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The diagnostic dilemma of gallbladder volvulus: Report of a Case.

Anuradha R. Bhama

Department of Surgery, University of Iowa, Iowa City, Iowa,USA

Abdi Ahari

Mercy Medical Center, North Iowa, St. Mason City, Iowa, USA

Hui Sen Chong

Department of Surgery, University of Iowa, Iowa City, Iowa,USA

E-mail : huisen-chong@uiowa.edu

DOI: 10.15761/GIMCI.1000109

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Abstract

Gallbladder volvulus is a rare condition that typically affects elderly patients who present with a presumed diagnosis of acute cholecystitis.  Often preoperative imaging is unable to definitively diagnosis volvulus.A 90 year old female presented with a four day history of abdominal pain and was found to have peritoneal signs on examination.  CT scan was obtained concerning for necrosis of the gallbladder. She was taken for emergent laparoscopic cholecystectomy, which was converted to an open procedure upon the realization of volvulus.The patient’s postoperative recovery was uneventful and she was discharged to a nursing facility on postoperative day four.Gallbladder volvulus should be considered in the differential diagnosis of the elderly patient with presumed acute cholecystitis.

Key words

Gallbladder volvulus, elderly, acute abdomen

Introduction

Gallbladder volvulus is a known but rare condition that often presents with acute abdomen in the elderly population. Less than 500 cases have been previously reported and the incidence is unknown. Only a few have reported a preoperative diagnosis of gallbladder volvulus, and imaging remains non-diagnostic. Patients are presumed to have acute cholecystitis in the setting of normal liver function testing. Gallbladder volvulus requires immediate operative intervention to avoid potential complications, while acute cholecystitis usually does not require immediate surgical attention. Though this is a rare condition, it is important to includegallbladder volvulus in the differential diagnosis when evaluating an elderly patient with acute onset of right upper quadrant pain.

Case report

A 90 year old female with no past surgical history presented with four days of abdominal pain, nausea, vomiting and anorexia. She reported no fevers or change in bowel habits. Physical examination revealed an afebrile hemodynamically stable patient. Her abdomen was soft, mildly distended but was extremely tender to palpation at the right upper quadrant region. The tenderness was associated with involuntary guarding. No mass was appreciated. The remainder of her physical exam was within normal limits. Laboratory evaluation revealed a white blood cell count of 14,800 and normal liver function test. CT scan of the abdomen and pelvis revealed a distended and likely necrotic gallbladder without cholelithiasis (Figure 1). This was associated with fat stranding and a significant amount of pericholecystic fluid. The patient was taken to the operating room for laparoscopic cholecystectomy. Upon diagnostic laparoscopy, the patient’s gallbladder was found to be distended, necrotic andvolvulized on its mesentery, along the axis of the cystic duct and cystic artery (Figure 2 & 3). As the anatomy was unclear, the case was converted to an open procedure via a right subcostal incision. The gallbladder was detorsed and the cystic duct and artery were then clearly identified and ligated. The gallbladder was noted to be nonadherent to the liver and was easily resected. The patient’s postoperative course was uneventful and she was discharged to a skilled nursing facility on postoperative day four. Final pathology revealed acute cholecystitis with extensive hemorrhage, focal acute inflammation and loss of surface mucosa. No cholelithiasis was identified.

Figure 1: CT scan demonstrating enlarged gall bladder (labelled GB) without stones.

Figure 2: Intraoperative photo of distended and necrotic gall bladder.

Figure 3: Intraoperative photo of twisted cystic duct pedicle.

Discussion

Acute torsion of the gallbladder is a rare entity in the United States. Initially reported by Wendel in 1898[1], this phenomenon has been described by several authors internationally and seems to have become more common in the past decade.

