Surg Radiol Anat DOI 10.1007/s00276-014-1263-0

Letter to the Editor

Gallbladder agenesis: laparoscopic views of a significant diagnostic challenge Sergio Castorina · Roberto Scilletta · Jacques Domergue 

Received: 12 December 2013 / Accepted: 23 January 2014 © Springer-Verlag France 2014

Introduction The common symptoms of cholelithiasis as reported in the literature are right upper quadrant abdominal pain (90 %), nausea and vomiting (66 %), fatty food intolerance (37 %), dyspepsia (30 %), and jaundice (35 %). As found in some studies, these symptoms are common even if the gallbladder is not involved. Gallbladder agenesis (GA) is a rare congenital anomaly characterized by the absence of the gallbladder in conjunction with a normal bile duct system. Women are more commonly affected (at a 3:1 ratio) and typically present in the second or third decade of life [3]. Diagnosis is not easy, and ultrasound (US) and magnetic resonance (MR) [2], or a laparoscopy is usually necessary. A 33-year-old woman presented to our hospital with right upper quadrant pain. The pain was dull, aching, sudden in onset, colicky in nature, and radiated to her right scapula. Associated symptoms included nausea. These symptoms were worsened by meals, and particularly by fatty food. The episodes of pain would last for 45–90 min following each meal. The patient presented to the emergency department 4 weeks after the onset of symptoms and, given concerns

about the biliary nature of her pain, was evaluated by the surgical service. She had an abdominal ultrasound, which showed a difficult visualization of her gallbladder. She subsequently underwent an MR scan (Fig. 1), which was read looking for possible acute cholecystitis or a sclerotic and atrophic gallbladder. The exam evidenced an anomaly in the anatomy of the pancreatic duct, suggesting a hypothesis of pancreas divisum (an anatomical finding related to GA). She was discharged with plans for possible laparoscopic cholecystectomy in 4–6 weeks. In the interim, she had recurrence of her symptoms, and again presented to our department. Her laboratory testing was notable for an unremarkable basic metabolic panel and liver enzymes. At this point, we decided to do a laparoscopy [1] to resolve any doubt. No gallbladder was visualized,

S. Castorina  Department of Biomedical Sciences, University of Catania, Fondazione Mediterranea G.B. Morgagni, Catania, Italy e-mail: [email protected] R. Scilletta (*)  Department of Surgical Sciences, University of Catania, Fondazione Mediterranea G.B. Morgagni, Catania, Italy e-mail: [email protected] J. Domergue  L’Institut régional du Cancer de Montpellier-ICM, Montpellier, France

Fig. 1  MRI image of the biliary tract

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exploration, we decided to abort the procedure after about 15 min. We then decided to discharge the patient the day after, giving smooth muscle relaxants and the indication to execute a sphincterotomy if the therapy failed, as per Malde’s algorithm [4]. There are no specific guidelines on how to manage patients with GA. Malde’s algorithm advises further radiologic investigation (MRCP, TC, ECRP, based on local availability) in symptomatic patients when a US scan is not conclusive for a diagnosis. In any event, if the diagnosis is made during surgery, the operative strategy is finalized to exclude an aberrant gallbladder, and the diagnosis should be reconfirmed postoperatively by careful US scan. Conflict of interest The authors have no conflicts of interest to declare.

References Fig. 2  Laparoscopic views of the gallbladder's agenesis

and we found only a dilatation of the common bile duct (Fig. 2), so after examination of the most common sites for ectopic gallbladder (intrahepatic, retrohepatic, on the left side, within the leaves of the lesser omentum, within the falciform ligament, retroduodenal, retropancreatic, retroperitoneal), and to avoid complications from prolonged

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1. Castorina S, Luca T, Privitera G, El-Bernawi H (2012) An evidence-based approach for laparoscopic inguinal hernia repair: lessons learned from over 1,000 repairs. Clin Anat 25(6):687– 696. doi:10.1002/ca.22022 2. Joliat GR, Shubert CR, Farley DR (2013) Isolated congenital agenesis of the gallbladder and cystic duct: report of a case. J Surg Educ 70(1):117–120. doi:10.1016/j.jsurg.2012.07.001 3. Kasi PM, Ramirez R, Rogal SS, Littleton K, Fasanella KE (2011) Gallbladder agenesis. Case Rep Gastroenterol 5(3):654–662. doi:10.1159/000334988 4. Malde S (2010) Gallbladder agenesis diagnosed intra-operatively: a case report. J Med Case Rep 4:285

Gallbladder agenesis: laparoscopic views of a significant diagnostic challenge.

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