Hindawi Publishing Corporation
Case Reports in Gastrointestinal Medicine
Volume 2011, Article ID 470658, 4 pages
MultiseptateGallbladderin anAsymptomatic Child
Dylan Wanaguru,1AshishJiwane,1AndrewS.Day,2,3and SusanAdams1
1Department of Paediatric Surgery, Sydney Children’s Hospital, University of New South Wales, High Street, Randwick, Sydney,
NSW 2031, Australia
2Department of Gastroenterology, University of New South Wales, High Street, Randwick, NSW 2031, Australia
3Sydney Children’s Hospital and School of Women’s and Children’s Health, University of New South Wales, High Street, Randwick,
NSW 2031, Australia
Correspondence should be addressed to Dylan Wanaguru, firstname.lastname@example.org
Received 3 July 2011; Accepted 21 July 2011
Academic Editors: F.-Y. Chang, K. Haruma, and A. J. Lembo
Copyright © 2011 Dylan Wanaguru et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
A one-year-old child being investigated for urinary tract infection was diagnosed with a multiseptate gallbladder. The patient
remains asymptomatic, and investigations demonstrate no associated anomalies. Forty-three cases, including 13 cases in children
were identified in the literature. Their presentation and managementwere reviewed.
Multiseptate gallbladder (MSG) is a rare congenital anomaly
with less than 50 cases described in the English literature. Of
these, 13 are in paediatric patients [1–9]. We report a case
of MSG in a one-year-old child. We review the data from
the published literature to consider the most appropriate
management of symptomatic and asymptomatic children,
including whether or not cholecystectomy is indicated.
A nine-month-old, previously well, female infant presented
with an acute episode of vomiting and was diagnosed with
an Escherichia coli urinary tract infection (UTI). Renal tract
ultrasound was normal, but the gallbladder (GB) was inci-
dentally noted to have “multiple thin smooth septa, giving
a honeycomb appearance,” consistent with MSG (Figure 1).
No other biliary tract abnormality was noted. The UTI was
treated, and the child subsequently remained asymptomatic.
Repeat ultrasound six months later showed the images
were unaltered. Liver function tests were normal apart from
a raised alkaline phosphatase 1632U/L (age appropriate
normal range 80–450). Magnetic resonance cholangiopan-
creaticography (MRCP) confirmed the diagnosis of MSG,
and excluded intra- and extrahepatic biliary and pancreatic
anomalies. Nuclear medicine HIDA (hepatobiliary imino-
flow at any level of the biliary tree.
and Tandon . It is characterised by multiple thin septa-
tions within the gallbladder lumen, giving a honeycomb-like
appearance. Simon and Tandon  proposed that this was
due to incomplete vacuolisation of the developing gallblad-
der bud. Bhagavan et al.  have suggested that MSG may
be a result of the solid embryonic GB growing faster than its
bed and investing peritoneum, causing aberrant bends and
kinks. The same authors also postulate that a variation in the
wrinkling, lobulation, and clefting of the gallbladder (seen
in cat and guinea pig embryos) may result in multiseptation
Including the current case, 44 cases are described in the
English literature, with a male-to-female ratio of almost 1:2.
Overall the mean age at diagnosis of these individuals was
28.6 years (range from 15 days to 70 years). Thirty of these
cases were in adults [10–36]. Thirteen have been reported in
children: eight being female (Table 1) [1–9]. Most children
2Case Reports in Gastrointestinal Medicine
Table 1: Published reports of multiseptate gallbladder in children and adolescents (aged less than 16 years).
