Abstract
Micro-gallbladder is a rare clinical entity and mostly linked with cystic fibrosis (CF), which is an autosomal recessive disease involving a protein Cystic fibrosis transmembrane conductance regulator (CFTR) which regulates secretion and absorption in the pulmonary, reproductive and gastrointestinal systems including the liver. Biliary secretion becomes hyperviscous, leading to cholestasis and partial obstruction of the cystic duct. This causes recurrent cholecystitis and gallstone formation. Ultimately, atrophy of the gallbladder results, thus a ‘micro-gallbladder’ defined as being <2–3 cm in length and 0.5–1.5 cm in width. A shrunken gallbladder from recurrent attacks of gallstone-induced cholecystitis is not typically termed as a micro-gallbladder. Laparoscopic cholecystectomy is definitive treatment for symptomatic micro-gallbladder, even though most cases are managed conservatively without surgery. We report a case of symptomatic micro-gallbladder in a non-CF patient, managed successfully by laparoscopic cholecystectomy.
Case report
A 28-year-old women presented with complaints of pain in the right upper abdominal quadrant. She had no tenderness or organomegaly and Murphy’s sign was negative. Her full blood count and liver function tests were within normal limits. On ultrasonography, the gallbladder was not well visualised, but a normal common bile duct (Figure 1(a)) was found. Magnetic resonance cholangiopancreatography (MRCP) showed a 0.96 × 0.64 cm gallbladder with no thickening of its wall, nor pericholecystic fluid and an eccentric T2 hypo-intense mass 0.25 cm in size in its dependent part. A micro-gallbladder was diagnosed, but tests for cystic fibrosis (CF; sweat chloride level and CFTR mutation on genetic analysis) were negative. Her serum α-1-antitrypsin level and autoimmune analysis were likewise within normal limits.
(a) USG of abdomen. Gallbladder is not visualised on USG abdomen. Common bile duct is well visualised and normal. (b) Operative specimen of gall bladder. Gallbladder is grossly looking normal, well distended measuring 1.9 cm in length and 1 cm in width. (c) Histopathology of gallbladder. Showing intact and mildly hyperplastic columnar epithelium of the gall bladder mucosa with paucity of inflammation and fibrosis in the lamina propria. USG: Ultrasonography.
A day-case laparoscopic cholecystectomy was carried out without complication. The gallbladder measured 1.9 × 1 cm (Figure 1(b)), and its section showed normal mucosa and a single stone 4 mm in size. Histopathology revealed an intact and mildly hyperplastic columnar epithelium of the gall bladder mucosa with little inflammation and fibrosis in the lamina propria (Figure 1(c)).
Discussion
Micro-gallbladder is associated with CF and rarely with other conditions like α-1 antitrypsin deficiency, idiopathic neonatal hepatitis and biliary atresia.1–4 Up to one-third of patients with CF have gallbladder-related abnormalities.1–3 Chronic calculous cholecystitis may also cause recurrent inflammation and severe fibrosis resulting in atrophy of gallbladder. Non-visualisation of the gallbladder on initial ultrasound scan raised the suspicion of agenesis or intrahepatic gallbladder; thus an MRCP was carried out to better visualise the biliary tree.4,5 No repeated episodes of acute cholecystitis leading to fibrosis and contracture of the gallbladder could be justified by her history or from morphology or histopathology of gallbladder specimen.
Laparoscopic cholecystectomy for micro-gallbladder may not be easy. Grasping of gallbladder fundus may be difficult. Both holding and retracting the gallbladder neck to visualise the hepato-cystic (Calot’s) triangle and delineating the anatomy may also be demanding. 6 A short cystic duct may pose difficulty while applying clips.
Thus, an asymptomatic or relatively painless micro-gallbladder may be best left alone.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
