Concomitant functional gallbladder disorder and left-sided gallbladder: A case report

Abstract

BACKGROUND

Ectopic gallbladder, occurring in 0.1% to 0.7% of the population, is rarely found in the left liver lobe without situs inversus totalis. Functional gallbladder disorder (FGBD), characterized by biliary pain without stones or sludge, affects 8% of men and 21% of women. No prior cases of concomitant FGBD and left-sided gallbladder have been reported, posing diagnostic and surgical challenges.

CASE SUMMARY

A 73-year-old woman with a 20-year history of epigastric pain was diagnosed with a left-sided gallbladder and FGBD based on imaging findings and impaired gallbladder contraction. Laparoscopic cholecystectomy was performed and confirmed the ectopic gallbladder adherent to the left liver lobe. Postoperative pathology revealed no abnormalities, and the patient achieved complete symptom resolution at three-month follow-up.

CONCLUSION

This is the first reported case of FGBD with a left-sided gallbladder. Preoperative imaging, such as magnetic resonance cholangiopancreatography or computed tomography, is crucial for identifying anatomical variations of the gallbladder. Laparoscopic cholecystectomy is feasible but requires careful planning to avoid complications.

Key Words: Ectopic gallbladder; Functional gallbladder disorder; Abdominal pain; Laparoscopic cholecystectomy; Gallbladder anatomical variation; Case report

Core Tip: This first-documented case describes a 73-year-old woman with two concurrent diagnoses: Functional gallbladder disorder and left-sided gallbladder, presenting with 20-year epigastric pain. Preoperative magnetic resonance imaging and computed tomography imaging were pivotal in identifying the ectopic gallbladder adherent to the left hepatic lobe. Laparoscopic cholecystectomy successfully resolved symptoms despite anatomical complexity, with postoperative pathology confirming absence of stones, sludge, or inflammation. The case highlights the necessity of advanced preoperative imaging (e.g., magnetic resonance pancreatography) to map biliary anatomy and guide surgical strategies in ectopic gallbladder cases. Clinicians should consider dual gallbladder pathologies in chronic abdominal pain and prioritize laparoscopic approaches with intraoperative flexibility to mitigate bile duct injury risks.

INTRODUCTION

The gallbladder is typically located in the gallbladder fossa on the posterior aspect of the right lobe of the liver. When the gallbladder is found in other locations, it is defined as ectopic. The incidence of ectopic gallbladder is approximately 0.1% to 0.7%[1]. The main positional variations include: (1) Under the left liver lobe; (2) Intrahepatic; (3) Transverse; (4) Retroplaced (retrohepatic or retroperitoneal); and (5) Floating[1,2]. Among these, cases of gallbladder located in the left lobe of the liver without situs inversus totalis are exceedingly rare[3].

The presence of an ectopic gallbladder, particularly in cases where it is left-sided, can complicate both diagnosis and management. The abnormal positioning of the gallbladder may contribute to motility dysfunction, potentially leading to functional gallbladder disorder (FGBD). FGBD is characterized by biliary pain in patients with an intact gallbladder and the absence of stones or sludge[4]. The prevalence of FGBD is approximately 8% in men and 21% in women[5]. FGBD is now listed as an indication for cholecystectomy in 10%-20% of adults[6], although it is rarely diagnosed outside the United States[7].

To date, there have been no reported cases of concomitant FGBD and left-sided gallbladder. Both conditions can cause abdominal pain, making it difficult to differentiate them from other diseases. Additionally, due to the anatomical ectopia of the gallbladder, surgical challenges may arise during cholecystectomy, potentially resulting in injury to the bile ducts or blood vessels. Therefore, this case report aimed to provide a reference and insights for the diagnosis and treatment concomitant FGBD and left-sided gallbladder.

CASE PRESENTATION

Chief complaints

A 73-year-old woman presented with intermittent epigastric colicky pain for over 20 years, without any other associated symptoms.

History of present illness

The patient had experienced intermittent epigastric colicky pain for more than two decades.

History of past illness

The patient had a history of well-controlled hypertension for 5 years and no prior surgical interventions.

Personal and family history

No special personal or family history of diseases was mentioned by the patient.

