Multiseptate gallbladder accompanied by an incomplete annular pancreas in a 19-year male patient: A case report

Abstract

Multiseptate gallbladder (MG) is a rare congenital malformation that may occur as an isolated anomaly or in conjunction with other abnormalities of the pancreaticobiliary, urinary, and gastrointestinal systems. The coexistence of MG with an annular pancreas is an exceedingly rare phenomenon. The diagnosis is typically established using abdominal ultrasound; however, further imaging modalities are often required to delineate the detailed anatomy and to identify any associated anomalies within the pancreaticobiliary system. We present a case of a symptomatic MG associated with an incomplete annular pancreas. This case underscores the importance of considering additional congenital anomalies in patients diagnosed with MG, as such associations may influence clinical management and outcomes.

Introduction

Multiseptate gallbladder (MG), also referred to as “honeycomb gallbladder,” represents a rare congenital anomaly and is infrequently encountered as an incidental radiological finding. It is defined by the presence of more than 3 septa within the gallbladder lumen [1]. Clinically, MG may be asymptomatic or manifest with nonspecific symptoms, most commonly episodic abdominal pain. The condition can occur in isolation or be associated with other congenital anomalies involving the pancreaticobiliary, urinary, and gastrointestinal systems [2]. To date, the coexistence of MG with an incomplete annular pancreas has not been previously reported. No consensus regarding the optimal management of MG has been established. Patients with symptomatic annular pancreas may present with bowel obstruction or remain asymptomatic [3]. Consequently, therapeutic strategies should be individualized. This report describes a male patient presenting with symptomatic MG and an incomplete annular pancreas, diagnosed via abdominal computed tomography (CT). Informed consent for publication was obtained from the patient at the time of initial presentation.

Case report

A 19-year-old male presented to the outpatient clinic with a 2-year history of epigastric pain and occasional vomiting, not associated with food intake. Despite the intermittent nature of his symptoms, he initially sought evaluation by a gastroenterologist. The patient had no significant past medical or surgical history, and his family history was unremarkable. Laboratory investigations, including cholestasis markers, were within normal limits as follows: Hemoglobin level of 14.5 g/dL (13.0-17.0 g/dL), white blood cell count of 6.8 × 10⁹/L (4.0-10.0 × 10⁹/L), platelet count of 250 × 10⁹/L (150-400 × 10⁹/L), serum creatinine level of 0.9 mg/dL (0.6-1.3 mg/dL), serum blood urea nitrogen level of 14 mg/dL (7-20 mg/dL), Alanine Aminotransferase level of 22 U/L (7-56 U/L), Aspartate Aminotransferase level of 20 U/L (10-40 U/L), Alkaline Phosphatase level of 75 U/L (44-147 U/L), total Bilirubin level of 0.8 mg/dL (0.1-1.2 mg/dL), albumin level of 4.2 g/dL (3.5-5.0 g/dL), serum glucose level of 92 mg/dL (70-99 mg/dL), sodium level of 139 mmol/L (135-145 mmol/L), potassium level of 4.1 mmol/L (3.5-5.1 mmol/L), chloride level of 102 mmol/L (98-107 mmol/L) and bicarbonate level of 24 mmol/L (22-29 mmol/L). Abdominal ultrasonography revealed a multiseptate gallbladder without gallstones. Gastroscopy showed no abnormalities. However, testing for Helicobacter pylori was positive, and the infection was treated with a combination of 2 antibiotics and a proton pump inhibitor. In addition, the gastroenterologist prescribed ursodeoxycholic acid. Despite this therapy, the patient’s symptoms persisted. Consequently, an abdominal computed tomography scan was performed, which confirmed the presence of a multiseptate gallbladder and identified an incomplete annular pancreas, without evidence of duodenal obstruction on imaging (Fig. 1, Fig. 2, Fig. 3; Video 1). Given the rarity of the condition and the patient’s young age, the surgical team recommended a conservative, nonoperative approach with symptomatic management and close follow-up. However, after several attempts, the patient was lost to follow-up and could not be reached for subsequent evaluation.

