WOS: 000208903500015PubMed ID: 23243652Duplication of the gallbladder, a rare congenital anomaly, is important in clinical practice as it may cause some clinical, surgical, and diagnostic problems. This anomaly is also important for surgeons due to the increased risk of complications especially after laparoscopic cholecystectomy. We report ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography findings in two cases of a symptomatic duplicated gallbladder

Gocmen, Rahsan

Yesilkaya, Yakup

Medical Ultrasonography

Kırşehir Ahi Evran University Institutional Repository

Case report Med Ultrason2012, Vol. 14, no. 4, 358-360AbstractDuplication of the gallbladder, a rare congenital anomaly, is important in clinical practice as it may cause some clinical, surgical, and diagnostic problems. This anomaly is also important for surgeons due to the increased risk of complications especially after laparoscopic cholecystectomy. We report ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography findings in two cases of a symptomatic duplicated gallbladder.Keywords: duplication, gallbladder, ultrasound, magnetic resonance imaging, computed tomography.Imaging findings of gallbladder duplication due to two cases: case report and review of literature Rahsan Gocmen1, Yakup Yesilkaya21Department of Radiology, Hacettepe University Hospital, Turkey2Department of Radiology, Kirsehir Ahi Evran University Hospital, TurkeyReceived 15.06.2012 Accepted 02.07.2012    Med Ultrason  2012, Vol. 14, No 4, 358-360 Corresponding author: Yakup Yesilkaya, MD  Ahi Evran University, Educational and  Research Hospital, Department of Radiology  Kırsehir  40100, Turkey  Phone: +90-386-213-45-15,   Fax: +90-386-213-33-98,   E-mail: dryakup23@hotmail.comIntroductionDouble gallbladder is a very rare congenital biliary anomaly with a reported incidence of one per 4,000-5,000 persons [1,2]. It is important in clinical practice be-cause it may cause some clinical, surgical, and imaging problems. Several entities may mimic a duplicate gall-bladder including a folded gallbladder, choledochal cyst, phrygian cap, pericholecystic fluid, gallbladder diver-ticulum and vascular band across the gallbladder [2,3]. Congenital anomalies of the gallbladder and anatomical variations of their positions are associated with an in-creased risk of complications after laparoscopic chole-cystectomy. The pre-operative diagnosis of this anomaly is especially important to prevent possible surgical com-plications and repeated laparotomies [4-6]. We describe here two cases of gallbladder duplication, visualized by different imaging modalities.Case 1The patient is a 35-year-old woman with no medical history. She was admitted in the surgery department due to chronic right upper quadrant pain. Physical exam showed slight tenderness in the right upper quadrant and negative Murphy’s sign. Admission laboratory findings, including transaminases, lactic dehydrogenase, total bilirubin, alka-line phosphatase, and white blood cell count, were within normal limits. Her temperature was 37.5°C and the rest of  her vital signs were normal. Ultrasonography (US) of the abdomen showed two separated ellipsoid-shaped cystic structures with a well-defined wall, side by side in the gallbladder fossa (fig 1). The US examination two hours after a meal containing fat and eggs showed that both cystic structures were contracted, with smaller sizes. There was no evidence of gallbladder stones, sludge, or inflamation of the wall. These findings closely resembled gallbladder duplication. Magnetic resonance cholangio-pancreatography (MRCP) revealed a true duplication of the gallbladder (fig 2). Surgery treatment was recom-mended but the patient refused the surgical intervention.359Med Ultrason 2012; 14(4): 358-360Fig 1. Ultrasound image of abdomen showing two adjacent fluid-filled structures and cystic ducts in gallbladder fossa (arrows). Fig 3. Ultrasound image of abdomen showing two adjacent fluid-filled structuresFig 4. Axial computed tomography images of ab-domen demonstrating gallbladder duplication (ar-rows).Fig 2. Magnetic resonance imaging showed gall-bladder duplication.Case 2The patient is a 45-year-old woman with no medi-cal history. She was admitted to the surgery department because of chronic right upper quadrant pain and nau-sea.  Physical examination was normal. Murphy’s sign was negative. Admission laboratory tests were all within normal limits. Her temperature was 37.0°C, and the rest of her vital signs were normal. An US of the abdomen showed two separated ellipsoid-shaped cystic structures with a well-defined wall, side by side in the gallbladder fossa (fig 3).  