CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 11 (2015) 18–20
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Gallbladder duplication Yagan Pillay ∗ Department of General Surgery, Victoria Hospital, Prince Albert Parkland Health Region, Prince Albert S6V8C3, SK, Canada
a r t i c l e
i n f o
Article history: Received 2 February 2015 Received in revised form 24 March 2015 Accepted 3 April 2015 Available online 11 April 2015 Keywords: Congenital Double gallbladder Cholelithiasis Cholecystectomy
a b s t r a c t INTRODUCTION: Gallbladder duplication is a rare congenital malformation that occurs in about one in 4000 births. Congenital anomalies of the gallbladder and anatomical variations of their positions are associated with an increased risk of complications after laparoscopic cholecystectomy. PRESENTATION OF CASE: We report the case of a double gallbladder in a fifty-six year old man. He presented with recurrent episodes of biliary colic. Pre-operative imaging confirmed the diagnosis. He subsequently underwent surgery for biliary colic. DISCUSSION: Inspection of the resected gallbladder specimen showed that it consisted of two chambers with a single cystic duct, which communicated through a common ostium. Both chambers had cholelithiasis. There were two cystic arteries as well. Duplication of the gallbladder has an incidence of approximately 1: 4000. However, the exact incidence of this rare anomaly cannot be accurately assessed, since the only cases which have been identified are those that became symptomatic or were encountered as incidental findings during surgery, imaging studies or at autopsy. CONCLUSION: Duplication of the gallbladder is a rare congenital abnormality, which requires special attention to the biliary ductal and arterial anatomy. Laparoscopic cholecystectomy with intraoperative cholangiography is the appropriate treatment in a symptomatic gallbladder. The removal of an asymptomatic double gallbladder remains controversial. © 2015 The Author. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Gallbladder duplication is a rare congenital malformation, that occurs in about one in 3800–4000 births. Congenital anomalies of the gallbladder and anatomical variations of their positions are associated with an increased risk of complications after laparoscopic cholecystectomy. Preoperative imaging is often helpful for diagnosis. Congenital malformations are considered one of the most important predisposing factors for iatrogenic bile duct injuries during cholecystectomy, especially in the era of laparoscopic cholecystectomy. These malformations could be associated with the development of cholelithiasis, due to inadequate bile drainage. Laparoscopic cholecystectomy is the treatment of choice. If the intraoperative anatomy is not clear then an intra-operative cholangiogram should be performed.
2. Case report A 56 year old male patient was referred for biliary colic and right upper quadrant pain Fig. 1. There was an association with
∗ Fax: +1 306 7643091. E-mail address: [email protected]
fatty foods. The pain had been there for one week intermittently. There were two previous episodes as well that responded to conservative management in the past year. No history of fever or jaundice. His medical history included type two diabetes. He was on oral hypoglycaemic medication for this condition. There was a history of alcohol ingestion and smoking with a 15 year pack history. Clinically, his abdomen was soft and non tender with no masses and no clinical signs of jaundice. No herniae were noted. Blood results were normal. Ultrasound showed a large gallbladder with no signs of cholecystitis Fig. 2. The differential diagnosis included a double gallbladder or a gallbladder with a larger floppy fundus. Patient then had a CT scan of the abdomen and an MRCP which confirmed the diagnosis. He was booked for a laparoscopic cholecystectomy which was performed without incident. Intraoperatively the cystic duct was clearly identified, so an intraoperative cholangiogram was not performed. The patient had an uneventful recovery and was discharged home on post operative day two. Inspection of the pathology specimen revealed a double gallbladder draining into a common cystic duct. The pathology report revealed a specimen weighing 40.2 g consisting of a double gallbladder Fig. 3. Measurements were 8.0 cm × 3.5 cm and 8.0 cm × 2.5 cm. Both specimens were attached at the proximal part. The mucosa appeared normal. Cholecystectomy specimen showing features of a mild chronic cholecystitis. The macroscopic appearance is in keeping with a double gallbladder. No malignancy was seen Fig. 4.
http://dx.doi.org/10.1016/j.ijscr.2015.04.002 2210-2612/© 2015 The Author. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS Y. Pillay / International Journal of Surgery Case Reports 11 (2015) 18–20
Fig. 1. MRCP showing double gallbladder(arrows).
