Photoclinic: Pseudo-Strawberry Gallbladder (Chronic Cholecystitis)

A 43-year-old man presented with intermittent upper abdominal pain, which had begun the previous day after eating toast. Assuming different positions did not provide relief. Robert P. Blereau, MD, of Morgan City, La, writes that an ultrasonogram of the patient’s gallbladder showed numerous nonshadowing filling defects, no dilated intrahepatic bile ducts, and no thickening of the gallbladder wall (A ). Laparoscopic cholecystectomy was performed. The resected gallbladder showed cobblestoning of the mucosa, suggestive of a pseudo-strawberry gallbladder (B ). Microscopic examination of the gallbladder revealed a bosselated mucosa with pseudopolypoid changes without true stalks, as are seen with polyps. Discrete chronic inflammation was present with sites of diverticular components— Rokitansky-Aschoff sinuses—embedded in the muscular wall. Examples of hyperplastic cholecystosis that may project as nonshadowing filling defects in the gallbladder on an ultrasonogram include cholesterolosis (true strawberry gallbladder), adenomyomatosis, adenoma, neuromatosis, elastosis, adiposis, and interstitial and pericholecystic fibromatosis. All are benign and of uncertain clinical significance.1  The possibility of stones must also be considered whenever there are nonshadowing defects in the gallbladder on an ultrasonogram. The appropriate treatment of a pseudo-strawberry gallbladder is controversial. Nuclear biliary scans that show decreased ejection fraction of the gallbladder may assist in determining the need for cholecystectomy. This patient has been asymptomatic since the procedure. REFERENCE: 1. Weissleder R, Wittenberg J, Harisinghani MG. Primer of Diagnostic Imaging. 3rd ed. Philadelphia: Mosby; 2003:228-229.