This condition often occurs in elderly, thin females, who present with acute abdomen and signs suggestive of acute cholecystitis, specifically right upper quadrant pain without jaundice. A spectrum of abdominal exam findings has been described. Findings have included mild right upper quadrant pain, palpation of a mass, frank peritonitis[2,3], or suspected acute appendicitis[4,5]. On laboratory evaluation, these patients do not exhibit signs ofbiliary obstruction or elevation of liver function tests. However, leukocytosis may be present, indicating an inflammatory response. Our patient presented with this clinical picture, including peritoneal signs on exam and no signs of biliary obstruction on laboratory evaluation.

Table 1 summarizes all of the reported cases in the English literature since the advent of laparoscopic cholecystectomy by Enrich Muhe[6]. As described above, most of thesepatients are elderly female patients who presented with RUQ pain without a palpable abdominal mass. In most cases, the initial diagnosis was acute or acalculouscholecystitis. However, seven out of 45 cases were diagnosed as gallbladder volvulus preoperatively. Interestingly, a majority of these cases were diagnosed on CT scan, which is not the traditional imaging modality for gallbladder pathology. In hind-sight, our patient’s torsion was visible on CT scan. Unlike our patient, most of the patients who presented with gallbladder volvulus did not have peritonitis or an acute abdomen. They therefore underwent further workup with hepatobiliary iminodiacetic acid (HIDA) scan, magnetic resonance imaging (MRI), or magnetic resonance cholangiopancreatography (MRCP), which revealed findings of a volvulized gallbladder.

 

Author, year

N

Age

Sex

Signs & Symptoms

Peritonitis

Attempted Methods of Diagnosis

Suspected preopdiagnosis

Method of Diagnosis

Lap

v

Open

Outcome

1

McHenrey [7]

2

87

F

epigastric pain

no

AXR, US

AC

exploration

open

uncomplicated

     

80

F

generalized abdominal pain

no

AXR

partial large bowel obstruction

exploration

open

uncomplicated

2

Van der Veken[8]

1

83

F

RLQ  pain

no

AXR

acute appendicitis

exploration

open

uncomplicated

                       

3

Alden[9]

2

78

F

RUQ pain

no

US

AC

exploration

open

uncomplicated

   

1

91

F

chest and abdominal pain

no

US

AC

exploration

open

uncomplicated

4

Macdonald [10]

1

74

M

RUQ pain and abdominal mass

no

none

AC

exploration

open

uncomplicated

5

Gonzalez-Fisher [11]

1

56

F

RUQ pain

no

US

AC

exploration

open

uncomplicated

6

Nguyen [12]

1

91

F

crampy abdominal pain

no

AXR, US, CT,

AC

exploration

laparoscopy

uncomplicated

7

Schroder [13]

1

18

F

       

exploration

laparoscopy

 

8

Hamdi [14]

1

90

F

RUQ pain

no

AXR, US

AC

exploration

open

uncomplicated

9

McAleese [15]

1

85

F

RUQ pain

no

US

AC

exploration

laparoscopy

postoperative bleeding diverticuli requiring redadmission

10

Christoudias [16]

1

82

F

left chest pain

no

US

AC

exploration

laparoscopy

uncomplicated

11

Losken [17]

1

80

F

epigastric pain

no

AXR

bowel obstruction

AC

open

uncomplicated

12

Ikematsu [18]

6

77-91

F

             

13

Khosraviani [19]

1

86

F

RUQ pain and abdominal mass

no

US

AC

exploration

not commented

uncomplicated

14

Usui [20]

1

78

F

epigastric pain

no

CT, US, MRI, MRCP,

GBV

MRCP

open

uncomplicated

15

Rajagopal [21]

1

70

F

RUQ pain and abdominal mass

no

US, CT

AC

exploration

open

uncomplicated

16

Kim [22]

1

73

F

n/a

n/a

n/a

n/a

n/a

n/a

n/a

17

Ortiz-Gonzalez [23]

1

90

F

RUQ pain

yes

AXR

acute appendicitis

exploration

open

uncomplicated

18

Cho [24]

