POSI GRAD. MED. J. (1966), 42, 213

Case Reports

DIAGNOSIS AND TREATMENT OF DUPLICATIONOF THE GALL BLADDER

D. B. MACKIE, F.R.C.S.

Registrar, Department of Surgical Studies, The Middlesex Hospital, Londonz, W. 1.

DUPLICATION of the gall iblader is 'a rare anomaly,Boyden (1926) finding two cases following 9,221autopsies and a further three after review of9,970 cholecystograms. Although it is a well-doicumen'ted abnormiality with over one hundredexamples descriibed, the majority of these havebeen diagnosed only 'by radiological methods asthe patienlts were not referred for surgery,(Golob and Kantor, 1942; Ragalb and El-Ghaffer,1951; Hemmati, 1963). The number of instancesdiagnosed pre-operattively, confirmed at lapar-dtomy and subsequenitly examined pathologically,appear to ebe seven. iIn six of these cases,symptoms were directly attributaible to disease inone or both of the gall-bladders as stones werepresen't in alt least one of the vesicles in all cases(Table 1). The seventth case, that 'of Oldfield andWriight i(1950) is excluded as the authors wereof the opinion that the most likely diagnosis intheir case was acute appendicitis and that inretrospect 'the 'symptoms were not referable tothe duplicated gall 'bladder. Furthermore, thecholecystogram showed two normally functioninggaill ibladders, post-operative examination revealedno stones and mnicroscopic examination did notsuggest previous acute inflammatory disease ineither gall bladder. The purpose of this paperis to descrilbe a further example of duplication.Case ReportFemale. Aged 58.History: Originally investigated in 1962 for episodicepigastric pain by 'barium meal examination whichwas normal. Although a straight X-ray of theabdomen showed gall stones '(Fig. 1) furtherinvestigation of the biliary system was not carriedout. In 1965 following further attacks of epigastricpain, none of which was associated with jaundice,an intravenous cholangiogram was performed whichshowed a double, gall 'bladder with stones in bothorgans and calculi:in both cystic ducts (Fig. 2). Onegall bladder contained predominantly facetted stoneswhilst the other was filled mainly with "limey bile".Apart from mild epigastric tenderness, noabnormality was found on examination.Operation: '(By Professor Le Quesne on 12.4.65).The abdomen was opened through a right subcostalincision and duplication was confirmed. The twogall bladders were intimately 'bound together by acommon peritoneal covering and two cystic ductswere traced and seen to enter the common bileduct separately. The cystic artery, which was abranch of the common hepatic artery, passed anteriorto the common bile duct before dividing into two.The anatomy of this case is identical to that ofCameron (1952). Stones were readily palpable in

FIG '1.-Plain X-ray of the right hypochondriumshowing 'facetted stones in the upper gall bladderand limey bile in the 'lower vesicle. In additiontwo separa'te shadows are seen and these wereinterpreted as stones impac'ted in each cystic duct.

both organs and a 'per-operaltive dholangiogramperformed through the inferior cystic duct showedan entirely normal common bile duct. The post-operative recovery was uneventful and the patientwas discharged on the tenth post-operative day.Morbid Anatomy: Complete double gall bladder,ensheathed in a layer of peritoneum, and havingtwo cystic ducts (Figs. 3 and 4). 'Both gall bladderscontained calculi, mixed stones predominating inone and calcium carbonate in the other. Stones ofsimilar composition were impacted in -the necks ofboth vesicles.Histology: The walls of both gall bladders arefairly uniformly thickened, showing muscularhypertrophy, epithelial crypts and sinus formation.There is diffuse chronic inflammatory cell infiltrationin the walls of both organs.

DiscussionThe true double gall 'bladder-vesica fellea

duplex-has itwo separate and distinct vesicles,each of Which has its own cystic duet. It istherefore possible for one organ to functionindependently of the other. Duplex gall 'bladders

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214 POSTGRADUATE MEDICAL JOURNAL March, 1966

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FIG. 2.-Intravenous cholangiogram demonstrating anormal common bile duct.

are subdivided into H and Y variations.1. H Type. The cystic ducts do not unite 'but

en,ter separately into ,the common bile ductor into either of the hepa'tic ducts. It is themore common variation.

2. Y Type. The two cystic ducts unite to forma common channel which then enters thecommon ibile duct.

A third variation has been described on oneoccasion (Croudace, 1931) in which one cysticduct entered the common 'bile duct while theother passed directly inrto the substance of theliver. The accessory duct was not, however,traced 'to its conclusion and on embryologicalgrounds it is most unlikely that a cystic ductshould join a small intrahepatic ductule. It ismore probable that this case was an exampleof the H variety with the accessory cystic ductmerely traversing a portion of liver tissue onits course oto Ithe right 'hepatic duct.

