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ABDOMINAL IMAGING Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 2  |  Page : 237-238
Gall bladder tuberculosis presenting as a multiloculated cystic mass on CT


Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi-110029, India

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Keywords: Gall Bladder Tuberculosis (GBTB), Multiloculated cystic mass

How to cite this article:
Gulati M S, Seith A, Paul S B. Gall bladder tuberculosis presenting as a multiloculated cystic mass on CT. Indian J Radiol Imaging 2002;12:237-8

How to cite this URL:
Gulati M S, Seith A, Paul S B. Gall bladder tuberculosis presenting as a multiloculated cystic mass on CT. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Nov 17];12:237-8. Available from: http://www.ijri.org/text.asp?2002/12/2/237/28454

   Introduction Top


Tuberculosis (TB) of the gallbladder (GB) is rare. To date only about 50 cases have been reported [1],[2] with most of these being diagnosed only on histological examination after cholecystectomy. We report a case of gall bladder tuberculosis (GBTB) which was accidentally detected on CT scan in conjunction with adrenal TB in a patient of Addisons disease. We describe the unusual CT appearance of the gall bladder in this case with the tubercular aetiology being confirmed by an US guided fine needle aspiration cytology (FNAC).


   Case Report Top


A 60 year old woman presented with increasing weakness, anorexia and skin pigmentation of three months duration with mild right upper quadrant abdominal pain for one month. Clinical examination of the patient revealed wasting of the axial muscles with increased pigmentation over the elbows, hand creases and areolae. Abdominal examination revealed a mildly tender right hypochondrium without organomegaly. Investigations revealed relatively low blood glucose levels (62mg%), low early morning cortisol levels (3 microgm%) and high serum potassium (5.1 mEq/l) and ACTH levels. The chest radiograph revealed bilateral upper zone fibrotic parenchymal lesions and hilar adenopathy.

Contrast enhanced CT scan of the abdomen revealed bilateral enlarged adrenals. The right adrenal was the larger of the two and showed multiple necrotic areas with enhancing walls and incomplete internal septations [Figure - 1]. No adrenal calcification was demonstrable. In addition, there was a multi-loculated cystic mass with enhancing thickened walls and internal septations in the gallbladder fossa [Figure - 2]. The liver was normal and the biliary channels did not reveal any dilatation. No gallstones were identified on sonography or CT. Based on these imaging findings and keeping in mind the high incidence of TB in our region, a provisional diagnosis of bilateral adrenal TB along with probable involvement of the gallbladder was made. Ultrasound guided fine needle aspiration biopsy of the right adrenal and from the thickened septae in the gallbladder was performed each of which revealed caseating granulomas and presence of acid-fast-bacilli confirming the diagnosis of TB.


   Discussion Top


The world-wide estimation of infectious TB is about 15-20 million cases [3]. It is especially rampant in the developing and the underdeveloped parts of the world. Despite this massive prevalence of TB only about 50 cases of GBTB have been reported in the literature so far. The normal GB is highly resistant to tubercular infection. Presence of inhibitory factors in the bile is reported to be responsible for this special resistance [1]. The presence of an underlying pathology in the form of cholelithiasis or cystic duct obstruction is said to be essential for the development of GBTB [1],[2].

Four types of GBTB have been described. A) Miliary TB in children with ulcerating tubercles in the gallbladder. B) GBTB in association with severe generalized TB. C) isolated GBTB. D) Gallbladder involvement in association with TB in other intra peritoneal organs [1]. The fourth group is said to be the commonest type [2]. Our case belonged to the second type because of the presence of TB in the adrenals and in the lungs. The route of infection in GBTB can be canalicular, lymphatic or hematogenous [1],[4].

The clinical presentation is often vague and non-specific. Anorexia, fever, weight loss, abdominal pain, diarrhoea with or without jaundice has been described [1],[2],[4].The notable feature in our case was the Addisonian presentation accompanied by a vague right upper quadrant pain in the absence of any biliary symptoms.

Imaging morphology of GBTB has rarely been described. GB with abnormally thickened walls with underlying cholelithiasis has been described in the available surgical reports [1]. Jain et al have reported a case wherein the GB was enlarged with thickened walls, presence of gallstones and an intraluminal mass simulating a GB carcinoma was present [4].A dilated GB with a large stone located in the neck simulating acute cholecystitis has also been reported [5]. Presence of features like portal, mesenteric and retroperitoneal adenopathy, mesenteric thickening and ascites if present favour the diagnosis of TB [4],[5]. None of these hitherto described features were present in our case who presented with enlarged necrotic adrenal masses. To the best of our knowledge a similar CT appearance of multiloculated, thick walled GB as seen in our patient, has not been previously described. It also emphasises the not so uncommon multi-organ involvement and atypical presentation of TB.

In conclusion we emphasise that GBTB has no pathognomonic diagnostic imaging features. Few descriptions of its imaging morphology show that it can mimic acute cholecystitis [5], Chronic cholecystitis[1] and a GB mass[4]. Our case report aims to add to the existing spectrum this appearance of a multi loculated thick walled GB. We also highlight the role of FNAC/aspiration to confirm the diagnosis.

 
   References Top

1.Bergdahl L, Boquist L. Tuberculosis of gallbladder. Br. J Surg 1972; 59:289-292.  Back to cited text no. 1    
2.Abasca J, Martin F, Abreu I et al . Atypical hepatic tuberculosis presenting as obstructive jaundice. Am J Gastro Enterol 1985; 83:1183-1186.  Back to cited text no. 2    
3.Park K. Tuberculosis. In: K Park. Park's Textbook of preventive and social medicine. Jabalpur: M/s Banarsidas Bhanot. 1997:138-151.  Back to cited text no. 3    
4.Jain R, Sawhney S, Bhargava D, Berry M. Gallbladder tuberculosis: sonogrphic appearance J. Clin Ultrasound 1995; 23:327-329.  Back to cited text no. 4    
5.Abu-Zidane F. M, Zayat I. Gallbladder tuberculosis (a case report and a review of the literature) Hepatogastroentrol 1999, 46(29):2804-6.  Back to cited text no. 5    

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Correspondence Address:
M S Gulati
Assistant Professor of Radiodiagnosis (AIIMS), B-3/185, Janak Puri, New Delhi-110 058
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2]

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