19
Fig. 3. Axial CT showing gallbladder duplication(arrows).
Fig. 4. Duplication Gallbladder.
Fig. 2. CT scan coronal view with gallbladder duplication(arrows).
3. Discussion Duplication of the gallbladder has an incidence of approximately 1:4000. However, the exact incidence of this rare anomaly cannot be accurately assessed, since the only cases which can be identified are those that became symptomatic or were encountered as incidental findings during laparotomy, imaging studies or at autopsy. Duplication of the gallbladder can be classified into 2 main types Fig. 5. The first is the bi-lobed gallbladder (Vesica fellea divisum), where a longitudinal septum or invaginating cleft separates the lumen into 2 chambers. In these cases, both gallbladders share a common embryological origin (primordium). The second is the double gallbladder (Vesica fellea du-plex), where there are 2 separate gallbladders with their own cystic ducts. In these cases, we have to accept a double embryological origin (dual primordium). In our case, the gallbladder consisted of 2 separate chambers, which were connected through a narrow ostium. Both chambers shared a common cystic artery but the second chamber appeared to have a second narrow cystic duct, which drained to the right hepatic
Fig. 5. Common cystic duct(arrow).
duct. We believe that the presence of the ostium between the 2 chambers may have led to the progressive obliteration of the draining cystic duct of the second chamber. Differential diagnosis includes gallbladder diverticula, gallbladder fold, Phrygian cap, choledocal cyst, pericholecystic fluid, focal adenomyomatosis, and
CASE REPORT – OPEN ACCESS 20
Y. Pillay / International Journal of Surgery Case Reports 11 (2015) 18–20
Conflicts of interest Not applicable. Funding No funding. Consent No consent obtained as the patient has demised two years later. Author contribution Yagan Pillay – only author. Further reading
Fig. 6. Boydens classification.
intraperitoneal fibrous bands Fig. 6. The clinical significance associated with a duplicated gallbladder is similar to those encountered in a single gallbladder. This includes acute or chronic cholecystis, cholelithiasis, empyema, torsion, cholecystocolic fistula, and carcinoma. There are no specific symptoms attributable to a double gallbladder. Simultaneous removal of both gallbladders at surgery is recommended to avoid cholecystis and biliary colic in the remaining organ. Duplication of the gallbladder is a rare congenital abnormality, which requires special attention to the biliary ductal and arterial anatomy. Laparoscopic cholecystectomy with intraoperative cholangiography is the appropriate treatment in a symptomatic gallbladder. The removal of an asymptomatic double gallbladder remains controversial.
[1] E.S. Boyden, The accessory gallbladder: an embryological and comparative study of aberrant biliary vesicles occurring in man and the domestic mammals, Am. J. Anat. 38 (1926) 177–231. [2] A. Goel, K.N. Srivastava, A.K. Rana, Double gall-bladder-a laparoscopic management, Surg. Laparosc. Endosc. Percutan. Tech. 13 (2003)348–349. [3] R.E. Gross, Congenital anomalies of the gallbladder: a review of the literature and a report of a case associated with hepatic duct carcinoma, Arch. Surg. 32 (1936) 131–162. [4] B. Wani, G. Kolte, V. Rathod, A. Bhole, A cholelithiasic double gallbladder, J. Chir. vol. 5 (Nr. 4) (2009) 1584–9341, ISSN. [5] B. Papaziogas, C. Lazaridis, G. Paraskevas, J. Koutelidakis, P. Katsinelos, B. Oikonomou, G. Chatzimavroudis, M. Grigoriou, K. Atmatzidis, A variant of the double gallbladder, a possible cause of cholelithiasis, Folia Morphol. (Warsz) 64 (August (3)) (2005) 229–232. [6] G. Desolneux, S. Mucci, J. Lebigot, J.P. Arnaud, A. Hamy, Duplication of the gallbladder a case report Gastroenterol. Res. Pract. 2009 (2009) 3, http://dx.doi.org/10.1155/2009/483473, Article ID 483473. [7] S.K. Ghosh, Laparoscopic cholecystectomy in double gallbladder with dual pathology, J. Minim. Access Surg. 10 (April (2)) (2014) 93–96, http://dx.doi.org/10.4103/0972-9941.129963.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Gallbladder duplication Yagan Pillay ∗ Department of General Surgery, Victoria Hospital, Prince Albert Parkland Health Region, Prince Albert S6V8C3, SK, Canada
a r t i c l e
i n f o
Article history: Received 2 February 2015 Received in revised form 24 March 2015 Accepted 3 April 2015 Available online 11 April 2015 Keywords: Congenital Double gallbladder Cholelithiasis Cholecystectomy
