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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 4  |  Page : 230-232

Incomplete gallbladder volvulus: A case report of a rare entity


Department of Visceral and General Surgery, Regional Hospital of Zaghouan, Zaghouan, Tunisia

Date of Submission05-Apr-2019
Date of Acceptance09-Jul-2019
Date of Web Publication11-Nov-2019

Correspondence Address:
Malek Bouhani
Cite Elhabib Ezzahra, 2034, Tunis
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_28_19

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  Abstract 


Gallbladder volvulus (GV) is described as the twist of the gallbladder. Unless diagnosed and treated early, it is a rare fatal condition. It often affects aged patients who present with a presumed acute cholecystitis diagnosis. A 92-year-old female presented with a 2-day history of hypochondria pain. The physical examination found a palpable gallbladder and peritoneal signs without jaundice. Blood tests showed acute renal failure without hyper-leucocytosis. An abdomino-pelvic non-contrast-enhanced computed tomography scan was performed and showed an unusual configuration of the gallbladder. She received an emergent laparotomy. At surgery, hyperaemic and incomplete rotated gallbladder was observed and cholecystectomy was performed. The patient's post-operative recovery was favourable. Early diagnosis and efficient surgical treatment are essential to reduce this entity's complications. Physicians should be guided by clinical signs and radiographic studies to diagnose GV correctly.

Keywords: Gallbladder, incomplete, volvulus


How to cite this article:
Bouhani M, Attaoui MA. Incomplete gallbladder volvulus: A case report of a rare entity. Hamdan Med J 2019;12:230-2

How to cite this URL:
Bouhani M, Attaoui MA. Incomplete gallbladder volvulus: A case report of a rare entity. Hamdan Med J [serial online] 2019 [cited 2019 Dec 6];12:230-2. Available from: http://www.hamdanjournal.org/text.asp?2019/12/4/230/270675




  Introduction Top


Gallbladder volvulus (GV) remains an uncommon diagnosis. Roughly 500 cases have been reported before since Wendel first reported as a 'floating gallbladder' in 1898.[1],[2] Since the turn of the 21st century, the incidence appears to have increased, probably due to increasing life expectancy around the world.[3] GV is characterised by a gallbladder rotation around its mesentery along the axis of the cystic duct and artery.[4] GV is a condition that threatens life. GV causes ischemia, necrosis, perforation and biliary peritonitis due to the blockage of biliary drainage and arterial flow. The potential for gallbladder gangrene and perforation can be avoided, and an excellent prognosis is achieved with timely diagnosis and surgery, as reported in this rare case of incomplete GV.[5] The mortality rate for the disease is currently quite low at approximately 5%.[6]


  Case Report Top


A 92-year-old woman presented an intense onset of right upper quadrant pain to the emergency room. Previously, she had minimal medical co-morbidities in her usual state of health. Her medical history for osteoarthritis is significant. She has not had a surgical past. Her family history was meaningless.

She was haemodynamically normal on physical examination. The relevant findings in her right upper and lower abdominal quadrants were tenderness to palpation and a palpable gallbladder. The blood tests revealed an acute renal failure within normal limits of counting white blood cell and liver function tests.

We performed a non-contrast-enhanced computed tomography (CT) scan due to acute renal failure. CT demonstrated a largely distended gallbladder, with wall thickening and a horizontal axis [Figure 1].
Figure 1: Computed tomography demonstrating the dilated and relatively inferiorly placed gallbladder, with wall thickening and a horizontal axis

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The patient was hospitalised for acute cholecystitis treatment involving bowel rest and antibiotics. We performed an open cholecystectomy, due to excessive size of the gallbladder. A hyperaemic gallbladder in the right lower quadrant was identified at laparotomy and was inadherent to the liver bed. Around the cystic duct and cystic artery, the gallbladder was torsed incompletely (180°). The gallbladder was so mobile and was easily removed after simple cystic artery and duct ligation [Figure 2]. The specimen's inspection revealed significant thickening of the gallbladder wall and lack of gallstones. Postoperative management was straightforward and the patient was discharged three days after to a rehabilitation facility. Final pathology revealed severe acute cholecystitis with transmural oedema and acute serositis.
Figure 2: Intraoperative image of gallbladder torsion. Intraoperative picture showing the acute incomplete torsion of the cystic duct, with hyperaemic floating gallbladder

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  Discussion Top


GV is characterised by viscera rotation on its mesentery. This rotation leads to a cut-off of its arterial supply and bile flow, which is responsible for the brutal clinical appearance. Gallbladder wall thickening, hydrops and gangrene develop, respectively, by gallbladder torsion.

