Abstract
Introduction
Angiodysplasia is a term used to describe distinct mucosal vascular ectasias found mainly in the gastrointestinal tract. Angiodysplasia of the gallbladder is exceedingly rare.
Presentation of case
We encountered a patient who presented with biliary colic and subsequently underwent an elective laparoscopic cholecystectomy. The angiodysplasia of the gallbladder was found incidentally on histopathological examination of the excised gallbladder.
Discussion
Review of the literature showed only one other reported case of angiodysplasia of the gallbladder. The condition may be found incidentally after histopathological examination of the gallbladder removed for gallstone; or it may present with haemobilia.
Conclusion
We presented an extremely rare case of angiodysplasia of the gallbladder, which was found incidentally after histopathological examination of the gallbladder removed for gallstone. Angiodysplasia of the gallbladder has the potential to bleed. Laparoscopic cholecystectomy is effective in providing a definitive cure.
Keywords: Gallbladder, Angiodysplasia, Laparoscopic cholecystectomy
1. Introduction
Angiodysplasia is a term used to describe distinct gastrointestinal mucosal vascular ectasias that are not associated with cutaneous lesions, systemic vascular disease or a familial syndrome.1,2 Its occurrence in the gallbladder is exceedingly rare, with only one case having previously been reported in the literature.3 We presented herein a case of angiodysplasia of the gallbladder, found incidentally on histopathological examination of the excised gallbladder of a patient who underwent an elective laparoscopic cholecystectomy for biliary colic.
2. Case presentation
A 36-year-old woman was referred to the Department of General Surgery of our hospital with a 6-month history of dyspepsia and intermittent colicky right upper quadrant abdominal pain. She had no other significant past medical history and had no previous history of gastrointestinal bleed. Abdominal ultrasound scan showed multiple gallstones within the gallbladder, with normal extra- and intra-hepatic bile ducts, normal liver and pancreas. Routine haematological and biochemical tests including liver function and haemoglobin were normal. The patient underwent an elective laparoscopic cholecystectomy. There was no intra-operative or post-operative complication and the patient was discharged home on post-operative day one. The patient remained well at 8 month's follow-up.
Histopathological examination of the gallbladder showed the mucosa focally ulcerated, with focal widening of the mucosal folds due to the accumulation of foamy histiocytes. There was a moderate chronic inflammatory cell infiltrate. The muscular layer was hypertrophic; features consistent with chronic cholecystitis. The most unusual feature of the gallbladder was the presence of large dilated vessels in the serosa, extending through the muscular layer onto the submucosa and mucosa (Fig. 1). The appearances were those of angiodysplasia of the gallbladder.
Fig. 1.
Angiodysplasia of the gallbladder showing large ectactic vessels in the muscular layer extending into the submucosa and mucosa. H&E ×40.
3. Discussion
Angiodysplasia is described mainly in the gastrointestinal tract.1,2 In the lower gastrointestinal tract, it is commonly found in the colon,4 and in the upper gastrointestinal tract it occurs most often in the stomach and duodenum.5 Other rare reported sites of angiodysplsia are the appendix6 and minor papilla.7 The pathogenesis of angiodysplasia is not completely understood. Colonic angiodysplasia are presumed to be degenerative in nature, secondary to either intermittent obstruction of the submucosal veins or hypoxemia and the pathogenesis of upper intestinal angiodysplasia is most likely related to a degenerative process.8 Most commonly, the angiodysplastic lesions are typically seen in elderly patients of both genders.8 The clinical presentation of angiodysplasia varies from an incidental finding in an otherwise asymptomatic person to occult bleeding or an acute massive hemorrhage.2 Angiodysplasia has been purported to occur with higher frequency in patients with renal failure, von Willebrand's disease, aortic stenosis, cirrhosis, and pulmonary disease.2
The occurrence of angiodysplasia in the gallbladder is exceedingly rare. Yudt et al. reported a case of a haemobilia from angiodysplasia of the gallbladder in a 78-year-old man presented with gastrointestinal bleed.3 The patient underwent a 99mTc-labelled red cell scintigraphy for the investigation of the obscure gastrointestinal bleed which demonstrated radiotracer within the gallbladder, with the attendant pathological findings of angiodyplasia of the gallbladder. Angiodysplaisa of the gallbladder may be asymptomatic and is only discovered incidentally on histopathological examination of the excised gallbladder (as seen in our case). The pathogenesis of angiodysplasia of the gallbladder is unknown but is likely to be the result of distension and contraction of the gallbladder causing intermittent obstruction of the vessels which penetrate through the muscular wall. This occlusion subsequently leads to focal dilatation and tortuosity of the overlying mucosal vessels, similar to that postulated for colonic angiodysplasia.9
Laparoscopic cholecystectomy is curative for the treatment of angiodysplasia of the gallbladder, as evident from our case. We did not encounter any technical difficulties during the operation and the patient recovered fully with no post-operative complications.
4. Conclusions
We presented an extremely rare case of angiodysplasia of the gallbladder which was found incidentally after histopathological examination of the gallbladder removed laparoscopically for gallstone. Angiodysplasia of the gallbladder has the potential to bleed, as evident by the only other reported case of angiodysplasia of the gallbladder, where the patient may present with haemobilia. Laparoscopic cholecystectomy is effective in providing a definitive cure in our case.
Conflicts of interest statement
None.
Funding
None.
Ethical approval statement
Written approval from patient obtained.
Author's contributions
K.Y.Y.K. contributed toward the study design, data collection, data analysis, writing, and literature search and P.U.T. was responsible for the data collection, data analysis, writing, literature search, and image provision.
Contributor Information
Kenneth Y.Y. Kok, Email: koky@brunet.bn.
Pemasiri U. Telisinghe, Email: ptelisinghe@yahoo.com.sg.
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