Acute gallbladder torsion - a continued pre-operative diagnostic dilemma

Abstract

Acute gallbladder volvulus continues to remain a relatively uncommon process, manifesting itself usually during exploration for an acute surgical abdomen with a presumptive diagnosis of acute cholecystitis. The pathophysiology is that of mechanical organo-axial torsion along the gallbladder's longitudinal axis involving the cystic duct and cystic artery, and with a pre-requisite of local mesenteric redundancy. The demographic tendency is septua- and octo-genarians of the female sex, and its overall incidence is increasing, this being attributed to increasing life expectancy. We discuss two cases of elderly, fragile women presenting to the emergency department complaining of sudden onset right upper quadrant abdominal pain. Their subsequent evaluation suggested acute cholecystitis. Ultimately both were taken to the operating room where the correct diagnosis of gallbladder torsion was made. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging; the remainder were found intra-operatively. Consequently, a delay in diagnosis can have devastating patient outcomes. Herein we propose a necessary high index of suspicion for gallbladder volvulus in the outlined patient demographic with symptoms and signs mimicking acute cholecystitis.

Gallbladder Disease in an Elderly Patient

“…Laparoscopy can be attempted when gallbladder volvulus is recognized early, but it is often unsuccessful. 5 If laparoscopy is attempted, the gallbladder must be untwisted to avoid injury to the common duct, which can be tented up from the volvulus.…”

Volvulus of Gall Bladder-Case Report and Review of Literature

“…Volvulus of gall bladder is relatively uncommon condition with no more than 500 cases reported in literature [9]. Gall bladder volvulus or torsion, when gall bladder rotates either clockwise or anticlockwise around its mesentery along the axis of cystic duct and cystic artery causing complete obstruction of blood flow and biliary damage, resulting in acute gangrenous cholecystititis [3]. Anatomical variations of peritoneal covering of gall bladder are well known.…”

“…More than 400 cases are reported in literature [1,2]. Volvulus of gall bladder is more common in elderly females between 7 th and 8 th decades and female to male ratio of 3:1 [3]. Causes has been attributed to anatomical variations of gall bladder mesentry and loss of visceral fat, as well mesentery with cystic duct and artery known as floating gall bladder [4][5][6][7].…”

Volvulus of gall bladder: case report

“…9 Gall bladder volvulus or torsion, when gall bladder rotates either clockwise or anticlockwise around its mesentery along the axis of cystic duct and cystic artery causing complete obstruction of blood flow and biliary damage, resulting in acute gangrenous cholecystititis. 3 Anatomical variations of peritoneal covering of gall bladder are well known. There are five recognized positions of gall bladder in relation to liver.…”

“…1,2 Volvulus of gall bladder is more common in elderly females between 7 th and 8 th decades and female to male ratio of 3:1. 3 Causes has been attributed to anatomical variations of gall bladder mesentery and loss of visceral fat, as well mesentery with cystic duct and artery known as floating gall bladder. [4][5][6][7] when there is strong peristaltic movement or when the stomach contracts, intestines may turn and curl the gall bladder.…”