Diagnosis and treatment of duplication of the gall bladder.

DUPLICATION of the gall iblader is 'a rare anomaly, Boyden (1926) finding two cases following 9,221 autopsies and a further three after review of 9,970 cholecystograms. Although it is a welldoicumen'ted abnormiality with over one hundred examples descriibed, the majority of these have been diagnosed only 'by radiological methods as the patienlts were not referred for surgery, (Golob and Kantor, 1942; Ragalb and El-Ghaffer, 1951; Hemmati, 1963). The number of instances diagnosed pre-operattively, confirmed at lapardtomy and subsequenitly examined pathologically, appear to ebe seven. iIn six of these cases, symptoms were directly attributaible to disease in one or both of the gall-bladders as stones were presen't in alt least one of the vesicles in all cases (Table 1). The seventth case, that 'of Oldfield and Wriight i(1950) is excluded as the authors were of the opinion that the most likely diagnosis in their case was acute appendicitis and that in retrospect 'the 'symptoms were not referable to the duplicated gall 'bladder. Furthermore, the cholecystogram showed two normally functioning gaill ibladders, post-operative examination revealed no stones and mnicroscopic examination did not suggest previous acute inflammatory disease in either gall bladder. The purpose of this paper is to descrilbe a further example of duplication. Case Report Female. Aged 58. History: Originally investigated in 1962 for episodic epigastric pain by 'barium meal examination which was normal. Although a straight X-ray of the abdomen showed gall stones '(Fig. 1) further investigation of the biliary system was not carried out. In 1965 following further attacks of epigastric pain, none of which was associated with jaundice, an intravenous cholangiogram was performed which showed a double, gall 'bladder with stones in both organs and calculi:in both cystic ducts (Fig. 2). One gall bladder contained predominantly facetted stones whilst the other was filled mainly with "limey bile". Apart from mild epigastric tenderness, no abnormality was found on examination. Operation: '(By Professor Le Quesne on 12.4.65). The abdomen was opened through a right subcostal incision and duplication was confirmed. The two gall bladders were intimately 'bound together by a common peritoneal covering and two cystic ducts were traced and seen to enter the common bile duct separately. The cystic artery, which was a branch of the common hepatic artery, passed anterior to the common bile duct before dividing into two. The anatomy of this case is identical to that of Cameron (1952). Stones were readily palpable in FIG '1.-Plain X-ray of the right hypochondrium showing 'facetted stones in the upper gall bladder and limey bile in the 'lower vesicle. In addition two separa'te shadows are seen and these were interpreted as stones impac'ted in each cystic duct.