Letter to Editor
Open Access
Acute Torsion of the Gallbladder
Haithem Zaafouri*, Skander Mrad, Noomen Haoues, Rabii Noomene and Abderraouf Cherif
1Department of general surgery, Habib Thameur hospital, 8 Ali Ben Ayed Street’s, Monftfleury 1008, Tunis, Tunisia
*Corresponding author: Zaafouri Haithem, Associate professor, Habib Thameur hospital, Tunisia, Tel: +21697348839; E-mail:
@
Received: June 05, 2014; Accepted: July 10, 2014; Published: July 22, 2014
Citation: Zaafouri H, Mrad S, Haoues N, Noomene R, Cherif A (2014) Acute Torsion of the Gallbladder. Gastroenterol Pancreatol Liver Disord 1(2): 1-2. http://dx.doi.org/10.15226/2374-815X/1/2/00108
Introduction Top
Gallbladder volvulus is a rare cause of a traumatic, acute
abdomen which is often very difficult to diagnose pre-operatively.
Precise etiology of gallbladder torsion remains unknown, but it
is believed that it occur in anatomically predisposed patients.
Preoperative diagnosis of gallbladder torsion remains difficult
and most cases are found as a surprise at surgery.
This case demonstrated that gallbladder torsion is another possible mechanism for acute gangrenous cholecystitis.
This case demonstrated that gallbladder torsion is another possible mechanism for acute gangrenous cholecystitis.
Case PresentationTop
An 89 year old man presented to the emergency department
with a two days history of acute onset abdominal pain in the
upper right quadrant, with fever, vomiting and malaise. His
medical history included peptic ulcer disease and tobacco abuse.
There was no significant relevant past surgical history. He was
dehydrated at presentation with the following vital signs: HR-
86 b/min, BP-100/50 mmHg, T-38.5°C. Focused abdominal
examination demonstrated tenderness to palpation in the right
upper quadrant, and a positive Murphy’s sign. Laboratory blood
tests revealed a leukocytosis of 22.7×103/L, C-reactive protein of
48 mg/L and normal kidney and liver function tests. Abdominal
ultrasonography (Figure 1) and computed tomography (CT)
scan (Figure 2) showed a clearly enlarged gallbladder with
a thickened wall of 7 mm, with fluid sub-hepatically. They
demonstrated no gallstone. Free air within the gallbladder wall
was not seen. He was admitted to our hospital with the diagnosis
of acute cholecystitis. After resuscitation emergency laparotomy
through a midline incision was performed. On entering the
abdominal cavity, a gangrenous distended gallbladder with
omentum adhesed to it circumferentially was immediately noted
(Figure 3). It was rotated more than 360 degrees anticlockwise
around its mesentery. The gallbladder torsion was reduced and
a cholecystectomy was then performed in the standard fashion,
with placement of a drain in the gallbladder fossa. No gallbladder
stones were found in the specimen. Histology revealed transmural
necrosis consistent with volvulus. His post-operative course was
unremarkable and he was discharged on post-operative day 3.
DiscussionTop
Gallbladder volvulus occurs predominantly in older people with a female to male sex ratio of 3:1 [1]. Since its first description
in 1898 by Wendel [2], there have been over 500 documented
cases in the literature.
Figure 1: Transverse ultrasonogram of the gallbladder shows a markedly
thickened gallbladder wall (a) and fluid collection (b).
Figure 2: Abdominal CT scan demonstrates a markedly distended gallbladder.
Figure 3: Torsion of the gall bladder with gangrene
The etiology is thought that a long gallbladder mesentery with minimal or no attachment to the liver facilitates the longitudinal
axis of the gallbladder to twist on its vascular root resulting in
ischemia, necrosis and perforation [3,4]. Boonstra [5] suggested
that torsion happens only in the absence of hepatic attachments
and fixation to the liver. The disease carries a significant morbidity
and mortality due to the risk of necrosis and perforation of the
gallbladder. The reported mortality in the literature is up to 6%
[6].
