AJR 2005; 184:S88-S90
© American Roentgen Ray Society
Double Gallbladder Diagnosed on Contrast-Enhanced MR Cholangiography with Mangafodipir Trisodium
Laurent Milot1,
Christian Partensky2,
Jean-Yves Scoazec3,
Pierre-Jean Valette1 and
Frank Pilleul1
1 Hopital Edoaurd Herriot, Radiologie Digestive, Lyon, France.
2 Hopital Edouard Herriot, Chirurgie Digestive, Lyon, France.
3 Hopital Edouard Herriot, Anatomie Pathologique, Lyon, France.
Received April 6, 2004;
accepted after revision May 11, 2004.
Address correspondence to F. Pilleul
(frank.pilleul{at}chu-lyon.fr).
Introduction
Duplication of the gallbladder is a rare anomaly of the biliary
tract that may cause a medical or surgical problem if not diagnosed. MR
cholangiography (MRC) has clearly shown capabilities for the diagnosis of
biliary diseases [1]. We
describe here a case of gallbladder duplication, visualized by MRC with
mangafodipir trisodium, which has never been shown before, and we discuss the
importance of this kind of imagery if double gallbladder is suspected.
Case Report
The patient is a 46-year-old woman with no medical history and was admitted
to the surgery department because of chronic right upper quadrant (RUQ) pain.
The pain started after a meal and was associated with nausea. Physical
examination revealed a soft, nondistended abdomen and no tenderness in the RUQ
without peritoneal signs. Murphy's sign was negative. Her temperature was
37.5°C, and the rest of her vital signs were normal. Laboratory analysis
of liver function was normal. A sonographic examination revealed a normal
gallbladder without sign of cholecystitis and stones within a small
attenuating lesion in the hepatic IV segment, suggesting a diagnosis of
gallbladder duplication. MRC was performed on a 1.5-T clinical unit (Symphony
Quantum; Siemens) with a body phased-array coil for further evaluation of the
biliary tree and characterization of the hepatic IV segment lesion. The MRC
protocol was performed before and after the perfusion of mangafodipir
trisodium (0.1 mL/kg; maximum dose, 15 mL), including the following sequences:
before perfusion, an axial and coronal T2-weighted half-Fourier single-shot
fast spin-echo (HASTE) without fat suppression (TR/TE, 
/110 msec; slice
thickness, 4 mm); and a coronal thick-slab single-shot turbo-spin-echo (TR/TE,
/1,100; slice thickness, 60 mm). One hour after IV contrast perfusion,
coronal volumetric 3D spoiled gradient-echo acquisitions of the liver and
biliary system were done using two interpolated sequences with intermittent
fat-suppression pulses (TR/TE, 4.5/1.9; flip angle, 25-40°; matrix,
128-160 x 512; field of view, 300-375 mm using a rectangular field of
view and 80-112 partitions for a slice thickness of 
2 mm). The imaging
time for all sequences was kept to less than 25 sec to facilitate
breathholding during the acquisition. HASTE images revealed a normal
gallbladder without stones and associated with a cystic lesion with stones in
the IV segment of the liver (Fig.
1A). After perfusion of mangafodipir trisodium and
maximum-intensity-projection reconstruction, we showed a cystic lesion full of
stones, enhanced by mangafodipir trisodium and connected with a common hepatic
duct by a thin canal different from the cystic duct (Figs.
1B,
1C and
1D). The gallbladder was in the
normal location without stones, and a normal cystic duct was identified. A
diagnosis of double gallbladder was made, and the patient underwent a surgical
procedure to remove the two gallbladders. The surgical results confirmed the
diagnosis and the presence of two separate cystic ducts. Pathologic
examination revealed chronic inflammation of the abnormal gallbladder
(Fig. 1E).
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Fig. 1A. —46-year-old woman with chronic right upper quadrant pain and
normal laboratory analysis. HASTE sequence in coronal plane identifies a
normal gallbladder without stones associated with cystic lesion with stones in
segment IV of the liver.
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Fig. 1B. —46-year-old woman with chronic right upper quadrant pain and
normal laboratory analysis. Thin maximum-intensity-projection (MIP)
reconstructions show enhancement of the cystic lesion full of stones, and thin
canal connected to common hepatic duct (white arrow).
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Fig. 1C. —46-year-old woman with chronic right upper quadrant pain and
normal laboratory analysis. Coronal volumetric 3D spoiled gradient-echo
acquisitions of liver and biliary system 1 hr after IV Teslascan perfusion
show gallbladder (g) in normal situation without stone, and normal cystic
duct.
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Fig. 1E. —46-year-old woman with chronic right upper quadrant pain and
normal laboratory analysis. Pathologic examination shows two removed
gallbladders and abnormal cystic duct of upper gallbladder.
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Discussion
Duplication of the gallbladder is a rare anomaly of the biliary tract,
occurring at a rate of 0.25/1,000 in one autopsy series
[2]. Several classifications
have been proposed according to anatomic or embryologic development of the
gallbladder. Boyden [2]
classified double gallbladder in bilobed gallbladder and in true duplicated
gallbladder, with two types according to the connection of the cystic ducts.
Gross [3] classified double
gallbladder into six types, designated A to F, and Harlaftis et al.
[4] classified double
gallbladder into two groups. The case described here falls under the Boyden
ductal-type, Gross B-type, and Harlaftis ductal-type classifications.
This condition tends to lead to biliary complications, such as
cholelithiasis and acute cholecystitis of both gallbladders. The clinical
features are usually RUQ pain and tenderness and sometimes jaundice
[5].
Surgical treatment consists of the removal of both gallbladders to prevent
later complications [5,
6] and requires precise
detection, especially when laparoscopic cholecystectomy is performed
[6].
Although duplication of the gallbladder may be suspected on abdominal
sonography for abdominal pain in the presence of two cystic formations in
gallbladder fossa with contraction of one or both after a meal, this diagnosis
remains difficult to prove [7].
Furthermore, sonography cannot adequately determine the type of duplication
[5,
7]. Some authors have used oral
cholangiography with a 60% sensitivity
[4] or computed tomography
scanning with oral cholangiography. Although endoscopic retrograde
cholangiopancreatography (ERCP) seems to be the gold standard examination for
confirming the diagnosis, the disadvantages of this approach include
invasiveness and a high rate of false-negatives
[8].
MRC is a noninvasive technique widely used in the evaluation of biliary
tract abnormalities, including stones, anatomic variations, and preoperative
drainage [1]. Therefore, MRC
has become the imaging technique of choice at many institutions in the workup
of patients with a biliary tract abnormality. In our case, MRC with
mangafodipir trisodium allowed us to determine the exact type of duplication,
information that is necessary prior to surgical treatment
[6].
Contrast-enhanced MRC with IV mangafodipir trisodium can provide anatomic
and functional information [8].
Mangafodipir trisodium is an MRI hepatobiliary contrast agent primarily
excreted via bile. Normal biliary systems show enhancement on gradientecho
images 10-20 min after administration of mangafodipir trisodium. In this
context, because of biliary filling, mangafodipir trisodium MRC confirmed that
both cystic lesions were gallbladders, thus excluding differential diagnoses,
and showed two different cystic ducts to verify the classification.
Duplication of the gallbladder is a rare congenital abnormality that
requires surgical treatment. To prevent biliary damage, a precise preoperative
diagnosis is necessary. Because MRC with mangafodipir trisodium perfusion is
equivalent to ERCP for obtaining an exact diagnosis and is a noninvasive
method, it should be the first exam performed in a case of suspected double
gallbladder. The increased use of MRC in clinical practice will probably yield
more accurate diagnoses.
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