|Year : 2015 | Volume
| Issue : 4 | Page : 269-271
Duplication of gallbladder: A rare congenital malformation
Onteddu Joji Reddy, Jamkhana Abdul Gafoor, Balla Suresh, Polysetty Obuleswar Prasad
Department of Radiology, Government General Hospital, Kurnool, Andhra Pradesh, India
|Date of Web Publication||14-Dec-2015|
Onteddu Joji Reddy
Department of Radiology, Government General Hospital, Bhudhawarapeta, Kurnool, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Gallbladder duplication is a rare anatomic malformation, which can now be detected by preoperative imaging study. We report a case of a symptomatic duplicated gallbladder, successfully treated by laparoscopic cholecystectomy. This anomaly is important for surgeons to know because of the associated anatomical variations of the main bile duct and hepatic artery and increased risk of common bile duct injury.
Keywords: Cholecystectomy, duplication, gallbladder
|How to cite this article:|
Reddy OJ, Gafoor JA, Suresh B, Prasad PO. Duplication of gallbladder: A rare congenital malformation. J NTR Univ Health Sci 2015;4:269-71
| Introduction|| |
Gallbladder duplication is a rare congenital malformation, occurring in about one per 3,000-4,000 births.  Gallbladder duplication though uncommon, should be considered when an additional cystic structure is seen in the right upper quadrant. Recognition of the presence of duplicated gallbladder is a relatively benign condition; however, there has been an increased prevalence of cholelithiasis and intermittent cystic duct obstruction that has been reported with duplication. Congenital anomalies of the gallbladder and anatomical variations of its position are associated with an increased risk of complications during laparoscopic cholecystectomy.  Preoperative imaging should be helpful in diagnosis.
| Case report|| |
A 55-year-old female came to the hospital with the chief complaint of recurrent right upper quadrant pain associated with fever since the past 6 months. Physical examination showed slight tenderness in the right upper quadrant. Laboratory values found elevated white blood cell count and C-reactive protein associated with mild elevation of total bilurubin, transaminases, and alkaline phosphatase. Ultrasound (US) of the abdomen showed a distended gallbladder with well-circumscribed large calculi attached to the wall of gallbladder at the body of gallbladder and another cystic structure was noted adjacent to the gallbladder. The common bile duct was normal and no intrahepatic bile duct (IHBD) was present. With this imaging of the findings, we suspected a septated gallbladder or congenital duplication of the gallbladder. Contrast-enhanced computed tomography (CECT) (16 slice GE) of the abdomen was performed, which showed that two separate gallbladders were present [Figure 1]a-d. One gallbladder showed 2 × 2 cm calculi with wall-thickening and minimal pericholecystic fluid collection present. The other gallbladder showed minimal wall-thickening. Cystic ducts were not clearly visualized and there was no dilatation of the common bile duct and no intrahepatic biliary dilatation. With this imaging of the findings, we diagnosed congenital duplication of the gallbladder with gallbladder calculi. The patient was posted for laparoscopic cholecystectomy and excision of both gallbladders was done after ligating both the cystic ducts. Intraoperatively, two separate individual gallbladders with two separate cystic ducts were seen in the gallbladder fossa with multiple adhesions between the two gallbladders and liver [Figure 2]a-c. Due to inflammation and adhesions in the gallbladder fossa, dissection along the cystic ducts became difficult. To avoid complication, both the cystic ducts were ligated and excision of both the gallbladders was done after releasing the adhesions [Figure 2]d. Intraoperative cholangiogram was not performed in our case.
