MILITARY MEDICINE, 176. 1:119.

2011

Possible Vicarious Contrast Excretion Causing Symptomatic Cholelithiasis

Capt Andrew B. Hall, USAF MC; Capt Andrea Blake, USAF MC; Maj Brad Wheeler, USAF MC; Maj Robert Cromen USAF MC
ABSTRACT A case report of a unique malleable, rubbery, white mass found at cholecystectomy after a diagnosis of symptomatic cholelithiasis. This likely represents either a unique form of a calcium-containing or contrast-containing stone. There are no reported incidents of vicarious contrast stones and calciutii-containing stones are reported to be crystalline and hard.

INTRODUCTION A 70-y/o female presents to the emergency room (ER) with acute right upper quadrant pain after a chronic history of postprandial pain for at least 1 year. Ultrasound (u/s) of the right upper quadrant revealed a 3-mm echogenic focus interpreted as a polyp and no pericholecystic fluid or wall thickening. Computed tomography (CT) of the patient's abdomen and pelvis was obtained in the FR for further evaluation of her pain given the bland u/s findings and her previous history of multiple abdominal operations and colon cancer. It revealed a large radiopaque mass at the fundus of the gallbladder (Figs. 1 and 2) without extension beyond the gallbladder wall, which was interpreted as a 1.5-cm gallstone occupying the tnajority of the gallbladder. A hepatobiliary imino-diacetic acid (HIDA) scan was performed, which showed rapid uptake and excretion of radiotracer from the gallbladder. Patient history revealed a substantial level of contrast exposure within months before her presenting symptoms, with multiple intravenous to oral (IV/PO) contrast CT .scans obtained throughout her course of therapy for adenocarcinoma of the right colon. Her treatment was further complicated by chronic renal insufficiency and exocrine pancreatic insufficiency that developed during chemotherapy. The patient was taken electively to the operating room approximately 1 week following her FR evaluation for persistent symptoms consistent with chronic cholecystitis, likely secondary to cholelithiasis, despite her discordant imaging findings. A laparoscopic cholecystectomy was attetnpted and converted to open secondary to extensive adhesions from the previous open right hemicoleetomy. Upon completion of the procedure, the gallbladder was examined. It revealed no gross mucosal abnormalities, polyps, or typical pigmented or cholesterol gallstones. However, an approximately 1.5-cm at greatest diameter rubbery, putty-like, malleable, white-gray mass was present within the gallbladder consistent with the

CT findings. Postoperatively, the patient experienced a typical recovery expected after open cholecystectomy and had complete resolution of her postprandial abdominal symptoms. The mass was sent in formalin to the pathology department where it was found to be molded to the bottom of the container and had hardened (Fig. 3). The stone was sent to the Division of Environmental Pathology at the Armed Forces Institute of Pathology for further analysis. Infrared spectra were obtained from the surface, which did not identify bilirubin, cholesterol, or exogenous material. Scanning electron microscopy with energy dispersive X-ray analysis revealed calcium, phosphorus, oxygen, and carbon with a minor component of sodium. DISCUSSION A purely noncholesterol, nonbilirubin, noncalcium palmitate/ phosphate stone is an uncommon entity. Natural stones routinely include some element of calcium, but frequently contain a mixture of other constituents. Natural stones from experience are hard, firm, or fracturable objects, upon exam at the time of cholecystectomy the object was putty-like and easily malleable, only solidifying after being sent in formalin. This odd gross exam finding, with uncommon chemical constituents, means this represents either a calcium phosphate stone of a unique consistency or a soft mass composed of vicariously excreted contrast. Natural stones frequently include some element of calcium and the ratios are dependent on the patient's sex, genetics, and underlying metabolic or pathologic processes.' Most stones are also homogenous, containing most commonly calcium bilirubinate. Pure calcium phosphate and calcium apatite stones also regularly occur at a rate of 3.7% and 0.2%, respectively, and contain the identified phosphorous.- These pure stones are normally crystalline and hard. The mass on initial discovery was very rubbery and malleable, which is inconsistent with normal gallstones. This could indicate a mixed stone with different properties; however, common compounds in mixed stones such as bilirubin and cholesterol were not identified. Vicarious contrast excretion in the gallbladder is a common radiographie finding, but the formation of a symptomatic contrast stone is unreported in the literature. While the exact

Keesler Medical Center, 301 Fisher Street, Keesler AFB. MS 39534. The opinions and/or assertions contained herein are solely those of the authors and should not be construed as reflecting those of the U.S. Air Force. Department of Defense, or U.S. Government.

