Abstract

Strawberry gallbladder is a benign medical condition that refers to the surface appearance of the gallbladder mucosa. It occurs due to precipitations of lipids and macrophages in the lamina propria of the gallbladder wall.

We report the case of a 44-year-old female patient who presented to the emergency department with a few days history of biliary colic. Investigations showed elevated AST, ALT, and hypercholesteremia. Ultrasound abdomen demonstrated a mild fatty liver and multiple GB polyps. Laparoscopic cholecystectomy was performed. Histopathologic features were consistent with diffuse cholesterolosis.

Strawberry gallbladder is a distinctive type of cholecystosis. It is caused by irreversible alteration in the anatomic and morphologic aspects of the gallbladder lining. This entity is usually identified after surgery. Symptomatic patients with cholesterolosis will benefit from cholecystectomy.

1. Introduction

Gallbladder diseases, including cholelithiasis and cholecystitis, are common conditions encountered in clinical practice. Nonetheless, some rare diseases of the gallbladder wall like polyps, cholesterolosis, and adenomyomatosis are less prevalent [1].

Strawberry gallbladder or diffuse cholesterolosis is a unique cholecystopathy characterized by a reddening and granular appearance of the gallbladder mucosa, resembling the surface of a strawberry [2]. Although its incidence remains unknown, it is estimated to present in approximately 10% of cholecystectomies [3].

In our manuscript, we describe the case of a young female patient with symptomatic gallbladder polyps and relevant risk factors who was discovered postoperatively to have a strawberry gallbladder.

2. Case Report

A 44-year-old female patient known to have dyslipidemia, presented to the emergency department complaining of right upper quadrant abdominal pain of 3 days duration. Pain was colicky in nature, related to food, associated with nausea and vomiting. History goes back to the last year when she experienced repeated bouts of biliary colic that were alleviated with paracetamol. The patient is a heavy smoker and moderate alcohol consumer.

Physical examination revealed normal vital signs, an overweight patient with RUQ tenderness, and a negative Murphy sign. Initial laboratory tests showed raised cholesterol LDL, alanine transferase, and gamma-glutamyl transferase levels. The ultrasonographic images demonstrated a distended gallbladder with thickened inner lining and multiple polyps (Figure 1). The patient was referred to the hepatobiliary unit for further investigations and management. Tumor markers were unremarkable, and clinical history was not worrisome (no weight loss, no jaundice, and absent family history of GB cancer). We decided to go for surgery since the patient was symptomatic.

Intraoperative Findings

Intraoperatively, the gallbladder appeared slightly inflamed with a thickened wall. Laparoscopic cholecystectomy was performed, and the specimen was retrieved in an endobag. A gross image of the gallbladder showed diffuse, granular, and reddened dots on the surface containing cholesterol polyps resembling a strawberry outline (Figure 2,3), while the histopathological assessment displayed extensive mucosal hypertrophy and hyperplasia (Figure 4) and bulbous villi that contain aggregates of foamy lipid-laden macrophages suggesting cholesterolosis (Figure 5).

Postoperative Course

The postoperative course was uneventful. The patient was advised on a low-fat diet and modification of lifestyle as well as follow-up for her hypercholesteremia.

3. Discussion

Cholesterolosis is an idiopathic condition that is often diagnosed incidentally after cholecystectomy. Although the underlying pathophysiology is not fully understood, it is believed to be linked to chronic inflammation of the gallbladder lining. Along with the accumulation of lipids and macrophages in the lamina propria, this can lead to focal, diffuse, and polypoid proliferative changes. Diffuse cholesterolosis is also called strawberry gallbladder [4].

Strawberry gallbladder is related to the typical stippled appearance of the mucosal surface on gross examination that resembles a strawberry outline. It is usually noncancerous and primarily affects females and obese patients [5]. In addition, smoking and alcohol history could play a role in the pathogenesis of strawberry gallbladder [6].

Embryologically, biliary epithelium resembles the intestinal epithelium, which renders it capable of absorbing cholesterol from the bile. Gallbladders with normal function have the capacity to absorb esterified and non-esterified cholesterol from the bile [7]. The esterification process of cholesterol occurs in the endoplasmic reticulum, which then creates lipid droplets that are released into the intercellular space. Eventually, they get phagocytosed by macrophages [8].

Several hypotheses exist to explain the accumulation of lipids, such as cholesterol esters and triglycerides, in cholesterolosis cases [9]. Possible causes include excessive cholesterol absorption from the bloodstream directly, abnormal emptying of lipids from the gallbladder due to underlying mechanical factors, and defects in cholesterol metabolism and excretion within the macrophages [10].

According to the literature, there is no exact pathogenetic pathway to this complex condition. Patients who suffer from cholesterolosis and cholesterol stones usually have supersaturated bile [11]. Some articles showed that high cholesterol increases the risk of cholesterolosis. In contrast, other studies have concluded that the relationship between hypercholesterolemia and cholesterolosis is still inconsistent [11,12].

Hyperplastic cholecystosis manifests in variable clinical pictures. Some patients may remain asymptomatic or might present with symptoms of biliary colic, while others might exhibit acute cholecystitis and pancreatitis. Although cholesterolosis is linked to chronic cholecystitis, interestingly, studies did not confirm any increase in the risk of gallbladder cancer [13].

Differential Diagnosis

Adenomyomatosis is another rare gallbladder disease that should be considered a differential diagnosis for cholesterolosis. Compared to strawberry gallbladder, adenomyomatosis is characterized by hyperplasia and in-folding of the gallbladder lining, which leads to the formation of Rokitansky-Aschoff sinuses [14]. While both conditions can present with a similar macroscopic appearance, the presence of these sinuses is the key distinguishing feature [15].

Radiological Examination

Preoperative radiological examination is often required to rule out other potential gallbladder pathologies, including acute cholecystitis and gallbladder carcinoma [16]. Although a gross assessment of the gallbladder displays the presence of strawberry gallbladder, microscopic findings are necessary to confirm the diagnosis [17,18].

Treatment

The definitive treatment for such cases is the removal of the gallbladder only when indicated. Our patient's symptoms were completely relieved after surgery. Follow-up showed improvement in her laboratory findings after treatment with statins and lifestyle modifications.

4. Conclusion

Strawberry gallbladder is an idiopathic non-neoplastic condition caused by diffuse gallbladder wall cholesterolosis. Knowledge of this pathology and familiarity with its radiologic characteristics are important to establish a proper diagnosis and provide appropriate management.

References

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