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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