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FIGURE 1. Ultrasound of the gallbladder with no identifiable gallstones. FIGURE 3. Photograph of solidified gallbladder mass.

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FIGURE 2. gallstone.

CT image of the abdomen with arrow indicating a large

pathways are unknown, intravenous contrast is found to be excreted throughout the gastrointestinal tract.^ Typically, the contrast appears only in the gallbladder and colon and it is theorized that the water absorption abilities of these organs are able to concentrate the contrast to the point of radio-opaqueness.'* Vicarious excretion is more typically seen in certain patients and with certain types of contrast. The protein binding percentage of the contrast agent is one of the primary factors affecting excretion and is thought to encourage hepatobiliary excretion.' As an example, Ioxaglate, which has one of the highest protein binding percentages at 13.95%, bas a biliary opacification rate approaching 60% at 12 to 25 hours.* At our facility we use exclusively Iodixanol as an IV agent, which has a protein binding percentage of 4.25%. The hepatobiliary

excretion is thought to be facilitated by renal disease due to a higher rate of vicarious excretion seen in patients with renal disorders.^ The theory behind this is that the increased circulation time of intravenous agents allows for greater opportunities for hepatobiliary excretion.' A natural stone of this unique character could be a result of the pancreatic insufficiency or other medical conditions the patient had. A previous study has implicated pancreatic enzymes in the formation of calcium stones." The patient in this case had pancreatic insufficiency, which could have resulted in nonpbysiologic imbalance of enzymeseither a relative deficiency of native secretions or excess of exogenous enzymes. This leads to a theory that this mixture of pancreatic secretions could have resulted in a unique calcium stone with malleable properties. Without additional data or similar cases, the exact composition of the pancreatic secretions cannot be ascertained. We present a patient with a combination of comorbid conditions and an unusual gallstone/mass. Vicariously excreted contrast leading to formation of this mass is our best theoretical explanation. It is speculated that over the years leading up to this encounter the patient had slowly been accruing the contrast components within her gallbladder, which bad ultimately led to tbe production of the "stone." Tbis patient did have some element of renal dysfunction making hepatobiliary excretion more of a factor. Tbe lack of iodine in the analysis of the stone is potentially explained by the biliary tract's ability to uptake iodine.' Other chemical agents in addition to iodine, such as edentate calcium disodium, in contrast,would likely be metabolized or excreted elsewbere, such as in the urine. Interstingly, the rapid excretion of radiotracer seen during the HIDA scan suggests that there was at least some preserved gallbladder function, although as her disease progressed, increasing dysfunction would theoretically allow increased time for desiccation of the intravenous contrast.

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The gallstone composition findings eould be best explained by one of two possibilitieseither it is a very rare naturally occurring form of a gallstone or vicarious excretion of a medical compound. Her symptoms suggest the mass was likely causing intermittent symptoms secondary to obstruction of the cystic duct. After cholecystectomy, the patient was relieved of her symptoms and recovered well. Overall this appears to be a benign entity behaving clinically as typical symptomatic gallstone disease. If other incidents of similar stones are reported after contrast administration, our hope is a correlation can be made to either a natural or artificial source. REFERENCES
1. Sutor DJ. Wooley S: A statistical survey of the composition of gallstones in eight countries. Gut 1971; 12:55-64.

2. Yoo E. Oh H, Lee S: Gallstone analysis using Fourier transform infrared spectroscopy (FT-IR). Clin Chem Lab Med 2008; 46(3): 376-81. 3. Meholic A. Davis M. Bonniati C: Vicarious gastric excretion of intravenous contrast. Atn J Physiol Imaging 1991 ; 6: 197-200. 4. Lautin E. Friedman A: Vicarious excretion of contrast media. JAMA 1982; 247(11): 1608-10. 5. Nwoye U, Padberg F, Sadeghi-Nejad H: Vicarious excretion of parenteral contrast material after endova.scular abdominal aortic aneurysm repair. Vase Endovascular Surg 2008; 42(5): 494-6. 6. Hopper K. Weingast G. Rudikoff J. et al: Vicarious excretion of watersoluble contrast media into the gallbladder in patients with normal serum creatinine. Invest Radiol 1988; 23: 604-8. 7. Segall H: Gallbladder visualization following the injection of diatrizoate. Am J Roentgenol Radium Ther NucI Med 1969; 107(1): 21-6. 8. Gallstone composition. BMJ 1973; 2(5859): 132-3. 9. Carlisle M. Cortes A. McDougall I: Uptake of I-13I in the biliary tract: a potential cause of a false-positive result of scintiscan. Clin Nuc Med 1998; 23(8): 524-7.

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