Massive Mucinous Ascites

Question: A 67-year-old man was referred and admitted because of massive ascites that had been identified 2 weeks earlier. He had been healthy without any previous history of disease. Physical examination revealed his abdomen to be markedly distended; however, no tenderness or muscle defense was observed. Abdominal ultrasonography revealed massive ascites containing fibrin-like precipitates. The gallbladder seemed to be filled with mass shadow with an irregular and mosaic echo pattern, and the gallbladder wall was absent. The radial mass shadow was also observed to continue into the abdominal cavity like seaweed through the ruptured gallbladder wall (Figure A). No bloodstream sign was observed in the mass shadow in the gallbladder by Doppler ultrasonography. Abdominal computed tomography (CT) also showed massive ascites. There seemed to be an absence of the gallbladder wall, as observed by ultrasonography, and the gallbladder was filled with ascites through the wall. A tumor with contrast enhancement was observed in the neck of the gallbladder by contrast enhanced CT (Figure B, arrows). There was no tumor observed in the liver. No dilation of the intra- or extrahepatic biliary duct was observed. The initial laboratory tests included a white blood cell count of 8200/uL, a C-reactive protein level of 6.05 mg/dL (normal range, up to 0.20), and a total