S1543 Flank Pain: A Common Presentation of a Rare Disease

Abstract

INTRODUCTION: Lymphangiomas are benign lesions believed to arise from malformations of sequestered lymphatic tissue. Less than 1% occur intraabdominally, and of these, only 0.8-1% arise from the gallbladder. Most arise in children less than five years old, but they often go unrecognized until adulthood when masses enlarge to cause symptoms. CASE DESCRIPTION/METHODS: A 28-year-old female with history of recurrent urinary tract infections (UTIs) presented to the hospital with three days of worsening right flank pain, polyuria, nausea, vomiting and chills. Exam noted costovertebral angle tenderness. Urinalysis was positive for >50 white blood cells, leukocyte esterase, and nitrite. Comprehensive metabolic panel, acute hepatitis panel, and pancreatic enzymes were normal. The patient was given ceftriaxone and discharged on cefdinir for treatment of acute pyelonephritis. Her polyuria improved, but she continued to experience nausea, vomiting, chills, right flank pain and developed a new right upper quadrant pain. CT scan of the abdomen revealed a decompressed gallbladder with significant wall edema. Abdominal ultrasound noted large multiloculated fluid collection in the gallbladder fossa (Figure 1). MRCP found marked thickening of the gallbladder wall and fluid signal with internal septations (Figure 2). The findings were consistent with gallbladder lymphangioma. Laparoscopic cholecystectomy was performed uneventfully. Intra-operatively, a lobulated cystic structure was noted in the gallbladder fossa (Figure 3). Pathology confirmed gallbladder lymphangioma. She had an uneventful post-operative course and was discharged home. DISCUSSION: Lymphangiomas are rare benign tumors with variable clinical presentations ranging from asymptomatic to nonspecific symptoms such as nausea, vomiting, and abdominal discomfort. Until recently, it was difficult to diagnose without pathology, but this paradigm has changed with advanced imaging such as MRI/MRCP which can depict the location of the mass relative to the gallbladder. Complete surgical resection is the standard of care, as unperturbed growth can cause disruption of surrounding structures and vessels. Our case highlights a common presentation of a rare entity. The presence of a more common co-existing diagnosis of UTI added to the difficulty in detecting her rare pathology. This emphasizes the import of maintaining a broad differential diagnosis, especially when symptoms do not resolve with standard care.Figure 1.: Grayscale and color doppler sonographic imaging of the gallbladder shows multiloculated cystic mass with mild hyperemia along the contracted gallbladder wall.Figure 2.: Axial T2-weighted magnetic resonance imaging shows high-signal-intensity gallbladder wall edema (red asterick) with low-intensity signal internal septations and lobulated irregular mucosa (yellow arrow).Figure 3.: Gross appearance of lobulated cystic structure (green arrow) near gallbladder fossa on laparoscopy.