Anomalous presentation of a case of carcinoma of the gall bladder with gall stones (a case report).
Gall bladder disease with or without stones is not uncommon in our country. The various manifestations of gall stones are well documented. The higher incidence of carcinoma of the gall bladder due to long standing gall stones in the gall bladder is also well documented.,,,
In this report, a case of gall bladder carcinoma (diagnosed at post mortem) with a stone in the parietal wall is described.
A 50 year old, female, non-obese patient was admitted with the complaints of distension of abdomen, jaundice and a tender swelling in the right hypochondrium since the last two months. The jaundice was gradually deepening with itching all over the body and the swelling had gradually increased and was well localised at the time of presentation. There was no history of vomiting or hematemesis or clay coloured stools; no history of jaundice in the past: no history of alcoholism or blood or mucus in the stools; no history of fever or colicky abdominal pain suggestive of gall bladder disease.
On examination, there was pallor and edema of feet. Per abdomen examination revealed gaseous distension and a tender, warm, soft swelling, about 6 cm in diameter over the right hypochondrium. The liver was palpable 2 cm below the costal margin and extending into the epigastrium. There was no other lump palpable in the abdomen; no supraclavicular lymph nodes were also palpable. Per rectal and per vaginal examinations did not reveal any abnormality.
Investigations showed hemoglobin 8 gm%, WBC count: 8000/cmm, and ESR: 15 mm at the end of the 1st hour. Total serum proteins were low with albumin of 3 gm% and globulin of 1.5 gm%. SGOT and SGPT were marginally raised. Serum bilirubin was 18 mg%, predominantly direct. The alkaline phosphatase was raised to 150 IU. Prothrombin time was slightly greater than normal.
The lump was tapped with a No. 16 needle and some pus with blood was aspirated. As the patient's condition precluded general anaesthesia, a regular incision and drainage was carried out under local anaesthesia. Pus and blood was drained and a yellowish, smooth, brittle stone was found in the intermuscular plane. There was no obvious connection between the abscess cavity and the peritoneal cavity. The stone was found to be an amorphous gall stone with outer white striations and a brownish yellow soft nucleus on cut section.
The patient was then subjected to a percutaneous transhepatic cholangiogram with drainage, which showed a block at the porta hepatis with no dye entering the common bile duct or duodenum. A liver scan showed the liver to be studded with metastases. HEDA scan -was non contributory as both gall bladder and biliary system were not visualised. Even with the PTC, the bilirubin did not decrease appreciably and internal stenting was attempted but failed. The patient's condition deteriorated and she went into hepato-renal shutdown and expired.
Biochemical analysis of the stone revealed the following:
Chemical tests: 1. Libermann-Burchard test; Positive for cholesterol. 2. Salkowski's test: Positive for cholesterol.
Microscopic examination showed characteristic rhombic and plate like crystals with re-entrant angles diagnostic of cholesterol.
On postmortem examination, the liver was found to be enlarged, 5-6 cm below the costal margin. The surface of the liver as well as cut section showed multiple, well circumscribed, nodular areas, 2-5 cm in diameter, confluent at places with necrotic centre. The intervening liver parenchyma was necrotic with abscess on the surface. There were enlarged lymph nodes at the porta hepatis. A normal gall bladder could not be identified. A biliary fistula was not seen, communicating to the exterior. The gall bladder contained 5-6 white and faceted gall stones. The proximal end of the gall bladder showed a circumferential growth with a thickness of 3 cm, hard, irregular, adherent to adjacent structures.
Impression: Metastases in the liver from carcinoma of the gall bladder.
Carcinoma of the gall bladder comprises less than 2% of all cancers. Its cause is uncertain but cholelithiasis and chemical\ carcinogens are thought to be contributor. The tumour grows slowly spreading by local invasion.
It commonly remains asymptomatic or presents with symptoms of benign cholelithiasis like pain, nausea, vomiting and jaundice. Hence, it is rarely diagnosed preoperatively unless accompanied by metastases which preclude curative resection.
The overall 5 year survival rate after diagnosis is less than 5%. There are three reasons for the poor survival rate: (1) a nonspecific and mild clinical picture (2) a predilection for occurrence in the elderly (3) early metastasis to organs and structures which are not easily resectable. It is therefore suggested that all gall bladders be opened and inspected after removal and that specimens from suspicious areas be studied by frozen section analysis. This is particularly important in patients beyond 65 years of age. If carcinoma is detected and there is no evidence of dissemination, cholecystectomy and en bloc wedge resection of the liver bed as well as adherent nonvital tissue should be performed.
We are thankful to the Dean, Seth G. S. Medical College and K.E.M. Hospital for having granted permission to publish this article.