Physical examination

Mild tenderness was noted in the upper abdomen. No rebound tenderness was found. No jaundice was observed in the skin or sclera.

Laboratory examinations

Laboratory tests showed normal levels of inflammatory markers, liver enzymes, conjugated bilirubin, and amylase/lipase.

Imaging examinations

Computed tomography (CT scan showed that the gallbladder was located below the ligamentum teres hepatis, with a suspected attachment to the left lobe of the liver (Figure 1). Abdominal ultrasonography revealed no abnormalities in the liver, bile ducts, gallbladder, pancreas, or spleen. Endoscopic ultrasound (EUS) revealed chronic superficial gastritis, but no gallstones or extrahepatic biliary dilation was detected. Fatty meal-stimulated, ultrasound-guided gallbladder emptying tests were conducted twice, confirming impaired gallbladder contraction (Figure 2). A meal consisting of 40 g of fat was administered, and ultrasound imaging was conducted 60-90 minutes postprandially to assess gallbladder contraction. An ejection fraction (GBEF) of less than 35% was considered indicative of impaired gallbladder motility, which further supported the diagnosis of FGBD in this patient.

Figure 1 Abdominal computed tomography revealed suspected ectopic gallbladder. A-D: Abdominal computed tomography revealed the gallbladder located below the round ligament of the liver, with a suspected attachment to the left lobe of the liver.

Figure 2 Fatty meal-stimulated, ultrasound-guided gallbladder emptying test revealed impaired gallbladder contraction. A: Gallbladder was measured 8.1 cm × 4.8 cm × 4.6 cm before fatty meal; B: After 60 minutes, the gallbladder was 8.3 cm × 5.2 cm × 4.5 cm; C: To confirm the accuracy the test was repeated in the second day. At that time the gallbladder measured 8.0 cm × 4.4 cm × 4.3 cm before the fatty meal; D: 90 minutes after the meal, the gallbladder was 7.9 cm × 4.2 cm × 4.4 cm.

FINAL DIAGNOSIS

The patient was diagnosed with FGBD and left-sided ectopic gallbladder.

TREATMENT

Considering the presence of FGBD and potential gallbladder ectopia, laparoscopic cholecystectomy was performed. Intraoperatively, the majority of the gallbladder was found adhering to the left lateral lobe of the liver, with a small portion attached to the ligamentum teres hepatis. The common hepatic duct and common bile duct were located below the ligamentum teres hepatis (Figure 3). Following the surgery, an anatomical examination of the excised gallbladder revealed dark green bile with a uniform texture. No stones or sludge were observed, and the pathological report indicated no significant pathological changes in the gallbladder (Figure 4).

Figure 3 Left-sided gallbladder was confirmed during the operation. A: After performing laparoscopic exploration in the abdomen, we discovered that the gallbladder was located below the ligamentum teres hepatis and left lateral lobe of the liver; B: We performed decompression of the gallbladder in order to visualize the boundaries of the gallbladder clearly. As a result, we observed that the majority of the gallbladder was attached to the left lateral lobe of the liver, with a smaller portion attached to the ligamentum teres.(The dashed line in the figure is the dividing line between the gallbladder and the round ligament of the liver); C: After dissecting the triangle of Calot, we found no abnormalities in the cystic duct, common hepatic duct, or common bile duct; D: Following gallbladder removal, we confirmed that the gallbladder bed was located on the left lateral lobe of the liver.

Figure 4 Pathology showed the thickness of the gallbladder wall was 0.1-0.2 cm. The gallbladder was grayish-white, the mucosal surface was dark green, the mucosal surface was smooth, and the folds were visible. No significant abnormal pathological findings were found (hematoxylin-eosin staining, × 100).

OUTCOME AND FOLLOW-UP

The patient was discharged on the fifth postoperative day with significant relief of abdominal pain. After three months of follow-up, the patient's symptoms completely resolved (Supplementary Figure 1).

