Original Article - NJBMS171 Original Article Sreelekha.D1 , Swayam Jothi Dorairaj.S2, Lalitha.R3,...

171

Original Article

1 2 3 4Sreelekha.D , Swayam Jothi Dorairaj. S , Lalitha.R , Sujatha.N

ABSTRACT

Introduction: Routine imaging of the gallbladder demonstrates many imaging variants, including

anomalies in location, number and configuration. This study is carried out to observe the various

anomalies of gall bladder.

Materials and Methods: 57 gall bladder and liver specimens removed from cadavers from the

department of Anatomy at Sri Sathya Sai Medical College and Research Institute, Kancheepuram,

were studied after obtaining due ethical committee clearance.

Results: The folded fundus of the gall bladder the Phrygian cap was seen in 5 of 57 specimens.

Hartmann's pouch is simply an asymmetric bulging of the infundibulum and the neck of the gall

bladder close to the point of exit of the cystic duct, instead of a gradual tapering to the duct. This was

observed in 4 specimens. Congenital absence of gall bladder was observed in one liver specimen.

This liver showed multiple abscesses. Section of the liver was made to see the presence of

intrahepatic gall bladder. There was no gall bladder. Bits of liver tissue were sent for

histopathological study. The tissue showed biliary cirrhosis.

Conclusion: A preoperative diagnosis of congenital absence of the gall bladder is difficult and there

are no group of symptoms or signs which are of value in making such a diagnosis. These anomalies,

although in themselves are very rare, are so often the site of serious pathologic changes that they

become important both from a clinical and anatomic point of view.

Keywords: Phrygian cap, Hartmann's pouch, Congenital absence of gall bladder, Biliary cirrhosis.

INTRODUCTION:

all bladder is flask shaped and usually

lies attached to the inferior surface of the Gright lobe of the liver by connective

tissue. It lies in a shallow fossa in the liver

parenchyma covered by peritoneum continued

from the liver surface.

The body of the gall bladder tapers towards the

neck, which lies in the porta hepatis. The junction

of the body and neck is sometimes straight, more

often angular. The neck may show a pouch like

dilatation towards the right (Hartmann's pouch). It

has been shown to be a pathologic feature. The neck

turns sharply downwards as it becomes continuous 1with the cystic duct.

Address for correspondence:

Dr. R. Lalitha, Assistant Professor, Department of Anatomy, Meenakshi Medical College, Hospital and Research Institute,

Kancheepuram. E mail: [email protected]. Ph: 9943963663

1Asst. Professor, Dept. of Anatomy, Sree Balaji Medical College & Hospital, BIHER University, Chromepet, TN, India.2Professor and HOD, Dept. of Anatomy, Shri Sathya Sai Medical college & Research Institute.3Asst. Professor, Dept. of Anatomy, Meenakshi Medical College Hospital & Research Instituite, Kancheepuram, TN, India.4Tutor in Anatomy, Shri Sathya Sai Medical College, Hospital & Research Institute, Ammapettai, Kancheepuram District.

National Journal of Basic Medical Sciences | Volume 8 | Issue 4 | 2018

A study on Anomalies of Gall Bladder

http://dx.doi.org/10.31975/NJBMS.2018.8401

172

gall bladder. As gall bladder is often a common site

of open and laparoscopic procedures, this study

was done to observe the different congenital

anomalies in the adult cadavers.

MATERIALS & METHODS:

57 adult human cadavers between 20 to 68 years of

age were studied during routine dissection in the

department of Anatomy Shri Sathya Sai Medical

College, Tiruporur, after obtaining ethical

committee clearance.

Exclusion Criteria:

Cadavers with abdominal surgery or any

pathologies were excluded from the study.

RESULTS:

The folded fundus of gall bladder (Fig 1) – its

appearance in cholecystogram is referred to as

“Phrygian Cap”. Folded fundus of the gall bladder

was seen in 5 of 57 specimens of the present study.

Hartmann's pouch is simply an asymmetric bulging

of the infundibulum and neck of the gall bladder

close to the point of exit of the cystic duct, instead

of a gradual tapering to the duct. This was observed

in 4 specimens (Fig 2).

