Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 906  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::Related articles
 ::  Article in PDF (12 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed13611    
    Printed236    
    Emailed11    
    PDF Downloaded189    
    Comments [Add]    
    Cited by others 3    

Recommend this journal


 


 
CASE REPORT
Year : 1996  |  Volume : 42  |  Issue : 3  |  Page : 80-2

Agenesis of gall bladder--a diagnostic dilemma.


Department of General Surgery & Gastroenterology Surgical Services, Seth GS Medical College, Parel, Mumbai.

Correspondence Address:
K T Vijay
Department of General Surgery & Gastroenterology Surgical Services, Seth GS Medical College, Parel, Mumbai.

Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 0009715323

Rights and PermissionsRights and Permissions


 :: Abstract 

A case of suspected chronic cholecystitis who underwent laparotomy, was found to have agenesis of gall bladder. Standard investigative modalities which are done for chronic cholecystitis might be fallacious and baffling. Agenesis of gall bladder should be kept in mind whenever the gall bladder is improperly visualised in routine imaging methods.


Keywords: Abnormalities, radiography,Case Report, Cholangiography, Cholecystitis, diagnosis,surgery,Chronic Disease, Diagnostic Errors, Female, Gallbladder, abnormalities,Human, Middle Age, Monitoring, Intraoperative,


How to cite this article:
Vijay K T, Kocher H H, Koti R S, Bapat R D. Agenesis of gall bladder--a diagnostic dilemma. J Postgrad Med 1996;42:80

How to cite this URL:
Vijay K T, Kocher H H, Koti R S, Bapat R D. Agenesis of gall bladder--a diagnostic dilemma. J Postgrad Med [serial online] 1996 [cited 2019 Sep 24];42:80. Available from: http://www.jpgmonline.com/text.asp?1996/42/3/80/432





  ::   Introduction Top


Agenesis of gall bladder is an extremely rare clinical condition. In a collected review of 1,501,061 autopsy cases, only 237 cases of agenesis of gall bladder were found'. It is difficult to diagnose gall bladder agenesis preoperatively as investigations tend to be misleading and therefore it is diagnosed intraoperatively.


  ::   Case report Top


IRS, a 50 year old female patient presented with chronic right hypochondria] pain of 6 month duration, associated with dyspepsia, epigastric pain and retrosternal burning without fever, jaundice or vomiting and intolerance to fatty food.

On examination, the patient was anicteric. Abdominal examination was unremarkable. All biochemical and hematological investigations were within normal limits. Upper gastrointestinal endoscopy showed normal findings. Ultrasonography of right hypochondrium was shown to have hyperechoic area in gall bladder fossa, which was reported as a very small and contracted gall bladder. CBD was 8 mm. A HIDA scan study showed a normal liver with normal biliary bowel transit time. Gall bladder was not visualised throughout the study, even after a fatty meal. There was evidence of mild dilatation of right hepatic duct and common bile duct with mild tracer hold up which rapidly cleared after a meal. HIDA scan was suggestive of chronic cholecystitis with dilatation of CBD. A clinical diagnosis of chronic acalculus cholecystitis was made and the patient was posted for elective cholecystectomy with CBD exploration. Intraoperatively. the gall bladder was found to be absent. A meticulous search was made to locate the gall bladder in other possible sites. A per-operative cholangiogram was done which showed mildly dilated extrahepatic biliary system with non-visualisation of gall bladder. There was no filling defect in the biliary tree. There was free flow of dye into the duodenum [Figure - 1]. The diagnosis of cholecystic agenesis was made on table and the abdomen was closed.

Postoperative recovery was uneventful. On the 10th postoperative day, a CT scan of the abdomen was performed after ingestion of Telepac tablets to document the agenesis of gall bladder; which also failed to demonstrate the gall bladder [Figure - 2]. However, it showed multiple cysts in both the kidneys. Family screening was not possible as relatives were not available. The patient was asymptomatic at the 3 month follow up.


  ::   Discussion Top


Agenesis of gall bladder is an extremely rare condition with an incidence of 0,01-0.02%[2]. Several studies have revealed a strong familial association with this condition[2]. Any defect in the developmental process leads to the agenesis of gall bladder. This anomaly is transmitted as non-sex linked trait with variable penetration the actual incidence is not known[3].

