The Amazing Invisible Gallbladder

December 27, 2007 7:45 AM

I know you aren't my doctor (or even my mother's doctor), but if you *a* doctor can you please help me connect these dots regarding a gallbladder?

My mother was admitted to the hospital last night, after months of increasing abdominal pain and other GI symptoms. She has never had her gallbladder surgically removed. I can say absolutely firsthand that it has not been removed in the past fifteen years since I have been directly involved in her medical care, and if it had been removed prior to that there would be a very visible scar. In the past month she has had two ultrasounds, two CT scans, a HIDA scan, and several x-rays. None of them have been able to see the gallbladder, although the tests do consistently show an enlarged common bile duct. Frankly, some of the doctors have basically treated my mother like she is stupid, and just doesn't remember having her gallbladder removed, but that's just not the kind of thing that a person would forget, and in any case she has never had to be on any kind of modified diet (spicy foods to not bother her, etc.). Apparently, though, the blood tests do not show any signs of a distressed gallbladder.

I am currently waiting for the hospital doctor to come by on rounds, and hopefully he will be able to answer my question, but in the meantime can anyone explain to my how to reconcile never having the gallbladder removed, but also having it not appear in any diagnostic test? On the one hand I don't want to be an unreasonbly difficult patient's advocate, but on the other hand I just can't stand by and watch my mother get worse and worse while the doctors seem to be doing nothing of substance to help her....

posted by Lokheed to health & fitness (11 comments total)

Medical anomaly?

Of course Occam's razor dictates that it is absent for other reasons.
posted by i_am_a_Jedi at 8:00 AM on December 27, 2007

Agenesis Of The Gall Bladder And Cystic Duct

Abstract
Congenital absence of gall bladder is a very rare but well recognised congenital abnormality, the reported incidence ranging between 0.01 and 0.05%. To our knowledge, this is the 1st case reported from UK that was diagnosed by imaging modalities avoiding laparotomy. Laparoscopic cholecystectomy was attempted on a suspected case of chronic cholecystitis and was found to have congenital absence of gall bladder and cystic duct. The diagnosis was confirmed by CT Scan and ERCP post operatively. Standard investigations for chronic cholecystitis are misleading. Agenesis of gall bladder should be highly suspected whenever the gall bladder is not visualised on ultrasonography or at laparoscopy done on misinterpreted ultrasound. If the gall bladder is not seen at laparoscopy, further procedure should be avoided and agenesis should be confirmed by a combination of imaging modalities namely CT Scan, MRCP, laparoscopic or endoscopic ultrasound, if available. If the gall bladder is not visualised at preoperative ultrasound a combination of above imaging modalities should be used for diagnosis without recourse to laparoscopy / laparotomy.
posted by jamjam at 8:05 AM on December 27, 2007

Um, Occam's razor actually dictates that it is absent for precisely that reason. The obvious explanation if the gallbladder was never removed is that the gallbladder was never there. How is that contra-indicated by Occam's razor?

I have a friend whose son has only one kidney. No kidney was ever removed. Occam's razor does not indicate that the missing kidney was removed by aliens. Rather, it never developed (even though not developing a normal organ is very rare).
posted by TeatimeGrommit at 8:47 AM on December 27, 2007

Frankly, some of the doctors have basically treated my mother like she is stupid, and just doesn't remember having her gallbladder removed, but that's just not the kind of thing that a person would forget, and in any case she has never had to be on any kind of modified diet (spicy foods to not bother her, etc.). Apparently, though, the blood tests do not show any signs of a distressed gallbladder.

I'm not a doctor. But I did just have my gallbladder removed, and I have played the role of patient advocate when my mom was going through testing and eventual surgery for colon cancer, so I do totally feel your pain.

Stay calm and composed with the doctors, but have your list of questions ready. Carry a notebook in case you think of something to ask. Yeah, sometimes they'll be incredibly condescending and it's incredibly frustrating. Take a deep breath, take the high road, don't accuse them of not caring or being incompetent -- that's no way to convince them that this gallbladder wasn't a "forgotten" surgery. (How do they explain the lack of scar, though?)

You have two issues here: the missing gallbladder, and what the heck is causing her symptoms. As linked upthread, she could just never have had a gallbladder. Another possibility is that it was removed during some other surgical procedure and it wasn't really made clear to her that multiple procedures were done. Has she had any previous major abdominal surgery? How complete are her records?

There are an awful lot of things that can cause GI issues besides gallbladder. I'm no medical expert, but I did do a TON of research to calm myself when I was freaking out about my own surgery, so from an overeducated laypersons point-of-view, I would wonder if she had stones in the bile duct...but that would be reflected in the bloodwork. Here's a site explaining liver function tests. Here's another site explaining all kinds of lab tests.