Congenital absence of gall bladder was observed in

one liver (Fig.3). That liver showed multiple

abscesses. Section of the liver was made to see the

presence of intrahepatic gall bladder (Fig.4). There

was no gall bladder. Bits of liver tissue were sent

for histopathological study. The tissue showed

biliary cirrhosis (Fig 5).

Arey, however, demonstrated that the primordium

of the liver and biliary system begins in the 3-mm

human embryo as a hepatic diverticulum from the

area of the future duodenum. From this

diverticulum a ventrocaudal sacculation forms the

future gallbladder and its duct. The lumen is later

obliterated but is again re-established by the end of

the 15-millimeter stage. Thus, from an

embryological standpoint, two mechanisms exist

for agenesis of the gallbladder. There may be

failure to form the ventrocaudal sacculation, or

failure to recannulize after becoming solid.

Complete failure of the primordial tissue to

sacculate at the 3-mm stage is most probably the

cause for complete absence or true agenesis of the

gallbladder and its duct. This is in contrast to

reports in the literature of hypoplasia or atresia of

the organ. In hypoplasia, the analogen after

becoming solid, probably fails to recannulize.

Thus, a completely different condition from

agenesis is created a vestigial or rudimentary

s tructure which persis ts in the adult .

Nonfunctioning, solid tissue remnants of other

endodermal structures, such as esophagus and

intestine, may also have a development analogous 2to hypoplasia of the gallbladder.

Anatomically the gall bladder is positioned at a

location where any interventional or diagnostic

procedure done needs knowledge and precision.

Congenital anomaly of the gall bladder has been

reported earlier by various authors. In the present

day, an advance in radiologic imaging has made it

easier in studying the anatomical variations of the


Sreelekha.D, et.al : Anomalies of Gall Bladder

173

Fig 1. Arrow showing folded fundus of gall bladder, Fig 2. Arrow showing Hartmann's pouch, Fig 3.

Congenital absence of gall bladder, Fig 4. Macroscopically- multiple abscesses

Fig 5. Histopathological finding—biliary cirrosis is seen



Fig-1

Fig-3

Fig-2

Fig-4

174

Latimer, Mendesy and Hage quoted various

estimates of 0.065%, 0.3% and 0.075%.12 Finney

and Owen stated that congenital absence of the gall

bladder has been said to be about twice as common 13in women's as in men.

Jacob Rabinovitch et al in 1958, studied in a series

of cases and stated that there were five cases with

complete absence of the gall bladder in the series;

they were all incidental findings discovered at

autopsy. It is of interest to note that all of the

patients in this series were males. These anomalies

do not as rule present clinical problems unless the

patient shows symptoms which mimic gallbladder

disease. Cholecystography will fail of course to

visualize the gall bladder in such instances and will

give an erroneous impression of a non-functioning

or diseased gall bladder. This may sometimes lead

to unnecessary surgery unless the condition is 14

borne in mind.

Walter H Gerwig and et al, reported that congenital

absence of the gallbladder and cystic duct was

demonstrable in a study of six patients and a review

of 49 cases. None of these individuals showed any

other abnormality of the extrahepaticbiliary 15system.

Gall bladder and cystic duct agenesia can be

particularly complex, and if echography shows

hypogenesia or gall bladder scleroatrophy, there is

a high risk of mistaking the common bile duct for

supposed gallbladder scleroatrophy, with the 16

danger of either injuring or cutting it.

Although the number of cases described did not

exceed 300 until 1982, the study of prenatal

diagnosis revealed seven cases of gallbladder

agenesia. It is believed that this malformation can

appear at any time and should thus be taken into 17, 18consideration.



DISCUSSION:

Folded fundus of gall bladder was first described by

Bartel (1916) who reported 43 cases at autopsy.3

Boyden (1935) found the anomaly in 7.5% of the 80

autopsy specimens and in 3.6% of the

cholecystograms while Lichtenstein (1937) 4,5reported 3% in 212 specimens.

According to Hollinshead, the gall bladder is

relatively constant in its development and the two

most significant variations are the folded fundus 6

and variation at the neck of the gall bladder. The

folded fundus of the gall bladder, also called as the

Phrygian cap, was reported in 3-7.5% of gall 5

bladder. They proposed that it could be due to a

disproportion between the size of the gall bladder

and that of the gallbladder bed, but without any 5

pathological significance.

