Tumefactive sludge mimicking gallbladder neoplasm: A case report and review of the literature

Abstract

Biliary sludge (or very thick bile) is mainly comprised of calcium bilirubinate granules and lesser amounts of cholesterol crystals, and it can produce a layer of low amplitude of echoes in the most dependent part of the gallbladder (GB). In tumefactive biliary sludge, low-amplitude echoes do not form a fluid–fluid level but instead tend to give the appearance of a polypoid mass that is bounded by a smooth margin, round, and lobulated. Differential diagnoses for an echogenic mass in the GB lumen include GB carcinoma, tumefactive sludge, and gangrenous cholecystitis. In this case report, we describe a rare case in which biliary sludge did not form a fluid–fluid level but tended to accumulate and appear as a polypoid mass within the lumen of the GB. The lesion was finally identified as being tumefactive sludge mimicking neoplasm of the GB.

Diagnostic Point-of-Care Ultrasound (POCUS) for Abdominal Pain: A Case of Tumefactive Sludge

“…Annually, about one million people are diagnosed with gallstone disease [4]. The formation of gallstones results from the precipitation of the main components of bile when they exceed their solubility concentration, and their main components are cholesterol and bilirubin [2][3][4]. Currently, the method of choice for evaluating GB disease is ultrasound, considering its safety, non-invasiveness, and real-time imaging, with a diagnostic accuracy of about 90% [1,3,[5][6][7].…”

“…The formation of gallstones results from the precipitation of the main components of bile when they exceed their solubility concentration, and their main components are cholesterol and bilirubin [2][3][4]. Currently, the method of choice for evaluating GB disease is ultrasound, considering its safety, non-invasiveness, and real-time imaging, with a diagnostic accuracy of about 90% [1,3,[5][6][7]. Despite this, it is important to note the subjectivity of the operator, the limitations associated with the body biotope, and the presence of intraintestinal gas that may require the use of other imaging techniques, namely CT scan and MRI [2,4,6,7].…”

“…Through POCUS, it is possible to assess the presence of GB wall thickening, pericholestatic fluid, common bile duct dilation, and the presence of perivesicular fluid, demonstrating a sensitivity of 89.8% and a specificity of 88.0% in the diagnosis of cholecystitis [1,8]. Despite the high sensitivity and specificity of ultrasound for GB diseases, differential diagnoses of less common pathologies depend on other imaging methods [3,4,7].…”

“…The biliary sludge is an extremely viscous sediment, consisting essentially of calcium bilirubinate granules and cholesterol crystals, which appear in ultrasound-like low-level echoes that lay in the dependent portion of the GB without acoustic shadowing [2,3,6]. Due to its high viscosity, the movement of the biliary sludge is poor or very slow, which often leads to a mass-like configuration, called tumefactive biliary sludge [3,7].…”

“…Tumefactive sludge translates the precipitation of solid particles from bile and has a global estimated incidence of 2% with higher numbers often associated with pregnancy, patients with rapid weight loss, critically ill patients under parenteral nutrition, drugs such as Ceftriaxone and Octreotide and those with sickle disease or other causes of hemolysis [2,3]. Tumefactive sludge has a benign evolution, although it may be associated with complications such as biliary colic, acute cholangitis, and pancreatitis.…”