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    CHOLECYSTITIS WITH CHOLELITHIASIS WITH TUBERCULAR PATHOLOGY: A CASE REPORT

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    IJAR JOURNAL
    An extremely uncommon condition that manifests as calculous or acalculous cholecystitis is gallbladder tuberculosis (GBTB). It is challenging to make an accurate preoperative diagnosis of GBTB, and this literature survey emphasizes that postcholecystectomy or postmortem diagnosis is the norm in the majority of patients. Although GBTB is a very rare condition, people from endemic areas who have risk factors including a history of tuberculosis or underlying immunosuppression should be suspected of

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    CHOLECYSTITIS WITH CHOLELITHIASIS WITH TUBERCULAR PATHOLOGY: A CASE REPORT

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    IJAR JOURNAL
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    An extremely uncommon condition that manifests as calculous or acalculous cholecystitis is gallbladder tuberculosis (GBTB). It is challenging to make an accurate preoperative diagnosis of GBTB, and this literature survey emphasizes that postcholecystectomy or postmortem diagnosis is the norm in the majority of patients. Although GBTB is a very rare condition, people from endemic areas who have risk factors including a history of tuberculosis or underlying immunosuppression should be suspected of

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    An extremely uncommon condition that manifests as calculous or acalculous cholecystitis is gallbladder tuberculosis (GBTB). It is challenging to make an accurate preoperative diagnosis of GBTB, and this literature survey emphasizes that postcholecystectomy or postmortem diagnosis is the norm in the majority of patients. Although GBTB is a very rare condition, people from endemic areas who have risk factors including a history of tuberculosis or underlying immunosuppression should be suspected of

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    © All Rights Reserved
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    Download as pdf or txt
    3 views4 pages

    CHOLECYSTITIS WITH CHOLELITHIASIS WITH TUBERCULAR PATHOLOGY: A CASE REPORT

    Uploaded by

    IJAR JOURNAL
    An extremely uncommon condition that manifests as calculous or acalculous cholecystitis is gallbladder tuberculosis (GBTB). It is challenging to make an accurate preoperative diagnosis of GBTB, and this literature survey emphasizes that postcholecystectomy or postmortem diagnosis is the norm in the majority of patients. Although GBTB is a very rare condition, people from endemic areas who have risk factors including a history of tuberculosis or underlying immunosuppression should be suspected of

    Copyright:

    © All Rights Reserved
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    of 4

    ISSN: 2320-5407 Int. J. Adv. Res.

    12(10), 1203-1206

    Journal Homepage: - www.journalijar.com

    Article DOI: 10.21474/IJAR01/19744


    DOI URL: http://dx.doi.org/10.21474/IJAR01/19744

    RESEARCH ARTICLE
    CHOLECYSTITIS WITH CHOLELITHIASIS WITH TUBERCULAR PATHOLOGY: A CASE REPORT

    Dr. Ayushi Arya (J.R)1, Dr. Ranjana (J.R)1 and Dr. Mohanvir Kaur2
    1. Junior Resident, Government Medical College, Patiala.
    2. Associate Professor, Government Medical College, Patiala.
    ……………………………………………………………………………………………………....
    Manuscript Info Abstract
    ……………………. ………………………………………………………………
    Manuscript History An extremely uncommon condition that manifests as calculous or
    Received: 27 August 2024 acalculous cholecystitis is gallbladder tuberculosis (GBTB). It is
    Final Accepted: 29 September 2024 challenging to make an accurate preoperative diagnosis of GBTB, and
    Published: October 2024 this literature survey emphasizes that postcholecystectomy or
    postmortem diagnosis is the norm in the majority of patients. Although
    Key words:-
    Gall Bladder (GB), Tuberculosis(TB), GBTB is a very rare condition, people from endemic areas who have
    Granulomatous inflammation risk factors including a history of tuberculosis or underlying
    immunosuppression should be suspected of having it. Since
    radiography lacks pathognomic features, gallbladder tuberculosis is
    only diagnosed through histology of the removed specimen. Here, we
    detail an extremely unique case of gallbladder tuberculosis that was
    unexpectedly discovered during histopathological examination.

