Mucocele of the gallbladder

A mucocele of the gallbladder forms when a stone impacts in the cystic duct but bacterial infection does not occur. Bile is reabsorbed but the epithelium continues to secrete mucous, and the gallbladder becomes distended (Figs. 29, 30) 1252, 1253. It is easily palpable and may even be visible, but it is not tender. Such patients have somewhat subdued but nevertheless persistent symptoms, often including distressing nausea. If infection does occur an empyema may develop rapidly. In either circumstance a cholecystectomy is required. Rarely a mucocele of the gallbladder may perforate. Although pseudomyxoma peritonei has been reported to follow rupture of a mucocele it probably only follows rupture of a cystadenoma or cystadenocarcinoma of the gallbladder.

 

Torsion of the gallbladder

Infarction of the gallbladder due to torsion or volvulus is a rare event. Two anatomical anomalies permit torsion. Firstly the gallbladder may have no attachment to the liver, lying free in the peritoneal cavity suspended only by the cystic duct and artery. Secondly, and more commonly, the gallbladder is suspended from the liver by a narrow mesentery. Acute torsion causes right-sided abdominal pain and the tense, infarcted gallbladder may be palpable (Fig. 31) 1254. It is often misdiagnosed as acute appendicitis. Intermittent torsion can occur and produces periodic bouts of pain.

 

Biliary pain without stones

A small group of patients, usually young women, presents with pain in the right hypochondrium which, in the opinion of everyone who sees them, is typical biliary pain. However, all conventional biliary investigations, which may be repeated on several occasions, are normal. Furthermore a minority benefit from cholecystectomy even though no pathological abnormality is discovered in the gallbladder at operation.

 

Now that cholesterolosis and adenomyomatosis can be excluded by ultrasound studies before operation interest has centred on the possibility that these patients have a functional disorder of the biliary tract. This idea has received support from the discovery that some develop identical pain following an intravenous injection of cholecystokinin, and it was hoped that this would identify those who would benefit from a cholecystectomy. This test has not turned out to be so specific, but there are a number of other experimental tests of gallbladder and biliary function which may help us to understand these patients better in the future.

 

In practical terms, it is essential to exclude the irritable bowel syndrome which can produce symptoms very similar to those of biliary pain. After explaining the position very carefully to the patient it is reasonable to proceed to a cholecystectomy. Unfortunately the pain persists after operation in some patients; these form part of a group of patients with postcholecystectomy pain.

 

Management of gallbladder stones

The first successful cholecystectomy was performed by Langenbuch in 1882, and since then the operation has become the standard treatment for gallbladder stones. It is both safe and effective by modern surgical standards. However, there are deaths and complications following the operation and it takes 6 to 8 weeks to recover following a conventional open operation. An alternative to surgery would clearly be useful. Our understanding of the biochemistry of gallstone formation first led to the development of drugs which dissolve cholesterol gallstones. Further developments have produced a bewildering array of methods for removing or dissolving stones without the disadvantages of surgery.

 

Alternatives to cholecystectomy

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