Coronary Artery Disease and Gallbladder Inflammatory Pseudopolyps

Axial MR image demonstrating multiple small gallbladder polypoid lesions characterized by contrast enhancement in a 78-year-old male hospitalized for acute chest pain due to coronary artery disease who showed fever and emesis during hospitalization and had signs of acute acalculous cholecystitis at computed tomography. Given the overall clinical conditions and the MR features, the inflammatory origin of the polyps was considered. The patient underwent cholecystectomy and the histological diagnosis of gallbladder inflammatory pseudopolyps was confirmed. This rare entity represents 5–10% of all gallbladder polyps, and their differentiation from benign and malignant tumors might be challenging especially in acalculous patients, thus surgery is often performed.

A 78-year-old man was admitted to the emergency room of our tertiary center for acute chest pain due to coronary artery disease and underwent coronary artery bypass. During the hospitalization he had fever and emesis. Thus, he underwent contrast enhanced computed tomography demonstrating acute acalculous cholecystitis with localized gallbladder perforation ( Figure 1a). Ultrasound-guided percutaneous transhepatic cholecystostomy was performed and antibiotic therapy administered. Ninety days later, a Magnetic Resonance (MR) scan showed multiple small gallbladder polyps characterized by contrast enhancement without any evidence of gallbladder stones (Figure 1b). The radiological findings were compatible with an inflammatory etiology of the polypoid lesions although, especially because of the lack of gallbladder stones and previous MR scans, neoplastic polyps could not be completely excluded. The patient underwent cholecystectomy and the histological diagnosis of gallbladder inflammatory pseudopolyps (GIP) was confirmed (Figure 2a,b).
Acute acalculous cholecystitis, even complicated by perforation, often occurs in postsurgical adults while in children it is often caused by infectious disease or immune-mediated disorders. Moreover, it can be associated with cardiovascular diseases, in particular with coronary artery disease and in children with Kawasaki Disease [1][2][3][4]. The etiology of acalculous cholecystitis is often unknown, even though it has been correlated with biliary hypokinesia and local ischemia [5][6][7][8].
The radiological literature regarding rare pseudotumors like GIP, which represents 5-10% of all gallbladder polyps, is scarce, and, even if they are usually multiple and small (<10 mm), a differentiation from benign and malignant tumors might be challenging. Mucosal irritation, granulation, and fibrous tissue, usually due to gallstones and/or chronic inflammation may cause GIPs [9][10][11].
The rarity of our case in which the occurrence of GIP is probably related to acalculous cholecystitis subsequent to acute coronary artery disease, is highlighted by the results of the brief literature search, without any restrictions on language and publication date, we conducted on Pubmed on the 4 January 2022. Indeed, using the keywords "(gallbladder inflammatory pseudopolyps) AND (coronary artery disease)" no records could be identified while applying the keywords "(acute acalculous cholecystitis) AND (coronary artery disease)" and "(acalculous cholecystitis) AND (inflammatory polyps)", only 16 and one records were identified, respectively [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. Three of the 16 records were excluded because they were not fully matching [25][26][27] and the single record deriving from the second search is not reported in Table 1 since it is a narrative review [28]. The records of the search are summarized in Table 1.     Thus, our case demonstrates that, although rarely, GIP may occur in patients with acalculous cholecystitis even associated with coronary artery disease and can be easily diagnosed at MR. Given the clinical course of our patient, the etiology and the benign nature of the pseudopolyps could have been assumed. Nevertheless, since the malignant behavior of gallbladder lesions is not easily excluded at imaging, especially in acalculous and symptomatic patients with an unknown/partially known clinical history, surgery still plays a dominant role and histology remains the gold standard for a precise characterization.

Informed Consent Statement:
The patient provided informed consent for the description and publication of the case.

Conflicts of Interest:
The authors declare no conflict of interest.