The study done by Sreekanth et al in 100 liver and

gall bladder specimens in 2016, they observed

folded fundus in 2 GB (2%) and folded neck in 4 7

GB (4%) folded fundus and neck 02 (02%).

In the present study, the folded fundus of the gall

bladder formed 8.47% in 57 specimens.

Hartmann's pouch has been regarded as contrast

feature of normal gall bladder by Hollinshead

(1983), Mc Gregor (1986), Keith.L.Moore (2006)

and Standring (2008) but it was considered 6,8,9,10

pathological by few. In a study done by

Nadeem et al (2016), Hartmann's pouch was 11present in 7.14 % of the specimens.

In the present study the Hartmann's pouch was

observed in 6.77% of 57 specimens.

The incidence of congenital absence of the gall

bladder is certainly low, but it is not known exactly.

175National Journal of Basic Medical Sciences | Volume 8 | Issue 4 | 2018


In the presence of confused or poorly defined

anatomy, the possibility of biliary tree congenital

anomaly must be taken in consideration.

Congenital biliary duct malformations may provide

a real surprise during laparoscopic surgery, and

when surgeons come across them, greater care

should be taken. The use of electrocoagulation

should be limited, and no structure should be

sectioned until a clear picture of the vascular tree

and bile ducts has been obtained. If necessary, an

intraoperative cholangiography should be carried

out in order to define anatomy of the duct.

Subsequently, if doubt still remains or if the

surgeon's experience in laparoscopic surgery is

limited, the operation should be converted to an

open procedure before any avoidable 19complications occur.

Latimer made an analysis of the data with respect to

age and sex, symptoms, preoperative diagnosis,

whether found at operation or autopsy, and attempts

to prove an intrahepatic gall bladder was made by

studying 71 cases. Of the 7I cases, 34 gave histories

indicating biliary tract disease. In the series upon

whom operations were performed, the gallbladder

was reported as absent in all 34 cases, while the

cystic duct was reported absent only I5 cases.

Twenty-one cases showed that common duct

dilated two times. Stones were also seen in two 20

cases.

In the present study absence of Gall bladder was

seen in only one liver out of 57 specimens.

Microscopically it showed biliary cirrhosis. It has

been estimated that absence of the gallbladder

occurs in about one-sixth of cases with atresia of the

bile ducts. The literature testifies that the condition

is compatible with normal life, and that the

anomaly is not accompanied by compensatory 14dilatation of the bile ducts.

Dharmendra kumar et al in his study concluded that

congenital anomalies and anatomical variations of

extra- hepatic biliary tree though are not common

but can be of clinical importance and sufficient care

must be taken if present. So every surgeon should

assess for these anomalies during laparoscopic

cholecystectomy in order to prevent inadvertent

ductal clipping, ductal injuries, strictures and

bleeding problems. Awareness of these anomalies

will decrease morbidity, conversion and re-21

exploration in patients having anomalies.

CONCLUSION:

For evident reasons, a preoperative diagnosis of

congenital absence of the gall bladder is extremely

difficult, if not impossible. This fact is well

illustrated in previous studies by the ratio of cases

found at autopsy to those discovered at surgery.

There is no group of symptoms or signs which are

of value in making such a diagnosis. Routine

imaging of the gallbladder demonstrates a wide

array of imaging variants, including anomalies in

location, number, and configuration. An awareness

of these normal variants may prevent misdiagnosis

and will aid in evaluation of differential diagnostic

possibilities.

ACKNOWLEDGEMENTS:

I wish to thank Prof. Dr.Swayam jothi Dorairaj,

Professor and HOD of Anatomy, for providing me

with the research material and Dr. Anurada,

Professor and HOD of Pathology, for helping me

with the reposting of the slide.

CONFLICTS OF INTEREST: None



REFERENCES:

1. Hollinshead's Textbook of Anatomy.5th edn,

Lippincott – Raven, 1997; 573.

2. Arey, L. B (1940) Developmental Anatomy.

A Textbook and Lab Manual of Embryology.

Philadelphia, , W. B. Saunders Company. As

appeared in: Nelson, W., F. F. Hatch and H.

M. Jackson: Congenital Absence of the

Gallbladder. Surgery, 1949; 25:916.

3. B a r t e l . J C h o l e l i t h i a s i s a n d

Korperkonstitution cholelithotripsie.

