Diagnostic Radiology
The Wandering Gallbladder 1
•
spleen, duodenum, and small bowel had normal relationshipsand attachments. A total abdominal visceropexy was performed and at the time of discharge, the symptoms had subsided with no further elevation of bilirubin.
Robert L. Chlavarlnl, M.D., Stanley F. Chang, M.D., and Jerry D. Westerfield, M.D. Anunusual case of a hypermobile gallbladder and liver is presented. The liver and gallbladder, supported only by a long midline falciform ligament, rotated freely from the right to the left upper quadrant. Because of a long gastrohepatic ligament and mesocolon, intermittent volvulus of the stomach and colon were associated findings.
DISCUSSION An abnormally positioned gallbladder or liver is not all that uncommon when one considers ptotic gallbladders or hepatoptosis. Steele (8) collected 100 cases of the latter and most radiologists have seen one or more pelvic gallbladders. For this reason, it is mandatory that a thorough search of the entire abdomen be made before calling nonvisualization on an oral cholecystogram. The point has previously been stressed by others (3). Left-sided gallbladders are a good deal less common. As of 1966, only 25 cases had been reported (5). Their anatomic relationships varied widely but their mobility was limited. Retroperitoneal gallbladders as well as other ectopic locations have also been described (1). Our case demonstrates hypermobility in a transverse plane rather than in a vertical direction. Abnormal mobility of the stomach and colon was seen as well. It was postulated that the abnormal mesenteric attachments allowed intermittent volvulus of the stomach and colon which explained the pa: tient's transient obstructive symptoms. Further, postulation of a torsion of the common duct also explained the intermittent jaundice seen in this case. In a search of the medical literature, we were able to find only 3 similarly reported cases (2, 4, 7), the first in the Russian literature. All presented with various colonic obstructive patterns. All displayed abnormal liver fixation. Two of the 3 patients showed an elongated transverse mesocolon. Interestingly enough, all were men under 30 years of age. In 1963, Large (6) reported a case of left-sided liver and gallbladder with an associated incomplete rotation of the intestine. However, at operation the liver was simply shifted over to the left side of the abdomen and hypermobility of the liver and stomach was not noted. On initial examination, one might think one is simply dealing with hepatodiaphragmatic interposition of the bowel (Chilaiditi's syndrome). This finding is said to occur in 0.025% of mass chest roentgenogram surveys (9) and in general, it is thought that this finding in adults, in itself, is of no clinical significance. It must be differentiated from free intraperitoneal air or the presence of a subdiaphragmatic abscess. Our case illustrates that when dilated bowel is noted under the right diaphragm and there is an absence of the usual liver shadow, the radiologist should suggest the possibility of abnormal liver fixation. Our case also serves to re-emphasize the necessity of a full abdominal film with non-visualizing gallbladders.
Cholecystography. Gallbladder, radiography. Intestines, volvulus • Liver, radiography. Stomach, volvulus
INDEX TERMS:
Radiology 115:47-48, April 1975
• ABNORMALITIES of intestinal rotation and fixation 1"\ are a relatively common finding. When there is also lack of fixation of the liver, allowing its free movement with the gallbladder from side to side, the case is very rare indeed. To our knowledge only 3 similar cases have been reported (2, 4, 7). CASE REPORT A 22-year-old white man was referred to the University Hospital with a history of almost daily abdominal pain dating back as far as he could remember. His mother remembered that he had had frequent "stomach aches since the age of four." Since age 10, the patient recalls a pattern emerging. He would feel fine during the day, capable of carrying on normal activities. Then, 20-30 minutes after supper, he would experience severe crampy, non-radiating, lower abdominal pain which would often double him up. This was relieved only after many minutes of rolling about on the floor, and usuallyterminated with the passage of flatus. Many visits to physicians, including psychiatrists, had not been fruitful. Medicationsand diets were of little help. Within the last six months, the patient was hospitalized twice for the above symptoms. Abdominal films showed a markedly dilated colon which led to a suspicion of Hirschsprung's disease. Workup, including a rectal biopsy, did not bear this out. Barium enemas and colonoscopy revealed a dilated colon only. Upper gastrointestinalseries were repeatedly negative and an intravenous cholangiogram (done because of transient hyperbilirubinemia) was normal. Admission physical at University Hospital was unremarkable. laboratory values were normal except for a sporadically elevated bilirubin. The chest film showed a large collection of right upper quadrant gas, but was otherwise normal (Fig. 1). During oral cholecystography, initial coned-down oblique radiographs of the right upper quadrant failed to reveal an opacified gallbladder but confirmed abundant, colonic gas just beneath the right hemidiaphragm. The normal liver density was not seen (Fig. 2). A film of the entire abdomen revealed a normally opacified gallbladder in the left upper quadrant (Fig. 3). Subsequently, during the UGI series, the gallbladdergraduallyshifted into the right upper quadrant (Fig. 4). The stomach, which initially presented to the right of the midline, later occupied a more normal position on the left (Fig. 5). The liver density, which was not identified on earlier films, was later seen quite prominently in its normal position. A markedly dilatedtransverse colon was also noted. At operation, a markedly dilated stomach and transverse colon were seen. The liver was suspended only by the falciform ligament.
