GB agenesis - Forum

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Billroth

Re: GB agenesis - Ärzteforum

Post#11 »

Here is a hypothetical case... A patient who has no GB but has "biliary" symptoms has an ultrasound which is said to show a contracted GB with stones - no mention is made of an unusual position of this GB.
He undergoes laparoscopy, and a careful examination is made of his right upper quadrant. No GB is found, and no cystic duct is found. The underside of the liver is carefully examined (according to Sherlock and Dooley "diseases of the liver and biliary system" 10th edition intrahepatic GBs ALWAYS have a portion visible on the underside). The supradoudenal portion of the CBD is also examined.
A needle cholangiogram is entirely normal, with no evidence of a cystic duct.
Would you have the Surgeon dissect around the CBD and down to the ampulla? That might well lead to an ischaemic stricture. Surely it is more reasonable to say that if the "GB with stones" that the ultrasonographer "saw" was in one of those ectopic situations, he would have said so.
It is certainly correct to say that the patients we describe could have ectopic GBs or rudimentary GBs (i.e. blind cystic ducts), but that is such a remote possibility that it should be discounted.

I do take the point you have raised, and suggest that we should describe these patients as having "missing" GBs (as in missing presumed dead) rather than as having GB agenesis.


canadian

Re: GB agenesis - Ärzteforum

Post#12 »

Just this week. What a coincidence! Found during a laparotomy for huge
benign ovarian cyst in 50 year old. Preop abd ultrasound showed normal
appearing gallbladder, no stones. Intraop could only identify rounded liver
at the GB fossa. GB completely covered with liver.

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Surgeon

Re: GB agenesis - Ärzteforum

Post#13 »

This is not GB agenesis

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Treatment guru

Re: GB agenesis - Ärzteforum

Post#14 »

Quite so, this is not agenesis, but you will remember that I
asked the list if anyone had seen a true intrahepatic Gall bladder. In
Sheila Sherlock's book she states that there is always a portion of the
gall bladder visible from the underside of the liver. Sounds as though
she was wrong in this case.

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Resident

Re: GB agenesis - Ärzteforum

Post#15 »

Thanks for explaining to me your point of view, as agenesis of
gallbladder is a rare congenital condition occurring in 13 to 65 per 100,000
population, it was important to fulfill the criteria I have mentioned in my
previous posting to distinguish it from ectopic or missing gallbladder. The
following two facts are important when we are dealing with the situation of
missing gallbladder;

1- The cystic duct almost always opens to the right side of CBD, regardless
of the position of gallbladder.

2- Although cholangiogram is an essential step in the diagnosis of missing
gallbladder, it is by no means 100% accurate in the diagnosis, as non
visualisation of the gallbladder does not necessarily means its absence but
it simply means non filling of the gallbladder. In ERCP it is not uncommon
not to be able to visualize the gallbladder, even with deep cannulation of
CBD and high pressure of dye injection. As surgeons we may not be aware of
this point, as we always do operative cholangiogram to visualize the biliary
tree and not the gallbladder.

For these two points it is an important step to dissect the CBD
after doing cholangiogram. By dissection I mean inspection of the RIGHT side
of CBD from the upper border of pancreatic head to the porta hepatis, the
level of its division. There is no need to dissect into the pancreas or
liver, also there is no need to skeletonise the CBD completely endangering
its blood supply.

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A Doctor

Re: GB agenesis - Ärzteforum

Post#16 »

Resident wrote: For these two points it is an important step to dissect the CBD
after doing cholangiogram. By dissection I mean inspection of the RIGHT side
of CBD from the upper border of pancreatic head to the porta hepatis, the
level of its division. There is no need to dissect into the pancreas or
liver, also there is no need to skeletonise the CBD completely endangering
its blood supply.


just a comment:
There is a need to dissect the common duct into the liver tree, for
there is a small percentage of cytic ducts originating from the right
hepatic duct. This is a well known danger in lap. CHE.