Gallbladder volvulus is frequently misdiagnosed as acute
acalculous cholecystitis, as no single clinical, serologic, or
radiographic finding is pathognomonic. To make the diagnosis
of gallbladder torsion is difficult, with less than 10% of cases
reported pre-operatively in the literature [7].
Gallbladder volvulus is frequently misdiagnosed as acute
acalculous cholecystitis, as no single clinical, serologic, or
radiographic finding is pathognomonic. To make the diagnosis
of gallbladder torsion is difficult, with less than 10% of cases
reported pre-operatively in the literature [7].
Abdominal computer tomography (CT) with iodinated
contrast injection shows the gallbladder to be horizontal and
located outside of the gallbladder bed together with torsion
of the cystic pedicle and a ‘‘whirl sign’’. It is worth noting that
3-dimensional reconstructed CT may be useful in preoperative
diagnosis of gallbladder torsion [9].
Treatment is surgical with urgent cholecystectomy because of
the risk of gallbladder perforation. Initial release of the torsion on
the gallbladder can reduce the risk of damage to the biliary tract. Prognosis is excellent if expeditious cholecystectomy is
performed. If treatment is delayed, infarction and perforation
resulting in bilious peritonitis increase the mortality rate to
approximately 5%.
Conclusion
Gallbladder volvulus is a rare cause of acute cholecystitis,
which is occasionally difficult to diagnose pre-operatively.
Having a high index of suspicion for other causes of acute
cholecystitis in the absence of simple gall stone obstruction,
or when investigation results do not correlate with the clinical
presentation, gallbladder torsion should still be considered even
if it is an extremely rare entity. Gallbladder torsion mandates
emergent cholecystectomy, to avoid visceral perforation, bilious
peritonitis, and hemodynamic instability
- Alkhalili E, Bencsath K. Gallbladder torsion with acute cholecystitis and gross necrosis. BMJ Case Rep. 2014. doi: 10.1136/bcr-2014- 204917.
- Pottorf BJ, Alfaro L, Hollis HW. A Clinician’s Guide to the Diagnosis and Management of Gallbladder Volvulus. Perm J. 2013; 17(2):80-3. doi: 10.7812/TPP/12-118
- Chalret du Rieu M, Carrere N. Volvulus de la vesicule biliaire. Journal de Chirurgie Viscerale. 2012; 149(2):172-3
- Gabizon S, Bradshaw K, Jeyarajan E, Alzubaidy R, and Liew V. Gallbladder Torsion: A Diagnostic Challenge. Case Rep Surg. 2014. doi: 10.1155/2014/902814.
- Boonstra EA, van Etten B, Prins TR, Sieders E, van Leeuwen BL. Torsion of the Gallbladder. J Gastrointest Surg. 2012;16(4):882–4. doi: 10.1007/s11605-011-1712-6.
- Reilly DJ, Kalogeropoulos G, Thiruchelvam D. Torsion of the Gallbladder: a systematic review. HPB (Oxford). 2012;14(10):669–72. doi: 10.1111/j.1477-2574.2012.00513.x.
- Boer J, Boerma D, and De Vries Reilingh TS. A gallbladder torsion presenting as acute cholecystitis in an elderly woman: a case report. J Med Case Rep. 2011; 5(1):588. doi: 10.1186/1752-1947-5-588.
- Lau WY, Fan ST, Wong SH. Acute torsion of the gall bladder in the aged: a re-emphasis on clinical diagnosis. Aust N Z J Surg. 1982; 52(5):492–4.
- Yokoi T, Miyata K, Yuasa N, Takeuchi E, Goto Y, Miyake H, et al. Twisted cystic artery disclosed by 3-dimensional computed tomography angiography for torsion of the gallbladder. Am J Surg. 2011; 201(5):33–4. doi: 10.1016/j.amjsurg.2010.04.026.