Abdominal tuberculosis is common in developing countries, but gall bladder involvement is extremely rare. The diagnosis of gall bladder tuberculosis is often not suspected prior to surgery or a biopsy. This paper presents a case of gall bladder tuberculosis in a 40-year-old female, who presented with clinical features of chronic cholecystitis. Abdominal ultrasound showed a dilated gall bladder with multiple gall stones located in the fundus, with no other appreciable features. The patient had a retrograde open cholecystectomy and treated with antitubercular drugs. The literature on this topic is reviewed. Keywords: Gall bladder, granulomatous cholecystitis, tuberculosis
The incidence of abdominal tuberculosis is increasing and the familiarity with its clinical presentation shortens its diagnostic time and improves its management. With the rise of HIV/AIDS globally, the problem has increased manifold. However, gall bladder tuberculosis is uncommon and rare, with only 50 cases reported in the literature till 2003. [1] Here, we present a case of gall bladder tuberculosis in a 40-year-old female patient and reviews the literature of gall bladder tuberculosis.
A 40-year-old female presented with intermittent pain in the right upper quadrant associated with fatty meal intolerance for 2 months. No fever, sweating, or weight loss was reported. She denied any history of hepatitis or tuberculosis. Physical examination was entirely normal apart from a slight tenderness in the right upper quadrant. There was no evidence of icterus, lymphadenopathy, or hepatosplenomegaly. Haemogram and liver function tests were normal except for elevated ESR and positive tuberculin test. Chest roentgenogram was also normal. Abdominal ultrasonography showed cholelithiasis and minimal wall thickening. With the diagnosis of symptomatic cholelithiasis, the patient underwent elective open cholecystectomy. The gall bladder was partially adhered to the omentum and colon, with its thick wall making anatomy difficult in the Calot’s triangle. Retrograde cholecystectomy was done and postoperative recovery was uneventful. Pathological findings: grossly the gall bladder measured 8 x 3.5 cm in size with 1.0 cm of wall thickness. The serosal surface was focally dull and congested. Mucosa was predominantly bile stained with focal areas of yellowish discoloration. Multiple multifaceted stones were recovered. Microscopic examination revealed granulomatous inflammation with langhan’s giant cells and caseation [Figure 1]. Acid fast bacilli could not be demonstrated in our case.
Gastrointestinal tuberculosis is commonly seen in the form of tuberculous peritonitis or involvement of the abdominal lymph nodes. Gall bladder tuberculosis is very rare worldwide, with only 50 cases reported in the literature till 2003. [1] Generally speaking, the gall bladder mucosa is highly resistant to tubercular infection, possibly due to the inhibitory effect of concentrated bile acids in the gall bladder lumen. [1],[2],[3] Cholelithiasis and cystic duct obstruction are considered the most important factors in the development of gall bladder tuberculosis. [3],[4],[5] The infection usually spreads via the hematogenous route or from adjacent caseating lymph nodes or peritoneal tubercles. [2],[3],[6] Gall bladder tuberculosis occurs most commonly in women over 30 years of age [3],[4] and cholelithiasis is associated in more than 70% of cases. [1] Quite similarly, our patient was a 40-year-old lady with cholelithiasis. Clinical presentation is variable and includes features of chronic cholecystitis, carcinoma gall bladder, and non-specific systemic symptoms. [1],[2] Essop et al. [7] reported that liver enzymes were elevated in more than 60% of their patients with tuberculous involvement of liver. However, our patient had normal liver function tests. Sonographic and CT findings of gall bladder tuberculosis, such as an enlarged gall bladder, thickened gall bladder wall, soft tissue masses, and intrahepatic bilomas are non-specific, and the diagnosis is usually made on the basis of histological examination. [2],[3],[6]
Source of Support: None, Conflict of Interest: None
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