DISCUSSION

The incidence of variations in the cystic duct in patients with ectopic gallbladders ranges from approximately 18% to 23%[8]. To avoid inadvertent injury during surgery, several important considerations should be taken into account during the perioperative management of such patients: (1) Preoperative imaging should be used to assess for any cystic duct variations, as this is crucial in preventing bile duct injury during the surgical procedure; (2) Once laparoscopic access is established, if an ectopic gallbladder is identified, the position of the trocar should be adjusted promptly and flexibly to ensure the surgeon can comfortably and efficiently access the target area (Figure 5); and (3) The anatomy of the gallbladder triangle in these patients may differ from that of typical cases, so during dissection, it is essential to confirm the position of the cystic duct. Dissection should proceed along the cystic duct toward the common bile duct, exposing the junction of the cystic duct, common hepatic duct, and common bile duct. Additionally, at least one-third of the gallbladder bed should be dissected further to ensure adequate exposure.

Figure 5 During surgery, a 10 mm trocar was initially inserted at the navel for observation. Upon observing the left-sided gallbladder, a second 10 mm trocar was inserted at the midline of the left clavicle, 3 cm below the left costal margin. A 5 mm trocar was inserted at the right anterior axillary line, 3 cm below the right costal margin.

In our case, a gallbladder emptying test using ultrasound after fatty meal stimulation was applied to assess gallbladder motility. Although this non-invasive test is valuable and practical in clinical settings, its diagnostic accuracy remains limited due to the lack of standardized protocols regarding timing, meal composition, and criteria for abnormal contraction. These limitations may reduce the reproducibility and diagnostic confidence of the test. Therefore, while useful in selected cases, particularly when hepatobiliary iminodiacetic acid scans are not feasible, this approach should be interpreted cautiously and ideally complemented by other clinical and imaging findings. It is worth noting that the patient presented with ectopic gallbladder and FGBD concomitantly, both of which can contribute to abdominal pain. Guerin et al[1] referred to the possibility of ectopic gallbladder herniation into the foramen of Winslow, particularly when prompted by nearby peristaltic bowel movements, which may predispose it to torsion. This condition can potentially lead to abdominal pain caused by torsion-related biliary obstruction.

Additionally, functional gallbladder disease can also cause abdominal pain, which may arise from increased gallbladder pressure due to either structural or functional outflow obstruction[5]. Velanovich[9] and Brugge et al[10] reported increased crystal formation in the bile or gallbladder walls in patients with functional biliary pain who had undergone cholecystectomy, suggesting that bile saturation or gallbladder dysmotility may result in crystal growth, eventually leading to gallstones or chronic inflammation. Studies have also found an association between microlithiasis and a delayed GBEF on scintigraphy[11]. However, in the present case, the absence of bile sludge and crystals in the patient's bile raises the question of whether she had sphincter of Oddi dysfunction[12]. Therefore, further examination is needed to clarify this question. While we did not perform endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry preoperatively, we retrospectively recognize the potential value of this approach, especially in patients with persistent or unclear symptoms. However, ERCP is an invasive procedure associated with non-negligible risks, and in the absence of elevated liver enzymes or biliary dilation, its diagnostic yield is relatively low. Thus, a careful risk-benefit assessment should be made before considering ERCP with manometry in suspected sphincter of Oddi disorders cases.

Furthermore, the postoperative pathological examination did not reveal any definitive abnormalities. Therefore, further research is needed to investigate whether there are neurologically related functional disorders in the patient's gallbladder.

CONCLUSION

We report the first case of FGBD combined with a left-sided gallbladder. Up till now, there has been limited experience in the diagnosis and treatment of such cases. We believe that such patients often seek medical attention due to upper abdominal pain. Therefore, before considering the possibility of FGBD and gallbladder ectopia, it is crucial to rule out other abdominal organ diseases that may cause pain, such as upper gastrointestinal ulcers or perforations. Furthermore, it is essential to develop appropriate preoperative plans to address different variations that may occur during surgery to minimize the risk of surgical-related injury to the bile ducts and blood vessels. Thus, doctors should make the best use of imaging examinations to recognize variations in the gallbladder, cystic duct, and extrahepatic bile ducts preoperatively. Recommended examinations include magnetic resonance pancreatography, ERCP, and CT, among others. Lastly, high-resolution laparoscopy can provide clear visualization of anatomical abnormalities in the patient. Therefore, laparoscopic surgery should be considered a feasible option whenever possible. However, blind puncture must be avoided to minimize the risk of iatrogenic organ injury.