A study on Anomalies of Gall Bladder. Sreelekha.D, Swayam Jothi Dorairaj. S, Lalitha.R, Sujatha.N

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1 Original Article Sreelekha.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. A study on Anomalies of Gall Bladder 1 Asst. Professor, Dept. of Anatomy, Sree Balaji Medical College & Hospital, BIHER University, Chromepet, TN, India. 2 Professor and HOD, Dept. of Anatomy, Shri Sathya Sai Medical college & Research Institute. 3 Asst. Professor, Dept. of Anatomy, Meenakshi Medical College Hospital & Research Instituite, Kancheepuram, TN, India. 4 Tutor in Anatomy, Shri Sathya Sai Medical College, Hospital & Research Institute, Ammapettai, Kancheepuram District. 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. histopathological study. The tissue showed biliary cirrhosis. Bits of liver tissue were sent for 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 1 with the cystic duct. Address for correspondence: Dr. R. Lalitha, Assistant Professor, Department of Anatomy, Meenakshi Medical College, Hospital and Research Institute, Kancheepuram. E mail: doctorlalitha07@gmail.com. Ph:

2 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 structure which persists in the adult. Nonfunctioning, solid tissue remnants of other endodermal structures, such as esophagus and intestine, may also have a development analogous 2 to 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 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). 172

3 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-1 Fig-2 Fig-3 Fig-4 Fig 5. Histopathological finding biliary cirrosis is seen 173

4 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) 4,5 reported 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 11 present 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. 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 13 in 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 15 system. 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, 18 consideration. 174

5 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 19 complications 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 14 dilatation 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 175

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