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
National Journal of Basic Medical Sciences | Volume 8 | Issue 4 | 2018
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
National Journal of Basic Medical Sciences | Volume 8 | Issue 4 | 2018
Sreelekha.D, et.al : Anomalies of Gall Bladder
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.
National Journal of Basic Medical Sciences | Volume 8 | Issue 4 | 2018
Sreelekha.D, et.al : Anomalies of Gall Bladder
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
Sreelekha.D, et.al : Anomalies of Gall Bladder
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
176National Journal of Basic Medical Sciences | Volume 8 | Issue 4 | 2018
Sreelekha.D, et.al : Anomalies of Gall Bladder
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Received on 15/05/2018 Revised on 30/05/2018 Accepted on 08/06/2018