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Roentgen Diagnosis of the Strawberry Gall Bladder

1940; Radiological Society of North America; Volume: 34; Issue: 4 Linguagem: Inglês

10.1148/34.4.391

1527-1315

George Levene, Robert M. Lowman, Egon G. Wissing,

Cholangiocarcinoma and Gallbladder Cancer Studies

A GREAT advance in the diagnosis of gall-bladder disease was made with the advent of cholecystography. The accuracy of this method, as proven by operative findings, is probably not excelled by any other diagnostic procedure. Yet statistics of this sort are necessarily incomplete. No exact check is available on the diagnosis of cases which do not go to operation, and these include, for the greater part, those reported as “negative” or “normal” gall bladders. The strawberry gall bladder, also referred to as cholesterosis or lipoidosis of the gall bladder, is one of the earliest forms of gall-bladder disease. There is still a conflict of opinion as to whether the process is of metabolic or inflammatory origin. In most cases, probably both factors are involved (1, 2). The mucosa and sub-mucosa become edematous and absorption is impaired. The normal process of bile concentration, which is accomplished by absorption of water, bile pigments, and cholesterol, is disturbed, so that only water and bile pigments are taken up. The cholesterol which remains in the vesicle soon reaches a high concentration and precipitates in the form of small particles, deposited mostly on the tips of the villi. If the gall bladder is sectioned at this time and washed free of bile, it will present the appearance of a ripe strawberry. There will be small, yellowish specks on a deep red base (Plate I). Microscopically, there is noted infiltration with lymphocytes and plasma cells (Fig. 1). The process may be diffuse or localized to a single area of mucosa. The symptoms are comparatively mild, but definite. Most patients complain of indigestion, gas, and distress after meals. Jaundice and colicky pain are absent, though not infrequently there may be a sallow skin and right upper quadrant or epigastric discomfort. The condition is much more common in women and its onset is frequently in relation to a recent pregnancy. This occurrence suggests an endocrine or metabolic origin. In our series of 30 proven cases, the sex distribution was 3.3 per cent males and 96.7 per cent females. Roentgen Diagnosis.—Cholecystography, as commonly practised, is not adequate for diagnosis, since a film taken some 14 hours after administration of dye and another taken after a fat meal will, of themselves, fail to demonstrate the changes which constitute the diagnostic criteria. It must be remembered that the gall-bladder mucosa is extremely redundant, so that, in spite of disseminated mild involutionary changes, sufficient functioning mucous membrane remains to concentrate bile. Cholecystograms, therefore, usually show a good gall-bladder shadow (Fig. 2). After the first film has been inspected, the patient is given a motor meal consisting of four egg-yolks (the whites are discarded to diminish bulk) and eight ounces of 40 per cent cream, flavored with ginger ale.