a b s t r a c t INTRODUCTION: Gallbladder duplication is a rare congenital malformation that occurs in about one in 4000 births. Congenital anomalies of the gallbladder and anatomical variations of their positions are associated with an increased risk of complications after laparoscopic cholecystectomy. PRESENTATION OF CASE: We report the case of a double gallbladder in a fifty-six year old man. He presented with recurrent episodes of biliary colic. Pre-operative imaging confirmed the diagnosis. He subsequently underwent surgery for biliary colic. DISCUSSION: Inspection of the resected gallbladder specimen showed that it consisted of two chambers with a single cystic duct, which communicated through a common ostium. Both chambers had cholelithiasis. There were two cystic arteries as well. Duplication of the gallbladder has an incidence of approximately 1: 4000. However, the exact incidence of this rare anomaly cannot be accurately assessed, since the only cases which have been identified are those that became symptomatic or were encountered as incidental findings during surgery, imaging studies or at autopsy. CONCLUSION: Duplication of the gallbladder is a rare congenital abnormality, which requires special attention to the biliary ductal and arterial anatomy. Laparoscopic cholecystectomy with intraoperative cholangiography is the appropriate treatment in a symptomatic gallbladder. The removal of an asymptomatic double gallbladder remains controversial. © 2015 The Author. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Gallbladder duplication is a rare congenital malformation, that occurs in about one in 3800–4000 births. Congenital anomalies of the gallbladder and anatomical variations of their positions are associated with an increased risk of complications after laparoscopic cholecystectomy. Preoperative imaging is often helpful for diagnosis. Congenital malformations are considered one of the most important predisposing factors for iatrogenic bile duct injuries during cholecystectomy, especially in the era of laparoscopic cholecystectomy. These malformations could be associated with the development of cholelithiasis, due to inadequate bile drainage. Laparoscopic cholecystectomy is the treatment of choice. If the intraoperative anatomy is not clear then an intra-operative cholangiogram should be performed.
2. Case report A 56 year old male patient was referred for biliary colic and right upper quadrant pain Fig. 1. There was an association with
∗ Fax: +1 306 7643091. E-mail address: [email protected]
fatty foods. The pain had been there for one week intermittently. There were two previous episodes as well that responded to conservative management in the past year. No history of fever or jaundice. His medical history included type two diabetes. He was on oral hypoglycaemic medication for this condition. There was a history of alcohol ingestion and smoking with a 15 year pack history. Clinically, his abdomen was soft and non tender with no masses and no clinical signs of jaundice. No herniae were noted. Blood results were normal. Ultrasound showed a large gallbladder with no signs of cholecystitis Fig. 2. The differential diagnosis included a double gallbladder or a gallbladder with a larger floppy fundus. Patient then had a CT scan of the abdomen and an MRCP which confirmed the diagnosis. He was booked for a laparoscopic cholecystectomy which was performed without incident. Intraoperatively the cystic duct was clearly identified, so an intraoperative cholangiogram was not performed. The patient had an uneventful recovery and was discharged home on post operative day two. Inspection of the pathology specimen revealed a double gallbladder draining into a common cystic duct. The pathology report revealed a specimen weighing 40.2 g consisting of a double gallbladder Fig. 3. Measurements were 8.0 cm × 3.5 cm and 8.0 cm × 2.5 cm. Both specimens were attached at the proximal part. The mucosa appeared normal. Cholecystectomy specimen showing features of a mild chronic cholecystitis. The macroscopic appearance is in keeping with a double gallbladder. No malignancy was seen Fig. 4.
http://dx.doi.org/10.1016/j.ijscr.2015.04.002 2210-2612/© 2015 The Author. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS Y. Pillay / International Journal of Surgery Case Reports 11 (2015) 18–20
Fig. 1. MRCP showing double gallbladder(arrows).