Frankfurt Z Pathol, 1916;. 2013-206.

4. Boyden, E.A the accessory gall bladder – an

embryological and comparative study of

aberrant biliary vesicles occuring in man and

the domestic mammals. Am.J.Anat.1926;

38:177,.

5. Lischtenstein M, Nicosia AJ. The Clinical

Significance Of Accessory Hepato-Biliary

Ducts. Annals Of Surgery.1955;141 (1), 120

-124.

6. Hollinshead WH Anatomy For Surgeons In

The Liver And The Gall Bladder, 3rd edn.

Harper And Row, Philadelphia, 1983; 2: 334.

7. Chakka Sreekanth, Makani ThanujaKumari,

Lattupalli Hema. Variations In The External

Morphology Of Gall Bladder: A Cadaveric

Study In South Coastal Population. IOSR

Journal of Dental and Medical Sciences;

15(9) 2016; 14-20.

8. Lee Mc Gregor, A., Decker, Gag. and Plessis,

DJD. Lee McGregor's synopsis of surgical

anatomy in the liver and biliary system. 12th

ed. Bombay: KM Verghese and Company,

1986; 78-103.

9. Moore, KL. and Dalley, AF. Clinically

oriented anatomy in abdomen. 5th ed.

Philadelphia: Lippincott Williams &

Wilkins, 2006; 302.

10. Standring, S. Gray's Anatomy: the

anatomical Basis of clinical practice in

gallbladder and biliary tree. 40th edn.

P h i l a d e l p h i a : E l s e v i e r C h u r c h i l l

Livingstone, 2008; 69: 1177-1181.

11. Nadeem et al. A study of the clinico-

anatomical variations in the shape and size of

gallbladder. J. Morphol. Sci. 2016; 33(2), 62-

67.

12. Earl.0. Latimer, Mendez, JR., M.D., and

W.J.Hage,M.D. Congenital absence of

gallbladder-report of three cases.Annals of

Surgery, august 1947; 126 ( 2), 229-242.

13. Finney, G.G, and Owen J.K. The surgical

aspect of congenital absence of the gall

bladder; Report of two cases. Ann. Surg.

1942: 115:736.

14. Rabinovitch J, Rabinovitch P, Rosenblatt P,

Pines B. Congenital anomalies of the

g a l l b l a d d e r . A n n s u r g . 1 9 5 8

aug;148(2):161–8.

15. Gerwig WH, Countryman LK, Gomez AC.

Congenital absence of the gallbladder and

cystic duct: report of six cases. Ann Surg.

1961 Jan;153(1):113–25.

16. Carbajo Caballero MA, Martin del Olmo JC,

Blanco Alvarez JI, Atienza Sánchez R.



Gallbladder and cystic duct absence.

SurgEndosc. 1997; 11:483-484.

17. Bronshtein M, Weiner Z, Abramovici H,

Erlik Y, Blumenfeld Z. Prenatal diagnosis of

gallbladder anomalies. Report of 17 cases.

PrenatDiagn. 1993; 13(9):851-86l.

18. Fernandez Pontes J, Walter Pinotti H.

Anomalias de la vesículabiliary del

sistemabiliar. In: Bockus HL, ed.

Gastroenterología (III). 3rd ed. Barcelona:

Salvat. 1981; 697- 712.

19. Schiffino L, Mouro J, Levard H, Dubois F. A

case of a left-sided gallbladder treated

surgically via laparoscopy. Ann ItalChir.

1993; 64(2):229-231.

20. Latimer, E.O., Mendesy, F.L., JR., And Hage,

W.J. congenital absence of gall bladder:

report of three cases. Ann.Surg. 1947; 126,

229.

21. Dharmendra Kumar, Pratik Shahil.

Anatomical Variations of Gall Bladder & its

association with post operative Outcome,

IOSR Journal of Dental and Medical

Sciences (IOSR-JDMS)16(5): 2017; 53-55.

Received on 15/05/2018 Revised on 30/05/2018 Accepted on 08/06/2018

Original Article - NJBMS171 Original Article Sreelekha.D1 , Swayam Jothi Dorairaj.S2, Lalitha.R3,...

Documents

Transcript of Original Article - NJBMS171 Original Article Sreelekha.D1 , Swayam Jothi Dorairaj.S2, Lalitha.R3,...