallbladder; a review of one hundred and forty eight cases with report of a double gallbladder. Arch Surg, 1936;32;131-162.
  2. Kramer, AJ, Bregman, A, Zeddies, CA, Guynn, VL. Gallbladder diverticulum: a case report and review of the literature. Am Surg, 1998;64;298-301.
    Pubmed
  3. Williams, I, Slavin, G, Cox, A, Simpson, P, de Lacey, G. Diverticular disease (adenomyomatosis) of the gallbladder: a radiological-pathological survey. Br J Radiol, 1986;59;29-34.
    Pubmed
  4. Garg, P, Dass, B. Multiple diverticula of gall bladder. Indian J Gastroenterol, 1998;17;32-33.
    Pubmed
  5. Sirakov, M, Trichkov, V, Megdanski, Kh, M?rmarov, M, Trichkov, Zh. Diverticula and pseudodiverticula of the gallbladder in chronic calculous cholecystitis. Khirurgiia (Sofiia), 1996;49;35-36.
    Pubmed
  6. Foster, DR. Triple gall bladder. Br J Radiol, 1981;54;817-818.
    Pubmed
  7. Kramer, EL, Rumancik, WM, Harkavy, L, Tiu, S, Banner, HJ, Sanger, JJ. Hepatobiliary scintigraphy of the compartmentalized gallbladder. AJR Am J Roentgenol, 1985;145;1205-1206.
    Pubmed
  8. Edell, S. A comparison of the "phrygian cap" deformity with bistable and gray scale ultrasound. J Clin Ultrasound, 1978;6;34-35.
    Pubmed

Article

Case Report

Gut Liver 2009; 3(2): 134-136

Published online June 30, 2009 https://doi.org/10.5009/gnl.2009.3.2.134

Copyright © Gut and Liver.

Gallbladder Pseudodiverticulosis Mimicking a Multiseptate Gallbladder with Stones

Tae Hoon Lee, Sang-Heum Park*, Ji-Young Park, Chang-Kyun Lee, Il-Kwun Chung, Hong Soo Kim, and Sun-Joo Kim

Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Cheonan Hospital, Cheonan, Korea.

Correspondence to: Sang-Heum Park. Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, 23-20, Bongmyeong-dong, Cheonan 330-721, Korea. Tel: +82-41-570-3676, Fax: +82-41-574-5762, pparksh@sch.ac.kr

Received: February 13, 2009; Accepted: March 19, 2009

Abstract

Gallbladder diverticula have the appearance of hernia-like protrusions of the gallbladder wall. This disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases. Gallbladder pseudodiverticula have an acquired cause, multiple fundal lesions, an association with gallstones, internal saccular lesions without external hernia-like protrusions, and little to no smooth muscle in the gallbladder wall. We report a unique anomaly of multiple pseudodiverticula presenting with calculous cholecystitis, which was pathologically different from true diverticula and had a unique shape similar to a bunch of grapes and a septation infilling pattern on endoscopic retrograde cholangiography.

Keywords: Gallbladder, Pseudodiverticulum

INTRODUCTION

Diverticular diseases of the gallbladder are unusual congenital or acquired diseases occurring only in 0.1% to 0.2% of cases in previous studies of resected gallbladder specimens.1-3 These diseases are divided into congenital (true) diverticula and acquired pseudodiverticula according to different developmental, clinical, and pathological features.4,5

We describe a unique imaging case of pseudodiverticulosis of the gallbladder mimicking multiseptate gallbladder accompanied with multiple stones, as confirmed by surgical operation.

CASE REPORT

A 70-year-old woman presented with right upper quadrant abdominal pain radiating to the right lower abdomen; the pain had begun to aggravate the subject 8 to 9 hours earlier. Her medical history contained no significant events or diseases. Clinical examination revealed mild tenderness in the right upper quadrant of the abdomen. Laboratory tests revealed the followings: white blood cell count, 8.900×109/L; hemoglobin, 13.4 g/dL; amylase, 36 IU/L; aspartate aminotransferase, 42 U/L; alanine aminotransferase, 50 U/L; and alkaline phosphatase, 162 IU/L. Abdominal ultrasonography revealed multiple hyperechoic lesions in the gallbladder and linear septum-like structures in the fundus of the gallbladder. Subsequently, endoscopic retrograde cholangiography (ERC) was performed to evaluate the lesion; it showed multiple linear septated radiolucent defects and a diffusely scattered bunch of grape-like saccular filling defects in the elongated gallbladder (Fig. 1). Operative findings showed a normal outer surface of the elongated gallbladder without any protruding lesions fixed on the gallbladder fossa of the liver (Fig. 2). Grossly, multiple black stones and a round saccular lesion with an intervening septum-like structure were noted on the dissected gallbladder specimen (Fig. 3). Microscopic findings showed mucosal gland structures downsloping into a thin muscle layer (characteristically, the muscle layer is not thickened), which was different from adenomyomatosis (Fig. 4).