REFERENCES 1. Blanton DE, Bream CA, Mandel SR'. Gallbladderectop' ia. A review of anomalies of position. Am J Roentgenol 121:396-400, Jun 1974 2. Cope E, Levy JI: Dislocation of the liver. S Afr Med J 40: 366-369, Apr 1966
The coronary and triangular ligaments were absent. The falciform ligament was elongated and midline. The lesser omentum and gastrocolic ligament were elongated as well. The entire colon, including the ascending and descending portions, was quite mobile on the mesentery. The transverse mesocolon was unusually long. The 1
From the Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich. Accepted for publication in November 1974. shan
47
48
ROBERT
L. CHIAVARINI
AND OTHERS
April 1975
Fig. 1. Admission chest radiograph demonstrating absence of normal liver density in right upper abdominal quadrant. The area is occupied by dilated colon. A stomach bubble is present on the left, excluding situs inversus. Fig. 2. Oblique view of right upper quadrant (RUQ): Note absence of liver density and gallbladder. Right diaphragm is elevated by the distended colon. Residual Telepaque is seen in the bowel. Fig. 3. Prone view of abdomen: Note liver density and gallbladder in left upper quadrant. Again, slightly dilated colon is noted in RUQ under the right diaphragm. Fig. 4. After administration of barium and fluoroscopy. The liver and gallbladder are now on the right and stomach lies somewhat to the right suggesting hypermobility of this organ, too. The duodenum is in its normal position. The dilated transverse colon now lies in the left upper quadrant (LUQ). Fig. 5. Later film after ingestion of barium. The stomach now lies primarily to the left of the midline. The liver and gallbladder remain in the RUQ. Again, note the dilated transverse colon with one loop lying in the LUQ superior to the stomach.
3. Etter LE: Left-sided gallbladder. Necessity for film of the entire abdomen in cholecystography. Am J Roentgenol 70:987-990, Dec 1953 4. Feins NR, Borger J: Torsion of the right lobe of the liver with partial obstruction of the colon. J Pediatr Surg 7:724-725, Dec 1972 5. Herrington JL Jr: Gallbladder arising from the left hepatic lobe. Am J Surg 112:106-109, Jul1966 6. Large AM: Left-sided gallbladder and liver without situs inversus. Arch Surg (Chicago) 87:982-985, Dec 1963 7. Sharov BK: [Unusual case of hepar mobile (wandering
liver)]. Vestn Roentgenol Radiol 35:63-64, Jan-Feb 1960 (in Russian) 8. Steele JD: Experimental evidence of biliary obstruction in floating liver. U Penn Med Bull 15:424-433, 1903 9. Torgersen J: Suprahepatic interposition of the colon and volvulus of the cecum. Am J Roentgenol 66: 747-751, Nov 1951 Department of Radiology University of Michigan Medical Center Ann Arbor, Mich. 48104
The Wandering Gallbladder 1
•
spleen, duodenum, and small bowel had normal relationshipsand attachments. A total abdominal visceropexy was performed and at the time of discharge, the symptoms had subsided with no further elevation of bilirubin.