The US examination two hours after stand-ardized fatty meal showed that both cystic structures were similar contracted. No gallbladder stones or sludge, or inflamation of the wall were found. Computed tom-ography (CT) confirmed the gallbladder duplication (fig 4). Surgery treatment was recommended but the surgical intervention was postponed by patient.DiscussionAnatomic duplications of the gallbladder are still classified according to Boyden’s three types: 1) Y gall-bladder consists of two completely separate gallblad-ders, each with a cystic duct. The two ducts join to form a common cystic duct before entering the common bile duct; 2) H or ductular gallbladder the cystic and acces-sory cystic ducts enter the common bile duct separately. This is the commonest variant of gallbladder duplica-tion; 3) trabecular gallbladder in which the accessory cystic duct enters the right intrahepatic system [7]. Gall-bladder duplication is important to be recognaise due to the clinical, surgical, and imaging difficulties. Accurate pre-operative diagnosis of this anomaly becomes im-portant to prevent possible surgical complications and repeated surgery. As most errors in gallbladder surgery result from failure to appreciate the anatomic variations 360 Rahsan Gocmen et al Imaging findings of gallbladder duplication due to two casesof the biliary system, the preoperative documentation of the anatomy has a critical role especially when consider-ing laparoscopic cholecystectomy. US is the first step for evaluation. However, US imaging alone presents some drawbacks and this technique does not always allow a precise diagnosis of gallbladder malformations. Several entities may mimic a duplicate gallbladder including a folded gallbladder, choledochal cyst, phrygian cap, pericholecystic fluid, gallbladder diverticulum, vascular band across the gallbladder and focal adenomyomatosis on US examination. US may demonstrate wall thick-ness, lumen pathology and the number of the gallblad-ders but is unable to define always the exact anatomy of the biliary tree. CT is available as simple imaging mo-dality of double gallbladder and the presence of mass can be identified. It should be supplemented with MRCP or endoscopic retrograde cholangiopancreatography (ERCP) to detail biliary tract anatomy and its variations. MRCP is a relatively new MR imaging technique that is used for noninvasive work-up of patients with biliary disease. A potential use of MRCP is evaluation of bile duct anatomy before cholecystectomy. By demonstrat-ing aberrant anatomy before surgery, the risk of bile duct injury should be reduced, especially during laparo-scopic cholecystectomy, which is associated with double the risk of bile duct injury compared with that of open cholecystectomy. MRCP is becoming the initial imaging tool for the biliary system, with ERCP reserved for ther-apeutic indications. MRCP is noninvasive, cheaper, uses no radiation, requires no anesthesia and less operator dependent; allows better visualization of biliary ducts when combined with conventional T1- and T2-weighted sequences [8]. Preoperative assessment of gallbladder duplication is very important and the diagnosis of this anomaly is beneficial to the patient.References 1. Keuntje H. Duplication of the gallbladder. Zentralbl Chir 1981;106:178-180. 2. Ozgen A, Akata D, Arat A et al. Gallbladder duplication: imaging findings and differential considerations. Abdom Imaging 1999;24:285-288. 3. Hekimoglu K, Bayrak A, Ulu F, Coskun M. Combined use of ultrasonography, MDCT and MRCP for the diagnosis of gallbladder duplication: case report. J Dig Dis 2010;11:115-118. 4. Singh B, Ramsaroop L, Allopi L et al. Duplicate gallblad-der: an unusual case report. Surg Radiol Anat 2006;28:654-657. 5. Maddox JM, Demers ML. Laparoscopic management of gallbladder duplication: a case report and review of litera-ture. JSLS 1999;3:137-140. 6. Safioleas MC, Papavassiliou VG, Moulakakis KG et al. Congenital duplication of the gallbladder. Am Surg 2006;72:217-220. 7. Nouira F, Taieb C, Hela L et al. Duplication of gallbladder. Tunis Med 2011;89:798-799. 8. Vitellas KM, Keogan MT, Spritzer CE, Nelson RC. MR cholangiopancreatography of bile and pancreatic duct ab-normalities with emphasis on the single-shot fast spin-echo technique. Radiographics 2000;20:939-957; quiz 1107-1108, 1112.

Imaging findings of gallbladder duplication due to two cases: case report and review of literature

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