Management of Dual Chambered Gallbladder with Apple Core Narrowing with Segmental Cholecystitis and Cholangitis from Choledocholithiasis

Abstract

Septated gallbladder is rare, when seen almost never have we seen an apple-core lesion with all the stones in one half of the gallbladder and none in the infundibulum but two in the bile duct. We present a case of a 58-year-old lady who presented with abdominal pain. She had normal vital signs except temperature of 100.2°F and right-upper-quadrant abdominal tenderness. Laboratory tests revealed, Total bilirubin of 1.4 mg/dl, Direct Bilirubin of 0.7 mg/dl, AST of 281 U/L, ALT of 367 U/L, ALP of 164 IU/L. Ultrasonography showed a Gallbladder wall of 3.6 mm, CBD diameter of 5 mm, and cholelithiasis. HIDA showed a visualization of the gallbladder in 60 min demonstrating patent cystic duct and later the duodenum. MR showed an apple-core like focal stricture in the midportion of the gallbladder with the distal half showing signs of inflammation, stones, and cholecystitis and a normal proximal gallbladder with normal extrahepatic bile ducts with no choledocholithiasis. She underwent Laparoscopic cholecystectomy with cholangiogram which demonstrated two CBD stones. One of them was removed with Lap trans-cystic-CBDE, later she needed ERCP to remove the other stone. She had a total of 6 days of hospital stay and had no future issues. Pathology did not reveal any malignancy. We demonstrate an unusual septated gallbladder with US, HIDA, MRI, and pathological correlation. An entity of partial chronic cholecystitis and choledocholithiasis should be considered in such a setting. Knowing the existence of apple-core lesion gallbladder should be helpful to manage rare presentation.