What is gallbladder hydrops in patients with a history of gallstones or other gallbladder diseases?

What is Gallbladder Hydrops?

Gallbladder hydrops is a progressive distention of the gallbladder caused by obstruction of the cystic duct or gallbladder neck, resulting in accumulation of clear, viscous, sterile fluid ("white bile") rather than normal bile. 1

Pathophysiology

The condition develops through a specific mechanism:

• Obstruction is the primary cause, typically from a gallstone impacted in the cystic duct or gallbladder neck 1, 2
• Following obstruction, mucosal inflammation develops, leading to disturbances in reabsorptive processes and increased mucous secretion 1
• The gallbladder contents transform into clear, viscous "white bile" that is sterile in nearly all cases (97% sterility rate) 1
• Intraluminal pressure increases significantly, averaging 61.5 cm saline (range 15-115 cm) 1
• The bile becomes roughly isotonic with blood (average 295 mosmol/kg) with bilirubin, bile salts, cholesterol, phospholipids, and protein reduced to non-measurable amounts or below 1 mg% 1

Clinical Presentation

Patients typically present with right upper quadrant pain, though the presentation can be variable:

• Exquisite right upper quadrant pain is the classic presentation 3
• Some patients may present with symptoms mimicking other conditions (e.g., viral gastroenteritis) 2
• Diabetic patients with neuropathy are at particularly high risk and may have atypical presentations due to impaired pain sensation 2

Diagnostic Approach

Ultrasound is the primary diagnostic modality:

• Gray-scale ultrasound readily identifies the distended gallbladder 4
• CT scan of the abdomen can reveal the hydropic gallbladder, which should be confirmed with abdominal ultrasonography 3
• The gallbladder appears markedly enlarged with clear fluid contents 1, 3

Critical Complications

Spontaneous perforation is a life-threatening complication, particularly in high-risk populations:

• Diabetic patients are at significantly elevated risk for spontaneous rupture of a hydropic gallbladder 2
• Perforation can result in septic shock and death 2
• This complication is often under-diagnosed due to varying diagnostic criteria used globally 2

Management Considerations

The approach depends on the clinical context:

• In pediatric cases (such as with mucocutaneous lymph node syndrome/Kawasaki disease), conservative management with ultrasound monitoring is appropriate, as the gallbladder typically returns to normal size within 15 days 4
• Surgery is indicated for complications of hydrops, not for distention alone in pediatric cases 4
• In adults, particularly those with symptomatic gallstone disease, cholecystectomy is the definitive treatment 1
• Diabetic patients require heightened vigilance due to their increased risk of spontaneous perforation 2

Important Clinical Pitfalls

• Hydrops can develop as a complication following biliary interventions, such as short-term stenting for dominant strictures in primary sclerosing cholangitis 5
• The condition may be associated with other biliary pathology, including common bile duct obstruction from various causes 6
• The sterile nature of the fluid does not eliminate the risk of serious complications, particularly perforation 1, 2