Torted gallbladder causing massive distension and gross necrosis; a rare surgical emergency

Abstract

Gallbladder torsion is rare and is more frequently seen in elderly women. Published case reports comment that diagnosis of this entity can be made preoperatively through imaging with some advocating removal laparoscopically. This case reports an elderly woman who underwent emergency laparotomy for a massively distended gallbladder with suspected cholecystitis. At laparotomy the gallbladder was found to be torted over 360° round its pedicle of the cystic duct and artery. The torsion was so pronounced that the gallbladder was massively distended and grossly necrotic with a high risk of perforation. As the pedicle was long the gallbladder was easily separated form the liver and removed in its entirety. This case presented significant diagnostic and management difficulties. By observing the clinical features in the triad of triads for gallbladder volvulus prompt diagnosis, investigation and treatment can be started for this rare emergency presentation.

Gallbladder Volvulus Presenting as Acute Appendicitis

“…In an attempt to help make the diagnosis of GV preoperatively, Lau developed what has become known as the “Triad of Triads” in 1982, which is used to help identify the clinical features of GV [ 12 , 13 ]. Triad 1 typically describes patient appearance: elderly, thin body habitus and chronic chest disease or spinal deformity [ 12 , 13 ]. Triad 2 describes patient symptoms: the typical right upper quadrant pain, sudden and early onset of this pain, and early onset emesis [ 12 , 13 ].…”

“…Triad 1 typically describes patient appearance: elderly, thin body habitus and chronic chest disease or spinal deformity [ 12 , 13 ]. Triad 2 describes patient symptoms: the typical right upper quadrant pain, sudden and early onset of this pain, and early onset emesis [ 12 , 13 ]. Finally, Triad 3 illustrates the physical signs of the patient: palpable right upper quadrant mass, lack of a toxic or jaundiced appearance, and a discrepancy between the pulse and temperature [ 12 , 13 ].…”

“…Triad 2 describes patient symptoms: the typical right upper quadrant pain, sudden and early onset of this pain, and early onset emesis [ 12 , 13 ]. Finally, Triad 3 illustrates the physical signs of the patient: palpable right upper quadrant mass, lack of a toxic or jaundiced appearance, and a discrepancy between the pulse and temperature [ 12 , 13 ]. Although this system was designed to identify patients with GV in an easier way, our case only demonstrated 4 out of the 9 previously described characteristics again making the diagnosis of GV in our patient very difficult.…”

Gallbladder volvulus mimicking a cardiac event – an unusual presentation

“…Patients most commonly present with symptoms mirroring acute cholecystitis [6,7]. On clinical examination there may be a positive Murphy's sign or a palpable mass in the right upper quadrant [2,6,7]. Other differential diagnoses include biliary colic, ascending cholangitis, pyelonephritis and right-sided colon malignancy.…”

Dual pathology—An unreported case

“…Gallbladder torsion is a rare condition with only a few cases which have been reported in recent literature [2] , [15] . Incidence has been estimated at one in 365,000 hospital admissions [15] .…”