'In -the seven cases reviewed, four cases ofduplication were of 'the H variety and one wasa Y anomaly .(Talble 1). In 'two cases the exactanatomy of the cystic ducts was not determined.In lall, fourteen gall ibladders were removed andof these eleven contained calculi. Two of thethree gall lbladders which were free of stoneswere examined histologically. One was entirelynormal ibut the other showed evidence of

FIG. 3.-Radiograph of excised specimen....... ........:" . ... .. ..-........ . -. ... w~~~~~~~~: ...'...... :iFIG. 4.;Photograph of apecimen showing complete

duplication together with ,the stones present ineach gall bladder.

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W:0 ^ ....... ~~~~~~~~~~~~~~~~~~.·i ·;:i i:...:

T.:....·iiiii _:..

dpicaio toete wit the·· stone prsn in·- ·····.ieachgallbladder.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~:

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March, 1966 MACKIE: Duplication of the Gall Bladder 215

TABLE 1

Author Age Sex Type Symptoms X-ray Pathology

Nichols 1926 51 M ? Recurrent attacks right Plain X-ray-two separate A. 2 stones[i hypochondrial pain rows of calculi B. 3 stones

Scott, Sames & 57 M ? Dyspepsia Cholecystogram-double A. 1 stoneSmith 1941 gall bladder with lobulated B. No stones

appearance ? stones ? Histology--MultipleI Ij~ ! polyps. cholesterol polyps

Cameron 1952 33 F H Indigestion and right Cholecystogram--double A. 2 stonesupper abdominal pain gall bladder with stones ir B. No stones

one vesicle Nio histol'ogyCorcoran & 32 F H Gall bladder colic with Cholecystogram-double A. Multiple stonesWallace 1954 fat intolerance gall bladder outlined B. Multiple stones

Owen & 42 F Y Dyspepsia Cholecystogram-sugges- A. Multiple stonesWallace Jones tive of duplication and IB. 1 stone

1962 confirmed with IVC.Good function in one,

I j ~~~~~I[poor in the other withI ' ~~I | multiple stones

Dunkerly 1964 29 M H Six attacks of epigastric Cholecystogram-Calculi A. Multiple stonespain lying outside a normally B. No stones

functioning vesicle. Dupli- Histology normalcation confirmed withIVC. Two cystic ductsoutlined

Mackie 1965 58 F H' Epigastric pain IVC. Two cystic ducts A. Multiple stonesoutlined. Multiple stones B. Multiple stones

l | ' ~ i jin each

cholesterolosis with cholesterol polyps rangingup to 0.3 cm. in length.

All the patients were investigated for attacksof upper abdominal pain, Ithough acutecholecystitis ,(Wilson, 1939), torsion of one gall'bladder (Recht, 1951), and carcinoma developingin one of the vesicles (Raymond and Thrift,1956), have Ibeen recorded. There are no specificsymptoms of duplication and pre-operativediagnosis is an incidental finding in the radio-logical investigation of the biliary system. Eitlherthe two gall lbladders and 'their cystic ducts willbe outlined with contrast, or the presence of asecond gall Ibladder is inferred 'by the recognitionof its stones lying outside the funcitioning gallibladder, (Dunkerly, 1964). The importance ofoblique views has Ibeen stressed by Ross (1956)for if one fundus is superimposed on its fellowa cleft gall Ibladder or a Phrygian cap deformitymay be simulated.

Because double gall bladders may functionindependently, further diagnostic difficulties occurwhen only one organ concen,trates dye. Williams(1957) reported a case in which the cholecysto-gram demonstrated calculi in a normally

functioning gall tbladder and no furtherabnormality was thought to be present. Duplica-tion was only diagnosed following a per-operativecholangiogram when a second cystic duct enteringthe right hepatic duct together with an accessorygall bladder were outlined. When the onlyfunctioning gall bladder is normal and containsno stones, cholecystography may then provepositively misleading in the evaluation of upperabdominal pain, as reported fby Moore andHurley (1954) and Hurwitz (1963). In both casesa diagnostic laparotomy was performed afterinvestigation of the biliary system had beenconsidered normal, and the operative findingswere identical-duplication of the gall bladderwith one normal organ in association with adiseased and non-functioning accessory vesicle.When surgery is advised, double cholecystec-

tomy is obvious if radiological examination hasdemonstrated stones in both organs or ifcalculi are palpated in each vesicle at operation.A diseased gall bladder inadvertently left in situmay lead later to considerable diagnostic problemsand Miibourne (1940) h,as reported a patient whounderwent cholecystectomy on two separate

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216 POSTGRADUATE MEDICAL JOURNAL March, 1966

occasions. If, however, one of the gall bladdersis considered to ibe normal, opinion differs as tothe correct procedure. Ryberg I(1960) recommendsthat when an accessory but otherwise normalgall bladder is found at operation it is justifialbleto lea e it in situ. Calculi may, however, befound in an accessory vesicle on opening it whennot only radiological examination but also directpalpation at operation had been considerednormal (Owen and Wallace Jones, 1962). More-over in the seven cases reviewed, eleven of 'thefourteen vesieles contained stones and one of thethree acalculous organs had numerous cholesterolstones. When duplication of the gall bladder isdiagnosed pre-operatively or if found unexpectedlyat operation, it is suggested that failure to removeboth vesicles is submitting the patient to anunnecessary risk and that the correct treatmentmust be double cholecystectomy in all cases.

