Triple gallbladder: radiological review

Abstract

Triple gallbladder represents a rare congenital anatomical abnormality that can be a diagnostic challenge in reason to its rarity and consequential difficulties with diagnosis and identification. A systematic review of all published literature between 1958 and 2022 was performed. We identified 20 previous studies that provided 20 cases of triple gallbladder; our case was also included in the analysis, making a total of 21 patients. All patients underwent on diagnostic imaging examinations. After 1985, 9 patients underwent US examination which allowed prompt recognition of triple gallbladder in 2 patients only. CT was performed in 3 patients and allowed the correct diagnosis in a case. In 4 patients, was performed MRCP which allowed the correct diagnosis of triple gallbladder in all patients. Preoperative imaging allows the recognition of triple gallbladder in 9 of 21 patients (43%); in 12 patients (57%) the diagnosis was intraoperative. On patients considered, 16/21 underwent cholecystectomy. In 15 cases, the excised gallbladders were submitted for histopathological characterization with detection of metaplasia of the mucosa in 3 patients, while papillary adenocarcinoma was found in one. Imaging plays a key role in the identification of the anatomical variants of gallbladder, especially triple gallbladder, as modern imaging techniques allow a detailed assessment of the course of the biliary tract for a correct preoperative diagnosis. It is also crucial to be aware of the association between this condition and the metaplasia phenomena with the development of adenocarcinoma, as this may influence the patient's course of treatment.

Keywords: Multiple cholecyst; Multiple gallbladders; Triple cholecyst; Triple gallbladder.

Fig. 1

Ultrasound examination showed three different gallbladders (numbers 1, 2, 3 in panels A and C) in the cholecystic fossa. To note the diffuse thickened, irregular and hyperechogenic wall of the most anterior gallbladder (panel B, number 1). PV portal vein

Fig. 2

A Coronal balanced turbo-field-echo (BTFE) sequence showed three different gallbladder one of which with irregular wall. B Anterior view of 3D-MIP magnetic resonance cholangiopancreatography (MRCP) with gradient and spin echo (GRASE) technique; to note the anterior gallbladder with irregular wall, fundal thickness (arrow) and higher T2 signal than two others. C Posterior view of 3D-MIP magnetic resonance cholangiopancreatography (MRCP) with gradient and spin echo (GRASE) technique; to note the confluence of the two posterior cystic ducts into a single duct (*)

Fig. 3

A Coronal balanced turbo-field-echo (BTFE) and B transverse T2-Spectral Adiabatic Inversion Recovery (SPAIR) sequence: to note the gallbladder with nodular thickness at fundus (white arrow)

Fig. 4

Illustration on coronal plane of our case showing the Y + H triple gallbladder morphology following the Harlaftis classification and the focal fundus wall thickness

Fig. 5

3D volume rendering reconstruction showing three different gallbladders one of which with irregular wall. RIA right-infero-anterior; SRP supero-right-posterior, ILA infero-left-anterior, LSP left-supero-posterior; IRP infero-right-posterior, RAS right-antero-superior, SLA supero-left-anterior, LPI left-postero-inferior

Fig. 6

A Transverse T2 showing three distinct gallbladders (numbers 1, 2 and 3) [123]. B Infero-lateral view of 3D-MIP magnetic resonance cholangiopancreatography (MRCP) with gradient and spin echo (GRASE) technique; to note the fundus of the three distinct gallbladders [123], the anterior with fundal thickness (*) and higher T2 signal than two others

Fig. 7

Anterior view of 3D-MIP magnetic resonance cholangiopancreatography (MRCP) with gradient and spin echo (GRASE) technique; to note the anterior gallbladder with irregular wall, fundal thickness (arrow) and higher T2 signal than two others and the confluence of the two posterior cystic ducts into a single duct (*)