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Retroperiton

 

Goubaa Mohamed MD Djerba Tunisia

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--- Arabic
This is a 29-year-old male with vague right upper quadrant abdominal pain, exacerbated by fatty food ingestion. Physical examination and laboratory tests were unremarkable. What is your diagnosis based on the ultrasound scans C'est un patient de 29 ans se présentant pour des douleurs abdominales vagues de l'hypochondre droit, aggravée par l'ingestion d'aliment gras. L'examen physiques et les analyses biologiques étaient sans anomalies. Quel est votre diagnostic en se basant sur ces images échographiques?

Case 1
Cas 1


polyp_ultrasound


polype_echographie


ultrasonography_gallbladder_polyp


doppler_gallbladder_tumor


vesicule_tumeur_echographie

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Differential
Différentiel
 

Case 2
Cas 2

 

Case 3
Cas 3

Click on the image below

 

 

The ultrasound examination detected hypoechoic polypoid structure (case 1) projecting into the gallbladder lumen. No posterior shadowing is evident. this foci do not have the other characteristic of gallstone, i.e., positioning in the most dependent portion of the gallbladder and distal acoustic shadowing (case 2 : small stone without shadowing ).
Color Doppler view shows the vascular pedicle of a polyp, which helps to distinguish this from tumefactive sludge (case 3 ).
L'échographie a détecté une structure polypoide hypoéchogène (cas 1) se projetant dans la lumière de la vésicule biliaire. Aucun cône d'ombre postérieur n'est visible et ce polype n'a pas n'a pas les autres caractéristiques du calcul biliaire, c.-à-d., mobile se plaçant dans différents endroits de la vésicule et générant un cône d'ombre postérieur (cas 2 : calcul mais sans cône d'ombre car petit).
L'examen au Doppler couleur montre le pédicule vasculaire d'un polype, qui aide à distinguer celui-ci de la boue biliaire (cas 3).

 

 

 

 

Small polyp in the gallbladder lumen
Petit polype de la vésicule biliaire

 


Gallbladder Polyp

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Arabic

Gallbladder polyps are usually asymptomatic lesions which are incidental findings in up to 5% of the population. The most common type are cholesterol polyps. Cholesterol polyps account for approximately 50% of all polypoid lesions of the gallbladder.
Cholesterol polyps are generally asymptomatic. Occasionally they are the cause of biliary colic.
Cholesterol polyps are usually 5 mm or less and only rarely get bigger than 10 mm.
Other types of gallbladder polyps occur but are less common than cholesterol polyps. These include adenomas, papillomas, leiomyomas, lipomas, and neuromas. These lesions are true neoplasms and are almost always solitary and are usually larger than cholesterol polyps.

Ultrasound
Ultrasonography is the most effective diagnostic method for detecting the polypoid lesion of the gallbladder.
The most common type are cholesterol polyps. These are reflective structures which project into the gallbladder lumen but do not cast an acoustic shadow. Unless on a long stalk they will remain fixed on turning the patient and are therefore distinguishable from stones.
They are attached to the wall by means of a slender stalk. The stalk is rarely seen so they typically appear as a mass that is adjacent to the wall but barely attached to the wall : this is referred to as the "ball on the wall" sign. There are usually multiple polyps, although it is not uncommon to detect only the largest one sonographically
They can be distinguished from gallbladder stones by their lack of a shadow and nonmobile nature and from sludge balls by their lack of mobility. Their small size and multiplicity help to distinguish them from true neoplasms of the gallbladder wall.
Supplementary US examination in the harmonic mode is advantageous : the polyps were more evident on harmonic images and The number of polyps revealed in US examination is larger in the harmonic mode..
Larger polyps may have detectable blood flow on color Doppler imaging

Differential
* Small adherent gallstones,
*Adenomyomatosis,
* Neurofibroma
* Papillomas
* Carcinoma.
* Metastatic disease to the gallbladder is very uncommon but can produce multiple polypoid lesions. Melanoma has the greatest tendency to spread to the gallbladder, and detection of gallbladder polyps should be viewed with a high level of suspicion in patients with a history of melanoma. Generally there will be other evidence of metastatic disease in the liver, lymph nodes, or elsewhere in the abdomen.

Management
Regarding gallbladder polyps, the risk for malignancy is increased when the lesion is greater than 1 cm especially in patients over 50 years of age. The current recommendations for resection of gallbladder polyps include any lesion that is enlarging, symptomatic, or greater than 1 cm. The recommendations for lesions less than 1 cm include follow-up and reevaluation of the lesion via repeat imaging studies.

REFERENCE
* 1 Rodriguez-Fernandez A, Gomez-Rio M, Medina-Benitez A, Moral JV, Ramos-Font C, Ramia-Angel JM, Llamas-Elvira JM, Ferron-Orihuela JA, Lardelli-Claret P.
Application of modern imaging methods in diagnosis of gallbladder cancer.
J Surg Oncol. 2006 Jun 15;93(8):650-64. Review. * 2 Puneet, Ragini R, Gupta SK, Singh S, Shukla VK.
Management of polypoidal lesions of gallbladder in laparoscopic era.
Trop Gastroenterol. 2005 Oct-Dec;26(4):205-10. Review.
* 3 Brogna A, Bucceri AM, Branciforte G, Travali S, Loreno M, Muratore LA, Catalano F.
Gallbladder benign neoplasms: relationship with lithiasis and cancer (ultrasonographic study).
* 4 Minerva Gastroenterol Dietol. 2001 Sep;47(3):103-9.
* Shah T, Wong T.
Management of gallbladder polyps.
Minerva Gastroenterol Dietol. 2003 Mar;49(1):23-30.
* 5 Paslawski M, Krupski W, Zlomaniec J.
The value of ultrasound harmonic imaging in the diagnostics of gall bladder cholesterol polyps.
Ann Univ Mariae Curie Sklodowska [Med]. 2004;59(2):293-7.
* 6 Leonetti G, Urbano V, Forte A, Bosco MR, Nasti AG, Simonelli I, Tchikoka B, Bezzi M.
[Polypoid lesions of the gallbladder: diagnostic and therapeutic problems]
G Chir. 2005 Apr;26(4):139-42.
* 7 Chattopadhyay D, Lochan R, Balupuri S, Gopinath BR, Wynne KS.
Outcome of gall bladder polypoidal lesions detected by transabdominal ultrasound scanning: a nine year experience.
World J Gastroenterol. 2005 Apr 14;11(14):2171-3.
* 8 Sun XJ, Shi JS, Han Y, Wang JS, Ren H.
Diagnosis and treatment of polypoid lesions of the gallbladder: report of 194 cases.
Hepatobiliary Pancreat Dis Int. 2004 Nov;3(4):591-4.
* 9 Li XY, Zheng CJ, Chen J, Zhang JX.
[Diagnosis and treatment of polypoid lesion of the gallbladder]
Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2003 Dec;25(6):689-93.
* 10 Collett JA, Allan RB, Chisholm RJ, Wilson IR, Burt MJ, Chapman BA.
Gallbladder polyps: prospective study.
J Ultrasound Med. 1998 Apr;17(4):207-11.
* 11 Hirooka Y, Naitoh Y, Goto H, Furukawa T, Ito A, Hayakawa T.
Differential diagnosis of gall-bladder masses using colour Doppler ultrasonography.
J Gastroenterol Hepatol. 1996 Sep;11(9):840-6.

 


 


 
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