|Year : 2017 | Volume
| Issue : 1 | Page : 45-47
Tuberculosis of the Gallbladder: A Case Report and Review
Anurag Mishra1, Prateek Gupta1, Nidhi Verma2, Surekha Yadav2
1 Department of Surgery, Maulana Azad Medical College, New Delhi, India
2 Department of Pathology, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||1-Mar-2017|
Department of Surgery, Maulana Azad Medical College, Room No. 230, 2nd Floor, B. L. Taneja Block, New Delhi, Delhi
Source of Support: None, Conflict of Interest: None
Gallbladder tuberculosis (GBTB) is an exceedingly rare finding presenting as calculous or acalculous cholecystitis. A correct, preoperative diagnosis of GBTB is difficult, and the literature review highlights the fact that most cases are diagnosed postcholecystectomy or at postmortem. We present a case of a 26-year-old woman who underwent laparoscopic cholecystectomy with preoperative diagnosis of cholelithiasis. GBTB was diagnosed by the histological examination. Routine histopathological examination of all cholecystectomy specimens should, therefore, be a standard practice.
Keywords: Cholecystitis, gallbladder, tuberculosis
|How to cite this article:|
Mishra A, Gupta P, Verma N, Yadav S. Tuberculosis of the Gallbladder: A Case Report and Review. MAMC J Med Sci 2017;3:45-7
| Introduction|| |
Cholelithiasis and associated cholecystitis of the gallbladder (GB) is a very common diagnosis made in patients presenting with right upper quadrant abdominal pain. A gallstone occurs as a secondary complication of GB infection. The infecting organisms are of many types, and mycobacterium as the causative organism is rarely found and suspected and much less frequently proven. Isolated tuberculosis (TB) of the GB is extremely rare, and the diagnosis of this disease is almost always overlooked, unless there is a high index of suspicion. The first case of gallbladder tuberculosis (GBTB) was reported in 1870 by Gaucher, and till now, less than 120 cases have been reported in the English medical literature., There is no pathognomonic presentation of GBTB, which may present with features of cholecystitis, a GB mass, obstructive jaundice due to associated enlarged pericholedochal lymph nodes, and nonspecific systemic symptoms such as abdominal pain, weight loss, low-grade fever, anorexia, vomiting, and abdominal mass. An ultrasound examination of GBTB yields nonspecific results. Preoperative diagnosis of GBTB is difficult, and more so in calculus cholecystitis, because most of the symptoms are attributed to gallstones. Herein, we present a case of a patient with symptomatic cholelithiasis diagnosed as GBTB postcholecystectomy on histopathological examination.
| Case Report|| |
A 26-year-old woman presented with a history of right upper abdominal pain associated with episodes of vomiting every 2–3 weeks for the past 1 year. No history of fever, jaundice, loss of appetite, or weight loss was reported.
Physical examination of the patient showed no abnormal findings. There was no evidence of peripheral lymphadenopathy or hepatosplenomegaly.
On further investigation, the liver enzymes, the hematological parameters, and the chest X-ray were normal. An abdominal ultrasound revealed a distended GB with multiple calculi (3–5 mm) and normal wall thickness; the portal vein and the common bile duct were grossly normal.
The patient underwent elective laparoscopic cholecystectomy.
Intraoperatively, the GB was distended with multiple calculi, the cystic duct was short and dilated, and dense adhesions were seen between the duodenum and the GB wall. The liver, the common bile duct, and the rest of the bowel were grossly normal.
The postoperative stay of the patient was uneventful, and the patient was discharged the next day. Currently, the patient is on regular follow-up and is asymptomatic.
Histological examination of the GB revealed a mucosa showing focal ulcerations and dense chronic inflammation in the subepithelium with few, scattered, noncaseating, epithelioid cell granulomas with giant cells although acid-fast stain was negative [Figure 1] and [Figure 2].
|Figure 1: A microphotograph showing a granuloma with giant cell (shown by arrow). A normal appearing gallbladder mucosa on the left side (shown by arrow head) (HE 40×)|
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|Figure 2: A microphotograph showing an epithelioid cell granuloma with a giant cell (shown by arrow) (HE 400×)|
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| Discussion|| |
GBTB represents 1% of the abdominal TB cases. The literature review revealed only three case reports of tuberculous cholecystitis without associated gallstones or common bile duct obstruction.
Cholelithiasis and cystic duct obstruction are considered as the most important factors in the development of GBTB, with cholelithiasis being present in 70% of the cases. It has been suggested that tuberculous bacilli, having negotiated the biliary passages, form a nidus for calculus formation. GB mucosa is highly resistant to tubercular infection, possibly because of the inhibitory effect of the concentrated bile acids in the GB lumen and the high alkalinity of the bile.
The infection usually spreads via the hematogenous route or from the adjacent, caseating lymph nodes or the peritoneal tubercles. GBTB can be manifested by a relatively nonspecific clinical presentation (abdominal pain, weight loss, low-grade fever, anorexia, vomiting, and abdominal mass), as seen in our case. It occurs most commonly in women over 30 years of age, and more so in the elderly population; however, our patient was a young woman. Preoperative diagnosis of GBTB is difficult, more so in the patients with calculus cholecystitis, because most of the symptoms are attributed to the gallstones, and the diagnosis is usually made by a histological examination of the GB specimen after cholecystectomy. An ultrasound examination of GBTB is nonspecific. On computed tomography (CT) scanning, Xu et al. revealed three different CT findings: micronodular lesion of the GB wall, a thickened wall, and a GB mass. CT may be a good method for diagnosing GBTB to identify the location and the size of the lesion, and the enhanced CT findings of GBTB are well correlated with the pathological features. In our case, CT scan was not done, because a clinical, ultrasound-based diagnosis of cholelithiasis was made with no suspicion of malignancy or TB. The treatment of GBTB is based on antitubercular chemotherapy, which is based on an attack treatment involving 2 months association with isoniazid (5 mg/kg), rifampicin (10 mg/kg), and pyrazinamide (25–30 mg/kg), followed by maintenance therapy for 4 months with isoniazid and rifampicin, and cholecystectomy when there are symptomatic gallstones. Because tuberculous cholecystitis is difficult to diagnose, all resected cholecystectomy specimens should be sent for histopathological examination for evidence of TB. Preoperative consideration for possible tubercular disease is imperative, because it might avoid surgery, as these cases can be managed medically.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]