SummaryA case of douible gall bladder which was

diagnosed Ipre-operatively and confirmed atlaparotomy is described and a further six casesare reviewed. The difficulties in diagnosis arediscussed and morbid anatomy is compared.Gall stones were ,found in eleven of the fourteengall 'bladders removed and only one organ wasproved to Ibe normal. It is suggested that doublecholecystectomy should 'be performed in all casesof gall 'bladder duplication.

I would like to thank Professor Le Quesne forhis permission to publish this case and for his helpin the preparation of the article; also Mr. M.Hobsley for the translation of foreign texts and formuch helpful criticism and Dr. J. Bielby for thepathological report.

REFERENCESBOYDEN, E. A. (1926): Accessory Gall Bladders,Amer. J. Anat., 38, 177.

CAMERON, L. (1952): Double Gall Bladder, Aust.N.Z., J. Surg., 21, 308.

CORCORAN, D. and WALLACE, K. K. (1954):Congenital Abnormalities of the Gall Bladder,Amer. Surg., 20, 709.

CROUDACE, W. H. (1931): Double Gall Bladder,Brit. mned. J., i, 707.

DUNKERLY, D. R. (1964): Double Gall IBladder, Proc.roy. Soc. Med., 57, 331.

GOLOB, M. and KANTOR, J. L. (1942): Double GallBladder. Two Cases, Amer. J. dig. Dis., 9, 120.

HEMMATI, A. (1963): On the Diagnosis of Duplica-tion of the Gall Bladder, Fortschr. Rontgenstr.,100, 413.

HURWITZ, A. (1963): Double Gall Bladder, J. MaineMed. Ass., 55, 79.

MILLBOURNE, E. ((1940): Ueber Die DoppelteGallenblase im Amschluss am Zwei BedbachetteFalle, Acta. Clin. Scand., 84, 97.

MOORE, T. C. and HURLEY, A. G. i(1954): CongenitalDuplication of the Gall Bladder, Surgery, 35, 283.

NICHOLS, B. H. (1926): Double Gall Bladder:Report of a Case, Radiology, 6, 255.

OLDFIELD, M. C. and WRIGHT, C. J. (1950): DoubleGall Bladder, Brit. J. Surg., 38, 116.

OWEN, R. A. C. and WALLACE JONES, D. R. (1962):A Case of Double Gall 'Bladder with UnusualFeatures, Brit. J. Surg., 49, 577.

RAGAB, M. M. and EL-GHAFFER, Y. A. (1951):Double Gall Bladder-Eight Cases, J. Egypt. med.Ass., 34, 315.

RAYMOND, S. W. and THRIST, C. B. (1956):Carcinoma of the Duplicated Gall Bladder, Illinoismed. J., 110, 239.

RECHT, W. (1952): Torsion of a Double Gall Bladder,Brit. J. Surg., 39, 342.

Ross, J. A. (1956): Double Gall Bladder with Reportof a Case, Brit. J. Radiol. N.S., 29, 109.

RYBERG, C. H. (1960): Gall Bladder Duplication-Case Report and Review of Literature, Acta. Chir.Scand., 119, 34.

SCOTT, W. R., SAMES, S. S., SMITH, H. A. (1941):Double Gall Bladder, Radiology, 37, 492.

WILLIAMS, J. L. '(1957): A Double Gall BladderDemonstrated by Operative Cholangiography,Postgrad. med. J., 33, 236.

WILSON, C. L. (1939): Double Gall Bladder withTwo Cystic Ducts and Two Cysts, Ann. Surg.,110, 60.

GRANULAR-CELL MYOBLASTOMA OF THE PITUITARY

A. TALERMAN, M.B., Ch.B., M.R.C.S., L.R.C.P. K. DAWSON-BUTTERWORTH, M.R.C.S., L.R.C.P.

Senior Registrar (Pathology), St. Mary's Hospital, Senior House Officer (Medicine), St. Mary's Hospital,Portsmouth Newport, 1.O.W.

THE following case is reported ,because of thedifficulty of making the diagnosis and its rarity.Case ReportMr. C.L.H., Age 69, was first attended medically

in 1946 with lobar pneumonia whilst on activeNaval service. The resultant emphysema and chronicbronchitis following this episode caused thim to beinvalided from ,the service. He was normotensive

for his age but considerably overweight.In 1952 he suffered a herniation of the 4th lumbar

intervertebral disc. At the same time, he was issuedwith a surgical belt to control his protuberantabdomen. Six years later he was reviewed andfound to be massively overweight, although he hada moderate appetite. His fat was of femininedistribution. He had mild hypertension (BP 180/100mm. Hg.). His obesity was treated with Preludin.

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