After a review of 400 cases of agenesis of gall bladder, three groups of presentations were noted:

a. Asymptomatic patients who are diagnosed as incidental finding on abdominal exploration for some other reason. (35%)

b. Symptomatic agenesis - One third of these patients will have dilated CBID and another one third will have stones in CBD 150%).

c. Children with congenital anomalies like agenesis of lung, Tetralogy of Fallot, anomalous extremities, genitourinary, and rarely gastrointestinal anomalies. The complexity of the situation makes this patient incompatible with survival (15-16%).

In symptomatic cholecystic agenesis, patients undergo surgery for right hypochondrial symptoms only to find no gall bladder on table. Common symptoms include chronic right upper quadrant pain (90%), dyspepsia (30%), nausea and vomiting (66%), fatty food intolerance (37%), jaundice (35%). Possible mechanisms of symptoms include primary duct stones, biliary dyskinesia or non-biliary disorder.

Commonly performed investigations tend to mislead the diagnosis of this clinical entity, as a result of which preoperative diagnosis is almost impossible Ultrasonography is highly operator dependent: periportal tissues or subhepatic peritoneal folds are usually focussed and interpreted as thick, contracted, shrunken or scarred gall bladder. Failure to see the gall bladder on HIDA scan and OCG is interpreted as non-functioning or diseased gall bladder. All cases of acute cholecystitis and several cases of chronic cholecystitis will have non-visualisation of gall bladder on HIDA and OCG. These fallacies in investigations often lead to an erroneous diagnosis of acalculus cholecystitis.

Intratoperatively, if the gall bladder is not visualised in its normal anatomic position, a thorough search should be carried out in the ectopic locations viz., intrahepatic, left sided, beneath the posteroinferior surface of liver between the leaves of lesser omentum, retroperitoneal, retrohepatic, within the falciform ligament. retropancreatic and retroduodenal. Any scar in porta hepatis and gall bladder fossa should be dissected. Complete  Kocherisation More Details of duodenum should be done. If all these manoeuvres fail to identify the gall bladder per-operative cholangiography is mandatory to look for:

a) intrahepatic gall bladder

b) ectopic gall bladder.

c) stones in CBD (which is the commonest association).

CBD exploration is carried out only if the cholangiogram shows calculi in CBD or CBD is dilated more than 20 mms. If cholangiogram is otherwise normal, nothing further needs to be done. These patients generally become asymptomatic in the postoperative period. A probable explanation that has been given is lysis of periportal and right hypochondrial adhesions at the time of surgery.

In conclusion, the diagnosis of gall bladder agenesis is probably impossible preoperatively and therefore remains a diagnostic dilemma.

 
 :: References Top

1.   Back to cited text no. 1    
2.Bennion RS. Agenesis of gall bladder without extrahepatic biliary atresia. Arch Surg 1988; 123:1257-1260.  Back to cited text no. 2    
3.Gupta S, Gupta K. Agenesis of gall bladder with choledocholithiasis. Int Surg 1974; 59:116.  Back to cited text no. 3    
4.Wilson JE. A case report with familial investigations. 1986; 94:106.  Back to cited text no. 4    
5.Sherson ND. The absent adkilt gall bladder Aust NZ J Surg 1970; 39:225-261.  Back to cited text no. 5    
6.Richard. Agenesis of gall bladder in symptomatic adults. Review of literature. J of Cl Gastroenterology 1993; Apr (16)(3):231-233.   Back to cited text no. 6    


    Figures

[Figure - 1], [Figure - 2]

This article has been cited by
1 Agenesis of the gallbladder: Difficulties in management
Bani-Hani KE
JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY. 2005; 20 (5): 671-675
[Pubmed]
2 Asymptomatic case of congenital absence of the gallbladder
Muguruma N, Okamura S, Ichikawa S, Tsujigami K, Suzuki M, Nakasono M, Kusaka Y, Tadatsu M, Okita Y, Ito S
J Med Invest. 2001; 48(1): 118-121
[Pubmed] | [PDF]
3 Agenesia de la vesícula biliar. Presentación de un caso estudiado por RM-colangiografía
J.L. Elorza Orúe
Cirugía Española. 2001; 69(4): 427-428
[VIEW]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow