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Cholecystitis and calculi in a diverticulum of the gallbladder
Cholecystitis and Calculi in a Diverticulum of the Gallbladder By E. G e o r g e Kassner a n d Donald H, Klotz, Jr.
ALLBLADDER diverticula generally have been incidentally discovered at operation, autopsy, or cholecystography and have very rarely been found in children. We recently encountered a 12-yr-old boy who had cholecystitis and calculi in a noncommunicating fundal diverticulum.
G
CASE REPORT A 12-yr-old boy was admitted after 4 days of intermittent right upper quadrant pain. The pain was sharp, lasted 5-10 sec, and did not radiate. He had a persistent fever of 101~176 but no chills. He had vomited twice each day. There was no jaundice and there had been no change in the color of his urine or feces. He had never experienced a similar illness and had never been hospitalized. Physical examination revealed a well-developed boy who winced on deep palpa*tion of the right subcostal region. No mass was palpable. The liver and spleen were not enlarged. Hematocrit was 45~, hemoglobin, 12.8 g/100 ml, and the white blood cell count was 9500 with 80~ polymorphs. Erytbrocyte morphology and sickling preparation were normal. Urinalysis and liver function tests were normal. A plain radiograph of the abdomen on the day of admission revealed a cluster of faceted calculi in the right upper quadrant (Fig. 1). A cholecystogram the following day demonstrated a wellopacified gallbladder. RadiograPhs in many projections showed the calculi to lie just beyond the fundus and always to be intimately associated with it. Contrast material never entered the chamber containing the calculi.
Fig. 1. Plain radiograph of the abdomen; close-up of the right upper quadrant. A cluster of faceted calculi lies to the right of L-3.
From the Departments of Radiology and Surgery (Division of Pediatric Surgery), State University of New York, Downstate Medical Center, Brooklyn, N. Y. Address for reprint requests: E. George Kassner, M.D., State University of New York, Downstate Medical Center, 450 Clarkson A re. (Box 45), Brooklyn, N. Y. 11203. 9 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. l O, No. 6 (December), 1975
967
968
KASSNER AND KLOTZ
Fig. 2. The gallbladder has been opened to show the main chamber (to left, above label), the fundal diverticulum, and the imperforate septum. A few calculi remain within the diverticulum. Cholecystectomy was done on the seventh hospital day. The gallbladder consisted of two separate c o m p a r t m e n t s covered by a continuous serosa and separated by a muscular septum through which no c o m m u n i c a t i n g tract could be identified. The contour of the gallbladder was indented at the level of the septum. The main c h a m b e r (gallbladder proper) contained green bile. The 2 x 3cm c h a m b e r arising at the fundus (diverticulum) contained yellow bile and was filled with calculi measuring up to 6 • 5 x 3 m m in size (Fig. 2) In both chambers mucosa and muscle coats were typical of gallbladder. There was mild acute cholecystitis of the fundal diverticulum: the gallbladder proper was free of inflammation. DISCUSSION
Gallbladder diverticula are rare. Only 25 were found in 29,701 resected gallbladders at the Mayo Clinic. ~ Most occur at the neck and are probably the result of incomplete regression of embryonic cystohepatic ducts. Two explanations have been proposed for fundal diverticula: (1) Incomplete resolution of the solid stage of gallbladder development that is present before the third fetal month. 2 (2) A constricting band of fetal origin, in which case diverticulum formation may be considered a stage beyond the fetal infolding that results in a Phrygian cap. 3 Contractility after fat ingestion radiographically distinguishes true congenital diverticula--which contain all layers of the gallbladder wall-from pseudodiverticuta resulting from inflammation or obstruction. 4 Noncommunicating fundal chambers, sometimes containing calculi, have rarely been encountered. 5 These have been considered to represent congenital diverticula that have lost their connection with the gallbladder proper as the result of inflammation. REFERENCES
1. Haring O M , Lewis FJ: in D o w d y GS (ed): The Biliary Tract. Philadelphia, Lea & Febiger, 1969, pp 12 13 2. Gross RE: Congenital anomalies of the gallbladder; review of 148 cases, with report of double gallbladder. Arch Surg 32:131 162, 1936
3. Bockus HL: Gastroenterology, Vol 3. Philadelphia, W.B. Saunders, 1946, pp 465-466 4. A r c o m a n o JP, Barnett JC: Diverticulum of gallbladder. A m J Digest Dis 4:556 559, 1959 5. Ritvo M, Shauffer IA: Gastrointestinal X-Ray Diagnosis. Philadelphia, Lea & Febiger, 1952, pp 630-631
ALLBLADDER diverticula generally have been incidentally discovered at operation, autopsy, or cholecystography and have very rarely been found in children. We recently encountered a 12-yr-old boy who had cholecystitis and calculi in a noncommunicating fundal diverticulum.
G
CASE REPORT A 12-yr-old boy was admitted after 4 days of intermittent right upper quadrant pain. The pain was sharp, lasted 5-10 sec, and did not radiate. He had a persistent fever of 101~176 but no chills. He had vomited twice each day. There was no jaundice and there had been no change in the color of his urine or feces. He had never experienced a similar illness and had never been hospitalized. Physical examination revealed a well-developed boy who winced on deep palpa*tion of the right subcostal region. No mass was palpable. The liver and spleen were not enlarged. Hematocrit was 45~, hemoglobin, 12.8 g/100 ml, and the white blood cell count was 9500 with 80~ polymorphs. Erytbrocyte morphology and sickling preparation were normal. Urinalysis and liver function tests were normal. A plain radiograph of the abdomen on the day of admission revealed a cluster of faceted calculi in the right upper quadrant (Fig. 1). A cholecystogram the following day demonstrated a wellopacified gallbladder. RadiograPhs in many projections showed the calculi to lie just beyond the fundus and always to be intimately associated with it. Contrast material never entered the chamber containing the calculi.
Fig. 1. Plain radiograph of the abdomen; close-up of the right upper quadrant. A cluster of faceted calculi lies to the right of L-3.
From the Departments of Radiology and Surgery (Division of Pediatric Surgery), State University of New York, Downstate Medical Center, Brooklyn, N. Y. Address for reprint requests: E. George Kassner, M.D., State University of New York, Downstate Medical Center, 450 Clarkson A re. (Box 45), Brooklyn, N. Y. 11203. 9 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. l O, No. 6 (December), 1975
967
968
KASSNER AND KLOTZ
Fig. 2. The gallbladder has been opened to show the main chamber (to left, above label), the fundal diverticulum, and the imperforate septum. A few calculi remain within the diverticulum. Cholecystectomy was done on the seventh hospital day. The gallbladder consisted of two separate c o m p a r t m e n t s covered by a continuous serosa and separated by a muscular septum through which no c o m m u n i c a t i n g tract could be identified. The contour of the gallbladder was indented at the level of the septum. The main c h a m b e r (gallbladder proper) contained green bile. The 2 x 3cm c h a m b e r arising at the fundus (diverticulum) contained yellow bile and was filled with calculi measuring up to 6 • 5 x 3 m m in size (Fig. 2) In both chambers mucosa and muscle coats were typical of gallbladder. There was mild acute cholecystitis of the fundal diverticulum: the gallbladder proper was free of inflammation. DISCUSSION
Gallbladder diverticula are rare. Only 25 were found in 29,701 resected gallbladders at the Mayo Clinic. ~ Most occur at the neck and are probably the result of incomplete regression of embryonic cystohepatic ducts. Two explanations have been proposed for fundal diverticula: (1) Incomplete resolution of the solid stage of gallbladder development that is present before the third fetal month. 2 (2) A constricting band of fetal origin, in which case diverticulum formation may be considered a stage beyond the fetal infolding that results in a Phrygian cap. 3 Contractility after fat ingestion radiographically distinguishes true congenital diverticula--which contain all layers of the gallbladder wall-from pseudodiverticuta resulting from inflammation or obstruction. 4 Noncommunicating fundal chambers, sometimes containing calculi, have rarely been encountered. 5 These have been considered to represent congenital diverticula that have lost their connection with the gallbladder proper as the result of inflammation. REFERENCES
1. Haring O M , Lewis FJ: in D o w d y GS (ed): The Biliary Tract. Philadelphia, Lea & Febiger, 1969, pp 12 13 2. Gross RE: Congenital anomalies of the gallbladder; review of 148 cases, with report of double gallbladder. Arch Surg 32:131 162, 1936
3. Bockus HL: Gastroenterology, Vol 3. Philadelphia, W.B. Saunders, 1946, pp 465-466 4. A r c o m a n o JP, Barnett JC: Diverticulum of gallbladder. A m J Digest Dis 4:556 559, 1959 5. Ritvo M, Shauffer IA: Gastrointestinal X-Ray Diagnosis. Philadelphia, Lea & Febiger, 1952, pp 630-631