1

94

F

RLQ pain and abdominal mass

no

CT

GBV

CT

laparoscopy

uncomplicated

19

Shaikh [25]

2

79

M

RUQ pain

no

US, CT

hydrops of GB

exploration

open

uncomplicated

     

84

M

RUQ pain

no

US

AC

exploration

laparoscopy

uncomplicated

20

Matsuhashi [26]

1

54

F

RUQ pain

no

US, CT, MRI, MRCP

necrotic gall bladder

exploration

open

uncomplicated

21

Tarhan [27]

1

70

M

RUQ pain

no

AXR, US

AC

exploration

open

wound infection

22

Faure [28]

1

84

F

RUQ pain and abdominal mass

no

US, CT

GBV

CT

laparosocpy

uncomplicated

23

Kimura [29]

1

11

M

RUQ pain

no

US, CT, MRI

GBV

MRI

laparoscopy

uncomplicated

24

Malherbe [30]

2

86

F

RUQ pain

no

US, CT, EUS

AC

exploration

open

uncomplicated

     

80

F

diffuse abdominal pain w palpable mass

no

CT

AC

exploration

laparoscopy

postoperative pleural effusions

25

Caliskan [31]

1

79

F

RUQ pain and abdominal mass

no

US

acalculouscholecystitis

exploration

open

uncomplicated

26

Lavy [32]

1

85

F

RUQ pain

yes

CT

GBV

CT

not commented

uncomplicated

27

Bagnato [33]

1

85

M

RUQ  pain

yes

AXR, US

acalculouscholecystitic

exploration

open

uncomplicated

28

Chen [34]

1

84

F

RUQ  pain

no

AXR, CT,

AC

exploration

open

uncomplicated

29

Chittal [35]

1

71

F

cecal volvulus

     

exploration

   

30

Inoue [36]

1

95

M

abdominal pain

no

CT, US, MRI, MRCP,

GBV

CT, MR

laparoscopy

uncomplicated

31

Mouawad [37]

1

99

F

RUQ pain

no

CT, HIDA, ERCP

AC

exploration

open

uncomplicated

32

Alevizos [38]

1

95

F

RUQ pain and abdominal mass

no

CT

n/a

exploration

laparoscopy

uncomplicated

33

Arslan [39]

1

47

M

RUQ pain

yes

US

AC

exploration

open

uncomplicated

34

Miyakura [40]

1

61

F

RUQ  pain

no

US, CT

GBV

CT

laparoscopy

uncomplicated

Table 1: Gall bladder volvulus case reports since advent of laparoscopic cholecystectomy in 1986.

Key: AC = acute cholecystitis; AXR = abdominal x-ray; CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; GBV = gall bladder volvulus; HIDA = hepatobiliary iminodiacetic acid scan; MRCP = magnetic resonance cholangiopancreatography; MRI = magnetic resonance imaging; US = ultrasound

From a clinical standpoint, gallbladder volvulus can show up on imaging as a distended, hydropic gallbladder with thickened wall and pericholecystic fluid. It has been previously suggested that ultrasound may be the instrumental for the diagnosis, with a triad of radiologic findings including: anterior localization of the gallbladder; increased volume of the gallbladder; and a severely thickened, multilayered gallbladder wall[14]. Our patient’s physical exam prompted evaluation in the emergency department with a CT scan. Chen et al. suggested that gallbladder volvulus can be identified on the CT scan using the “U to 9 to O” sign[34]; however, this sign was not evident on our patient’s imaging. Upon retrospective review of our patient’s CT scan, one can appreciate a twist of the gallbladder along the axis of the cystic duct (Figure 4). The use of MRCP to diagnose gallbladder volvulus has been reported [20,26]. However, the majority of these patients present with an acute abdomen, requiring prompt surgical intervention, thus negating any additional studies;a result, only 1% of reported cases of gallbladder volvulus werediagnosed preoperatively[41].

