Asif Zubair Bhatti, M Imtiaz Rasool, Masood Rashid, Safdar Ali Malik, Asim Shabbir, Umar Javeed, Abu Zar Manan.
Agenesis of Gall Bladder.
J Coll Physicians Surg Pak Jan ;11(12):770-2.

There are many congenital abnormalities related to extrahepatic biliary system. One of the rare anomalies is absence of gall bladder. We report a case of agenesis of gall bladder of a 70-year-old lady diagnosed clinically as obstructive jaundice. On exploration gall bladder was found to be absent.

Case Report: A 70-year-old postmenopausal female patient presented to the surgical outdoor with the complaints of pain in right hypochondrium, flatulent dyspepsia and fluctuating jaundice for 2 months. The pain was colicky in nature, severe in intensity, continuous and radiating to the tip of right shoulder. It was accompanied with 2-3 episodes of vomiting containing the food particles. During the course of fluctuating jaundice she started passing clay colored stools and dark urine. There was no complaint of pruritis, hematemesis, productive cough or any other systemic feature. She neither had significant past history of any biliary disease nor of any prolonged illness. There was also no family history of any biliary disease. She belonged to poor socioeconomic class. Physical examination revealed an emaciated, dehydrated markedly jaundiced patient. There was no lymphadenopathy, bruising, pallor, koilonychia, edema or clubbing. Her pulse was 100/min, low volume, regular with blood pressure of 130/80 mmHg. She was running low-grade fever. Abdomen was moderately distended with central umbilicus. Palpation revealed moderate tenderness in the right hypochondrium with no mass or visceromegaly. Percussion note was dull in the flanks. Fluid thrill was present.

Her blood investigation revealed low hemoglobin of 9.4 mg/dl, leucocytosis with 14,200 mm3 and raised ESR of 65 mm. Her liver function tests presented a picture of obstructive jaundice with serum bilirubin 8 mg/dl (normal=0.1-1.5 mg/dl), SGPT 614 IU (normal=30-40 IU) and alkaline phosphatase 936 (normal=150-200) IU. Serum albumin was 3.2 g/dl (normal=3.5-4.5). Urine was positive for bilirubin. Bleeding and clotting profile were within normal limits. Her hepatitis screen revealed positivity for HCV while HbsAg was negative. Ascitic fluid was tapped and sent for biochemistry, which showed transudative picture, with 125-cells/mm3, glucose 97 mg/dl, protein 2.0 gm/dl, polymorphs 18% and lymphocytes 82%. No malignant cells were seen. The patient was provisionally diagnosed as a case of obstructive jaundice with cirrhosis. To determine the level and cause of obstruction ultrasonography was done which revealed a common bile duct of 2 cm diameter with calculus of 1.5 cm in its distal segment. Gall bladder was not visualized. Her liver showed coarse echo texture. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out which confirmed the finding of ultrasonography. It showed markedly dilated common bile duct with sludge and stone in its distal segment. Gall bladder was not visualized while pancreatic duct and other extrahepatic system was normal. To relieve the obstructive jaundice common bile duct exploration was planned. After preparation, especially taking precaution against hepatitis C, the abdomen was opened through the right sub costal incision. On exploration spleen was found mildly enlarged and 500cc of ascitic fluid was drained. Gall bladder was absent from its fossa. Exploration was done to find it in any ectopic position but it turned out to be negative. CBD was explored and a stone of 1.5 cm diameter removed, T-tube was placed and abdomen closed after drainage. T-tube cholangiography was done on 12th day, which revealed no distal obstruction, free entry of dye into duodenum and mild intrahepatic duct dilatation

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