    Copyright, IJAR, 2024,. All rights reserved.


    ……………………………………………………………………………………………………....
    Introduction:-
    Cholelithiasis with concomitant cholecystitis of the gallbladder is a prevalent diagnosis given to an individuals who
    arrives with complain of pain abdominal in the right upper quadrant[1]. Isolated tuberculosis (TB) of the gallbladder
    is highly unusual because of its intrinsic capacity to resist tuberculous infections, and the diagnosis of this disease is
    nearly usually brushed aside[2-3]. The most typical clinical manifestations include fever, nausea,
    vomiting, anaemia, anorexia, weight loss, and discomfort in the abdomen. Ultrasonography can identify gallstones,
    wall thickening, or a tumour inside the gallbladder[4]. Gall bladder TB was first described by Gaucher in 1870.
    Since then, different presentations have been documented and reported through independent case studies[5]. In this
    report, we have highlighted a case of an immunocompetent patient with symptomatic cholelithiasis, diagnosed as
    GBTB postcholecystectomy on histopathological examination.

    Case Report
    A 48 year old Male presented with history of on and off pain upper abdomen since 4-5 months, which was not
    associated with nausea, vomiting or fever. There is no history of jaundice, loss of appetite, weight loss or any
    chronic illness in the past. No history reported for Tuberculosis in patient or any family member.

    After taking a detailed clinical history, ultrasonography of the abdomen revealed thickened and edematous
    gallbladder wall measuring 10mm. There is seen ill defined hetero-echoic collection with maximum depth of 2.3mm
    likely organised in pericholecystic region. Also there is suggestive of an echogenic foci giving dark acoustic shadow
    measuring 8.8mm in neck suggestive of cholelithiasis.

    Corresponding Author:- Dr. Ayushi Arya (J.R)


    Address:- Government Medical College, Patiala. 1203
    ISSN: 2320-5407 Int. J. Adv. Res. 12(10), 1203-1206

    After USG Abdomen clinician proceeded for Magnetic Resonance cholangiography (Upper Abdomen) which
    concluded as complex chronic cholecystitis with cholelithiasis and significant surrounding adhesions with streak of
    loculated fluid in pericholecystic regim close to fundal aspect- Rule out Concealed GB Perforation.

    The patient underwent a routine laparoscopic cholecystectomy which was uneventful. GB specimen sent for
    histopathological examination.

    Gross:-
    Received a specimen of gall bladder measuring 6X3X1cm. External surface is irregular with papillary excrescenses.
    In fundus there is widened area noted measuring 3x3.5 cm. On cut section, a black coloured stone retrived and
    numerous chalky white areas extending to the peritoneal layer seen. The cavity is obliterated.

    Figure:- (a) Shows numerous chalky white areas and (b) Shows obliterated cavity on cut section.

    Microscopic Examination:-
     Section from representative areas show features of chronic cholecystitis.
     Sections from thickened multiple chalky white areas shows widening of peri-muscular subserosal connective
    tissue.
     There are seen numerous epitheloid cell granuloma with focal caseous necrosis and multinucleated giant cells
    and Langhans type giant cells.
     These granulomas are involving the peritonal (serosal layer).

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    ISSN: 2320-5407 Int. J. Adv. Res. 12(10), 1203-1206

    Figure. (c):- Figure. (d):-

    Figure. (e):- Figure. (f):-

    Above figures represent sections from post-cholecystectomy specimen showing multiple epithelioid granulomas,
    multinucleated Langhans type giant cells with caseous necrosis in low power 4x (figure c), 10x (figure d and e) and
    High power 40x (figure f).

