Acute Cholecystitis-like Presentation in an Adult Patient with Gallbladder Agenesis: Case Report and Literature Review

Abstract

Introduction. Gallbladder agenesis (GA) is a rare congenital malformation, and majority are asymptomatic; however, symptomatic patients present with a clinical picture similar to biliary colic. Work up usually shows contracted gallbladder (GB) on ultrasound (US), and HIDA scan shows nonvisualization. Magnetic resonance cholangiopancreatography (MRCP) can be helpful in the diagnosis; however, the diagnosis without the latter can only be established intraoperatively. Management should be conservative treatment with antispasmodic drugs. Case Report. A 35-year-old female presented to the emergency department with nausea, vomiting, and worsening right upper quadrant (RUQ) abdominal pain. Vitals and laboratory values were unremarkable except for mild leukocytosis, and RUQ US reported “contracted GB, cholelithiasis, 4.2 mm wall thickness, and no ductal dilation.” Surgical consultation was prompted by the diagnosis of acute cholecystitis. The patient was transferred to the operating room for laparoscopic cholecystectomy; however, no GB was found, which was confirmed by intraoperative indocyanine green cholangiography. The procedure was aborted. Postoperatively, CT scan showed absent GB. A HIDA scan showed nonvisualization of the GB after 4 hours. Gastroenterology consultation was suggested to assess for peptic ulcer disease, stricture, or other etiology for her presenting symptoms, and the upper endoscopy showed gastritis. Upper GI with small bowel follow-through study showed mild delayed gastric emptying and contrast in the colon in 45 minutes. Conclusion. When US imaging findings are equivocal for nonvisualization of GB in a patient with no known history of prior cholecystectomy, additional imaging is required considering the diagnosis of gallbladder agenesis. MRCP is the test of choice. Management is usually conservative with smooth muscle relaxants without the need for surgical operation.

Gallbladder Agenesis Mimicking Chronic Cholecystitis in a Young Woman

“…Several case reports published had a similar clinical presentation of upper abdominal pain resembling biliary colic, along with normal or elevated laboratory workup and unclear radiological signs [1][2][3][4][5]7,[8][9][10]. Other common presentations include nausea and/or vomiting (66%), fatty food intolerance (37.5%), dyspepsia, bloating, and occasional jaundice [7].…”

“…Thus, the findings of abdominal ultrasound can be misleading, and MRCP is indicated to confirm a diagnosis of gallbladder agenesis (Figures 4, 5) [1,4,5].…”

“…Gallbladder agenesis is a congenital anomaly in the biliary system that was first reported in 1701 by Lemery et al [1]. It is a rare congenital abnormality of the biliary tree with an incidence of <0.1% (range: 0.04%-0.1%) [2] and a female preponderance of 3:1 [1,3]. Literature evidence suggests that only 500 similar clinical cases have been reported [4].…”

A Case Report on Gallbladder Agenesis: Not a Novelty but Still a Laparoscopic Surprise

“…Gallbladder agenesis (GA) is a rare embryological anomaly with an incidence of 10-65 per 100,000 [1][2][3][4][5]. GA is associated with congenital anomalies and its occurrence is sporadic [3,4,[6][7][8]. GA is commonly misinterpreted as acute cholecystitis with cystic duct obstruction [9].…”

“…No consensus is available on the appropriate management of GA and this reflects the heterogeneity of clinical scenarios and the variability of hospital facilities. For these reasons, many cases of GA have been described during the surgical procedure as an incidental finding [2][3][4]8,9]. Conversion to laparotomy and accurate investigation of the biliary anomaly for suspected gallbladder ectopy might be indicated although other colleagues discourage invasive and extensive surgical dissection with the aim of reducing exploration complications [13].…”