DISCUSSION

Gallbladder anomalies are diversely classified according to the shape and position of the Phrygian cap, multiseptation, and diverticula. ERC can be helpful in making a diagnosis and in the differentiation of these anomalous diseases. One septum or fold of the gallbladder between the fundus and the body is called the "Phrygian cap;" whereas, multiseptate gallbladders are characterized by multiple internal septa of various sizes, and a faintly bosselated external surface.6-8 Gallbladder diverticulum is an unusual congenital disease, which has the appearance of a hernia-like protrusion of the normal gallbladder wall. This disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases.1-3 Gallbladder pseudodiverticulum is a different type of adenomyomatosis pathologically, and can be differentiated from other similar anomalies based on some important factors. Pseudodiverticula have an acquired cause, multiple fundal lesions, an association with gallstones, internal saccular lesions without external hernia-like protrusions, and little to no smooth muscle in the gallbladder wall (Table 1).7,8

In our case, ERC revealed a unique shape similar to a bunch of grapes and a septation infilling pattern, contrasting with the fundus of a lengthened gallbladder. We found a multiseptate gallbladder; it was characterized by a "honeycomb" multicystic pattern and further characterized by multiple fixed lucent defects within an opacified gallbladder. However, operative findings showed a grossly normal gallbladder without any outpouches of the wall or inflammatory changes, and we could see multiple saccular outpouches internally with multiple gallstones when the gallbladder was opened. Histopathologic examination revealed multiple pseudodiverticula, which were characterized by multiple downslopings of the mucosal gland to a thin muscle layer of fundus. This lesion was different from the fundal type of lesion that is typical of adenomyomatosis or true diverticula, in terms of the definitive muscle thinness.

In summary, we diagnosed a unique, acquired anomaly of multiple pseudodiverticula presenting with calculous cholecystitis, which was pathologically different from true diverticula, adenomyomatosis, or multiseptate gallbladders.

Fig 1.

Figure 1.Endoscopic retrograde cholangiography showing multiple linear septated radiolucent defects and multiple variable-sized saccular filling defects in the gallbladder lumen.
Gut and Liver 2009; 3: 134-136https://doi.org/10.5009/gnl.2009.3.2.134

Fig 2.

Figure 2.Operative finding of a dilated gallbladder with a normal outer surface and no outpouching lesions.
Gut and Liver 2009; 3: 134-136https://doi.org/10.5009/gnl.2009.3.2.134

Fig 3.

Figure 3.Gross findings of a dissected specimen of gallbladder revealing multiple black stones and round saccular lesions with an intervening septum-like structure.
Gut and Liver 2009; 3: 134-136https://doi.org/10.5009/gnl.2009.3.2.134

Fig 4.

Figure 4.Microscopic findings: (A) the muscular layer was not thickened (H&E stain, orig. mag. ×10), and (B) mucosal gland structures downsloping into the thin muscle layer were also evident (H&E stain, orig. mag. ×100).
Gut and Liver 2009; 3: 134-136https://doi.org/10.5009/gnl.2009.3.2.134

Table 1 Differential Diagnosis of Gallbladder Pseudodiverticulosis, Congenital Diverticula, and Adenomyomatosis


References

  1. Gross, RE. Congenital anomalies of the gallbladder; a review of one hundred and forty eight cases with report of a double gallbladder. Arch Surg, 1936;32;131-162.
  2. Kramer, AJ, Bregman, A, Zeddies, CA, Guynn, VL. Gallbladder diverticulum: a case report and review of the literature. Am Surg, 1998;64;298-301.
    Pubmed
  3. Williams, I, Slavin, G, Cox, A, Simpson, P, de Lacey, G. Diverticular disease (adenomyomatosis) of the gallbladder: a radiological-pathological survey. Br J Radiol, 1986;59;29-34.
    Pubmed
  4. Garg, P, Dass, B. Multiple diverticula of gall bladder. Indian J Gastroenterol, 1998;17;32-33.
    Pubmed
  5. Sirakov, M, Trichkov, V, Megdanski, Kh, M?rmarov, M, Trichkov, Zh. Diverticula and pseudodiverticula of the gallbladder in chronic calculous cholecystitis. Khirurgiia (Sofiia), 1996;49;35-36.
    Pubmed
  6. Foster, DR. Triple gall bladder. Br J Radiol, 1981;54;817-818.
    Pubmed
  7. Kramer, EL, Rumancik, WM, Harkavy, L, Tiu, S, Banner, HJ, Sanger, JJ. Hepatobiliary scintigraphy of the compartmentalized gallbladder. AJR Am J Roentgenol, 1985;145;1205-1206.
    Pubmed
  8. Edell, S. A comparison of the "phrygian cap" deformity with bistable and gray scale ultrasound. J Clin Ultrasound, 1978;6;34-35.
    Pubmed
Gut and Liver

Vol.16 No.5
September, 2022

pISSN 1976-2283
eISSN 2005-1212

qrcode
qrcode

Share this article on :

  • line

Popular Keywords

Gut and LiverQR code Download
qr-code

Editorial Office