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ACUTE TUBERCULOUS CHOLECYSTITIS
M Faria, J Wani, R Ravishankar, S Desai, CH Kale
Dept. of Surgery, Rajawadi Municipal Hospital, Ghatkopar, Mumbai 400 077.
Tuberculosis of the gallbladder commonly occurs in women over the age of 30 years. Gallstones are often mociated with this lesion. Tuberculosis of the gallbladder has been described with or without other tuberculous lesions in approximately the same proportions. The common symptoms are similar to cholecystitis which is the most common preoperative diagnosis with the diagnosis of tuberculosis being made only after surgery or the histopathology report.Tuberculosis of the gallbladder is much rarer than local tuberculosis of the liver. Historically a case has been described by Lancereaux [2] . It has been observed that the clinical presentation of tuberculosis of the gallbladder is indistinguishable from that of cholecystitis, and tuberculosis is often associated with gall stones. The following case clearly illuminates this point.
CASE REPORT
KT a 50 year housewife was admitted with a long standing history of colicky right hypochondrium pain, radiating to the right shoulder, increasing after meals and associated with bilious vomiting. There was no history of clay coloured stools' jaundice, fever with chills, itching, haernatemesis or melaena. The patient had no history suggestive of tuberculosis like loss of weight, evening rise of temperature, chronic pulmonary complaints or any history of Koch's contact. On examination there was tenderness in the right hypochondrium, the liver was just palpable but the gallbladder was not felt. No other abnormality was found. The patient's routine biochemical reports were all normal with the ESR being 20 min. at I hr. Her X-ray chest was normal and the ultrasound examination of the liver showed normal liver architecture with the gall bladder showing multiple echogenic shadows with acoustic shadowing suggestive of gallbladder calculi and the common bile duct showing dilatation with calculi seen at the lower end. An ERCP was done showing normal common bile duct, hepatic duct and pancreatic duct with the absence of any stones or strictures. A diagnosis of gallstones was made and the patient was taken for surgery.
On exploration it was found that the gallbladder was inflamed, enlarged with the presence of multiple gall stones while the liver, common bile duct and the rest of the intraabdominal organs were normal. A cholecystectomy was done, and the specimen was sent for histopathology.
On gross examination the gallbladder was enlarged and inflamed with necrotic areas with the draining lymph nodes showing caseation. The slides showed that the gallbladder mucosa was eroded with marked necrosis of the thickened wall with tuberculous inflammation.
Subsequently the patient was put on anti-tuberculosis drugs. Presently six month later, the patient is symptom free and has gained weight.
DISCUSSION
The pathogenesis of gallbladder tuberculosis is unsettled as this complication seldom occurs in patients suffering from acute or chronic tuberculosis at any site. In most of these cases, the duodenal aspirate is free from bacilli. Attempts by Walters[6] to produce characteristic lesions in the gallbladder by the inoculation of tuberculous bacilli failed except in those cases where there was a previous lesion of the organ or ligation of the choledochal duct.
Most of the cases described were associated with calculous cholecystitis, some were associated with localized or generalized tuberculous peritonitis in which the lymph channels were held responsible for spread to the gallbladder while others after examination showed no tuberculous lesion in any other organ thus being labelled as of primary origin.[4]
Histologically the lesion may be in the form of a localized ulceration4 or there may be typical tuberculous nodules in the wall of varying size and number.[1] , [7]
Pain after meals, nausea, diarrhoea, fever and the presence of a tender lump in the right hypochondrium [3] are the most common symptoms. Jaundice is not frequent. Diagnosis is, therefore difficult and the aetiology of the cholecystitis sometimes passes unnoticed even in case of patients undergoing operation whose operative wound usually fistulizes, it being only then that the existence of tuberculosis is discovered.[3]
A diagnosis of tuberculous cholecystitis mandates cholecystectomy. Cholecystostomy checks only the immediate risk, but may result in a chronic fistula and hence is not advisable.
REFERENCES
1. Gonzalez GR. Tuberculosis de la vasicula biliar. Rev Aled de Chile 1943; 71 : 694-6.
2. Lancereaux E. Atlas d'anatomic pathologique, Victor Masson et Fils, Paris. 1871; 70.
3. Lazarus IA, Eisenberg AA. Tuberculosis of the gall bladder, a report of a case of primary tuberculous cholecystitis. Am J Surg 1934; 24 : 166-7 .
4. Simmonds M. Ueber Gal lenbl asent uberku lose, Centralbi. F AlIg Path U Path Anat 1908; 19: 225-6.
5. Vallejo EA. Acute tuberculous cholecystitis. Gastroenterology 1950; 16 :501-4.
6. Walters W, Church GT. Primary tuberculosis of the gall bladder, Minnesota Med. 1934; 17 : 580.
7. Walters and Snell. Diseases of the Gall Bladder and Bile Ducts, Philadelphia. 1948.
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