Author (reference)YearAgeSexBiliary symptomsAssociated anomaliesTreatment
Haslam et al. 1966 15F YesNilCholecystectomy
Pery et al. 19858F Yes Choledochal cyst
Fremond et al. 198913F YesNil Cholecystectomy
Adear and Barki 1990 12F No NilNil
Strauss et al. 19933M No NilNot detailed
Strauss et al.  19939F YesNil Not detailed
Strauss et al. 199316M Yes Nil Not detailed
Tan et al. 199314F Yes Choledochal cyst
Kocakoc et al.  20039MYes NilCholecystectomy
Erdogmus et al. 200410FYes NilCholecystectomy
Erdogmus et al. 200412M YesNilCholecystectomy
Total excision of cyst with
Bahadir et al. 200615 daysM Yes
Ectopic pancreas associated
with choledochal cyst
Present Case20081FNoNilMonitor with ultrasound
within the gallbladder.
were diagnosed in mid-to-late childhood (mean age 9.4
years) although one was detected at 15 days of age.
Biliary symptoms such as right upper quadrant pain,
nausea and vomiting are the most common complaints
in this condition, with 31 of the 44 cases presenting in
this manner. Only three of the 44 cases were associated
with cholelithiasis [8, 12, 13], and one was associated with
acute acalculous cholecystitis , but none of these were
in children. The presence of an associated biliary tract
abnormality is an important consideration in the assessment
of MSG. One case in a 46-year-old woman was associated
with anomalous pancreaticobiliary ductal union . The
three reported cases found to have associated choledochal
cysts were all in children (23% of paediatric cases). These
children presented with jaundice [2, 9] and a combination
of fever, nausea, and abdominal discomfort . Seven of
the remaining 10 children presented with biliary symptoms
[1, 3, 5, 7, 8]. The otherthree children (includingthe current
(MRCP) image confirming ultrasound findings of multiple septae
within the gallbladder.
The incidence of asymptomatic MSG in the community is
unknown, so it is not possible to comment on the likelihood
of symptoms developing in these children.
There is no reported association between uncomplicated
MSG and malignancy; however, there is a known link be-
tween biliary tract anomalies and cholangiocarcinoma. The
incidence of malignancy in choledochal cyst is reported
between 10% and 30%, and anomalous arrangement of
the pancreaticobiliary duct is considered to be a high-risk
factor for biliary tract malignancy [16, 17]. Consequently,
four of the reported cases of MSG (all adults) with such
associated abnormalities have an increased long-term risk of
Case Reports in Gastrointestinal Medicine3
The majority of reported cases were diagnosed on ultra-
der mucosa, polypoid cholesterolosis, hydatid cyst and acute
hepatitis [18, 19]. Kocakoc et al.  first reported the use
of MRCP to noninvasively define biliary and pancreatic
pathology in MSG. MRCP is useful in confirming the diag-
nosis and delineating any associated biliary tree pathology
and eliminates the potential complications associated with
endoscopic cholangiopancreaticography (ERCP).
Saimura et al.  conducted biliary manometry and
scintigraphy on a 30-year-old man with epigastric pain and
MSG.Impairment ofbileflow intoand outofthegallbladder
wasdemonstrated,supporting abiliary origin ofthepatient’s
pain. In the same study, Saimura and colleagues went on to
reproduce typical biliary colic in the patient by injection of
Cerulein to stimulate gallbladder contraction.
In symptomatic patients diagnosed with MSG, cholecys-
tectomy provides reliefof symptoms . The three children
with associated choledochal cyst were successfully treated
with excision of the extrahepatic biliary tree combined with
hepatojejunostomy or choledochoduodenostomy. In the 12
reported cases of asymptomatic and uncomplicated MSG,
including the three paediatric cases, management has been
nonoperative with regular followup.
MSG is a rare biliary anomaly that may be diagnosed in the
first decades of life. Associated biliary tract anomalies should
hood. Cholelithiasis is rarely associated with MSG, and has
MRCP, and HIDA scan is recommended. In the absence of
symptoms attributable to the MSG, or an associated biliary
tract anomaly, nonoperative management in children and
regular followup is reasonable. Symptomatic uncomplicated
MSG is successfully treated with cholecystectomy.
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