Robert L. Chlavarlnl, M.D., Stanley F. Chang, M.D., and Jerry D. Westerfield, M.D. Anunusual case of a hypermobile gallbladder and liver is presented. The liver and gallbladder, supported only by a long midline falciform ligament, rotated freely from the right to the left upper quadrant. Because of a long gastrohepatic ligament and mesocolon, intermittent volvulus of the stomach and colon were associated findings.
DISCUSSION An abnormally positioned gallbladder or liver is not all that uncommon when one considers ptotic gallbladders or hepatoptosis. Steele (8) collected 100 cases of the latter and most radiologists have seen one or more pelvic gallbladders. For this reason, it is mandatory that a thorough search of the entire abdomen be made before calling nonvisualization on an oral cholecystogram. The point has previously been stressed by others (3). Left-sided gallbladders are a good deal less common. As of 1966, only 25 cases had been reported (5). Their anatomic relationships varied widely but their mobility was limited. Retroperitoneal gallbladders as well as other ectopic locations have also been described (1). Our case demonstrates hypermobility in a transverse plane rather than in a vertical direction. Abnormal mobility of the stomach and colon was seen as well. It was postulated that the abnormal mesenteric attachments allowed intermittent volvulus of the stomach and colon which explained the pa: tient's transient obstructive symptoms. Further, postulation of a torsion of the common duct also explained the intermittent jaundice seen in this case. In a search of the medical literature, we were able to find only 3 similarly reported cases (2, 4, 7), the first in the Russian literature. All presented with various colonic obstructive patterns. All displayed abnormal liver fixation. Two of the 3 patients showed an elongated transverse mesocolon. Interestingly enough, all were men under 30 years of age. In 1963, Large (6) reported a case of left-sided liver and gallbladder with an associated incomplete rotation of the intestine. However, at operation the liver was simply shifted over to the left side of the abdomen and hypermobility of the liver and stomach was not noted. On initial examination, one might think one is simply dealing with hepatodiaphragmatic interposition of the bowel (Chilaiditi's syndrome). This finding is said to occur in 0.025% of mass chest roentgenogram surveys (9) and in general, it is thought that this finding in adults, in itself, is of no clinical significance. It must be differentiated from free intraperitoneal air or the presence of a subdiaphragmatic abscess. Our case illustrates that when dilated bowel is noted under the right diaphragm and there is an absence of the usual liver shadow, the radiologist should suggest the possibility of abnormal liver fixation. Our case also serves to re-emphasize the necessity of a full abdominal film with non-visualizing gallbladders.
Cholecystography. Gallbladder, radiography. Intestines, volvulus • Liver, radiography. Stomach, volvulus
INDEX TERMS:
Radiology 115:47-48, April 1975
• ABNORMALITIES of intestinal rotation and fixation 1"\ are a relatively common finding. When there is also lack of fixation of the liver, allowing its free movement with the gallbladder from side to side, the case is very rare indeed. To our knowledge only 3 similar cases have been reported (2, 4, 7). CASE REPORT A 22-year-old white man was referred to the University Hospital with a history of almost daily abdominal pain dating back as far as he could remember. His mother remembered that he had had frequent "stomach aches since the age of four." Since age 10, the patient recalls a pattern emerging. He would feel fine during the day, capable of carrying on normal activities. Then, 20-30 minutes after supper, he would experience severe crampy, non-radiating, lower abdominal pain which would often double him up. This was relieved only after many minutes of rolling about on the floor, and usuallyterminated with the passage of flatus. Many visits to physicians, including psychiatrists, had not been fruitful. Medicationsand diets were of little help. Within the last six months, the patient was hospitalized twice for the above symptoms. Abdominal films showed a markedly dilated colon which led to a suspicion of Hirschsprung's disease. Workup, including a rectal biopsy, did not bear this out. Barium enemas and colonoscopy revealed a dilated colon only. Upper gastrointestinalseries were repeatedly negative and an intravenous cholangiogram (done because of transient hyperbilirubinemia) was normal. Admission physical at University Hospital was unremarkable. laboratory values were normal except for a sporadically elevated bilirubin. The chest film showed a large collection of right upper quadrant gas, but was otherwise normal (Fig. 1). During oral cholecystography, initial coned-down oblique radiographs of the right upper quadrant failed to reveal an opacified gallbladder but confirmed abundant, colonic gas just beneath the right hemidiaphragm. The normal liver density was not seen (Fig. 2). A film of the entire abdomen revealed a normally opacified gallbladder in the left upper quadrant (Fig. 3). Subsequently, during the UGI series, the gallbladdergraduallyshifted into the right upper quadrant (Fig. 4). The stomach, which initially presented to the right of the midline, later occupied a more normal position on the left (Fig. 5). The liver density, which was not identified on earlier films, was later seen quite prominently in its normal position. A markedly dilatedtransverse colon was also noted. At operation, a markedly dilated stomach and transverse colon were seen. The liver was suspended only by the falciform ligament.