Figure 4: Twisted cystic duct pedicle on CT scan.

Conclusion

The exact cause of gallbladder volvulus remains unknown. Suggested mechanisms for torsion include: congenital deformities, a long peritoneal mesentery, generalized visceroptosis, forceful peristalsis of nearby organs, cholelithiasis, or atherosclerosis of the cystic artery[10,18]. The acute torsion initially results in venous congestion of the gallbladder, leading to engorgement of the organ, followed by acute internal hemorrhage as the mucosa becomes necrotic. This clinical entity has been described sporadically in the literature and remains a rare or under-reported phenomenon. While this diagnosis has been made radiographically, the use of imaging is difficult in cases where patients present with peritonitis requiring emergent operation.

The gallbladder in a gallbladder volvulus case can be resected laparoscopically; however, the triangle of Calot may be difficult to be identified due to torsion of the gallbladder along the cystic duct axis. Therefore, laparotomy may be necessary in order to safely evaluate the anatomy prior to its resection. To summarize, although rare, it is important to consider gallbladder volvulus as a differential diagnosis in the elderly patient with right upper quadrant pain and peritonitis, especially if the clinical situation does not permit time for additional radiographic studies.

Conflict of interest

Anuradha R. Bhama, MD and other co-authors have no conflict of interest.

References

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Editorial Information

Editor-in-Chief

Dario Marchetti
Baylor College of Medicine

Article Type

Research Article

Publication history

Received: March 09, 2016
Accepted: March 18, 2016
Published: March 25, 2016

Copyright

©2016 Bhama AR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Bhama AR, Ahari A, Chong HS(2016). The diagnostic dilemma of gallbladder volvulus: Report of a Case.Gen Int Med Clin Innov1: doi:10.15761/GIMCI.1000109

Corresponding author

Hui Sen Chong, MD

Department of Surgery, University of Iowa, 200 Hawkins Drive, Iowa City, Iowa 52241, Tel: 319-356-1616, Fax: 319-356-8682.

E-mail : huisen-chong@uiowa.edu

 

Author, year

N

Age

Sex

Signs & Symptoms

Peritonitis

Attempted Methods of Diagnosis

Suspected preopdiagnosis

Method of Diagnosis

Lap

v

Open

Outcome

1

McHenrey [7]

2

87

F

epigastric pain

no

AXR, US

AC

exploration

open

uncomplicated

     

80

F

generalized abdominal pain

no

AXR

partial large bowel obstruction

exploration

open

uncomplicated

2

Van der Veken[8]

1

83

F

RLQ  pain

no

AXR

acute appendicitis

exploration

open

uncomplicated

                       

3

Alden[9]

2

78

F

RUQ pain

no

US

AC

exploration

open

uncomplicated

   

1

91

F

chest and abdominal pain

no

US

AC

exploration

open

uncomplicated

4

Macdonald [10]

1

74

M

RUQ pain and abdominal mass

no

none

AC

exploration

open

uncomplicated

5

Gonzalez-Fisher [11]

1

56

F

RUQ pain

no

US

AC

exploration

open

uncomplicated

6

Nguyen [12]

1

91

F

crampy abdominal pain

no

AXR, US, CT,

AC

exploration

laparoscopy

uncomplicated

7

Schroder [13]

1

18

F

       

exploration

laparoscopy

 

8

Hamdi [14]

1

90

F

RUQ pain

no

AXR, US

AC

exploration

open

uncomplicated

9

McAleese [15]

1

85

F

RUQ pain

no

US

AC

exploration

laparoscopy

postoperative bleeding diverticuli requiring redadmission

10

Christoudias [16]

1

82

F

left chest pain

no

US

AC

exploration

laparoscopy

uncomplicated

11

Losken [17]

1

80

F

epigastric pain

no

AXR

bowel obstruction

AC

open

uncomplicated

12

Ikematsu [18]

