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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31824d0375
Images of the Month

An Adolescent Girl With Belly Pain: One Gallbladder Too Many?

Minar, Phillip*; Alonso, Maria H.; Smith, Milton T.; Kohli, Rohit*

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*Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition

Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati

Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine, Cincinnati, OH.

Address correspondence and reprint requests to Rohit Kohli, MBBS, MS, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229 (e-mail: rohit.kohli@cchmc.org).

Received 18 October, 2011

Accepted 25 January, 2012

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org).

The authors report no conflicts of interest.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

A 15-year-old previously healthy girl presented with 3 months of right upper quadrant abdominal pain, persistent nausea, and 7-kg weight loss. Her examination revealed right upper quadrant and epigastric tenderness. Laboratory investigations, including bilirubin and liver enzymes, were normal. An abdominal ultrasound revealed a contracted gallbladder and a small ovoid structure in the right upper quadrant suggesting a possible choledochal cyst. Magnetic resonance cholangiopancreatography better defined these lesions as a 2.8 × 2 × 2 cm “ovoid” cystic structure (small arrow in Fig. 1) and a gallbladder (larger arrow Fig. 1). On endoscopic retrograde cholangiopancreatography (ERCP), both structures were filled with contrast with 2 completely separate cystic ducts attached to the common duct (Fig. 2 and online-only images available at http://links.lww.com/MPG/A94).

Figure 1
Figure 1
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Figure 2
Figure 2
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She continued to be symptomatic and subsequently had a laparoscopic cholecystectomy. The intraoperative cholangiogram confirmed the ERCP findings. Accordingly, both gallbladders were removed. Examination of the resected specimens by histology confirmed 2 gallbladders and entirely separates cystic ducts (Fig. 3) (see online-only images).

Figure 3
Figure 3
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Duplicated gallbladder is a rare anomaly of the biliary system with the reported incidence between 1 in 3800 (1). The differential diagnosis for a cystic structure in the gallbladder region includes choledochal cyst, folded gallbladder, gallbladder diverticulum, focal adenomyomatosis, fibrous or vascular band, and duplication of any other structure in the biliary system (2). Although both ultrasound and magnetic resonance cholangiopancreatography are utilized in the evaluation of gallbladder anomalies, ERCP remains the criterion standard to define this biliary tree abnormalitity (3).

Causey et al (4) published a similar case and contend that defining the type of gallbladder duplication (based on the Harlaftis classification (5) of multiple gallbladders) will aid in the selection of operative technique. They reason that laparoscopy can be used for type 1 (the split primordial group, sharing a single cystic duct) and a traditional open approach should be used for type 2 (accessory gallbladder arising from separate primordium with two discrete ducts) (4). The consensus from multiple case reports has been to only operate on symptomatic patients and remove both gallbladders given the risk of continued symptoms and nonfunctionality of either structure.

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REFERENCES

1. Boyden EA. The accessory gall-bladder—an embryological and comparative study of aberrant biliary vesicles occurring in man and the domestic mammals. Am J Anat 1926; 38:177–231.

2. Miyajima N, Yamakawa T, Varma A, et al. Experience with laparoscopic double gallbladder removal. Surg Endosc 1995; 9:63–66.

3. Kim RD, Zendejas I, Velopulos C, et al. Duplicate gallbladder arising from the left hepatic duct: report of a case. Surg Today 2009; 39:536–539.

4. Causey MW, Miller S, Fernelius C, et al. Gallbladder duplication: evaluation, treatment, and classification. J Pediatr Surg 2010; 45:443–446.

5. Harlaftis N, Gray SW, Skandalakis JE. Multiple gallbladders. Surg Gynecol Obstet 1977; 145:928–934.

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