J Pathol Transl Med.  2018 Sep;52(5):339-343. 10.4132/jptm.2018.06.02.

Bile Granuloma Mimicking Peritoneal Seeding: A Case Report

• Jeong H
• Lee HW
• Jung HR
• Hwang I
• Kwon SY
• Kang YN
• Kim SP
• Choe M

• KMID: 2422101
• DOI: http://doi.org/10.4132/jptm.2018.06.02

Abstract

Laparoscopic cholecystectomy is a widely used treatment method for most cholelithiasis and is a relatively safe procedure. Foreign body granulomatous reaction to bile or gallstone spillage during laparoscopic cholecystectomy has rarely been reported. We report a case of bile granuloma after laparoscopic cholecystectomy, which mimicked peritoneal seeding. A 59-year-old Korean man presented with right upper quadrant pain. He underwent laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis. Pathologic examination revealed an incidental adenocarcinoma invading the lamina propria with acute cholecystitis and cholelithiasis. After 3 months, follow-up abdominal computed tomography revealed a subhepatic nodule, which showed hypermetabolism on positron emission tomography-computed tomography. Suspecting localized peritoneal seeding, wedge resection of the liver, wedge resection of the transverse colon, and omentectomy were performed. Pathologic examination of the resected specimens revealed multiple bile granulomas. Awareness of bile granuloma mimicking malignancy is noteworthy for patient management to reduce unnecessary procedure during postoperative surveillance.

Keyword

Bile; Granuloma; Cholecystectomy

MeSH Terms

Adenocarcinoma
Bile*
Cholecystectomy
Cholecystectomy, Laparoscopic
Cholecystitis, Acute
Cholelithiasis
Colon, Transverse
Electrons
Follow-Up Studies
Foreign Bodies
Gallstones
Granuloma*
Humans
Liver
Methods
Middle Aged
Mucous Membrane
Unnecessary Procedures

Figure

• 

  Fig. 1. Findings of abdominal computed tomography (CT) (A) and positron emission tomography–computed tomography (PET-CT) (B). Abdominal CT showed ill-defined mass lesions (arrow) in the right subhepatic space near the gallbladder bed. PET-CT demonstrated a focal hypermetabolic lesion (arrow) in the right subhepatic space.

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  Fig. 2. Gross finding of the specimens showed ill-defined yellow to brownish, variegated, nodular lesions (arrows) without necrosis in the liver (A) and the transverse colon (B).

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  Fig. 3. Microscopic findings of the lesion. The liver (A) and transverse colon (B) showed granulomatous inflammation, which consists of brown pigments and multinucleated giant cells with numerous lymphocytes (C). The pigment was greenish brown on Fouchet’s technique (D).

Reference

1. Townsend CM, Beauchamp RD, Evers BM, Mattox K. Sabiston textbook of surgery. Philadelphia: Saunders Elsevier;2017. p. 1493–500. 20th.

2. Kim BS, Joo SH, Kim HC. Spilled gallstones mimicking a retroperitoneal sarcoma following laparoscopic cholecystectomy. World J Gastroenterol. 2016; 22:4421–6.

3. Merchant SH, Haghir S, Gordon GB. Granulomatous peritonitis after laparoscopic cholecystectomy mimicking pelvic endometriosis. Obstet Gynecol. 2000; 96(5 Pt 2):830–1.

4. Famularo G, Remotti D, Galluzzo M, Gasbarrone L. Granulomatous peritonitis after laparoscopic cholecystectomy. JSLS. 2012; 16:481–4.

5. McVeigh G, McComiskey M, McCluggage WG. Peritoneal bile granulomas identified at Cesarean section and mimicking disseminated malignancy. Int J Surg Pathol. 2012; 20:89–91.

6. Radunovic M, Lazovic R, Popovic N, et al. Complications of laparoscopic cholecystectomy: our experience from a retrospective analysis. Open Access Maced J Med Sci. 2016; 4:641–6.

7. Lee W, Kwon J. Fate of lost gallstones during laparoscopic cholecystectomy. Korean J Hepatobiliary Pancreat Surg. 2013; 17:66–9.

8. Calik A, Topaloglu S, Topcu S, Turkyilmaz S, Kucuktulu U, Piskin B. Routine intraoperative aspiration of gallbladder during laparoscopic cholecystectomy. Surg Endosc. 2007; 21:1578–81.

9. Ezer A, Nursal TZ, Colakoglu T, Noyan T, Moray G, Haberal M. The impact of gallbladder aspiration during elective laparoscopic cholecystectomy: a prospective randomized study. Am J Surg. 2008; 196:456–9.

10. Siddiqui MR, Sajid MS, Nisar A, Ali H, Zaborszky A, Hasan F. A meta-analysis of outcomes after routine aspiration of the gallbladder during cholecystectomy. Int Surg. 2011; 96:21–7.

11. Pazouki A, Abdollahi A, Mehrabi Bahar M, et al. Evaluation of the incidence of complications of lost gallstones during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2014; 24:213–5.

12. Zehetner J, Shamiyeh A, Wayand W. Lost gallstones in laparoscopic cholecystectomy: all possible complications. Am J Surg. 2007; 193:73–8.

13. Suarez-Zamora DA, Barrera-Herrera LE, Caceres-Mileo R, Palau-Lazaro MA. Intraperitoneal granulomas unexpectedly found during a Cesarean delivery: a late complication of dropped gallstones. Case Rep Pathol. 2017; 2017:4873273.

14. Luo J, Mao Y, Cai S, Shen X, Chen S, Xie L. Post-nephrectomy foreign-body granuloma in the retroperitoneum mimicking lymph node metastasis of renal cell cancer. Onco Targets Ther. 2014; 7:2137–41.

15. Pantiora EV, Kontis EA, Michalaki V, et al. Granuloma mimicking local recurrence on PET/CT after liver resection of colorectal liver metastasis: a case report. Cureus. 2016; 8:e717.

16. Erdog˘an D, Bozkurt C, Özmen Ö, Boduroglu E, Sahin G. Foreign body reaction with high standard uptake value level in 18-FDG PET/CT mimicking relapse in an 8-year-old patient diagnosed with Hodgkin lymphoma: a case report. European J Pediatr Surg Rep. 2013; 1:60–2.

17. Kim SW, Shin HC, Kim IY, Baek MJ, Cho HD. Foreign body granulomas simulating recurrent tumors in patients following colorectal surgery for carcinoma: a report of two cases. Korean J Radiol. 2009; 10:313–8.