6

77-91

F

             

13

Khosraviani [19]

1

86

F

RUQ pain and abdominal mass

no

US

AC

exploration

not commented

uncomplicated

14

Usui [20]

1

78

F

epigastric pain

no

CT, US, MRI, MRCP,

GBV

MRCP

open

uncomplicated

15

Rajagopal [21]

1

70

F

RUQ pain and abdominal mass

no

US, CT

AC

exploration

open

uncomplicated

16

Kim [22]

1

73

F

n/a

n/a

n/a

n/a

n/a

n/a

n/a

17

Ortiz-Gonzalez [23]

1

90

F

RUQ pain

yes

AXR

acute appendicitis

exploration

open

uncomplicated

18

Cho [24]

1

94

F

RLQ pain and abdominal mass

no

CT

GBV

CT

laparoscopy

uncomplicated

19

Shaikh [25]

2

79

M

RUQ pain

no

US, CT

hydrops of GB

exploration

open

uncomplicated

     

84

M

RUQ pain

no

US

AC

exploration

laparoscopy

uncomplicated

20

Matsuhashi [26]

1

54

F

RUQ pain

no

US, CT, MRI, MRCP

necrotic gall bladder

exploration

open

uncomplicated

21

Tarhan [27]

1

70

M

RUQ pain

no

AXR, US

AC

exploration

open

wound infection

22

Faure [28]

1

84

F

RUQ pain and abdominal mass

no

US, CT

GBV

CT

laparosocpy

uncomplicated

23

Kimura [29]

1

11

M

RUQ pain

no

US, CT, MRI

GBV

MRI

laparoscopy

uncomplicated

24

Malherbe [30]

2

86

F

RUQ pain

no

US, CT, EUS

AC

exploration

open

uncomplicated

     

80

F

diffuse abdominal pain w palpable mass

no

CT

AC

exploration

laparoscopy

postoperative pleural effusions

25

Caliskan [31]

1

79

F

RUQ pain and abdominal mass

no

US

acalculouscholecystitis

exploration

open

uncomplicated

26

Lavy [32]

1

85

F

RUQ pain

yes

CT

GBV

CT

not commented

uncomplicated

27

Bagnato [33]

1

85

M

RUQ  pain

yes

AXR, US

acalculouscholecystitic

exploration

open

uncomplicated

28

Chen [34]

1

84

F

RUQ  pain

no

AXR, CT,

AC

exploration

open

uncomplicated

29

Chittal [35]

1

71

F

cecal volvulus

     

exploration

   

30

Inoue [36]

1

95

M

abdominal pain

no

CT, US, MRI, MRCP,

GBV

CT, MR

laparoscopy

uncomplicated

31

Mouawad [37]

1

99

F

RUQ pain

no

CT, HIDA, ERCP

AC

exploration

open

uncomplicated

32

Alevizos [38]

1

95

F

RUQ pain and abdominal mass

no

CT

n/a

exploration

laparoscopy

uncomplicated

33

Arslan [39]

1

47

M

RUQ pain

yes

US

AC

exploration

open

uncomplicated

34

Miyakura [40]

1

61

F

RUQ  pain

no

US, CT

GBV

CT

laparoscopy

uncomplicated

Table 1: Gall bladder volvulus case reports since advent of laparoscopic cholecystectomy in 1986.

Key: AC = acute cholecystitis; AXR = abdominal x-ray; CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; GBV = gall bladder volvulus; HIDA = hepatobiliary iminodiacetic acid scan; MRCP = magnetic resonance cholangiopancreatography; MRI = magnetic resonance imaging; US = ultrasound

Figure 1: CT scan demonstrating enlarged gall bladder (labelled GB) without stones.

Figure 2: Intraoperative photo of distended and necrotic gall bladder.

Figure 3: Intraoperative photo of twisted cystic duct pedicle.

Figure 4: Twisted cystic duct pedicle on CT scan.