The diagnostic dilemma of a gallbladder volvulus: An unusual case report and review of the literature

Twist of Fate: Diagnosing and Managing Gallbladder Volvulus in an Elderly Patient

Gallbladder volvulus (GV) is a rare surgical emergency characterized by the twisting of the gallbladder around its mesentery, leading to vascular compromise and gangrene. It is often misdiagnosed as acute gangrenous cholecystitis due to overlapping symptoms, making preoperative diagnosis challenging. Definitive identification is typically made intraoperatively. Contributory factors include advanced age, female gender, low body mass index, and increased gallbladder mobility. Urgent surgical intervention is crucial to prevent severe complications such as perforation and biliary peritonitis. We report a case of an elderly woman with a low BMI who had a history of right hemicolectomy for locally advanced cecal cancer and ongoing immunotherapy for pelvic recurrence. She presented with acute epigastric pain, nausea, and vomiting but no fever or jaundice. Examination revealed a tender upper abdomen with a palpable mass. Laboratory investigations showed leucocytosis with unremarkable CRP, liver, and renal function tests. A CT scan demonstrated a grossly distended midline gallbladder with a swirl sign at the cystic pedicle, consistent with GV. Supportive management was given, followed by urgent laparoscopic cholecystectomy. Intraoperatively, a gangrenous gallbladder twisted 360° twice around its mesentery was identified and safely removed without complications. The patient made an uneventful recovery and was discharged within 48 hours. This case underscores the diagnostic challenges of GV and highlights the importance of a high index of suspicion, particularly in elderly, frail patients with risk factors. Imaging findings such as the "swirl sign" and midline crossing of the gallbladder on CT scan aid preoperative diagnosis. Urgent surgical intervention remains the cornerstone of management, as delayed treatment can result in significant morbidity.

Gallbladder torsion

ABSTRACT

Gallbladder torsion is a rare cause of acute surgical abdomen. Early recognition and surgical intervention are important for reducing complications and improving postoperative patient outcomes, but standard imaging and laboratory evaluation typically are indistinguishable from those of acute cholecystitis. This article describes a patient with gangrenous cholecystitis secondary to torsion and summarizes recommendations for evaluation and management.

Gallbladder volvulus with preoperative and intraoperative imaging

Volvulus of the gallbladder is one of the rarest conditions to affect the gallbladder, however, it should remain an important differential. Typically, it is diagnosed in elderly women, but it has also been reported in children and men. The lack of unique distinguishing features make diagnosis difficult to distinguish between other gallbladder pathology such as acute cholecystitis; however, delayed recognition or non-operative management is associated with higher mortality. We present the case of a 92-year-old woman who presented with this pathology, had diagnosis established preoperatively and was successfully treated with a cholecystectomy.

Gallbladder Volvulus: A Review

Gallbladder volvulus is an uncommon condition that mostly affects older women. The cause of gallbladder volvulus is unknown, although intraoperative evidence of a floating gallbladder with a twisting of its pedicle, resulting in gallbladder ischemia, may lead to subsequent complications. Gallbladder volvulus symptoms are similar to acute cholecystitis, leading to delayed diagnosis and treatment. Early detection and prompt surgical intervention are critical for reducing morbidity and mortality. Even though numerous case reports have been published since 1898, gallbladder volvulus remains challenging to diagnose preoperatively. As a result, a high level of suspicion is required to prompt cholecystectomy and avoid further complications. We review the etiology, pathophysiology, clinical manifestation, diagnostic strategies, and treatment of this disease.

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.

The deceitful diagnosis of gallbladder volvulus: A case report

INTRODUCTION AND IMPORTANCE

The gallbladder volvulus is a rare but life-threatening condition characterized by an axial torsion of the gallbladder along the cystic pedicle, causing gallbladder ischemia and necrosis. This paper aims to present and discuss a rare case of gallbladder volvulus. This case report has been reported in line with the SCARE criteria 2020 [1].

CASE PRESENTATION

We report the case of a 90-year-old female patient who presented to the emergency room with sharp right upper abdominal quadrant pain of acute onset associated with vomiting, evolving for the last 12 h. She had no fever nor jaundice. Her body mass index (BMI) was 22. She had kyphosis, and scoliosis. Physical examination found tenderness with a palpable mass in the right upper abdominal quadrant. Laboratory test results showed leukocytosis at 11600 /mL and a high C-reactive protein rate at 40 mg/L revealed acute calculous cholecystitis features. However, emergency laparotomy was performed and discovered a gallbladder volvulus. A detorsion and cholecystectomy were performed with a good outcome.

CLINICAL DISCUSSION

The preoperative diagnosis of gallbladder volvulus is difficult due to its misleading clinical presentation mimicking acute cholecystitis. The presence of the three highly suggestive triad clinical signs should encourage the radiologist to search for a gallbladder with a horizontal orientation and located outside its anatomical fossa connected to the liver by a conical structure corresponding to the twisted pedicle in ultrasonography. Unlike ordinary acute cholecystitis, which may sometimes tolerate an initial conservative medical treatment, gallbladder volvulus management is always an emergency cholecystectomy.

CONCLUSION

Despite the clinical similarities with the classical acute calculous cholecystitis, gallbladder volvulus is more likely to result in fatal outcome. Therefore, a high level of clinical suspicion is necessary to save lives.