Case Report Intramural Gallstones Mimicking Typical Lithiasic Cholecystitis Stylianos Apostolidis, MD, PhD, Apostolos Zatagias, MD, and Alexandros Zevgaridis, MD Abstract: Gallstone disease is common in the western population. Intramural gallstones are rare, with only a few cases reported in the literature. We present a 30-year-old female patient with typical symp- toms of cholecystitis. The patient underwent laparoscopic cholecys- tectomy one month later. Dark greenish intramural gallstones were identified right after the resection of the gallbladder, and the patho- logic examination revealed adenomyomatosis of the gallbladder. To our knowledge, this is the first report of intramural gallstones pre- senting with cholecystitis. The presence of intramural gallstones is not easily detected during ultrasound examination, and does not affect the natural course or treatment of gallstone disease. Key Words: adenomyomatosis, cholecystitis, intramural gallstones A lthough cholelithiasis is a very common disorder, intra- mural gallstones are rare. Morgagni was the first to de- scribe intramural gallstones in 1761 1 and to date, there are only a few reports in the literature. In each of these cases, intramural gallstones represented incidental findings during autopsy 2 or during surgical procedures. 3,4 In one case, the patient underwent oral cholangiography, so the presence of intramural gallstones was already known prior to surgery. To the best of our knowledge, this is the first report of intramural gallstones found postoperatively after laparoscopic cholecys- tectomy for chronic lithiasic cholecystitis. Case Report A 30-year-old woman referred to our hospital with chronic pain in the right upper abdominal quadrant. She also reported distension, nausea, flatulence, and intoler- ance of fats. At clinical examination, she had a mild tenderness in the right upper abdominal quadrant. Abdominal ultrasound was performed, which revealed a dilated gallbladder and the presence of small gallstones adjacent to the thickened, partially calcificated wall. The hepatic ducts were not dilated and the liver was of nor- mal size and structure. The patient underwent conserva- tive treatment and was discharged after four days, with laparoscopic cholecystectomy scheduled one month later. During cholecystectomy, the gallbladder revealed loose adhesions with adjacent structures and was suc- cessfully removed. The patient recovered well from the operation. During the postoperative dissection of the gallbladder, small, dark greenish stones were discovered inside the thickened wall of the gallbladder (Figs. 1 and 2). The pathology report confirmed the diagnosis of in- tramural gallstones in a gallbladder that was 9 cm long and 2.5 cm wide, with a wall thickness of 1.3 cm. At different dissections, intramural dark greenish stones a few millimeters in diameter were found. The final diag- nosis was a gallbladder with lesions typical of chronic fibrous lithiasic cholecystitis and adenomyomatosis of the wall. Discussion Although gallstones are frequently found in the western population - 12% reported in the US, as compared to 2–3% reported in East Africa 5 - intramural gallstones are very rare. The term “intramural gallstone” refers to gallstones that are embedded in the gallbladder wall. 6 Adenomyomatosis of the gallbladder is characterized by a) mucosal hyperplasia; b) From the Surgical Department, Euromedica Kyanous Stavros General Hos- pital, Thessaloniki, Greece. Reprint requests to Apostolos Zatagias, MD, Euromedica Kyanous Stavros Hospital, 1st Viziis Street, 54636, Thessaloniki, Greece. Email: zatagias@ yahoo.com Accepted April 23, 2010. Copyright © 2011 by The Southern Medical Association 0038-4348/0-2000/10400-0059 Key Points • Intramural gallstones are rare, with few reported cases in the literature. • The presentation of cholecystitis with intramural gall- stones is extremely rare, requiring careful ultrasound examination to assist with the diagnosis. • Adenomyomatosis of the gallbladder is characterized by mucosal hyperplasia, thickening of the mucularis, and diverticula formations of the gallbladder wall. Southern Medical Journal • Volume 104, Number 1, January 2011 59