19
Fig. 3. Axial CT showing gallbladder duplication(arrows).
Fig. 4. Duplication Gallbladder.
Fig. 2. CT scan coronal view with gallbladder duplication(arrows).
3. Discussion Duplication of the gallbladder has an incidence of approximately 1:4000. However, the exact incidence of this rare anomaly cannot be accurately assessed, since the only cases which can be identified are those that became symptomatic or were encountered as incidental findings during laparotomy, imaging studies or at autopsy. Duplication of the gallbladder can be classified into 2 main types Fig. 5. The first is the bi-lobed gallbladder (Vesica fellea divisum), where a longitudinal septum or invaginating cleft separates the lumen into 2 chambers. In these cases, both gallbladders share a common embryological origin (primordium). The second is the double gallbladder (Vesica fellea du-plex), where there are 2 separate gallbladders with their own cystic ducts. In these cases, we have to accept a double embryological origin (dual primordium). In our case, the gallbladder consisted of 2 separate chambers, which were connected through a narrow ostium. Both chambers shared a common cystic artery but the second chamber appeared to have a second narrow cystic duct, which drained to the right hepatic
Fig. 5. Common cystic duct(arrow).
duct. We believe that the presence of the ostium between the 2 chambers may have led to the progressive obliteration of the draining cystic duct of the second chamber. Differential diagnosis includes gallbladder diverticula, gallbladder fold, Phrygian cap, choledocal cyst, pericholecystic fluid, focal adenomyomatosis, and
CASE REPORT – OPEN ACCESS 20
Y. Pillay / International Journal of Surgery Case Reports 11 (2015) 18–20
Conflicts of interest Not applicable. Funding No funding. Consent No consent obtained as the patient has demised two years later. Author contribution Yagan Pillay – only author. Further reading
Fig. 6. Boydens classification.
intraperitoneal fibrous bands Fig. 6. The clinical significance associated with a duplicated gallbladder is similar to those encountered in a single gallbladder. This includes acute or chronic cholecystis, cholelithiasis, empyema, torsion, cholecystocolic fistula, and carcinoma. There are no specific symptoms attributable to a double gallbladder. Simultaneous removal of both gallbladders at surgery is recommended to avoid cholecystis and biliary colic in the remaining organ. Duplication of the gallbladder is a rare congenital abnormality, which requires special attention to the biliary ductal and arterial anatomy. Laparoscopic cholecystectomy with intraoperative cholangiography is the appropriate treatment in a symptomatic gallbladder. The removal of an asymptomatic double gallbladder remains controversial.
[1] E.S. Boyden, The accessory gallbladder: an embryological and comparative study of aberrant biliary vesicles occurring in man and the domestic mammals, Am. J. Anat. 38 (1926) 177–231. [2] A. Goel, K.N. Srivastava, A.K. Rana, Double gall-bladder-a laparoscopic management, Surg. Laparosc. Endosc. Percutan. Tech. 13 (2003)348–349. [3] R.E. Gross, Congenital anomalies of the gallbladder: a review of the literature and a report of a case associated with hepatic duct carcinoma, Arch. Surg. 32 (1936) 131–162. [4] B. Wani, G. Kolte, V. Rathod, A. Bhole, A cholelithiasic double gallbladder, J. Chir. vol. 5 (Nr. 4) (2009) 1584–9341, ISSN. [5] B. Papaziogas, C. Lazaridis, G. Paraskevas, J. Koutelidakis, P. Katsinelos, B. Oikonomou, G. Chatzimavroudis, M. Grigoriou, K. Atmatzidis, A variant of the double gallbladder, a possible cause of cholelithiasis, Folia Morphol. (Warsz) 64 (August (3)) (2005) 229–232. [6] G. Desolneux, S. Mucci, J. Lebigot, J.P. Arnaud, A. Hamy, Duplication of the gallbladder a case report Gastroenterol. Res. Pract. 2009 (2009) 3, http://dx.doi.org/10.1155/2009/483473, Article ID 483473. [7] S.K. Ghosh, Laparoscopic cholecystectomy in double gallbladder with dual pathology, J. Minim. Access Surg. 10 (April (2)) (2014) 93–96, http://dx.doi.org/10.4103/0972-9941.129963.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
