We report the case of a 39-year-old male patient, with no toxic habits, with hypertension in losartan and secondary traumatic brain injury, admitted to the ICU after a traffic accident with multiple fractures.
The patient came to the emergency department with marked asthenia, cutaneous dryness and melenic stools of 7 days duration, associated with epigastric pain in recent days.
The patient had been treated with amoxicillin/clavulanic acid and ibuprofen for dental problems in the week prior to the onset of symptoms.
On arrival to the emergency department, the patient presented tachycardia at 133 bpm, with correct blood pressure and fever.
Examination revealed cutaneous-mucosal dryness, and the rest of the physical examination showed anodyne, except for a positive rectal examination for melena.
A general laboratory test was performed, highlighting a hemoglobin level of 3.5 mg/dl and elevation of transaminase (AST 150 U/L and ALT 318 U/L), with other values unchanged.
An urgent gastroscopy was performed, which showed active drooling bleeding at the duodenal level which seemed to come from the ampulla of Vater.
Examination with lateral vision duodenum showed fresh blood outflow through the greater papilla, this being a normal endoscopic appearance.
Subsequently, CT angiography was performed, which at that time did not detect signs of active bleeding, showing mild dilation of the intrahepatic and extrahepatic bile duct, with slightly thickened gallbladder walls.
Endoscopy showed occupation of the gallbladder by an irregular hyperechoic lesion, without posterior acoustic shadowing, and ruled out the presence of colitis.
A new imaging study (ultrasound and CT) was requested to study these findings, observing the occupation of the gallbladder by solid tissue, with enhancement compatible with tumor pathology, without signs of local or distant invasion.
A laparoscopic cholecystectomy was performed.
Macroscopic examination of the surgical specimen showed a gallbladder of 5 x 2.5 cm, observing a hairy polypoid lesion of 3 cm occupying completely its lumen, based on implantation in the gallbladder fundus.
Microscopic examination showed correspondence to intracystic papillary neoplasia of biliary type of 3 cm, with focal foveolar and intestinal gastric differentiation, with presence of low-grade dysplasia focal and without invasive component.
The adjacent biliary mucosa presented focal metaplasia and chronic pilocytic changes.
The resection margins were free of injury.
The immunohistochemical study was diffuse positive for CK7, MUC1 and MUC 5AC; and focal positive isolated for CDX2, MUC 2 and MUC 6.
At 6 months follow-up after surgery, the patient remains asymptomatic, with no new episodes of gastrointestinal bleeding.
