Acute gallbladder torsion - a continued pre-operative diagnostic dilemma
© Mouawad et al; licensee BioMed Central Ltd. 2011
Received: 4 February 2011
Accepted: 13 April 2011
Published: 13 April 2011
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.
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 primarily attributed to increasing life expectancy. Despite significant challenges in pre-operative diagnosis, a high index of suspicion and prompt surgical intervention results in an overall mortality of approximately 5 percent.
Case Report One
A 99-year-old Caucasian female presented with a 3 day history of acute onset right upper quadrant abdominal pain with intermittent radiation to the right flank and back. It was described as colicky in nature on a baseline dull character, and with no obvious precipitating, aggravating or relieving factors. Associated phenomena included anorexia and nausea, but no constitutional upset, vomiting, or change in bowel habit. Her medical history included peptic ulcer disease, uncontrolled hypertension, tobacco abuse, diverticulosis, a hiatal hernia, and dementia. Her surgical history was significant for an appendectomy.
Clinical physical examination revealed an apyrexic frail patient in no acute distress with stable vital signs. Focused abdominal examination demonstrated a soft, mildly distended abdomen with tenderness to palpation in the right upper quadrant, and a positive Murphy's sign. There was no overt peritonism. A reducible left inguinal hernia was also appreciated. Laboratory parameters yielded a mild leukocytosis with neutrophilia, and hypokalemia. Her liver function enzymes were elevated in a cholestatic distribution with a total bilirubin of 3.9 mg/dL, direct bilirubin of 0.9 mg/dL, and an alkaline phosphatase of 150 IU/L.
A cholecystostomy tube was planned, but due to unfavorable anatomy through the liver, it could not be performed. On hospital day 6, despite a normal white blood cell count and apyrexia, she complained of worsening abdominal pain. Following an appropriate pre-operative cardiac workup, the patient and DPOA then consented to an open cholecystectomy with a presumptive diagnosis of acute cholecystitis.
She succumbed from cardio-respiratory failure on post-operative day 4, and was made comfort care respecting her do not resuscitate wishes.
Case Report Two
An 89-year-old Caucasian female with no significant past medical history presented with acute right upper quadrant abdominal pain of approximately 5 hours duration. The pain radiated to the right flank, was crampy with intensities of sharpness, and was precipitated by a large meal. There were no aggravating or relieving factors. Associated phenomena included anorexia and nausea, but no fevers, chills or change in bowel habit. Her past surgical history was significant for an appendectomy.
After appropriate consent, the patient was taken to the operating room for a laparoscopic cholecystectomy with a pre-operative diagnosis of acute cholecystitis. After entering the peritoneal cavity and appropriate establishment of pneumoperitoneum, exploration quickly revealed an obvious necrotic gallbladder in the right upper quadrant. Further investigation noted that the gallbladder was twisted 180 degrees on its small pedicle with a thrombosed cystic artery. Following reduction of the torsion, the gallbladder was resected in the standard laparoscopic fashion. Histology demonstrated congested and ischemic serosa with necrotic mucosa consistent with torsion. Her post-operative course was unremarkable and she was discharged on post-operative day 1.
First reported by Wendel in 1898, and dubbed the "floating gallbladder", gallbladder volvulus is a recognized surgical entity . It commonly affects women in their seventies and eighties, and the increased incidence of this condition may be attributable to increasing life expectancy. Despite its predilection for older ages, it has also been described in the pediatric population as early as 2 years of age .
Multiple hypotheses have been proposed as to the mechanism of gallbladder torsion, but the exact etiology continues to be unidentified. The pre-requisite of local mesenteric redundancy however is necessary for organo-axial torsion around its pedicle. Two anatomic variants have been described: 1) a torsion-prone mesentery, and 2) a mesentery supporting only the cystic duct allowing a completely peritonealized gallbladder to hang free. The susceptibility for rotational instability may be compounded by the elderly's fat loss and tissue atrophy suspending the gallbladder freely . This was seen in both cases a probable precipitant for torsion.
Patients presenting to the emergency department with an acute surgical abdomen complaining of right upper quadrant abdominal pain invite a myriad of differentials including acute cholecystitis, choledochal cysts, choledocholithiasis, gastritis and peptic ulcer disease, intussusception, acute appendicitis, and nephrolithiasis. Laboratory parameters are equally unrewarding and non-specific noting general inflammatory changes.
The correct pre-operative diagnosis of gallbladder volvulus is very challenging, with less than a dozen cases having been diagnosed accurately with pre-operative imaging . Despite technological advances in various imaging modalities, definitive diagnosis is generally achieved intra-operatively . Historically, the classical finding seen on ultrasonography is that of a large, "floating gallbladder" that is exempt of stones. Other reports with computed tomography have noted an enlarged gallbladder that is outside of the gallbladder fossa, severe pericholecystic edema, and a prominent cystic artery to the right of the gallbladder [2, 7, 8]. This, however, continues to be relatively non-specific in clinical practice for intra-abdominal inflammation. Nuclear medicine scans with HIDA have been reported to demonstrate characteristic features pre-operatively . It is, however, with magnetic resonance imaging (MRI) that accurate visualization of a twisted cystic duct has been shown, and may provide an optimal alternative for precise pre-operative diagnosis .
Operative surgical intervention involving reducing the torsion followed by removal of the gallbladder is the treatment of gallbladder volvulus. With further surgical advances, this has been reported safely with laparoscopic approaches in both the adult and pediatric population regardless of obtaining the correct diagnosis of torsion before surgery [10–12].
Gallbladder volvulus continues to remain an uncommon surgical condition despite an increase in incidence. Although multiple imaging modalities are involved in attempting to obtain an accurate pre-operative diagnosis, no one has proven to be adequately sufficiently sensitive. The prompt diagnosis is critical to ensure that the patient undergoes an emergent index cholecystectomy rather than temporizing measures with antibiotics for a subsequent interval intervention. Herein we revisit and remind that the onus is on the surgeon to practice with a necessary high index of suspicion for gallbladder volvulus in the outlined patient demographic in order to circumvent treatment delays that may be fatal.
Written informed consent was obtained from the patients for publication of these case reports and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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