CASE HISTORY

This patient had been known to have a mucous polyp of the rectum since 1940 but she  persistently refused any treatment until November 1949 when a vesico-vaginal fistula had developed. On examination of the abdomen a hard mass could be palpated in the right hypochondrium and this was considered to be secondary deposits in the liver. At operation on the rectum, however, this mass was found to be an enlarged gall bladder, containing stones.The early post-operative course was smooth but after the 4th day she developed intestinal obstruction and died on 13.12.49. At post-mortem the intestinal obstruction was partly mechanical due to adhesion in the pelvis and there was bilateral bronchopneumonia. The gall bladder was enlarged, calcified and contained thick green shimmering fluid (almost certainly with a high cholesterol content) and many gall stones.

PATHOLOGY

The mounted specimen consists of half of the gall-bladder. It can be seen to be enlarged,  measuring 10 x 7cms and globular in shape; the outer surface is white and smooth; there is a  diverticulum at the fundus (the lower end of the specimen) and Hartmann's pouch is well formed (opposite end). On cut section the wall is thickened up to 3mm diameter and is  plaques. In the lumen are 4 facetted gall-stones; in the fundal diverticulum is a stone about  1.5cm diameter and a very small one; their cut surface show concentric lamellae indicating their infective origin; in Hartmann's pouch is a larger stone also showing concentric lamellae. The separate stone (also from the lumen) has an irregular surface with numerous small plaques - slightly resembling a mulberry and on section the central core is light yellow with radiate structure indicative of cholesterol; around this are concentric lamellae due to infection.