[Gallbladder volvulus: Diagnostic and surgical challenges]

Gallbladder Volvulus in an Elderly Patient: A Case Report and Review of Literature

Gallbladder volvulus is an uncommon cause of acute cholecystitis that results from the rotation of the gallbladder about its mesentery along the axis of the cystic pedicle. We present the case of an 87-year-old woman with acute abdominal pain in the right upper quadrant that began two days prior with no additional symptoms. The physical examination showed a large abdominal eventration on the right side and tenderness. A CT scan showed a distended gallbladder outside its liver bed and with a twist on its cystic pedicle, suggesting a gallbladder volvulus. Abdominal ultrasonography complementary revealed the gallbladder outside its vesicular fossa with incipient changes of acute cholecystitis but without evidence of gallstones. With the diagnosis of acute abdomen secondary to gallbladder volvulus, an emergency cholecystectomy was performed. The exact etiology of the gallbladder volvulus is unknown, although anatomical variants that predispose to its appearance have been described. The clinical presentation is similar to acute cholecystitis, so preoperative diagnosis can be challenging for both surgeons and radiologists and is often misdiagnosed. This is one of the few cases diagnosed with preoperative imaging techniques. Once diagnosed, the appropriate treatment is emergency cholecystectomy. Early diagnosis and surgical treatment are important before it progresses to necrosis, perforation, biliary peritonitis, and hemodynamic instability. Gallbladder volvulus is an uncommon condition. A high index of suspicion is required because the preoperative diagnosis is unusual. Once the diagnosis is established, the treatment is fundamentally surgical.

Atypical presentation of cholecystitis with torsion of the gallbladder diagnosed preoperatively in an unusual location

Objective:

An 87-year-old attended the emergency department with sharp upper abdominal pain, radiating to back with a pain score of 10/10. On examination, severe epigastric tenderness was noted. Past surgical history: bilateral salphingo-oopherectomy. Repair for paraumblical hernia and right total hip replacement. No history of cholecystectomy. Inflammatory markers were raised. Cholecystitis/gall bladder perforation was suspected and contrast CT was performed.

Methods:

CT abdomen and pelvis – in comparison to the previous CT scan which was done in 2018, where gall bladder was in the correct anatomical location, the gall bladder was not seen in the gall bladder fossa in the current study. However, a gall bladder like suspicious structure was noticed within the upper abdomen to the left of midline anterior to the gastric pylorus with significant inflammatory changes. Therefore, considering the clinical picture and CT findings, it was suggestive of acute cholecystitis with torsion of gall bladder.

Results:

Patient was started on i.v. antibiotics and laparoscopic assessment was carried out on the following day. Intraoperatively, the surgeons were unable to locate the gall bladder in its normal anatomical position, but incidentally found a mass in the left upper abdomen which appeared gangrenous. This was removed and sent for histopathology. Histology report confirmed that the specimen was gall bladder with features suggestive of pre-existing chronic cholecystitis, with recent venous infarction.

Conclusion:

Torsion of gall bladder is a very rare entity and if left untreated could lead to fatal sequelae of gangrene and perforation resulting in biliary peritonitis. There is evidence which suggest that torsion of gall bladder is more common in elderly females due to loss of visceral fat but the pre-operative diagnosis using imaging modalities has always been challenging. But in this particular case, the radiologist was able to make the precise diagnosis pre-operatively using the cross-sectional study of an advanced imaging modality like the CT scan with contrast which also helped the surgeons in making the decision for immediate surgery rather than planning for routine conservative management for acute cholecystitis. The importance of cross-sectional study with intravenous contrast in diagnosing unusual presentation of gall bladder related and potentially life-threatening abdominal pathology has been highlighted in this case study. It is also evident that how imaging modalities play a significant role in altering acute management plan.

A Rare Case of Partial Volvulus of the Gall Bladder Detected Preoperatively

A middle-aged woman with uterine fibroids presented with menorrhagia and diffuse abdominal pain. The patient was anemic, afebrile, anicteric, and had a palpable tender gall bladder. Initial whole abdomen ultrasonography was inconclusive, and computed tomography of her abdomen revealed partial volvulus of the gall bladder. Following optimization, the patient had undergone open cholecystectomy under general anesthesia. Intraoperatively, the gall bladder was distended, with edematous walls and rotated clockwise (270°) along the long axis to the cystic duct. We noted no gangrenous changes, and we performed detorsion of the gall bladder and cholecystectomy. Volvulus of the gall bladder can be associated with high mortality and morbidity. Good clinical examination, a high degree of suspicion given the presentation of the case, proper investigation, and timely management prevented poor outcomes in our case.

Vólvulo de la vesícula biliar

El vólvulo, o torsión de la vesícula biliar, es una enfermedad de la sexta a la octava décadas de la vida, condición excepcional por su poca frecuencia y síntomas atípicos. Dado que tiende a confundirse con la colecistitis de origen no litiásico, su diagnóstico suele ser intraoperatorio y puede llegar a causar complicaciones graves, como la gangrena y la sepsis biliar e incluso la muerte. Pese a que hace 120 años se hizo el primer reporte de caso, en la actualidad se notifican cada vez más casos en la población añosa. En este artículo se presentan dos casos clínicos de vólvulo de la vesícula biliar y se hace una revisión de la literatura.

First Report of Gallbladder Volvulus Managed with a Robotic Approach

Gallbladder volvulus (GV) is an axial twisting of the gallbladder (GB). If not treated on time, this condition has a mortality up to 6%. It is usually diagnosed intraoperatively, because it can mimic a typical acute cholecystitis. An 81-year-old female patient presented with an acute onset of right upper quadrant pain accompanied with nausea. The patient was admitted to receive treatment for acute cholecystitis after the findings of ultrasound imaging. Robotic-assisted cholecystectomy was the approach chosen. GV was diagnosed after initial diagnostic laparoscopy. Cholecystectomy was performed uneventfully. Indocyanine green fluorescence was used to assess the biliary anatomy. The postoperatory course went uneventful. The patient was discharged home on postoperatory day 2.