Fig. 1.

(A-B) Arterial phase of abdominal computerized tomography (axial scan) showing multiseptate gallbladder (arrow) in 2 different slices (A and B).

Fig. 2.

Arterial phase of abdominal computerized tomography (coronal scan) showing multiseptate gallbladder (arrow).

Fig. 3.

Arterial phase of abdominal computerized tomography (axial scan) showing incomplete annular pancreas around the second portion of the duodenum (arrow).

Discussion

The multiseptate gallbladder (MG) was first described by Knetsch in 1952 [2]. The reported median age at diagnosis is 23 years, with a slight female predominance. The etiology of this rare congenital anomaly remains uncertain. While embryological theories offer partial explanations for its development, there are also isolated reports of MG occurring secondary to trauma or inflammation [2].

A multiseptate, or "honeycomb," gallbladder can be asymptomatic and may be incidentally discovered during imaging for unrelated conditions [1]. However, symptomatic cases do occur. When symptomatic, MG typically presents with epigastric or right upper quadrant abdominal pain, biliary colic, vomiting, and occasionally jaundice [2].

Historically, oral cholecystography was used for gallbladder imaging [4]. Today, diagnosis is primarily made via abdominal ultrasound [1,2,5], while computed tomography can serve as an adjunct, particularly when evaluating for associated anomalies—as demonstrated in the present case. For further characterization of pancreaticobiliary anomalies, endoscopic retrograde cholangiopancreatography (ERCP) is often utilized [6]. However, magnetic resonance cholangiopancreatography (MRCP) has been reported to provide superior visualization of the multiseptate gallbladder and the biliary tree, making it a valuable diagnostic alternative [4,7].

The coexistence of MG with other pancreaticobiliary anomalies is exceedingly rare [6,8]. To our knowledge, this is the first reported case describing the simultaneous presence of a multiseptate gallbladder and an incomplete annular pancreas on radiological imaging.

Radiologically, the annular pancreas is categorized as complete or incomplete. In a review by Sandrasegaran et al., among 42 patients with the annular pancreas, 9 exhibited the incomplete form, characterized by involvement confined to the second portion of the duodenum—as observed in our case [9]. Based on cross-sectional imaging, the annular pancreas is further classified into 3 morphological subtypes according to the direction of pancreatic tissue encircling the duodenum:

• -Anterolateral extension.
• -Posterolateral extension.
• -Combined anterior and posterior extension (commonly referred to as the "crocodile jaw" appearance) [3].

In this case, CT imaging demonstrated an anterolateral extension of pancreatic tissue without evidence of duodenal obstruction.

Currently, no standardized treatment guidelines exist for MG. Conservative management has been successful in certain cases, while others have shown symptomatic improvement following cholecystectomy [10]. Conversely, there are reports of persistent symptoms even after surgical intervention [4]. Long-term symptom resolution with conservative treatment has also been documented [11].

The clinical presentation of an incomplete annular pancreas is typically asymptomatic. Nonetheless, there are cases in which it has been associated with intermittent bowel obstruction [3].

In our opinion, a tailored, case-by-case approach should guide treatment decisions, considering factors such as the patient’s age, the severity and duration of symptoms, and any associated anatomical anomalies.

Conclusion

A multiseptate gallbladder is typically not a diagnostic challenge for experienced radiologists. However, the potential for associated anatomical anomalies should be carefully considered. Therefore, the use of complementary imaging modalities—such as abdominal CT, MRCP, or ERCP—may be warranted for comprehensive evaluation. The coexistence of a multiseptate gallbladder with an incomplete annular pancreas, as observed in this case, represents a rare and previously unreported combination that underscores the importance of a thorough diagnostic assessment.

Patient consent

We declare that a written informed consent for publication of the article” Multiseptate gallbladder accompanied by an incomplete annular pancreas in a 19-year male patient” was obtained from the patient.

Appendix. Supplementary materials

Video 1

Video of the arterial CT phase (axial scan) showing the multiseptate gallbladder and the incomplete annular pancreas.