Indian Journal of Surgery, Vol. 67, No. 1, January-February, 2005, pp. 45-46
Tuberculosis of gall bladder without associated gall stones or cystic duct obstruction
Tanwani Rahul, Sharma Dhananjaya, Chandrakar Shiv Kumar
G-I Surgery Unit, Department of Surgery, Netaji Subhash Chandra Bose Government Medical College, Jabalpur - 482 003
Code Number: is05008
AbstractTuberculosis of the gall bladder, a rarity in itself, is always found associated with gallstones or cystic duct obstruction. The present case of tuberculosis of the gall bladder is being reported for its extreme rarity as it was without associated gallstones or cystic duct obstruction.
Keywords: Tuberculosis of the gall bladder, unusual presentation
An unusual case of tuberculosis of the gall bladder is being presented for its extreme rarity as it was not associated with gallstones or cystic duct obstruction.
A 30-year-old male patient presented with non-specific chronic abdominal pain for 2 years, with loss of appetite since one month. Past and family history was not significant. On clinical examination, apart from mild tenderness in the umbilical region, there was no other positive finding. On investigating, ultrasonography of abdomen showed enlarged lymph nodes at porta hepatis (44.3 x 27 mm), celiac (19.4 x 15 mm), pre splenic (68.6 x 41.8 mm) and right iliac fossa region (11.4 x 19.2 mm). Routine blood investigations, ESR, liver function tests, X-ray chest and plain X-ray abdomen did not show any abnormality. With an aim of taking biopsy from enlarged lymph nodes, the patient was explored by midline laparotomy under general anaesthesia. On exploration, multiple lymph nodes were found to be involved at different places, confirming the ultrasonographic findings. Liver, spleen and other viscera did not show any gross abnormality. Gall bladder wall thickness and serosal surface was normal but a hard nodule of 0.5 cm x 0.5 cm was palpable at the neck of the gall bladder, giving an impression of impacted stone in the neck. Biopsy was taken from the largest lymph node in the right iliac fossa region and cholecsytectomy was done. When the resected specimen was examined, it showed a gall bladder with normal thickness, normal cystic duct and normal serosal and mucosal surface. When the palpable nodule was sectioned, thick caseous material oozed out of it. Histopathological examination of the lymph node and gall bladder showed chronic granulomatous inflammation with presence of Langhan′s type of giant cells, suggestive of tubercular lymphadenitis and chronic tubercular cholecystitis [Figure - 1]. To rule out the possibility of immunodeficiency, he was subjected to ELISA test for Human Immunodeficiency Virus, which was negative. The postoperative period was uneventful and the patient was discharged on the 8th postoperative day on oral antitubercular drugs. The patient is asymptomatic after 6 months of regular follow-up.
Despite a high prevalence of tuberculosis of the gastrointestinal tract, tubercular involvement of the gall bladder is very rare, as only 41 cases were reported up to 1970. Rarity of tubercular involvement of the gall bladder has been attributed to the high alkalinity of bile and bile acid inhibiting the growth of tubercle bacillus. It has been suggested that cystic duct obstruction leads to the disappearance of bile acid from the gall bladder and therefore to a lowered resistance against this infection. Previous damage to the gall bladder due to gall stones seems to be a prerequisite for the development of tuberculous cholecystitis as almost all reported cases have coexistent gallstones. A search of the available literature revealed only two case reports of tubercular cholecystitis without associated gall stones or cystic/ common bile duct obstruction., But in both these cases there was per-operative evidence of adhesions around the gall bladder suggestive of chronic cholecystitis, while in our case there was no evidence of peri-cholecystic adhesions; the only abnormality was the hard nodule felt in the neck of the gall bladder. This case is being reported for its extreme rarity.
The problem of the diagnosis of tubercular involvement of the gall bladder is obvious as all the signs, symptoms and investigation are non-specific. Ironically, postoperative histopathological confirmation becomes the greatest tragedy of diagnosis because a condition that is curable medically has to follow surgery unavoidably.
Copyright 2005 - Indian Journal of Surgery
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