It is mostly seen in the elderly with a female preponderance (3:1) between the ages of 60 and 80, although around 50 paediatric cases have now been recorded.[2]

Various aetiologies can cause GV. It can be congenital with a long mesenteryis or it can have attaches to the gallbladder only at the cystic duct; this condition causes a free-floating gallbladder; there will be a predisposition to twisting.[7] Further, loss of visceral fat, liver atrophy, presence of a long mesentery, weight loss and spinal deformities seen in the elderly cause GV.[8],[9] Because more than half of the patients had no gallstones, the role of gallstones is less important.

The free-floating gallbladder can be complete with a rotation of 180 degrees or greater or incomplete rotation less than 180 degrees. Our patient showed the last category with incomplete rotation.

In the right upper quadrant, the physical examination reveals a tender mass. This described sign can be seen in severe acute cholecystitis alone, but the floating gallbladder may alert a physician for GV.

The appearance of GV on a CT scan is not pathognomonic to this condition in most cases. It can appear as classical cholecystitis. Kitagawa et al. described four diagnostic criteria: fluid collection in the gallbladder fossa, a change in the axis of the gallbladder from vertical to horizontal, a hyper-enhancing cyst duct to the right of the gallbladder and features of the gallbladder wall's intense inflammation.[10] We just found a wall thickness of gallbladder and change of its axis.

This case splendidly illustrates the complexities of managing a patient with GV. Acute cholecystitis was initially suspected although the radiological findings were poor. The abdomen rigidity in our case leads to emergency laparotomy, where the exact diagnosis was made. Per-operative findings showed just a twisted, hyperaemic gallbladder. The swiftness of the surgery leads to discovering GV at an early stage and limits adverse events.

This case demonstrates how difficult the diagnosis of GV is to make preoperatively for both surgeons and radiologists.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wendel AV. VI. A case of floating gall-bladder and kidney complicated by cholelithiasis, with perforation of the gall-bladder. Ann Surg 1898;27:199-202.  Back to cited text no. 1
    
2.
Reilly DJ, Kalogeropoulos G, Thiruchelvam D. Torsion of the gallbladder: A systematic review. HPB (Oxford) 2012;14:669-72.  Back to cited text no. 2
    
3.
Pu TW, Fu CY, Lu HE, Cheng WT. Complete body-neck torsion of the gallbladder: A case report. World J Gastroenterol 2014;20:14068-72.  Back to cited text no. 3
    
4.
Malherbe V, Dandrifosse AC, Detrembleur N, Denoel A. Torsion of the gallbladder: Two case reports. Acta Chir Belg 2008;108:130-2.  Back to cited text no. 4
    
5.
Amarillo HA, Pirchi ED, Mihura ME. Complete gallbladder and cystic pedicle torsion. Laparoscopic diagnosis and treatment. Surg Endosc 2003;17:832-3.  Back to cited text no. 5
    
6.
Nakao A, Matsuda T, Funabiki S, Mori T, Koguchi K, Iwado T, et al. Gallbladder torsion: Case report and review of 245 cases reported in the Japanese literature. J Hepatobiliary Pancreat Surg 1999;6:418-21.  Back to cited text no. 6
    
7.
Chilton CP, Mann CV. Torsion of the gallbladder in a nine-year-old boy. J R Soc Med 1980;73:141-3.  Back to cited text no. 7
    
8.
Cho YP, Kim HJ, Jung SM, Kang GH, Han MS, Jang HJ, et al. Torsion of the gallbladder: Report of a case. Yonsei Med J 2005;46:862-5.  Back to cited text no. 8
    
9.
Tarhan OR, Barut I, Dinelek H. Gallbladder volvulus: Review of the literature and report of a case. Turk J Gastroenterol 2006;17:209-11.  Back to cited text no. 9
    
10.
Kitagawa H, Nakada K, Enami T, Yamaguchi T, Kawaguchi F, Nakada M, et al. Two cases of torsion of the gallbladder diagnosed preoperatively. J Pediatr Surg 1997;32:1567-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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