|Figure 1: (a) CECT of the abdomen's axial section showing gallbladder (white arrow) with large calculi with wall-thickening (b) CECT of the abdomen's axial section showing another gallbladder (red arrow), which is partially distended (c) CECT of the coronal section showing two separate gallbladders with calculi in the first gallbladder (white arrow) and second gallbladder (red arrow), which is partially distended without the calculi. Minimal pericholecystic fluid collection is also seen (d) CECT of the abdomen's sagittal section showing two separate gallbladders with the first gallbladder with calculi (white arrow) and the second gallbladder (red arrow)|
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|Figure 2: (a and b) Laparoscopic intraoperative image showing two separate gallbladders (GB1,GB2) with two separate cystic ducts (asterisk) (c) Laparoscopic intraoperative image showing two separate gallbladders (GB1, GB2) in gallbladder fossa with adhesions and inflammation surrounding the gallbladders (d) Specimen showing two gallbladders after excision|
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| Discussion|| |
Duplication of the gallbladder is a rare congenital anomaly, occurring in about one per 3,000-4,000 births. It is thought to be due to exuberant budding of the developing biliary tree when the caudal bud of the hepatic diverticulum divides. , Because of associated anatomical variations of the cystic duct and hepatic artery, this congenital anomaly is important for surgeons to know. 
Anatomic variants of gallbladder duplication are differentiated according to Boyden's classification as follows [Figure 3]:
- Septated gallbladder.
- Fundic duplication.
- Body duplication with single cystic duct.
- Duplication of whole gallbladder with the two cystic ducts uniting before entering the common bile duct (Y-shaped).
- Complete type or ductular type, the two cystic ducts entering separately into the biliary tree (H-shaped type).
- Bilateral gallbladders.
|Figure 3: Boyden classification of congenital duplication of the gallbladder|
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Some authors classify duplication of the gallbladder based on its embryological development into two types:
Type 1: Split primordium group (septated 10.8%, bilobed 9.5% and Y-shaped 24.3%).
Type 2: Accessory gallbladder group [H-type (ductular) 48.6% and trabecular 2.7%].
In our patient, two separate gallbladders with two cystic ducts were seen but we did not know whether the two cystic ducts entered the common hepatic duct separately (H-type) or as a single channel after forming a single cystic duct (Y-type). Our patient would fit into either Y-type or H-type of gallbladder duplication according to Boyden's classification.
Differential diagnosis includes gallbladder diverticula, gallbladder fold, Phrygian cap, choledocal cyst, pericholecystic fluid, focal adenomyomatosis, and intraperitoneal fibrous bands.  There are no specific symptoms attributable to a double gallbladder. Simultaneous removal of both gallbladders at surgery is recommended to avoid cholecystitis and symptomatic gallstones in the remaining organ.  US is generally the first choice of imaging modality in patients with suspected biliary disease. US may diagnose gallbladder duplication if the viscera are located separately. Although US findings may suggest a double gallbladder, the cystic duct is usually not identified and it is often impossible to distinguish bilobed gallbladder from a true duplication by US. Duplication should be considered when two cystic ducts are present on preoperative imaging. Magnetic resonance (MR) cholangiography proved to be a valid, noninvasive imaging technique for the evaluation of patients with suspected anomalies of the gallbladder after initial scanning with US.  Helical computed tomography (CT) scan can also be helpful.  Duplication of the gallbladder has been detected by oral cholecystography, scintigraphy, and percutaneous transhepatic cholangiography but these examinations are not routinely used in patients with biliary disease. Concomitance with other congenital anomalies, such as an anomalous right hepatic artery, has been described and may lead to intraoperative injury. Laparoscopic removal of both gallbladders with intraoperative cholangiography seems to be the appropriate treatment. 
| Conclusion|| |
Duplication of the gallbladder is a rare congenital abnormality, which requires special attention from both radiologists and surgeons regarding the anatomical variants of the gallbladder and biliary system.
The authors are thankful to Dr. Anwar Hussain (Assistant Professor), Dr. Mahommad Jeelani (Associate Professor), Dr. S. Vijay Shankar (Assistant Professor), Dr. Govindarajulu (Assistant Professor), Dr. Subramanyam (Postgraduate), Department of General Surgery, Government General Hospital, Kurnool, Andhra Pradesh, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]