E0082 - A Striking Case of Mucinous Gallbladder Adenocarcinoma Mimicking Mirizzi’s Syndrome

Tuesday, October 25, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Natalie Savini, BS, MD

Scripps Green Internal Medicine Residency Program
San Diego, CA

Natalie Savini, BS, MD¹, David Leung, MD², Ki-Yoon Kim, MD³, Ali Y. Fakhreddine, MD⁴
¹Scripps Green Internal Medicine Residency Program, San Diego, CA; ²Scripps Green-Scripps Clinic, La Jolla, CA; ³Scripps, San Diego, CA; ⁴Scripps Clinic Medical Group, San Diego, CA

Introduction: Gallbladder carcinoma is the most common biliary malignancy in the United States. Here we describe a presentation of a mucinous adenocarcinoma of the gallbladder resulting in prominent gallbladder distension and biliary obstruction, which clinically imitated Mirizzi’s syndrome, a common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or gallbladder neck.

Case Description/Methods: A 49-year-old woman with no significant past medical history presented with 10 days of jaundice and a sharp, intermittent right upper quadrant pain. Vitals were within normal limits. Labs were significant for elevated aminotransferases, alkaline phosphatase, and bilirubin [Table 1].

CT and MRCP [Image A & B] revealed gallbladder distension with 2 large gallstones at the gallbladder neck, as well as significant dilatation of the intra and extrahepatic ducts with abrupt cut off of the common hepatic duct at the level of the adjacent gallstones. She underwent endoscopic retrograde cholangiopancreatography (ERCP), during which sphincterotomy revealed thick mucus, multiple calculi (up to 1 cm), and sludge. Biliary stents were placed in the CBD.

Due to persistently elevated liver chemistries, she underwent cholecystectomy a week later where an inflamed gallbladder was encountered. Total cholecystectomy was unsuccessful due to significant scarring. Retrieved surgical specimen revealed a 1cm gallbladder wall tumor and pathology demonstrated a well-differentiated invasive mucinous adenocarcinoma, stage pT1b [Image C]. Chemotherapy was initiated. Twelve months later, she passed due to complications from abdominal compartment syndrome due to large volume malignant ascites from omental metastases.

Discussion: Given the paucity of sensitive signs and testing, diagnosis of gallbladder adenocarcinoma is usually incidental or at an advanced stage. In this case, the presence of stones confounded the diagnosis as brushings were negative and the patient met clinical criteria for Mirizzi’s syndrome: right upper quadrant pain with jaundice, dilatation of the biliary system above the gallbladder neck, and a stone in the gallbladder neck.

The treatment of choice in resectable cases of mucinous adenocarcinoma of the gallbladder is radical cholecystectomy. Overall, the prognosis is poor as is seen in this case. In the largest series documenting outcomes of 15 cases, the three-year survival rate was 1% versus 39% seen in the comparator group with conventional gallbladder adenocarcinoma.

Figure: From top to bottom:
Image A
Image B
Image C

	Admission	Normal Range
WBC	7.1 K/mcL	3.4 - 11 K/mcL
Hgb	12.6 g/dL	11.9 - 15.3 g/dL
Platelets	182 K/mcL	150 - 425 K/mcL

Sodium	142 mmol/L	137 - 145 mmol/L
Potassium	3.9 mmol/L	3.5 - 5.1 mmol/L
Chloride	104 mmol/L	98 - 107 mmol/L
CO2	25 mmol/L	22 - 30 mmol/L
BUN	13 mg/dL	7 - 17 mg/dL
Creatinine	0.6 mg/dL	0.5 - 1.0 mg/dL
Glucose	113 mg/dL	70 - 125 mg/dL

Albumin	4.2 g/dL	3.5 - 5.0 g/dL
Total protein	8.6 g/dL	6.3 - 8.2 g/dL
Total bilirubin	9.0 mg/dL	0.2 - 1.3 mg/dL
Direct bilirubin	7/5 mg/dL	0.0 - 0.4 mg/dL
AST	106 U/L	14 - 36 U/L
ALT	246 U/L	< 34 U/L
Alkaline phosphatase	394 U/L	38 - 126 U/L
INR	1.0 seconds	0.9 - 1.1 seconds
Lactate	1.0 mmol/L	0.7 - 2.1 mmol/L

Table: WBC = white blood cells
Hgb = hemoglobin
BUN = blood urea nitrogen
AST = aspartate transaminase
ALT = alanine transaminase
INR = international normalized ratio

Disclosures:

Natalie Savini indicated no relevant financial relationships.

David Leung indicated no relevant financial relationships.

Ki-Yoon Kim indicated no relevant financial relationships.

Ali Fakhreddine indicated no relevant financial relationships.

Natalie Savini, BS, MD¹, David Leung, MD², Ki-Yoon Kim, MD³, Ali Y. Fakhreddine, MD⁴. E0082 - A Striking Case of Mucinous Gallbladder Adenocarcinoma Mimicking Mirizzi’s Syndrome, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.