Endoscopic Ultrasound

IMAGES AND VIDEOS
Year
: 2022  |  Volume : 11  |  Issue : 4  |  Page : 334--335

Immunoglobulin G4-related cholecystitis mimicking gallbladder cancer diagnosed by EUS-guided biopsy


Kosuke Nagai1, Masaki Kuwatani1, Yunosuke Takishin1, Ryutaro Furukawa1, Hajime Hirata1, Kazumichi Kawakubo1, Tomoko Mitsuhashi2, Naoya Sakamoto1,  
1 Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
2 Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan

Correspondence Address:
Masaki Kuwatani
Department of Gastroenterology and Hepatology, Hokkaido University Hospital, North 14, West 5, Kita-ku, Sapporo 060-8648
Japan




How to cite this article:
Nagai K, Kuwatani M, Takishin Y, Furukawa R, Hirata H, Kawakubo K, Mitsuhashi T, Sakamoto N. Immunoglobulin G4-related cholecystitis mimicking gallbladder cancer diagnosed by EUS-guided biopsy.Endosc Ultrasound 2022;11:334-335


How to cite this URL:
Nagai K, Kuwatani M, Takishin Y, Furukawa R, Hirata H, Kawakubo K, Mitsuhashi T, Sakamoto N. Immunoglobulin G4-related cholecystitis mimicking gallbladder cancer diagnosed by EUS-guided biopsy. Endosc Ultrasound [serial online] 2022 [cited 2022 Dec 8 ];11:334-335
Available from: http://www.eusjournal.com/text.asp?2022/11/4/334/325247


Full Text

A 70-year-old male with a history of hypertension and diabetes mellitus was referred to our hospital for workup of a gallbladder mass suspected to be gallbladder cancer on computed tomography images [Figure 1]a, which also showed stricture of the cystic duct and common bile duct (CBD). He had neither symptoms nor jaundice. Blood tests on admission were normal except for high levels of γ-glutamyl transpeptidase (122 U/L) and carbohydrate antigen 19-9 (167.0 U/mL). EUS revealed a hypoechoic and heterogeneous mass at the gallbladder neck [Figure 1]b connecting to wall thickening of the cystic duct and upper CBD and the normal pancreas [Figure 2]a, [Figure 2]b, [Figure 2]c. ERCP showed an upper CBD stricture with axial deviation [Figure 1]c, and ERCP-guided biopsy of the stricture revealed fibrosis and infiltration of mononuclear cells. Thus, we performed EUS-FNA for the mass of the gallbladder through the duodenal bulb with a 22-gauge Franseen needle, which surprisingly revealed abundant lymphoplasmacytic infiltration and storiform fibrosis with IgG4-positive plasma cells (>10 cells per high-power field) [Figure 3]a, [Figure 3]b, [Figure 3]c. The serum IgG4 level was then measured and found to be elevated at 282 mg/dL. Finally, we diagnosed it as IgG4-related sclerosing cholecystitis with cholangitis and administered steroids. After 1 month, we confirmed the mass shrinkage [Figure 3]d and normalization of the serum IgG4 level.{Figure 1}{Figure 2}{Figure 3}

Gallbladder involvement has been reported in only about 5.5% of patients with IgG4-related disease,[1] and IgG4-rerlated cholecystitis without pancreatitis has been reported in only eleven cases. Therefore, a mass lesion in the gallbladder on imaging studies can lead many physicians to misdiagnose gallbladder cancer.

Meanwhile, EUS-FNA for bile duct lesions and gallbladder masses has a high diagnostic ability and safety despite concerns about complications such as bile leakage and tumor seeding.[2],[3] Therefore, if it is difficult to obtain a pathological specimen of biliary lesions by endoscopic transpapillary biopsy for therapeutic strategies, EUS-FNA should be performed as aggressively as possible. The previous reports on IgG4-related cholecystitis showed that the pathological diagnosis could be performed by surgical resection or percutaneous biopsy of the gallbladder lesions; however, the present case was pathologically diagnosed by EUS-FNA for the first time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Masaki Kuwatani is an Editorial Board Member of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of this Editor and his research groups.

References

1Chen Y, Zhao J, Feng R, et al. Types of organ involvement in patients with immunoglobulin G4-related disease. Chin Med J (Engl) 2016;129:1525-32.
2Wu LM, Jiang XX, Gu HY, et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy in the evaluation of bile duct strictures and gallbladder masses: A systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2011;23:113-20.
3Sadeghi A, Mohamadnejad M, Islami F, et al. Diagnostic yield of EUS-guided FNA for malignant biliary stricture: A systematic review and meta-analysis. Gastrointest Endosc 2016;83:290-8.