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Lady Surgeon

Re: GB agenesis - Ärzteforum

Post#17 »

Perhaps you can help a little further. I have just seen a woman
of forty five with symptoms which suggest biliary disease without being
quite classical of biliary colic. She has had an ultrasound which is
reported as "No GB seen - presumed contracted GB containing stones.
Normal CBD". She has already seen another Surgeon who said "The GB is
contracted and must therefore contain stones"
What should I now do?
Options -
1. Proceed to Lap Chole
2. Proceed to Laparotomy
3. Repeat U/S
4. Other imaging - ERCP
Spiral CT or MRI with contrast
5. Other e.g. OGD (or EGD if you will!)

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Alalo

Re: GB agenesis - Ärzteforum

Post#18 »

As your patient is symptomatic, I would start with Lap. Chole. with a
very low threshold to convert, to open cholecystectomy, if the gallbladder is
small contracted with difficulty to display proper anatomy, or if the gallbladder
is absent.

Repeat U/S, ERCP, Spiral CT, MRI, or OGD, to my mind will not add any
useful information to that obtained by the initial U/S.

We have already agreed about the steps which should be followed in the
situation of a missing gallbladder.

User avatar
Loit

Re: GB agenesis - Ärzteforum

Post#19 »

I think it depends on how much you trust your ultrasonographer. IN my
institution spiral CT costs virtually nothing (about 10 Rand if you want
hard copy, if you use contrast about R100) and I find our ultrasounds
unreliable so I don't hesitate to do it.
Despite the flurry of case reports of absent or intrahepatic GB we all know
its jolly rare and the missing GB on USScan is almost always due to a
shrunken GB ie diseased, so go for your lap chole.
I'd be interested how many folk would do a routine G scope (assuming you are
allowed to do so by your gastroenterologists) before cholecystectomy to look
for DU or reflux disease that might be the real cause of symptoms attributed
to stones

John Dissector

Re: GB agenesis - Ärzteforum

Post#20 »

Lady Surgeon wrote:Perhaps you can help a little further. I have just seen a woman
of forty five with symptoms which suggest biliary disease without being
quite classical of biliary colic. She has had an ultrasound which is
reported as "No GB seen - presumed contracted GB containing stones.
Normal CBD". She has already seen another Surgeon who said "The GB is
contracted and must therefore contain stones"
What should I now do?


There must be a good way of keeping up with former discussions, but I can't
think of one--we have been down this same thread at least twice now in just
the past couple of maonths, but let me say it again--
One does not need to "see" stones to operate on a gallbladder--it has been
well established as far back as the first decades of this century(before GB
imaging when ALL decisions to operate for cholecystectomy were purely on
clinical grounds--and guess what--very similar rates of success as now with
all our technology) that a clinical picture consistent with biliary colic is
enough to do cholecystectomy--on that basis, relief of symptoms following
cholecystectomy (the endpoint we are all seeking) ranges from 80%-100%--guess
what the success is following positive U/S or OCG? 90% (not perfect!) Thius
isw an important concept to know to avoid a fortune in tests by those such as
yourself who apparently think that disabling GB disease can only occur in the
presence of stones, or that cholecystectomy cannot be done unlessw you
demonstrate some stones or any other pathology--not true! The literature, tho
obscure, is clear--Try South Med for a start on acquainting
yourself with the literature on this topic, and how completely worthless are
most of the tests that are touted in this irrational quest to find SOME
test--any test--that is abnormal. Why are we such sheep and are so insecure
with our own grasp of this area that we can't offer the patient the option of
cholecystectomy, explaining some of the uncertainties, when the symptoms are
of biliary colic but no demonstrable preop pathology? How do we get so
brainwashed by our morbid fear for our own wallets and liability when the
evidence in favor of this approach is so abundant? And if anyone again
mentions a concern with what the lawyers will say (i.e. who the heck cares!) I
think I'll finally be driven to fall on a sword--you will again have made me
lose faith in our profession, allowing another profession to dictate to you
how to practice what you have been trained and they have not. To me, this is
the whine of the insecure.

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