REFERENCES 1. Blanton DE, Bream CA, Mandel SR'. Gallbladderectop' ia. A review of anomalies of position. Am J Roentgenol 121:396-400, Jun 1974 2. Cope E, Levy JI: Dislocation of the liver. S Afr Med J 40: 366-369, Apr 1966
The coronary and triangular ligaments were absent. The falciform ligament was elongated and midline. The lesser omentum and gastrocolic ligament were elongated as well. The entire colon, including the ascending and descending portions, was quite mobile on the mesentery. The transverse mesocolon was unusually long. The 1
From the Department of Radiology, University of Michigan Medical Center, Ann Arbor, Mich. Accepted for publication in November 1974. shan
47
48
ROBERT
L. CHIAVARINI
AND OTHERS
April 1975
Fig. 1. Admission chest radiograph demonstrating absence of normal liver density in right upper abdominal quadrant. The area is occupied by dilated colon. A stomach bubble is present on the left, excluding situs inversus. Fig. 2. Oblique view of right upper quadrant (RUQ): Note absence of liver density and gallbladder. Right diaphragm is elevated by the distended colon. Residual Telepaque is seen in the bowel. Fig. 3. Prone view of abdomen: Note liver density and gallbladder in left upper quadrant. Again, slightly dilated colon is noted in RUQ under the right diaphragm. Fig. 4. After administration of barium and fluoroscopy. The liver and gallbladder are now on the right and stomach lies somewhat to the right suggesting hypermobility of this organ, too. The duodenum is in its normal position. The dilated transverse colon now lies in the left upper quadrant (LUQ). Fig. 5. Later film after ingestion of barium. The stomach now lies primarily to the left of the midline. The liver and gallbladder remain in the RUQ. Again, note the dilated transverse colon with one loop lying in the LUQ superior to the stomach.
3. Etter LE: Left-sided gallbladder. Necessity for film of the entire abdomen in cholecystography. Am J Roentgenol 70:987-990, Dec 1953 4. Feins NR, Borger J: Torsion of the right lobe of the liver with partial obstruction of the colon. J Pediatr Surg 7:724-725, Dec 1972 5. Herrington JL Jr: Gallbladder arising from the left hepatic lobe. Am J Surg 112:106-109, Jul1966 6. Large AM: Left-sided gallbladder and liver without situs inversus. Arch Surg (Chicago) 87:982-985, Dec 1963 7. Sharov BK: [Unusual case of hepar mobile (wandering
liver)]. Vestn Roentgenol Radiol 35:63-64, Jan-Feb 1960 (in Russian) 8. Steele JD: Experimental evidence of biliary obstruction in floating liver. U Penn Med Bull 15:424-433, 1903 9. Torgersen J: Suprahepatic interposition of the colon and volvulus of the cecum. Am J Roentgenol 66: 747-751, Nov 1951 Department of Radiology University of Michigan Medical Center Ann Arbor, Mich. 48104