As excruciating as it is to wait, it's no use asking them to wildly speculate, though it is fair to ask when they think they will have enough information to move forward with a diagnosis. Remember that they're not doing "nothing" though -- they're monitoring her, which is a significant part of forming any kind of diagnosis.

FYI, just so you have your story straight, if she had had gallbladder surgery, there wouldn't be any permanent dietary restrictions. And even the temporary restrictions have nothing to do with spiciness -- it's fat that's the issue.
posted by desuetude at 8:48 AM on December 27, 2007

Interesting, I will definitely ask about agenisis. Of course, it feels more than a bit hypochondriacal for me to essentially say, "hey doc, I know you went to medical school whereas I know virtually nothing about anatomy, but I spent a few hours on the internet this morning and came up with an extremely rare diagnosis....". I am pretty sure I can come up with a better way to phrase the question. In any case, really I am just trying to grasp how to make sense of apparently conflicting test data, so this helps.

In terms of abdominal surgery, she had her appendix out forty years ago when she was pregnant with me, and she actually did call that hospital to find out for sure if they had somehow removed her gallbladder as well without her realizing it. The records of that surgery show that the only thing done was the appendectomy. She also had a hysterectomy several years later, but they went nowhere near her gallbladder then.

I am off to the hospital again now, to see if any new information has emerged.
posted by Lokheed at 8:59 AM on December 27, 2007

The thing you need to find out from the doctors is this: Will their treatment of her symptoms differ significantly if she has a (well-hidden) gall bladder, or if she is missing one (through natural or artificial means)? If not, then you can table the mystery for now and just get her better. If it will be different, then they need to establish beyond all doubt that there is no gall bladder. I don't know what tests they run for that, but I'm sure there must be something they can do.

(Could she have had it removed as a very young child, and just not remember the whole event?)
posted by happyturtle at 9:31 AM on December 27, 2007

As I alluded to upthread, a physician would almost automatically presume (especially if that physician has never personally encountered the patient before) that the patient is either a poor historian (many many patients fit this bill) or that they were never made aware of their cholecystectomy that occured during a previous intra-abdominal surgical adventure. Given the rarity of gallbladder agenesis (especially compared against the relative commoness of unilateral renal agenesis - given as an example upthread) common sense and Occam's Razor both dictate that the patient's gallbladder is missing due to iatrogenic and not embryologic causes.
posted by i_am_a_Jedi at 10:44 AM on December 27, 2007

Well, the current verdict is that all of her symptoms point to a problem with the gallbladder. The fact that it does not show up on any of the diagnostic imagery can be explained my it having become calcified, which apparently would make it essentially invisible to the scans that have been done. The doctor has decided that the next step is to go in laporoscopically and actually look directly at what is going on in there, and if necessary to remove the gallbladder. Obviously if they go in and they *still* can't see a gallbladder, then all bets are off and we need to find another cause for all of her symptoms. Nothing surgically is going to happen today, but perhaps tomorrow we will know something more concrete.
posted by Lokheed at 10:44 AM on December 27, 2007

Note: the above diagnosis is my paraphrasing what the doctor said, to the best of my understanding. I am most certainly not a doctor, and I have no reason to doubt what he said even if I don't properly understand it.
posted by Lokheed at 10:47 AM on December 27, 2007

Good luck to your mom! Laparoscopic surgery is really miraculous. Here's hoping the simplest answer is the right one, because if it is her gallbladder, she's going to feel SO much better when it's removed -- she'll be a new woman. My AskMe about my gallbladder is here. I found the responses really comforting. I was kinda wiped out for about a month after the surgery, but I'm totally fine now.

Don't feel bad about asking the doctors a lot of questions to make sure that you and your mom understand what's going on. It's really overwhelming to be your own advocate when you're already in pain and weak. My mom would've been scared to death during her surgery if I hadn't piped up to ask questions that I know that she was too scared or intimidated to ask.
posted by desuetude at 12:20 PM on December 27, 2007

I doubt if anyone is still following this thread, but I thought I should come back and post a final comment in case it comes up later in searches. My mother had the laporoscopic surgery this morning, and it turns out that the gall bladder was extremely shrunken, hardened, and had attached itself to the side of my mother's stomach. The doctor things that she probably had a stone in her gall bladder, and that it eventually passed through the gallbladder and into the stomach, where she passed it without ever knowing it. The surgery went well, the gall bladder was separated from the stomach and then removed. There appear to be no perforations in the stomach, but they need to watch that for the next few days to be sure. Once she recovers from the surgery itself she should feel better than she has in ages.
posted by Lokheed at 12:24 PM on December 29, 2007 [2 favorites]