GB Mucocele: It’s Not About The Kiwi!: Our Case Of The Month November 2014

The ill-defined fat tells the sonographer where the primary pathology lies. In this case the adhesion pattern and more pronounced inflammation is attached to the GB with some ill defined echos extending to the pancreas. The + Murphy sign (pain upon imaging) noted by the sonographer was also key to recognizing the urgency of the presentation. The patient was on the surgical table approximately 3 hours after the text message was received notifying the specialist of the urgency.

Unfortunately a couple of articles that discuss Gall Bladder (GB) mucoceles talk about a “Kiwi” shape and that image stuck in many minds as an absolute necessity to call a GB a mucocele. But if you live by the U/S probe and check the SonoPath archive of hundreds of mucocele/surgical biliary cases like this one, you really have to have an imaginascope to derive “fruitful” images from the GB presentation with these patients. Especially when a GB leaks or perforates; it acts like a “flat tire” resembling a “smashed kiwi” or a “rotten tomato” perhaps. If you don’t forget about the “fruit” & make your move answering the ubiquitous question “What does this?”,  you may end up with a dead patient from bile peritonitis. These cases can be difficult to image because the echoes are ill-defined from all the omental inflammation that surrounds the GB, cystic duct, portal hilus, and often the pancreas with the presentation being misdiagnosed often as “pancreatitis” especially when the liver enzymes are not aggressive in the profile like this case. The CBC/Chem panel is often not exciting like this Labrador had on presentation with only a mild SAP and minor leukocytosis elevation with NORMAL Bili and ALT. Essentially the liver spills the enzymes not the GB, as the GB is mostly a fibrous and somehwat secretory structure. So, if the liver parenchyma is not affected and the body is largely “walling off” the infected mucocele with its omental band-aid, there is little to spill into the bloodstream as markers for us to detect on our blood work. That’s my island of pathology theory anyway derived from what’s in the sonopath archive and years of experience dealing wiht these cases in the field. Take a look for yourself and draw your own conclusions. Its all on line 24/7 for members. Still skeptical? Take a look at our GB mucocele survey from 8 experienced sonographers on how they manage GB mucoceles as well as our surgical biliary study showing only 25% of surgical biliary disease cases have clinical icterus. (http://sonopath.com/resources/research-publications). Interesting findings to remind us to rely on the probe, clinical intuition, perhaps the sonopath archive & forum (http://sonopath.com/signup), and forget about the ‘fruit” and go with your gut. In the end that’s what the pet owners come to use for; our “gut feeling” to do the right thing for their pet.