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|Year : 1983 | Volume
| Issue : 4 | Page : 258-60
Tuberculosis of gall bladder (a case report).
Ahmad MN, Zargar HU, Shahdad NA, Sapru AA, Kaur SS
|How to cite this article:|
Ahmad M N, Zargar H U, Shahdad N A, Sapru A A, Kaur S S. Tuberculosis of gall bladder (a case report). J Postgrad Med 1983;29:258
Tuberculosis is not an uncommon disease seen in the valley of Kashmir. It usually involves lymph nodes, lungs, urogenital system, bones and intestine. The incidence of tuberculosis of gall bladder is very low. The present case which is reported here, is the third case of its nature encountered in the last 19 years in our institution. The first such case from Kashmir was reported by Akhter et all and the second by Misgar et al.
The first case of tuberculosis of gall bladder in the world literature was described in 1870 by Gaucher. In 1908, Simmonds collected 8 cases from the literature including two of his own cases. Since then, more cases of the disease have been added to the world literature and 41 cases were reported upto 1970.
G. H., a 42 year old male reported to. the surgical services of S.M.H.S. Hospital, Srinagar, Kashmir on 1-8-1982 with complaints of mild pain in the right upper abdomen radiating to the right shoulder and fatty dyspepsia of 1½ years duration. There was no history of haematemesis, melana, jaundice, fever, rigors or chills. There was no past or family history of tuberculosis. The patient was never hospitalized or investigated previously.
On examination, the patient was found to be averagely built and Well nourished. He had no cyanosis, jaundice or edema. There was no generalized lymphadenopathy. His pulse and blood pressure were within normal limits. The examination of abdomen revealed mild tenderness on deep palpation in the right hypochondrium. There was no rigidity or rebound tenderness and no lump was palpable. There was no organomegaly and no free fluid was present in the abdomen. Per rectal examination was normal. The rest of the systemic examination did not reveal any abnormality. A provisional diagnosis of chronic cholecystitis was made and the patient was admitted for investigations.
Investigations revealed normal haemogram, urine analysis and stool examination. Blood sugar, blood urea and serum creatinine were all within normal limits. Liver function tests showed bilirubin to be 0.4 mg%, total proteins 7.4 gm%, albumin 4.2 gm%, total globulins 3.2 gm%, and serum alkaline phosphatase 8 K.A. Units. The skiagram of the chest and E.C.G. were normal. Plain X-ray of the abdomen did not show any radio-opaque shadow in the gall bladder or common bile duct areas. Oral cholecytography did not visualize the gall bladder even after double dose. The diagnosis of chronic cholecystitis was confirmed and the patient was advised to undergo surgery.
Laparotomy was done on 23-8-1982 under general anaesthesia; the abdomen was opened by Kocher's incision which revealed lot of adhesions around the gall bladder, which were lysed. The gall bladder was small and fibrosed with a thick wall. No stone was felt in it. The common bile duct was normal. A few small tubercles were seen mostly towards the fundus on the serosal surface of the gall bladder but there were no signs of peritoneal tuberculosis.
Cholecystectomy was performed and the gall bladder, when cut open, showed no growth or tubercles on its mucosal surface. A suspicion of tuberculosis of the gall bladder was then made because of a few tubercles seen over the serosal layer. The patient had a very smooth and uneventful post-operative period. The extirpated gall bladder was studied histopathologically; the microscopic examination revealed granulomatous lesions with Langhan's giant cells and the picture was consistent with tuberculosis of the gall bladder [Fig:1]. The patient was discharged on antitubercular treatment on 30-9-1982. Since then, he is regularly attending our follow up clinics and is symptom-free.
The incidence of gall bladder tuberculosis is very low, although the frequency of cholecystitis has increased during the past decades. Various reasons given for the low incidence of gall bladder tuberculosis include failure to recognize the condition or a special resistence of the gall bladder to the tubercle bacillus. It is not clearly known whether the infection can occur in a normal gall bladder. Kettler has proposed that the absence of tubercles from the mucosa indicates a haematogenous or lymphogenic spread of infection whereas tubercles mainly localized in the mucosa denote canalicular dissemination and tubercles scattered over the serous layer of the gall bladder might indicate dissemination via the peritoneal cavity.
Clinical studies denote that stones may be of pathogenic significance for the development of tuberculosis in the gall bladder. Most of the cases of tuberculosis of gall bladder reported in the literature had stones in the gall bladder or had obstruction of the cystic duct or common bile duct. In our case, there was neither stone in the gall bladder nor any obstruction of the cystic duct. The tuberculosis of gall bladder in the present case was probably secondary to nonspecific infection of the gall bladder which probably had lowered the resistence of the gall bladder and the involvement of serous coat by tubercles might be either haematogenous or lymphogenic from some distant focus which could not be traced out.
|1.||Akhter, A., Zargar, H. U., Kaul, H. K and Bhan, B. M.: Tuberculosis of gall bladder; A case report and brief review of the literature. Ind. J. Surg., 37: 218-220, 1975. |
|2.||Bergdahl, L. and Boquist, L.: Tuberculosis of gall bladder. Brit. J. Surg., 59: 289-292, 1972. |
|3.||Gaucher (1870): Quoted by Bergdahl and Boquist (1972). |
|4.||Kettler, L. H.: "Lehrbuch der Speziellen Pathologischen Anatomie". Vol. 11, Part 2, Editors: E. Kaufmann and M. Steammler, de Grayter, Berlin, 1958, p. 1292. |
|5.||Misgar, M. S., Kariholu, P. L., Bhat, D. N., Fazilli, F., Yousuf, M. and Mujahid, S.: Tuberculosis of gall bladder. J. Ind. Med. Assoc., 74: 196-197, 1980. |
|6.||Rankin, F. W. and Massie, F. M.: Primary tuberculosis of gall bladder. Ann. Surg., 83: 800-846, 1926. |
|7.||Schondube, W.: "Die Erkrankungen der Gallenwege." Enke, Stuttgardt, 1956, p. 163. |
|8.||Simmonds, M. Z.: Zentbl. Allg. Path. Anat., 19: 225, 1908. Quoted by Bergdahl and Boquist (1972). |