    Discussion:-
    In developing countries, 10% of all cases of tuberculosis involve the abdomen; in contrast, GBTB accounts for 1%
    of cases of abdominal TB in places where the disease is prevalent [1,4]. Overall, the gallbladder itself has a strong
    resistant against tubercular infection, probably because of its inhibitory action of bile[6]. According to Sir BOA
    Moynihan, ‘ a gallstone is a tomb stone erected to the memory of the organism within it’ . The GB is exposed to
    infectious pathogens through the bloodstream or lymphatic circulation from a focus nearby. Streptococci, coli form,
    typhoid bacilli and actinomyces are the organisms that are commonly encountered in gallstones and GB having an
    aetiology of infection. Mycobacterium can also be an another possible explaination of cholelithiasis and/or
    cholecystitis, particularly when tuberculosis is spread out to the peritoneum and lymph nodes in the surrounding
    area[7]. The presence of stones is believed to have significant role. The very seldom tuberculous involvement of the
    GB might be perhaps because of hypovascularity of the GB sac and raised alkalinity of concentrated bile inside it for
    the development of the tuberculous infection in the present case[7,8]. Weitz (1955) has proposed the following
    classification of tuberculosis of the gall-bladder :-
    I. Miliary tuberculosis in children with ulcerating tubercles in the gall-bladder.
    2. Severe general tuberculosis in conjunction with gallbladder tuberculosis.
    3. Tuberculosis that is restricted to the gallbladder is often unintentionally found when examining extirpated
    gallbladders under a microscope.

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    ISSN: 2320-5407 Int. J. Adv. Res. 12(10), 1203-1206

    4. Involvement of the gallbladder in associated with TB in other peritoneal organs.


    According to the above classification this Case belong to group 3[8]. The two most significant risk factors for
    gallbladder tuberculosis development are thought to be cholelithiasis and obstruction of the cystic duct. The
    haematogenous pathway, nearby caseating lymph nodes, or peritoneal tubercles are the usual ways that the infection
    spreads. Gallstones is correlated in more than 70% of cases[9].

    Conclusion:-
    Gallbladder tuberculosis is an exceptionally unusual manifestation of abdominal TB. Preoperative diagnosis is not
    feasible due to a lack of accurate diagnostic tests; thus, a significant level of suspicion and more awareness are
    required. In our case, the most common cause of granulomatous inflammation of gall bladder is tuberculosis. When
    a patient has a gallbladder mass or uneven thickening of the gallbladder wall, TB should always be considered as a
    differential diagnosis. Therefore, all resected cholecystectomy specimens should be sent for histopathological
    analysis.

    Reference:-
    1) Mishra, Anurag; Gupta, Prateek; Verma, Nidhi1; Yadav, Surekha1. Tuberculosis of the Gallbladder: A Case
    Report and Review. MAMC Journal of Medical Sciences 3(1):p 45-47, Jan– Apr 2017.
    2) Valecha, Bhavna. (2019). A Rare Case Report of Granulomatous Inflammation of Gall Bladder with Review of
    Literature. Saudi Journal of Pathology and Microbiology. 04. 846-848.
    3) Chan KS, Shelat VG, Tan CH, Tang YL, Junnarkar SP. Isolated gallbladder tuberculosis mimicking acute
    cholecystitis: A case report. World J Gastrointest Surg. 2020 Mar 27;12(3):123-128. doi: 10.4240/wjgs.v12.i3.123.
    4) Sagar, Mala & Rawat, Shalini & Verma, Anuragini & Singh, Anurag & Singh, Uma Shankar. (2022). Gallbladder
    tuberculosis: A rare case report with review of literature. Indian Journal of Case Reports. 8. 311-313.
    5) Gupta A, Gupta A, Anjum R, Agrawal S, Mallik D. A comprehensive review on Primary gallbladder tuberculosis.
    Pol Przegl Chir. 2018 Apr 30;90(2):10-12.
    6) Yu R, Liu Y. Gallbladder tuberculosis: case report. Chin Med J (Engl). 2002 Aug;115(8):1259-61.
    7) Verma SK, Mishra AK, Jaiswal AK. Tuberculosis of gallbladder neck: a cause of cholecystitis with cholelithiasis.
    BMJ Case Rep. 2013 Feb 13;2013:bcr2012008007.
    8) Bergdahl L, Boquist L. Tuberculosis of the gall-bladder. Br J Surg 1972; 59: 289-292
    9) Lakhey P, Shreshtha ML, Sayami G, Khakurel MP. Gall bladder tuberculosis: A rare entity. J Inst Med
    2006;28:53-4.

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